Cochrane Db Syst Rev
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Cochrane Db Syst Rev · Jan 2009
ReviewAdvance treatment directives for people with severe mental illness.
An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting. ⋯ There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.
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Cochrane Db Syst Rev · Jan 2009
ReviewIron supplementation for reducing morbidity and mortality in children with HIV.
The most prevalent haematologic disturbance associated with HIV in children (apart from CD4 lymphocytopenia) is anaemia. Anaemia associated with HIV arises from multiple mechanisms, including the direct inhibitory effect of HIV on red cell precursors, other locally prevalent and/or opportunistic infections, micronutrient deficiency, anaemia of chronic disease, and as a consequence of medicines given for HIV and/or other concurrent illnesses. Iron deficiency is the most common cause of nutritional anaemia globally. There is significant geographical overlap of areas of the world where iron deficiency anaemia (IDA) and paediatric HIV are distributed. Given the high prevalence of IDA, it is likely that many HIV-infected children also are iron deficient. The contribution of iron deficiency to anaemia in HIV-infected children has been described but is incompletely understood. Currently, iron supplementation for anaemic infants and children is routinely practiced without any obvious effect in most developing countries, which bear most of the burden of global paediatric HIV infections.Because iron deficiency and IDA are common in HIV-infected children in high-prevalence areas and because there are concerns about possible deleterious effects of iron, this review aims to assess the evidence for iron supplementation for reducing morbidity and mortality in HIV-infected children. ⋯ High-quality RCTs of iron supplementation are urgently required, especially in areas with significant overlap of high prevalence of HIV, iron deficiency anaemia, and malaria. Policy makers should prioritise funding for these trials.
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Cochrane Db Syst Rev · Jan 2009
ReviewMetformin added to insulin therapy for type 1 diabetes mellitus in adolescents.
In adolescents with type 1 diabetes, insulin resistance likely plays a role in the deterioration of metabolic control. In type 1 diabetes, addition of metformin to insulin therapy, to improve insulin sensitivity, has been assessed in a few trials involving few patients or in uncontrolled studies of short duration. No systematic reviews are available up to date to summarize the evidence about metformin addition to insulin therapy in adolescents with type 1 diabetes. ⋯ There is some evidence suggesting improvement of metabolic control in poorly controlled adolescents with type 1 diabetes, on addition of metformin to insulin therapy. Stronger evidence is required from larger studies, carried out over longer time periods to document the long-term effects on metabolic control, health-related quality of life as well as morbidity and mortality in those patients.
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Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery. ⋯ Though stent grafting of the thoracic aorta is technically feasible and non-randomised studies suggest reduction of early outcomes such as paraplegia, mortality and hospital stay, high quality randomised controlled trials assessing all clinically relevant outcomes including open-conversion, aneurysm exclusion, endoleaks, and late mortality are needed.
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Cochrane Db Syst Rev · Jan 2009
Review Comparative StudyIntrarectal quinine versus intravenous or intramuscular quinine for treating Plasmodium falciparum malaria.
In children with falciparum malaria, a proprietary quinine preparation (adjusted to make it less acidic) administered rectally may be easier to use and less painful than intramuscular or intravenous administration. However, rectal quinine may be less effective. ⋯ We detected no difference in the effect on parasites and clinical illness for intrarectal quinine, but most trials were small. Pain may be less with intrarectal proprietary, buffered quinine preparations (made less acidic by adjustment of the pH to 4.5). Further larger trials in patients with severe malaria and in adults are required before the intrarectal route can be recommended.