BACKGROUND: Patients with brain tumour usually suffer from increased pressure in the skull due to swelling of brain tissue. A swollen brain renders surgical removal of the brain tumour difficult. To ease surgical tumour removal, measures are taken to reduce brain swelling, often referred to as brain relaxation. Brain relaxation can be achieved with intravenous fluids such as mannitol or hypertonic saline. This review was conducted to find out which of the two fluids may have a greater impact on brain relaxation.OBJECTIVES: To compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy.METHODS:Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), Medline via Ovid SP (1966 to October 2013) and Embase via Ovid SP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.Clinicaltrials.gov. Selection criteria: We included randomized controlled trials (RCTs) that compared the use of hypertonic saline versus mannitol for brain relaxation. We also included studies in which any other method used for intraoperative brain relaxation was compared with mannitol or hypertonic saline. Primary outcomes were longest follow-up mortality, Glasgow Outcome Scale score at three months and any adverse events related to mannitol or hypertonic saline. Secondary outcomes were intraoperative brain relaxation, intensive care unit (ICU) stay, hospital stay and quality of life. Data collection and analysis:We used standardized methods for conducting a systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a fixed-effect model when no evidence was found of significant heterogeneity between studies, and a random-effects model when heterogeneity was likely.MAIN RESULTS: We included six RCTs with 527 participants. Only one RCT was judged to be at low risk of bias. The remaining five RCTs were at unclear or high risk of bias. No trial mentioned the primary outcomes of longest follow-up mortality, Glasgow Outcome Scale score at three months or any adverse events related to mannitol or hypertonic saline. Three trials mentioned the secondary outcomes of intraoperative brain relaxation, hospital stay and ICU stay; quality of life was not reported in any of the trials. Brain relaxation was inadequate in 42 of 197 participants in the hypertonic saline group and in 68 of 190 participants in the mannitol group. The risk ratio for brain bulge or tense brain in the hypertonic saline group was 0.60 (95% confidence interval (CI) 0.44 to 0.83, low-quality evidence). One trial reported ICU and hospital stay. The mean (standard deviation (SD)) duration of ICU stay in the mannitol and hypertonic saline groups was 1.28 (0.5) and 1.25 (0.5) days (P value 0.64), respectively; the mean (SD) duration of hospital stay in the mannitol and hypertonic saline groups was 5.7 (0.7) and 5.7 (0.8) days (P value 1.00), respectively.AUTHORS' CONCLUSIONS: From the limited data available on the use of mannitol and hypertonic saline for brain relaxation during craniotomy, it is suggested that hypertonic saline significantly reduces the risk of tense brain during craniotomy. A single trial suggests that ICU stay and hospital stay are comparable with the use of mannitol or hypertonic saline. However, focus on other related important issues such as long-term mortality, long-term outcome, adverse events and quality of life is needed.

Este estudio utiliza datos de la Encuesta Nacional de Salud Familiar (International Institute for Population Sciences 1995) realizada en el estado de Tamil Nadu, India. Se desarrollaron modelos de Cox para analizar el efecto de la lactancia materna cuando varía en el tiempo y el factor tiempo depende de los intervalos genésicos. La lactancia materna sólo mejora la probabilidad de acceder a un nivel más alto en cada intervalo de nacimiento. Otros factores que entraron en los modelos fueron en el intervalo del primer parto: nivel educativo de la madre (secundaria y superior) y trabajo de la madre; en el intervalo del segundo parto: nivel de supervivencia en el índice de vida infantil y nivel educativo del padre (secundaria y superior), y en el intervalo del tercer parto: lactancia materna más 22 meses. Cada uno de los anteriores es un factor protector para ampliar el intervalo entre nacimientos en el estudio. Además, este estudio confirma los modelos desarrollados en los servicios públicos de predicción para los intervalos genésicos.

The present study uses data from National Family Health Survey (NFHS-1) 1992-93 (International Institute for Population Sciences 1995) conducted in the state of Tamil Nadu, India. Cox models were developed to analyze the effect of breastfeeding as time varying and time dependent factor on birth intervals. Breastfeeding alone improved the log likelihood up to a higher level in each birth interval. Other factors that entered into the models were: at first birth interval, womens education (high school & above) and working status of women; at second birth interval, survival status of index child alive and husbands education (high school & above), and at third birth interval, breastfeeding more than 22 month were found to be protective factors for next births. Validation of the developed models was done through bootstrapping to predict birth intervals.