Evaluation of the benefits and risks of hormone replacement therapy.
(41/1807)
OBJECTIVE: To review recent data on outcome of hormone replacement therapy in postmenopausal women. DATA SOURCES: Medline search of the literature and local data. STUDY SELECTION: Data on efficacy of hormone replacement and its unwanted side effects were examined. DATA EXTRACTION: Statistical data were extracted from published studies and meta-analyses. DATA SYNTHESIS: Statistical data came mainly from observational studies and not from randomised trials, and were therefore subject to bias. Overall, it would appear reasonable to say that risks for breast and endometrial cancers, as well as thromboembolism, were increased, while the risks for cardiovascular death and osteoporotic fractures were reduced by hormone replacement therapy. Locally, for every 100,000 women treated for 3 to 5 years, there may be 22 fewer cardiac deaths, 10 to 20 more cases of breast cancer, seven more cases of endometrial cancer, 10 more cases of thromboembolic disease, and slightly fewer cases of osteoporotic fracture. CONCLUSION: Reported data and risk estimates have been derived predominantly from data on white Caucasian women. Their baseline risk may be different from those of Chinese women. A low baseline risk in the local population may influence treatment results, and large-scale randomised trials are needed to give a definitive answer. (+info)
Debate: Albumin administration should not be avoided.
(42/1807)
The recent Cochrane report on albumin administration is analysed and criticised on the grounds of clinical methodology, content and interpretation. Although it is naive and illogical to treat hypoalbuminaemia with albumin infusions, a more balanced view on the use of albumin for resuscitation in acute hypovolaemia is necessary. Once the acute phase of critical illness is past, interstitial volume is often expanded causing oedema, with a low plasma volume. We argue for the use of salt-poor albumin solutions in this situation and conclude that, on current evidence, the assertion that albumin should be avoided in all situations is irrational and untenable. (+info)
Debate: Albumin administration should be avoided in the critically ill.
(43/1807)
The benefit of albumin administration in the critically ill patient is unproven. Epidemiological evidence suggests that there is an increase in death among patients with burns, hypoalbuminaemia, and hypotension treated with human albumin solution (HAS). In critical illness, hypoalbuminaemia is a result of transcapillary leak, decreased synthesis, large volume body fluid losses, and dilution caused by fluid resuscitation. When treating patients with hypoalbuminaemia, efforts must be centred around correction of the underlying disorder rather than reversal of hypoalbuminaemia. Problems with using albumin arise because it is an expensive blood product, and can result in systemic changes that include cardiovascular, haematological, renal, pulmonary, and immunological effects. (+info)
Using evidence from different sources: an example using paracetamol 1000 mg plus codeine 60 mg.
(44/1807)
BACKGROUND: Meta-analysis usually restricts the information pooled, for instance using only randomised, double-blind, placebo-controlled trials. This neglects other types of high quality information. This review explores using different information for the combination of paracetamol 1000 mg and codeine 60 mg in acute postoperative pain. RESULTS: Randomised, double-blind, placebo-controlled trials of paracetamol 1000 mg and codeine 60 mg had an NNT of 2.2 (95% confidence interval 1.7 to 2.9) for at least 50% pain relief over four to six hours in three trials with 197 patients. Computer simulation of randomised trials demonstrated 92% confidence that the simulated NNT was within +/- 0.5 of the underlying value of 2.2 with this number of patients. The result was supported a rational dose-response relationship for different doses of paracetamol and codeine in 17 additional trials with 1,195 patients. Three controlled trials lacking a placebo and with 117 patients treated with of paracetamol 1000 mg and codeine 60 mg had 73% (95%CI 56% to 81%) of patients with at least 50% pain relief, compared with 57% (48% to 66%) in placebo controlled trials. Six trials in acute pain were omitted because of design issues, like the use of different pain measures or multiple dosing regimens. In each paracetamol 1000 mg and codeine 60 mg was shown to be better than placebo or comparators for at least one measure. CONCLUSIONS: Different designs of high quality trials can be used to support limited information used in meta-analysis without recourse to low quality trials that might be biased. (+info)
Lessons for search strategies from a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.
(45/1807)
BACKGROUND: A key aim when conducting systematic reviews of randomized controlled trials (RCTs) is to include all of the evidence, if possible. Serious bias may result if trials are missed through inadequate search strategies. OBJECTIVE: The objective was to evaluate the search plan for identifying RCTs in nutrition as part of a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture. DESIGN: We identified potential studies by searching the electronic databases BIOSIS, CABNAR, CINAHL, EMBASE, HEALTHSTAR, and MEDLINE; reference lists in trial reports; and other relevant articles. We also contacted investigators and other experts for information and searched 4 nutrition journals by hand. RESULTS: We identified 15 RCTs that met the predefined inclusion criteria. The search plan identified 8 trials each in EMBASE, HEALTHSTAR, and MEDLINE and 7 in BIOSIS and CABNAR. BIOSIS was the only electronic database source of 2 trials. Eleven trials were identified by searching electronic databases and 2 unpublished trials were identified via experts in the field. We found one trial, published only as a conference abstract, by searching nutrition journals by hand. After publication of the protocol for the review in The Cochrane Library, we were informed of another unpublished trial. CONCLUSIONS: We found that a limited search plan based on only MEDLINE or one of the other commonly available databases would have failed to locate nearly one-half of the studies. To protect against bias, the search plan for a systematic review of nutritional interventions should be comprehensive. (+info)
Reporting of outcomes in arthritis trials measured on ordinal and interval scales is inadequate in relation to meta-analysis.
(46/1807)
OBJECTIVES: To study whether the reporting of clinical outcomes in arthritis trials measured on ordinal and interval scales is adequate in relation to meta-analysis. METHODS: Systematic review of randomised trials of non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis. Optimal reporting was defined as data in the original ordered categories for global evaluation and pain, and as mean and SD for number of tender joints and grip strength, and if a visual analogue scale had been used to measure pain. RESULTS: A total of 144 trials were included. The median sample size was 60 patients. The quality of the reporting increased over time for three of the four variables. Global evaluation was optimally reported in 52 of the 127 trials (41%) in which it was recorded. Pain was optimally reported in 27 of 98 trials (28%), number of tender joints in 41 of 123 trials (33%), and grip strength in 34 of 124 trials (27%). Even if rather broad criteria are adopted, only about half of the data were reported in a potentially useful way for a meta-analysis. CONCLUSIONS: Arthritis trials have been reported inadequately in relation to meta-analysis. As most trials are underpowered, meta-analysis is indispensable and the deficit therefore needs urgent improvement. Investigators should specify a priori what constitutes an important treatment effect and report numbers of patients improved. (+info)
Future possibilities in the prevention of breast cancer: breast cancer prevention trials.
(47/1807)
The available results from breast cancer chemoprevention trials are reviewed. Four trials using tamoxifen have been performed, of which three have reported efficacy results. A fifth trial using raloxifene has also been reported. The largest tamoxifen trial showed approximately 50% reduction in breast cancer incidence in the short term, but the two smaller trials did not find any reduction. Greater agreement exists for side effects; incidences of thromboembolic disease and endometrial cancers are raised approximately threefold when tamoxifen is used for 5 years. The possible reasons for the discrepancy in breast cancer reduction are explored. A review of trial parameters does not clearly explain this difference, and a meta-analysis indicates that all results are compatible with a 40% reduction in short-term incidence. Several important questions remain regarding the clinical implications of this result, including the effect on mortality, the appropriate risk groups for chemoprevention and the long-term effects on incidence. Continued follow up of these trials is crucial for resolving these issues. (+info)
Future possibilities in the prevention of breast cancer: fat and fiber and breast cancer research.
(48/1807)
The potential for a reduction in dietary fat or for an increase in dietary fiber to reduce breast cancer risk has been debated for some years. It is argued here that available research data, even though extensive, leave open hypotheses ranging from little or no potential to major public health potential for breast cancer prevention by means of these dietary maneuvers. Some elements of a research strategy for testing these and other dietary breast cancer prevention hypotheses are described. (+info)