Cochrane Db Syst Rev
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Cochrane Db Syst Rev · Jan 2000
ReviewActive versus expectant management in the third stage of labour.
Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord. ⋯ Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).
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Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. By definition prior psychological trauma plays a causal role in the disorder, and psychotherapy is a widely accepted intervention. Nevertheless there is growing evidence that PTSD is characterized by specific psychobiological dysfunctions, and this has contributed to a growing interest in the use of medication in its treatment. ⋯ Medication treatments can be effective in PTSD, acting to reduce its core symptoms, and should be considered as part of the treatment of this disorder. The existing evidence base does not provide sufficient data to suggest particular predictors of response to treatment, or to demonstrate that any particular class of medication is more effective or better tolerated than any other. However, the largest trials showing efficacy to date have been with the SSRIs, and in contrast, there have been negative studies of some agents. Given the high prevalence and enormous personal and societal costs of PTSD, there is a need for additional controlled trials in this area. Additional questions for future research include the effects of medication on quality of life in PTSD, appropriate dose and duration of medication, the use of medication in different trauma groups, in pediatric and geriatric subjects, and the value of early (prophylactic), combined (with psychotherapy), and long-term (maintenance) medication treatment.
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The burden of cardiovascular disease world-wide is one of great concern to patients and health care agencies alike. Circulatory diseases, including myocardial infarction (MI) and stroke, kill more people than any other disease. Cardiac rehabilitation aims to restore patients who have suffered myocardial infarction to optimal health through exercise only based rehabilitation or comprehensive cardiac rehabilitation (eg. smoking cessation advice, diet and counselling as well as exercise). Data from two published and widely cited meta-analyses (Oldridge 1988, O'Connor 1989) of over 4,000 patients each have demonstrated that patients randomised to exercise-based cardiac rehabilitation after MI have a statistically significant reduction in all-cause and cardiac mortality of about 20 to 25% compared to patients receiving conventional care. However, the trials included were small and often of poor methodological quality. Incomplete literature review methods may have resulted in publication bias thereby resulting in an over-estimate of the benefit of cardiac rehabilitation. The randomised controlled trials used in the reviews have focused almost exclusively on low-risk, middle-aged males post MI, thereby excluding women and the elderly. ⋯ Exercise-based cardiac rehabilitation appears to be effective in reducing cardiac deaths but the evidence base is weakened by poor quality trials. It is not clear from this review whether exercise only or a comprehensive cardiac rehabilitation intervention is more beneficial. The population studied in this review is still predominately male, middle aged and low risk. Identification of the ethnic origin of the participants was seldom reported. (ABSTRACT TRUNCATED)
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Cochrane Db Syst Rev · Jan 2000
ReviewAntioxidant vitamin and mineral supplementation for preventing age-related macular degeneration.
Some observational studies have suggested that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration. ⋯ There is no evidence to date that people without age-related macular degeneration should take antioxidant vitamin and mineral supplements to prevent or delay the onset of the disease. The results of five large ongoing trials are awaited.
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Heavy menstrual bleeding (HMB) is an important cause of ill health in women. Medical therapy, with the avoidance of possibly unnecessary surgery, is an attractive treatment option. A wide variety of medications are available to reduce heavy menstrual bleeding but there is considerable variation in practice and uncertainty about the most appropriate therapy. Plasminogen activators are a group of enzymes that cause fibrinolysis (the dissolution of clots). An increase in the levels of plasminogen activators has been found in the endometrium of women with heavy menstrual bleeding compared to those with normal menstrual loss. Plasminogen activator inhibitors (antifibrinolytic agents) have therefore been promoted as a treatment for heavy menstrual bleeding. There has been a reluctance to prescribe tranexamic acid due to possible side effects of the drugs such as an increased risk of thrombogenic disease (deep venous thrombosis). Long term studies in Sweden, however, have shown that the rate of incidence of thrombosis in women treated with tranexamic acid is comparable with the spontaneous frequency of thrombosis in women. ⋯ Antifibrinolytic therapy causes a greater reduction in objective measurements of heavy menstrual bleeding when compared to placebo or other medical therapies (NSAIDS, oral luteal phase progestagens and ethamsylate). This treatment is not associated with an increase in side effects compared to placebo, NSAIDS, oral luteal phase progestagens or ethamsylate. Flooding and leakage and sex life is significantly improved after tranexamic acid therapy when compared with oral luteal progestogens but no other measures of quality of life were assessed. No study has used resource cost as an outcome. There are no data available within randomised controlled trials which record the frequency of thromboembolic events.