Revisiones sistemáticas de la región


Revisión de intervención - Cochrane
Título del protocolo en proceso: Therapeutic vaccines for advanced non-small cell lung cancer
Autores:Pascual, Maria Amparo; Pascual, Maria Amparo; Cortés-Jofré, Marcela; Uranga, Rolando; Torres Pombert, Ania; Lopez-Saura, Pedro A.; Arango Prado, Maria del Carmen; Caballero Aguirrechu, Iraida; Pacheco, Cecilia; Ortiz Reyes, Rosa Maria; Chuecas, Fernando; Monzon, Maicel; Mas Bermejo, Pedro Inocente
Líder de la revisión: Maria Amparo Pascual (Cuba).


Los efectos en la calidad de la atención sanitaria de las Guía de Práctica Clínica basadas en evidencia (GPCBE) de tratamiento de enfermedades cardiovasculares:
Revisión Sistemática

Anggie Ramírez Morera, Mario Tristan, Juan Carlos Vazquez

Antecedentes:
La elaboración de GPC basadas en la evidencia ha experimentado gran auge a nivel mundial a partir de la década de los 90s. Sin embargo se desconoce si estas recomendaciones de alta calidad tienen un impacto estadísticamente significativo en el correspondiente censo de pacientes en la cual son aplicadas. A pesar de la cantidad exorbitante de GPC de reciente publicación existen pocos estudios acerca de su efectividad en mejorar los resultados clínicos, el proceso o la estructura en el ámbito sanitario.

Objetivo:
El principal objetivo de este artículo corresponde a valorar el impacto que tienen dichas GPC basadas en evidencia sobre tres elementos: resultados de pacientes, proceso de manejo, estructura de salud.

Conclusiones:
En conclusión, hay un desequilibrio entre el número de GPCBE desarrolladas y el número de estudios de alta calidad que evalúen su efecto. El estudio logra demostrar en una forma débil que recomendaciones basadas en la evidencia pueden ser eficaces para mejorar el proceso y la estructura de la atención y en menor medida para mejorar los resultados en pacientes.
La variación en los efectos a través de las recomendaciones de las GPCBE, sugiere que es útil centrarse en el análisis de las barreras de adherencia y diseñar estrategias de implementación adaptadas a cada una de las recomendaciones, en lugar de a la GPCBE en su conjunto. Se necesita investigación adicional para determinar qué factores relacionados con la GPCBE y sus recomendaciones específicas son importantes en la predicción de la utilización de GPCBE y así obtener mejores resultados en los pacientes.

Implicaciones para la práctica:
La idea inicial para realizar esta revisión fue el de fortalecer los programas de desarrollo de GPCBE con una evaluación del efecto de las GPCBE sobre la calidad de la atención en salud y contar con evidencia confiable para sustentar la toma de decisiones dirigida a la construcción de GPCBE en países de mediano y bajo ingreso. Aunque el resultado no es fuerte a favor de las GPCBE como instrumento de mejoramiento de la calidad de atención, los resultados de ésta revisión deben de manejarse con cuidado, de manera que permitan una mejor priorización, desarrollo e implementación de las GPCBE. Es necesario enfatizar que la implementación estándar seguida hasta ahora debe ser revisada e incorporar nuevas estrategias piscosociales orientadas a conducir cambios en la práctica clínica y la práctica de la relación médico paciente.
Para la adecuada implementación de una GPCBE, se debe tomar en cuenta los probables beneficios y costos necesarios, para tener claro los resultados esperados. Los sistemas de salud que construyen GPCBE, deben maximizar esfuerzos en la adherencia del personal de salud en seguir las recomendaciones de las GPCBE y hacer el esfuerzo de evaluar el impacto de las mismas.

Implicaciones para la investigación:
Debido a que la investigación en este campo es tan incipiente y que los resultados no fueron concluyentes; es necesario conducir más investigaciones que evalúen el cambio que el uso de la GPCBE producen en la calidad de la atención sanitaria, dando un éfasis en los dominios menos estudiados como son: la estructura de los servicios de salud y los resultados de salud de los pacientes.


Vector and reservoir control for preventing leishmaniasis
González U, Pinart M, Sinclair D, Firooz A, Enk C, Vélez ID, Esterhuizen TM, Tristan M, Alvar J.
Cochrane Database Syst Rev. 2015 Aug 5;8:CD008736. doi: 10.1002/14651858.CD008736.pub2.
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BACKGROUND: 
Leishmaniasis is caused by the Leishmania parasite, and transmitted by infected phlebotomine sandflies. Of the two distinct clinical syndromes, cutaneous leishmaniasis (CL) affects the skin and mucous membranes, and visceral leishmaniasis (VL) affects internal organs. Approaches to prevent transmission include vector control by reducing human contact with infected sandflies, and reservoir control, by reducing the number of infected animals.
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OBJECTIVES: 
To assess the effects of vector and reservoir control interventions for cutaneous and for visceral leishmaniasis.
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MAIN RESULTS: 
We included 14 RCTs that evaluated a range of interventions across different settings. The study methods were generally poorly described, and consequently all included trials were judged to be at high or unclear risk of selection and reporting bias. Only seven trials reported clinical outcome data which limits our ability to make broad generalizations to different epidemiological settings and cultures. Cutaneous leishmaniasisOne four-arm RCT from Afghanistan compared indoor residual spraying (IRS), insecticide-treated bednets (ITNs), and insecticide-treated bedsheets, with no intervention. Over 15 months follow-up, all three insecticide-based interventions had a lower incidence of CL than the control area (IRS: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.38 to 0.97, 2892 participants, moderate quality evidence; ITNs: RR 0.32, 95% CI 0.18 to 0.56, 2954 participants, low quality evidence; ITS: RR 0.34, 95% CI 0.20 to 0.57, 2784 participants, low quality evidence). No difference was detected between the three interventions (low quality evidence). One additional trial of ITNs from Iran was underpowered to show a difference.Insecticide treated curtains were compared with no intervention in one RCT from Venezuela, where there were no CL episodes in the intervention areas over 12 months follow-up compared to 142 in control areas (RR 0.00, 95% CI 0.00 to 0.49, one trial, 2938 participants, low quality evidence).Personal protection using insecticide treated clothing was evaluated by two RCTs in soldiers, but the trials were underpowered to reliably detect effects on the incidence of CL (RR 0.40, 95% CI 0.13 to 1.20, two trials, 558 participants, low quality evidence). Visceral leishmaniasisIn a single RCT of ITNs versus no intervention from India and Nepal, the incidence of VL was low in both groups and no difference was detected (RR 0.99, 95% CI 0.46 to 2.15, one trial, 19,810 participants, moderate quality evidence).Two trials from Brazil evaluated the effects of culling infected dogs compared to no intervention or IRS. Although they report a reduction in seroconversion over 18 months follow-up, they did not measure or report effects on clinical disease.
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AUTHORS CONCLUSIONS: 
Using insecticides to reduce phlebotomine sandfly numbers may be effective at reducing the incidence of CL, but there is insufficient evidence from trials to know whether it is better to spray the internal walls of houses or to treat bednets, curtains, bedsheets or clothing.

Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women
Orozco LJ, Tristan M, Vreugdenhil MM, Salazar A.
0
BACKGROUND: 
Prophylactic oophorectomy alongside hysterectomy in premenopausal women is a common procedure. The decision to remove or conserve the ovaries is often based on the perceived risk for ovarian cancer and the need for additional gynecological surgical interventions, and is weighed against the perceived risk of negative health effects caused by surgically induced menopause. The evidence needed to recommend either prophylactic bilateral oophorectomy or conservation of ovaries at the time of hysterectomy in premenopausal women is limited. This is an update of the original version of this systematic review published in 2008.
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OBJECTIVES: 
To compare hysterectomy alone versus hysterectomy plus bilateral oophorectomy in women with benign gynecological conditions, with respect to rates of mortality or subsequent gynecological surgical interventions.
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MAIN RESULTS: 
Only one RCT comparing the benefits and risks of hysterectomy with or without oophorectomy was identified. The results of this pilot RCT have not been published and we have not been able to obtain the results. Therefore, no data could be included in this review.
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AUTHORS CONCLUSIONS: 
The conclusions of this review are limited by a lack of RCTs. Although no evidence is available from RCTs, there is growing evidence from observational studies that surgical menopause may impact negatively on cardiovascular health and all cause mortality.

Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women
Orozco LJ, Tristan M, Vreugdenhil MM, Salazar A.
Cochrane Database Syst Rev. 2014 Jul 28;7:CD005638
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UPDATE OF:
Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. [Cochrane Database Syst Rev. 2008]
0
BACKGROUND:
Prophylactic oophorectomy alongside hysterectomy in premenopausal women is a common procedure. The decision to remove or conserve the ovaries is often based on the perceived risk for ovarian cancer and the need for additional gynaecological surgical interventions,and is weighed against the perceived risk of negative health effects caused by surgically induced menopause. The evidence needed to recommend either prophylactic bilateral oophorectomy or conservation of ovaries at the time of hysterectomy in premenopausal women is limited. This is an update of the original version of this systematic review published in 2008.Objectives To compare hysterectomy alone versus hysterectomy plus bilateral oophorectomy in women with benign gynaecological conditions,with respect to rates of mortality or subsequent gynaecological surgical interventions.
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MAIN RESULTS:
Only one RCT comparing the benefits and risks of hysterectomy with or without oophorectomy was identified. The results of this pilot RCT have not been published and we have not been able to obtain the results. Therefore, no data could be included in this review. 
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AUTHORS CONCLUSIONS:
The conclusions of this review are limited by a lack of RCTs. Although no evidence is available from RCTs, there is growing evidence from observational studies that surgical menopause may impact negatively on cardiovascular health and all cause mortality.

Blood pressure targets for hypertension in people with diabetes mellitus
Arguedas JA, Leiva V, Wright JM. 
Cochrane Database Syst Rev. 2013 Oct 30;10:CD008277. doi: 10.1002/14651858.CD008277.pub2. Review
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BACKGROUND: 
When treating elevated blood pressure (BP), doctors often want to know what blood pressure target they should try to achieve. The standard blood pressure target in clinical practice for some time has been less than 140 - 160/90 - 100 mmHg for the general population of people with elevated blood pressure. Several clinical guidelines published in recent years have recommended lower targets (less than 130/80 mmHg) for people with diabetes mellitus. It is not known whether attempting to achieve targets lower than the standard target reduces mortality and morbidity in those with elevated blood pressure and diabetes.
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OBJECTIVES: 
To determine if 'lower' BP targets (any target less than 130/85 mmHg) are associated with reduction in mortality and morbidity compared with 'standard' BP targets (less than 140 - 160/90 - 100 mmHg) in people with diabetes.
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MAIN RESULTS: 
We found five randomized trials, recruiting a total of 7314 participants and with a mean follow-up of 4.5 years. Only one trial (ACCORD) compared outcomes associated with 'lower' (< 120 mmHg) or 'standard' (< 140 mmHg) systolic blood pressure targets in 4734 participants. Despite achieving a significantly lower BP (119.3/64.4 mmHg vs 133.5/70.5 mmHg, P < 0.0001), and using more antihypertensive medications, the only significant benefit in the group assigned to 'lower' systolic blood pressure (SBP) was a reduction in the incidence of stroke: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88, P = 0.009, absolute risk reduction 1.1%. The effect of SBP targets on mortality was compatible with both a reduction and increase in risk: RR 1.05 CI 0.84 to 1.30, low quality evidence. Trying to achieve the 'lower' SBP target was associated with a significant increase in the number of other serious adverse events: RR 2.58, 95% CI 1.70 to 3.91, P < 0.00001, absolute risk increase 2.0%.Four trials (ABCD-H, ABCD-N, ABCD-2V, and a subgroup of HOT) specifically compared clinical outcomes associated with 'lower' versus 'standard' targets for diastolic blood pressure (DBP) in people with diabetes. The total number of participants included in the DBP target analysis was 2580. Participants assigned to 'lower' DBP had a significantly lower achieved BP: 128/76 mmHg vs 135/83 mmHg, P < 0.0001. There was a trend towards reduction in total mortality in the group assigned to the 'lower' DBP target (RR 0.73, 95% CI 0.53 to 1.01), mainly due to a trend to lower non-cardiovascular mortality. There was no difference in stroke (RR 0.67, 95% CI 0.42 to 1.05), in myocardial infarction (RR 0.95, 95% CI 0.64 to 1.40) or in congestive heart failure (RR 1.06, 95% CI 0.58 to 1.92), low quality evidence. End-stage renal failure and total serious adverse events were not reported in any of the trials. A sensitivity analysis of trials comparing DBP targets < 80 mmHg (as suggested in clinical guidelines) versus < 90 mmHg showed similar results. There was a high risk of selection bias for every outcome analyzed in favor of the 'lower' target in the trials included for the analysis of DBP targets.
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AUTHORS CONCLUSIONS: 
At the present time, evidence from randomized trials does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and diabetes. More randomized controlled trials are needed, with future trials reporting total mortality, total serious adverse events as well as cardiovascular and renal events.

Mifepristone for uterine fibroids
Tristan M, Orozco LJ, Steed A, Ramírez-Morera A, Stone P.
Cochrane Database Syst Rev. 2012 Aug 15;8:CD007687. doi: 10.1002/14651858.CD007687.pub2
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BACKGROUND: 
Uterine fibroids are the most common benign uterine tumours present in women of reproductive age. Mifepristone (RU-486) competitively binds and inhibits progesterone receptors. Studies have suggested that fibroid growth depends on the sexual steroids. Mifepristone has been shown to decrease fibroid size. This review summarises the effects of mifepristone treatment on fibroids and the associated adverse effects as described in randomised controlled trials.
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OBJECTIVES: 
To determine the efficacy and safety of mifepristone for the management of uterine fibroids in pre-menopausal women.
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MAIN RESULTS: 
Three studies involving 112 participants were included. Comparison interventions included different dosages of mifepristone, placebo and vitamin B tablets. There is evidence that treatment with mifepristone relieves heavy menstrual bleeding compared with placebo (Peto OR 17.84; 95% CI 6.72 to 47.38; 2 RCTs, 77 women, I(2) = 0%). Three studies (Bagaria 2009; Engman 2009; Fiscella 2006) were included in the meta-analysis of this comparison. There was no evidence of an effect of mifepristone on the fibroid volume (standardised mean difference (SMD) -0.02; 95% CI -0.38 to 0.41; 99 women). Two studies (Bagaria 2009; Fiscella 2006) were included in the meta-analysis of this comparison. There was no evidence of an effect of mifepristone on uterine volume (mean difference (MD) -77.24; 95% CI -240.62 to 86.14; 72 women). The pooled data suggest an increased adverse event (abnormal endometrial histology) in the mifepristone group compared to placebo (OR 31.65; 95% CI 4.83 to 207.35; 2 RCTs; 54 women; I(2) = 0%). Only one study (Bagaria 2009) reported endometrial hyperplasia at the end of the therapy (12/19 women in the mifepristone group versus 0/16 in the placebo group; OR 55.0; 95% CI 2.86 to 105.67). Engman 2009 found a significantly higher rate of cystic glandular dilatation in women in the mifepristone group (5/8 women biopsied) compared with the placebo group (1/11 women biopsied) (OR 16.67; 95% CI 1.36 to 204.03). One study (Fiscella 2006) suggested significant improvements (P < 0.001) for specific quality of life outcomes.
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AUTHORS CONCLUSIONS: 
Mifepristone reduced heavy menstrual bleeding and improved fibroid-specific quality of life. However, it was not found to reduce fibroid volume. Further well-designed, adequately powered RCTs are needed before a recommendation can be made on the use of mifepristone for the treatment of uterine fibroids.

Treatments for symptomatic urinary tract infections during pregnancy
Vazquez JC, Abalos E.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD002256. doi: 10.1002/14651858.CD002256.pub2
0
UPDATE OF:
Treatments for symptomatic urinary tract infections during pregnancy. [Cochrane Database Syst Rev. 2003]
0
BACKGROUND: 
Urinary tract infections, including pyelonephritis, are serious complications that may lead to significant maternal and neonatal morbidity and mortality. There is a large number of drugs, and combination of them, available to treat urinary tract infections, most of them tested in non-pregnant women. Attempts to define the optimal antibiotic regimen for pregnancy have, therefore, been problematic.
0
OBJECTIVES: 
The objective of this review was to determine, from the best available evidence from randomised controlled trials, which agent is the most effective for the treatment of symptomatic urinary tract infections during pregnancy in terms of cure rates, recurrent infection, incidence of preterm delivery and premature rupture of membranes, admission to neonatal intensive care unit, need for change of antibiotic, and incidence of prolonged pyrexia.
0
MAIN RESULTS: 
We included 10 studies, recruiting a total of 1125 pregnant women. In most of the comparisons there were no significant differences between the treatments under study with regard to cure rates, recurrent infection, incidence of preterm delivery, admission to neonatal intensive care unit, need for change of antibiotic and incidence of prolonged pyrexia. When cefuroxime and cephradine were compared, there were better cure rates (29/49 versus 41/52) and fewer recurrences (20/49 versus 11/52) in the cefuroxime group. There was only one other statistically significant difference when comparing outpatient versus inpatient treatment. Gestational age at birth was greater in women from the outpatient group (38.86 versus 37.21), while birthweight was on average greater in the inpatient group (3120 versus 2659).
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AUTHORS CONCLUSIONS: 
Although antibiotic treatment is effective for the cure of urinary tract infections, there are insufficient data to recommend any specific drug regimen for treatment of symptomatic urinary tract infections during pregnancy. All the antibiotics studied were shown to be very effective in decreasing the incidence of the different outcomes. Complications were very rare. All included trials had very small sample sizes to reliably detect important differences between treatments. Future studies should evaluate the most promising antibiotics, in terms of class, timing, dose, acceptability, maternal and neonatal outcomes and costs.

Treatment blood pressure targets for hypertension
Arguedas JA, Perez MI, Wright JM.
Cochrane Database Syst Rev. 2009 Jul 8;(3):CD004349. doi: 10.1002/14651858.CD004349.pub2
0
BACKGROUND: 
When treating elevated blood pressure, doctors need to know what blood pressure (BP) target they should try to achieve. The standard of clinical practice for some time has been </= 140 - 160/ 90 - 100 mmHg. New guidelines are recommending BP targets lower than this standard. It is not known whether attempting to achieve targets lower than the standard reduces mortality and morbidity.
0
OBJECTIVES: 
To determine if lower BP targets (</= 135/85 mmHg) are associated with reduction in mortality and morbidity as compared with standard BP targets (</= 140-160/ 90-100 mmHg).
0
MAIN RESULTS: 
No trials comparing different systolic BP targets were found. Seven trials (22,089 subjects) comparing different diastolic BP targets were included. Despite a -4/-3 mmHg greater achieved reduction in systolic/diastolic BP, p< 0.001, attempting to achieve "lower targets" instead of "standard targets" did not change total mortality (RR 0.92, 95% CI 0.86-1.15), myocardial infarction (RR 0.90, 95% CI 0.74-1.09), stroke (RR 0.99, 95% CI 0.79-1.25) , congestive heart failure (RR 0.88, 95% CI 0.59-1.32), major cardiovascular events (RR 0.94, 95% CI 0.83-1.07), or end-stage renal disease (RR 1.01, 95% CI 0.81-1.27). The net health effect of lower targets cannot be fully assessed due to lack of information regarding all total serious adverse events and withdrawals due to adverse effects in 6 of 7 trials. A sensitivity analysis in diabetic patients and in patients with chronic renal disease also did not show a reduction in any of the mortality and morbidity outcomes with lower targets as compared to standard targets.
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AUTHORS CONCLUSIONS: 
Treating patients to lower than standard BP targets, </=140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients.

Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women
Orozco LJ, Salazar A, Clarke J, Tristan M.
0
UPDATE IN:
Hysterectomy versus hysterectomy plus oophorectomy for premenopausal women. [Cochrane Database Syst Rev. 2014]
0
BACKGROUND: 
Prophylactic oophorectomy alongside hysterectomy in premenopausal women is common. The decision to remove or conserve the ovaries is often based on the perceived risk for ovarian cancer and the need for other additional gynaecological surgical interventions. The benefits or harms of prophylactic bilateral oophorectomy at the time of hysterectomy in premenopausal women are unknown.
0
OBJECTIVES: 
To determine whether premenopausal women with hysterectomy without oophorectomy for benign gynaecological conditions versus hysterectomy plus bilateral oophorectomy would have a higher mortality rate and future gynaecological surgical interventions.
0
MAIN RESULTS: 
Of the 119 studies identified, only one controlled trial was included. Therefore, a quantitative meta-analysis was not feasible. The results of this study (with two publications) including 362 women were summarised in a narrative format. No randomised controlled trials were found. Neither publication reported on the primary outcomes stated in this review. The trial showed evidence of very low quality of a positive effect on psychological well-being for both groups at one year follow up. No significant differences were found between the groups of women studied regarding any aspect of their sexuality.
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AUTHORS CONCLUSIONS: 
The conclusions of this review are limited by the lack of data. More research of higher methodological quality is needed.

Treatments for symptomatic urinary tract infections during pregnancy
Vazquez JC, Villar J.
0
UPDATE IN:
Treatments for symptomatic urinary tract infections during pregnancy. [Cochrane Database Syst Rev. 2011]
UPDATE OF:
Treatments for symptomatic urinary tract infections during pregnancy. [Cochrane Database Syst Rev. 2000]
0
BACKGROUND: 
Urinary tract infections, including pyelonephritis, are serious complications that can result in significant maternal and neonatal morbidity and mortality. There is a large number of drugs, and combination of them, available to treat urinary tract infections, most of them tested in non-pregnant women. Attempts to define the optimal antibiotic regimen for pregnancy has, therefore, been problematic.
0
OBJECTIVES: 
The objective of this review was to try to determine, from the best available evidence from randomized control trials, which agent is most effective for the treatment of symptomatic urinary tract infections during pregnancy in terms of cure rates, recurrent infection, incidence of preterm delivery and premature rupture of membranes, admission to neonatal intensive care unit, need for change of antibiotic, and incidence of prolonged pyrexia.
0
MAIN RESULTS: 
Eight studies were included, recruiting a total of 905 pregnant women. In most of the comparisons there were no significant differences between studied treatments with regard to cure rates, recurrent infection, incidence of preterm delivery and premature rupture of membranes, admission to neonatal intensive care unit, need for change of antibiotic and incidence of prolonged pyrexia. Only when cefuroxime and cephradine were compared, were there better cure rates (29/49 versus 41/52) and less recurrences (20/49 versus 11/52) in the cefuroxime group, but the sample size is insufficient to ensure that differences found in the effect of the drugs were real.
0
REVIEWER'S CONCLUSIONS: 
Although antibiotic treatment is effective for the cure of urinary tract infections, there are insufficient data to recommend any specific treatment regimen for symptomatic urinary tract infections during pregnancy. All the antibiotics studied were shown to be very effective in decreasing the incidence of outcomes measured. Complications were very rare. All included trials had very small sample sizes to try to detect important differences between treatments. Future studies should evaluate the most promising antibiotics, in terms of class, timing, dose, acceptability, maternal and neonatal outcomes and costs.

Drugs for preventing lung cancer in healthy people
Caraballoso M, Sacristan M, Serra C, Bonfill X.
0
UPDATE IN:
Drugs for preventing lung cancer in healthy people. [Cochrane Database Syst Rev. 2012]
0
BACKGROUND: 
Some studies have suggested a protective effect of antioxidant nutrients on lung cancer. Observational epidemiological studies suggest an association between higher dietary levels of fruits and vegetables containing beta carotene and a lower risk of lung cancer.
0
OBJECTIVES: 
To determine whether vitamins, minerals and other potential agents, alone or in combination, reduce incidence and mortality from lung cancer in healthy people.
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MAIN RESULTS: 
Four studies were eligible for inclusion. All were population based trials, including a total of 109,394 participants. Two studies included smokers, one included workers exposed to asbestos and two studies were carried out in health professionals. A group of participants with no known risk factors for lung cancer was included in the study sample of two trials. Beta-carotene was evaluated in all trials, alone or combination with alpha-tocopherol or retinol, and one study tested alpha-tocopherol alone. Duration of treatment varied from 2 to 12 years and follow-up was from two to five years. All trials had a placebo group. For people with risk factors for lung cancer no reduction in lung cancer incidence or mortality was found in those taking vitamins alone compared with placebo (incidence of lung cancer: RR 0.98, 95% CI 0.81-1.19; lung cancer mortality: RR 0.93, 95% CI 0.73-1.19). For people with no known risk factors of lung cancer, none of the vitamins or their combinations appeared to have any effect. Combined data from three studies showed a non-statistically significant increased risk of lung cancer incidence (RR 1.11, 95% CI 0.94-1.33) and mortality (RR 1.05, 95% CI 0.87-1.28) for beta-carotene alone at pharmacological doses in groups with risk factors for lung cancer. When beta-carotene was combined with retinol, data from a single study showed that there was a statistically significant, increased risk of lung cancer incidence (RR 1.42, 95% CI 1.13-1.80) and mortality (RR 1.75, 95% CI 1.29-2.38) in people with risk factors for lung cancer who took both vitamins compared with those who took placebo. Data from also from one study showed that the combination of beta-carotene with alpha-tocopherol in people with risk factors for lung cancer was associated with a non-statistically significant increased risk of lung cancer incidence (RR 1.16, 95% CI 0.96-1.39) and mortality (RR 1.15, 95% CI 0.91-1.45). No effect was observed for total cancer incidence, mortality or all-cause mortality.
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REVIEWER'S CONCLUSIONS: 
There is currently no evidence to support recommending vitamins such as alpha-tocopherol, beta-carotene or retinol, alone or in combination, to prevent lung cancer. A harmful effect was found for beta-carotene with retinol at pharmacological doses in people with risk factors for lung cancer (smoking and/or occupational exposure to asbestos). More research from larger trials and with longer follow-up is needed to analyse the effectiveness of other supplements.

Treatments for symptomatic urinary tract infections during pregnancy
Vazquez JC, Villar J.
0
UPDATE IN:
Treatments for symptomatic urinary tract infections during pregnancy. [Cochrane Database Syst Rev. 2003]
0
BACKGROUND: 
Urinary tract infections, including pyelonephritis, are serious complications that can result in significant maternal and neonatal morbidity and mortality. There is a large number of drugs, and combination of them, available to treat urinary tract infections, most of them tested in non-pregnant women. Attempts to define the optimal antibiotic regimen for pregnancy has, therefore, been problematic.
0
OBJECTIVES: 
The objective of this review was to try to determine, from the best available evidence from randomized control trials, which agent is most effective for the treatment of symptomatic urinary tract infections during pregnancy in terms of cure rates, recurrent infection, incidence of preterm delivery and premature rupture of membranes, admission to neonatal intensive care unit, need for change of antibiotic, and incidence of prolonged pyrexia.
0
MAIN RESULTS: 
Five studies were included. There were no significant differences between studied treatments with regard to cure rates, recurrent infection, incidence of preterm delivery and premature rupture of membranes, admission to neonatal intensive care unit, need for change antibiotic and incidence of incidence of prolonged pyrexia.
0
REVIEWER'S CONCLUSIONS: 
Although antibiotic treatment is effective for the cure of urinary tract infections, there are insufficient data to recommend any specific treatment regimen for symptomatic urinary tract infections during pregnancy. All of the antibiotics studied were shown to be very effective in decreasing the incidence of outcomes measured. Complications were very rare. All included trials had very small sample sizes to try to detect important differences between treatments. Future studies should evaluate the most promising antibiotics, in terms of class, timing, dose, acceptability, maternal and neonatal outcomes and costs.

Drugs for preventing lung cancer in healthy people
Cortés-Jofré M, Rueda JR, Corsini-Muñoz G, Fonseca-Cortés C, Caraballoso M, Bonfill Cosp X.
Cochrane Database Syst Rev. 2012 Oct 17;10:CD002141. doi: 10.1002/14651858.CD002141.pub2.
0
UPDATE OF:
Drugs for preventing lung cancer in healthy people. Cochrane Database Syst Rev. 2003;(2):CD002141. Review. Update in: Cochrane Database Syst Rev. 2012;10:CD002141
0
BACKGROUND: 
This is an updated version of the original review published in Issue 2, 2003. Some studies have suggested a protective effect of antioxidant nutrients on lung cancer. Observational epidemiological studies suggest an association between higher dietary levels of fruits and vegetables containing beta-carotene and a lower risk of lung cancer.
0
OBJECTIVES: 
To determine whether vitamins, minerals and other potential agents, alone or in combination, reduce incidence and mortality from lung cancer in healthy people.
0
MAIN RESULTS: 
In the first version of this review four studies were included; in this review update, an additional five studies have been included. Four studies included only males and two only females; two studies included only participants considered at high risk, namely smokers or exposed to asbestos, and one study included people deficient in many micronutrients. Six studies analysed vitamin A, three vitamin C, four vitamin E, one selenium supplements, and six studied combinations of two or more products. All the RCTs included in this review were classified as being of low risk of bias.For people not at high risk of lung cancer and compared to placebo, none of the supplements of vitamins or minerals or their combinations resulted in a statistically significant difference in lung cancer incidence or mortality, except for a single study that included 7627 women and found a higher risk of lung cancer incidence for those taking vitamin C but not for total cancer incidence, but that effect was not seen in males or when the results for males and females were pooled.For people at high risk of lung cancer, such as smokers and those exposed to asbestos and compared to placebo, beta-carotene intake showed a small but statistically significant higher risk of lung cancer incidence, lung cancer mortality and for all-causes mortality.
0
AUTHORS CONCLUSIONS: 
There is no evidence for recommending supplements of vitamins A, C, E, selenium, either alone or in different combinations, for the prevention of lung cancer and lung cancer mortality in healthy people. There is some evidence that the use of beta-carotene supplements could be associated with a small increase in lung cancer incidence and mortality in smokers or persons exposed to asbestos.
0