Cochrane Db Syst Rev
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To determine whether antidepressants are clinically effective and acceptable for the treatment of depression in people who also have a physical illness. ⋯ The review provides evidence that antidepressants, significantly more frequently than either placebo or no treament, cause improvement in depression in patients with a wide range of physical diseases. About 4 patients would need to be treated with antidepressants to produce one recovery from depression which would not have occurred had they been given placebo (NNT 4.2, 95% CI 3.2-6.4). Antidepressants seem reasonably acceptable to patients, in that about 10 patients would need to be treated with antidepressants to produce one dropout from treatment which would not have occurred had they been given placebo (NNH 9.8, 95% CI 5.4-42.9). The evidence is consistent across the trials, apart from 2 trials in cancer, where the "atypical" antidepressant mianserin produced significantly less dropout than placebo. Trends towards tricyclics being more effective than SSRIs, but also more likely to produce dropout were noted, but these are based on non-randomised comparisons between trials. Problems with the evidence include most of the trials' use of observers, rather than patients, to decide on improvement, and concentration mainly on symptoms rather than function and quality of life. There is also a possibility of undetected negative trials. Nevertheless, the review provides evidence that use of antidepressants should at least be considered in those with both physical illness and depression. Regarding diagnosis, the existence of a cheap and readily available treatment for depression should encourage detailed assessment of persistent low mood in the physically ill.
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Health care professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions. ⋯ Simple advice has a small effect on cessation rates. Additional manoeuvres appear to have only a small effect, though more intensive interventions are marginally more effective than minimal interventions.
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Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Two forms of methylxanthine (caffeine and theophylline) have been used to stimulate breathing and so prevent apnea and its consequences. ⋯ Caffeine appears to have similar short term effects on apnea/bradycardia to theophylline. In view of the other therapeutic advantages of caffeine (a higher therapeutic ratio, more reliable enteral absorption and a longer half life) this is the preferred treatment for apnea in preterm infants. The possibility that higher doses of caffeine might be more effective in extremely preterm infants needs further evaluation in randomized clinical trials.
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Cochrane Db Syst Rev · Jan 2000
ReviewNeuromuscular paralysis for newborn infants receiving mechanical ventilation.
Ventilated newborn infants breathing in asynchrony with the ventilator are at risk for complications during mechanical ventilation, such as pneumothorax or intraventricular hemorrhage, and are exposed to more severe barotrauma, which consequently could impair their clinical outcome. Neuromuscular paralysis, which eliminates spontaneous breathing efforts of the infant, has potential advantages in this respect. However, a number of complications have been reported with muscle relaxation in infants, so that concerns exist regarding the safety of prolonged neuromuscular paralysis in newborn infants. ⋯ For ventilated preterm infants with evidence of asynchronous respiratory efforts, neuromuscular paralysis with pancuronium seems to have a favourable effect on intraventricular hemorrhage and possibly on air leak. Uncertainty remains, however, regarding the long term pulmonary and neurologic effects, and regarding the safety of prolonged use of pancuronium in ventilated newborn infants. There is no evidence from randomized trials on the effects of neuromuscular blocking agents other than pancuronium. Therefore, the routine use of pancuronium or any other neuromuscular blocking agent in ventilated newborn infants cannot be recommended based on current evidence.
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Because hyperventilation is often associated with a rapid fall in intracranial pressure, it has been assumed to be effective in the treatment of severe head injury. Hyperventilation reduces raised intracranial pressure by causing cerebral vasoconstriction and a reduction in cerebral blood flow. Whether reduced cerebral blood flow improves neurological outcome however, is unclear. ⋯ The data available are inadequate to assess any potential benefit or harm that might result from hyperventilation in severe head injury. Randomised controlled trials to assess the effectiveness of hyperventilation therapy following severe head injury are needed.