Cochrane Db Syst Rev
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Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. Methotrexate has broad immunomodulatory properties and is the most commonly used disease-modifying antirheumatic drug (DMARD). This is an update of a 2001 Cochrane review. It supports a living guideline for children and young people with JIA. ⋯ Oral methotrexate (5 mg/m2/week to 15 mg/m2/week) compared with placebo may increase the number of children and young people achieving treatment response but may have little or no effect on pain or participant global assessment of well-being. Oral methotrexate plus IAGC injections compared to IAGC injections alone may have little or no effect on the likelihood of sustained clinically inactive disease among children and young people with oligoarticular JIA. Similarly, methotrexate compared with leflunomide may have little or no effect on treatment response, function, and participant global assessment of well-being. Serious adverse events due to methotrexate appear to be rare. We will update this review as new evidence becomes available to inform the living guideline.
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Morton's neuroma (MN) is a painful neuropathy resulting from a benign enlargement of the common plantar digital nerve that occurs commonly in the third webspace and, less often, in the second webspace of the foot. Symptoms include burning or shooting pain in the webspace that extends to the toes, or the sensation of walking on a pebble. These impact on weight-bearing activities and quality of life. ⋯ Although there are many interventions for MN, few have been assessed in RCTs. There is low-certainty evidence that CS+LA may result in little to no difference in pain or function, and moderate-certainty evidence that UG CS+LA probably reduces pain and increases function for people with MN. Future trials should improve methodology to increase certainty of the evidence, and use optimal sample sizes to decrease imprecision.
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Cochrane Db Syst Rev · Feb 2024
ReviewMaternal postures for fetal malposition in late pregnancy for improving the health of mothers and their infants.
The optimal relationship of the fetus to the mother's birth canal is when the fetus is in the longitudinal lie, cephalic presentation with well-flexed head (vertex presentation), and in the occipito-anterior position. Fetal malposition is described as occipito-posterior (OP) when the back of the fetal head lies posteriorly in the mother's pelvis, and occipito-transverse (OT) when the back of the fetal head lies transversely in the mother's pelvis. The fetal head will often be deflexed and may extend further to a mento-anterior or mento-transverse position, where the chin is anterior or transverse to the maternal pelvis. Fetal malposition is associated with both maternal and fetal complications, including prolonged labour, fetal distress, maternal exhaustion, need for caesarean section, operative vaginal birth, and increased risk of perineal trauma and anal sphincter injuries. This review considered positional interventions in late pregnancy to correct fetal malposition. A separate Cochrane review addresses maternal postural position for fetal malposition during labour. ⋯ We did not identify evidence for guiding practice with respect to positional interventions for fetal malposition in late pregnancy. More studies are needed to understand the effect of positional interventions in late pregnancy. Future research on positional interventions for fetal malposition in late pregnancy should include follow-up to determine whether short-term correction of fetal position translates to improved pregnancy outcomes. This might include interventions commenced in late pregnancy and repeated as needed until the onset of labour. The latter would be included in the review on maternal positions during labour.
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Cochrane Db Syst Rev · Feb 2024
Review Meta AnalysisHalo sign on temporal artery ultrasound versus temporal artery biopsy for giant cell arteritis.
Giant cell arteritis (GCA) is a systemic, inflammatory vasculitis primarily affecting people over the age of 50 years. GCA is treated as a medical emergency due to the potential for sudden, irreversible visual loss. Temporal artery biopsy (TAB) is one of the five criteria of the American College of Rheumatology (ACR) 1990 classification, which is used to aid the diagnosis of GCA. TAB is an invasive test, and it can be slow to obtain a result due to delays in performing the procedure and the time taken for histopathologic assessment. Temporal artery ultrasonography (US) has been demonstrated to show findings in people with GCA such as the halo sign (a hypoechoic circumferential wall thickening due to oedema), stenosis or occlusion that can help to confirm a diagnosis more swiftly and less invasively, but requiring more subjective interpretation. This review will help to determine the role of these investigations in clinical practice. ⋯ There is limited published evidence on the accuracy of temporal artery US for detecting GCA. Ultrasound seems to be moderately sensitive when the specificity is good, but data were heterogeneous across studies and either did not use the same halo thickness threshold or did not report it. We can draw no conclusions from accuracy studies on whether US can replace TAB for diagnosing GCA given the very low certainty of the evidence. Future research could consider using the 2016 revision of the ACR criteria as a reference standard, which will limit incorporation bias of TAB into the reference standard.
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Cochrane Db Syst Rev · Feb 2024
ReviewCognitive behavioural therapy without medication for schizophrenia.
Cognitive behavioural therapy (CBT) can be effective in people with schizophrenia when provided in combination with antipsychotic medication. It remains unclear whether CBT could be safely and effectively offered in the absence of concomitant antipsychotic therapy. ⋯ This review is the first attempt to systematically synthesise the evidence about CBT delivered without medication to people with schizophrenia. The limited number of studies and low to very low certainty of the evidence prevented any strong conclusions. An important limitation in the available studies was that participants in the CBT without medication group (about 35% on average) received antipsychotic treatment, highlighting the challenges of this approach. Further high-quality RCTs are needed to provide additional data on the feasibility and efficacy of CBT without antipsychotics.