The Cochrane Library, 2007, Issue 1

January 24, 2007

Subcutaneous injection of pollen-extract can ward off symptoms of hayfever
Injecting small amounts of pollen-extract just below the skin in people who have hayfever can desensitize them to the pollen and reduce their symptoms. It also reduces the amount of medication they use.

These are the conclusions from a Cochrane Review of this therapy. The review pooled data from 51 trials involving a total of 2871 patients, 1645 of whom received an active treatment, while 1226 received an inactive placebo. Treatment consisted of an average of 18 injections spread over a range of times from three days to three years.

The review found that the treatment was safe, with serious adverse reactions to the therapy occurring in only four patients; one of whom had been given a placebo. Three had an anaphylactic reaction and one had an attack of asthma. All of them recovered fully and none dropped out of the trial as a result of these side-effects.

"Because of the very low, but real, risk of an adverse reaction, this treatment should only given in facilities that have full resuscitation back up. Unfortunately, in the UK, this means that it can only be given in specialized centres, which greatly limits its use," says Review Authors Moises Calderon, a Senior Clinical Fellow in the Department of Allergy and Respiratory Medicine at the Royal Brompton Hospital, London, and Professor Aziz Sheikh, Primary Care Research and Development at the University of Edinburgh.

The risk of an adverse reaction also means that it should not be given to people who also have asthma.

The Cochrane Review concluded that injection immunotherapy is a safe and valid treatment for patients with hayfever, and particularly those who have not responded to other treatments.

Calderon MA et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001936. DOI: 10.1002/14651858.CD001936.pub2.

Beta blockers are less effective than other drugs for first-line treatment of high blood pressure
Beta blocker drugs are commonly used in the initial attempts to lower blood pressure. However a Cochrane Review shows that they were not as good at reducing death or the severity of disease as other classes of drugs. Drugs that perform better include thiazides, calcium channel blockers and renin angiotensin system inhibitors.

Starting with the best therapy is important because even a modest reduction of blood pressure in people with hypertension can significantly reduce their risk of suffering from stroke or cardiovascular disease.

The Cochrane Review gathered data from 13 different randomized controlled trials that together involved over 91,000 participants. The effect of beta blockers was not significantly different from placebo in terms of total mortality or coronary heart disease. Beta blockers did, however, reduce the risk of stroke by 0.5% when compared to placebo, but in trials that compared beta blockers with calcium channel blockers (CCB), patients on CCB drugs had fewer strokes.

"The available evidence does not support the use of beta blockers as first-line drugs in the treatment of hypertension. This conclusion is based on the relatively weak effect of beta-blockers to reduce stroke and the absence of an effect on coronary heart disease when compared to placebo or no treatment," says Lead Review Author Charles Shey Wiysonge, who works at the Ministry of Public Health, in Yaoundé, Cameroon.

The beta blocker given to 75% of these participants was atenolol, and more research is needed to determine whether different beta blockers have different effects.

Wiysonge CS et al. Volmink J. Beta-blockers for hypertension. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002003. DOI: 10.1002/14651858.CD002003.pub2.

Viagra-like drugs can treat erectile dysfunction in men with diabetes
Around half of all men with diabetes have at least one episode during the course of their condition when they fail to maintain an erection sufficient for sexual intercourse. Many different strategies have been used to overcome this, but a Cochrane Review of clinical trials shows that three phosphodiesterase type 5 (PDE-5) inhibitors, sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) increased diabetic men's satisfaction with their sexual life, compared to placebo.

The PDE-5 drugs did introduce side-effects, such as headache and flushing, but these adverse reactions were not sufficiently severe to effect the men's perceived quality of life.

The data were drawn from eight trials that included a total of 1759 participants. Chosen at random, 976 were given a PDE-5 inhibitor, and 741 were given a placebo.

"If taken as prescribed and when no contra-indications exist, PDE-5 inhibitors provide a useful option for men with diabetes who suffer from erectile dysfunction," says Lead Review Author Moshe Vardi, who works at Carmel Medical Center, Haifa, Israel.

Vardi M et al. Phosphodiesterase inhibitors for erectile dysfunction in patients with diabetes mellitus. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002187. DOI: 10.1002/14651858.CD002187.pub3.

Coaching patients over 65 can help them to take an active role in general practice consultations
Older patients (+65 years) who are given pre-visit information booklets or a pre-visit coaching session ask more questions when they see a doctor than untrained patients. The trained patients also get more information from their doctors per question asked, and were also in a position to supply the doctor with more information. This added confidence did not, however, cause an increase in the length of appointments.

These conclusions were drawn from a systematic review that found only three studies looking at different ways of helping older patients get more out of visits to their doctor. This contrasts with a large number of studies that aim to encourage involvement between younger patients and their doctors.

"The low number of studies is interesting in itself, as it indicates that there has been relatively little effort given to finding ways of helping older people make the most of appointments with their doctor," says Lead Review Author Raymond Wetzels, who works in the Centre for Quality of Care Research, in Nijmegen, The Netherlands.

"It is important to respect patients' autonomy while at the same time helping to stimulate their active participation in their healthcare, and face-to-face coaching sessions, with or without additional written materials, may be the way forward," says Wetzels.

The Review Authors realize that it would not be practical to supply this coaching to the whole population, but feel that there is a case for identifying specific groups of patients who could benefit most from enhanced involvement in decision-making. In particular, this group could include those who want to be involved, but lack skills or confidence.

Wetzels R et al. Interventions for improving older patients' involvement in primary care episodes. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004273. DOI: 10.1002/14651858.CD004273.pub2.

School meals good, especially for poor children
School meals can improve physical and mental health of disadvantaged children.

Good nutrition is essential for healthy child development. One way of boosting children's intake is to give them food at school. Cochrane Reviewers looked to see whether school feeding programmes could produce benefits in terms of the children's physical, mental and psychosocial health.

They considered the data from 18 studies, nine of which had been carried out in low income countries and nine in high income countries.

In low income countries, compared to controls, school fed children's attendance increased by 4 to 6 days per year. Children who were fed at school also gained more than controls on maths achievement, and on some cognitive tasks requiring attention, mental flexibility and rapid processing of information.

Children in low income countries who were given meals gained weight faster than controls. In lower income countries, in trials that had been carefully regulated, fed children gained an average of 0.39kg more over 19 months than did controls. Gains of over 0.7 kg in 11.3 months were reported in less regulated trials. In high income countries children fed at school showed some increase in weight gain.

"The data collected so far indicate that disadvantaged children gain in several ways if they are given food at school. It is important to make sure that these meals contain sufficient energy, protein, and essential micronutrients says Lead Review Author Betsy Kristjansson, an Associate Professor at the School of Psychology and Institute of Population Health, University of Ottawa, Ottawa, Canada.

Kristjansson EA et al. School feeding for improving the physical and psychosocial health of disadvantaged elementary school children. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004676. DOI: 10.1002/14651858.CD004676.pub2.
Notes for editors

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ª Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, et al. Methodology and reports of systematic Reviews and meta-analysies: a comparison of Cochrane Reviews with articles published in paper-based journal.


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