ABSTRACT BACKGROUND: Irritable bowel syndrome (IBS) is a clinical disorder associated with high socioeconomic burden. Despite its importance, management of IBS remains difficult and several interventions have been hypothesized as beneficial for this condition. This study identified and summarized all Cochrane systematic reviews (SRs) about the effects of interventions for managing IBS patients. DESIGN AND SETTING: Review of systematic reviews, carried out in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: Review of Cochrane SRs addressing interventions for IBS. RESULTS: We included six SRs assessing acupuncture, bulking agents, antispasmodics, antidepressants, herbal medicines, homeopathy, hypnotherapy and psychological therapy for IBS. The certainty of evidence ranged from unknown to moderate, mainly due to imprecision in the estimates and high risk of bias from the primary studies included. There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life, compared with sham acupuncture. There was also very low certainty of evidence that homeopathic asafoetida, used alone or in association with nux, was better than placebo regarding self-reported overall improvement. CONCLUSION: There was moderate certainty of evidence that acupuncture had no important benefit regarding improvement of symptoms and quality of life. Further well-designed and well-conducted randomized clinical trials are needed in order to reduce the uncertainties regarding the most commonly used interventions for patients with IBS.
ABSTRACT CONTEXT AND OBJECTIVE: Insomnia is a frequent complaint that generates more than five million visits to doctors per year in the United States. This study summarizes all Cochrane systematic reviews (SRs) that evaluated interventions to treat insomnia. DESIGN AND SETTING: Review of SRs, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: A sensitive search was carried out in the Cochrane Database of Systematic Reviews to identify Cochrane SRs that assessed the effects of any type of intervention for people with insomnia. The results, main characteristics of the SRs and the certainty of the evidence obtained from them were synthesized and discussed. RESULTS: Seven SRs were included. They addressed the benefits and harm of acupuncture (n = 1), behavioral interventions (n = 1), music (n = 1), pharmacotherapy (n = 2), phototherapy (n = 1) and physical exercise (n = 1). The certainty of the evidence ranged from moderate to very low. CONCLUSION: Acupuncture, music, physical exercise, paroxetine, doxepin, trimipramine and trazodone seem to present some benefit for patients with insomnia. However, the uncertainty around these results means that no robust and definitive recommendations for clinical practice can be made until the benefits and harms from each intervention for patients with insomnia have been confirmed through further studies.
ABSTRACT BACKGROUND: The therapeutic effects of cannabinoid compounds have been the center of many investigations. This study provides a synthesis on all Cochrane systematic reviews (SRs) that assessed the use of cannabinoids as a therapeutic approach. DESIGN AND SETTING: Review of SRs, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). METHODS: A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the efficacy and safety of cannabinoids as a therapeutic approach. The results and key characteristics of all reviews included were summarized and discussed. RESULTS: Eight SRs were included. They assessed the use of cannabinoids for the following types of conditions: neurological (two SRs), psychiatric (two SRs), rheumatological (one SR), infectious (one SR) and oncological (two SRs). There was moderate-quality evidence showing that the use of cannabinoids reduced nausea and vomiting among adults, compared with placebo. Additionally, there was moderate-quality evidence showing that there was no difference between cannabinoids and prochlorperazine regarding the number of participants who reported vomiting, in this same population. CONCLUSIONS: This review identified eight Cochrane systematic reviews that provided evidence of unknown to moderate quality regarding the use of cannabinoids as a therapeutic intervention. Further studies are still imperative for solid conclusions to be reached regarding practical recommendations.
ABSTRACT CONTEXT AND OBJECTIVE: Psoriasis is a common chronic inflammatory skin disease characterized by abnormal and increased growth of the cells that produce keratin and abnormal functioning of the immune system. We aimed to summarize the evidence available regarding interventions for patients with psoriasis. DESIGN AND SETTING: Review of systematic reviews, developed in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify Cochrane systematic reviews that fulfilled the eligibility criteria. Two authors screened titles and abstracts that had been retrieved through the search strategy. The results from all the Cochrane systematic reviews that were included were summarized and presented in a narrative synthesis. RESULTS: We included six Cochrane systematic reviews assessing interventions for treating psoriasis. The findings from high-quality evidence were that (a) etanercept reduced the psoriasis severity index, compared with placebo and (b) steroids plus vitamin D, compared with vitamin D alone, improved the skin clearance rate, as assessed by investigators, but was associated with a higher proportion of participants who dropped out due to adverse events. For all other comparisons, the quality of the evidence ranged from moderate to very low. CONCLUSION: This review included six Cochrane systematic reviews that provided evidence ranging in quality from unknown to high, regarding management of psoriasis. Further randomized controlled trials are imperative to reduce the uncertainties relating to several treatments that are already used in clinical practice.
ABSTRACT BACKGROUND: Varicose veins affect nearly 30% of the world’s population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence. DESIGN AND SETTING: Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP). METHODS: Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date. RESULTS: 51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality. CONCLUSIONS: There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.
ABSTRACT BACKGROUND: This study identified and summarized all Cochrane systematic reviews (SRs) on the effects of ten integrative practices that were recently added to the Brazilian public healthcare system (SUS). DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp). METHODS: Review of Cochrane SRs on the following interventions were identified, summarized and critically assessed: apitherapy, aromatherapy, bioenergetics, family constellation, flower therapy, chromotherapy, geotherapy, hypnotherapy, hand imposition or ozone therapy. RESULTS: We included a total of 16 SRs: 4 on apitherapy, 4 on aromatherapy, 6 on hypnotherapy and 2 on ozone therapy. No Cochrane SR was found regarding bioenergetics, family constellation, chromotherapy, clay therapy, flower therapy or hand imposition. The only high-quality evidence was in relation to the potential benefit of apitherapy, specifically regarding some benefits from honey dressings for partial healing of burn wounds, for reduction of coughing among children with acute coughs and for preventing allergic reactions to insect stings. CONCLUSION: Except for some specific uses of apitherapy (honey for burn wounds and for acute coughs and bee venom for allergic reactions to insect stings), the use of ten integrative practices that have recently been incorporated into SUS does not seem to be supported by evidence from Cochrane SRs.
ABSTRACT CONTEXT AND OBJECTIVE: Cardiac arrest is associated with high morbidity and mortality and imposes a significant burden on the healthcare system. Management of cardiac arrest patients is complex and involves approaches with multiple interventions. Here, we aimed to summarize the available evidence regarding the interventions used in cardiac arrest cases. DESIGN AND SETTING: Review of systematic reviews (SRs), conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A systematic search was conducted to identify all Cochrane SRs that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included nine Cochrane SRs assessing compression techniques or devices (three SRs), defibrillation (two SRs) and other interventions (two SRs on hypothermia interventions, one on airway management and one on pharmacological intervention). The reviews included found qualities of evidence ranging from unknown to high, regarding the benefits of these interventions. CONCLUSION: This review included nine Cochrane systematic reviews that provided a diverse range of qualities of evidence (unknown to high) regarding interventions that are used in management of cardiac arrest. High-quality evidence was found by two systematic reviews as follows: (a) increased survival until hospital discharge with continuous compression, compared with interrupted chest compression, both administered by an untrained person and (b) no difference regarding the return of spontaneous circulation, comparing aminophylline and placebo, for bradyasystolic patients under cardiac arrest. Further studies are needed in order to reach solid conclusions.
ABSTRACT BACKGROUND: Urinary incontinence is a highly prevalent condition that impacts self-esteem and overall quality of life. Many non-surgical treatment options are available, ranging from pharmacological approaches to pelvic exercises. We aimed to summarize the available evidence regarding these non-surgical interventions. DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP). METHODS: A sensitive search was conducted to identify all Cochrane systematic reviews that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included 20 Cochrane systematic reviews: 4 assessing methods of vesical training, 3 evaluating pharmacological interventions, 4 studying pelvic floor muscle training approaches and 9 aimed at other alternatives (such as urethral injections, weighted vaginal cone use, acupuncture, biostimulation and radiofrequency therapy). The reviews found that the evidence regarding the benefits of these diverse interventions ranged in quality from low to high. CONCLUSIONS: This review included 20 Cochrane systematic reviews that provided evidence (of diverse quality) for non-pharmacological interventions for patients with urinary incontinence. Moderate to high quality of evidence was found favoring the use of pelvic floor muscle training among women with urinary incontinence. To establish solid conclusions for all the other comparisons, further studies of good methodological quality are needed.
ABSTRACT BACKGROUND: Probiotics have been used for a range of clinical situations and their use is strongly encouraged by the media worldwide. This study identified and summarized all Cochrane systematic reviews about the preventive effects of probiotics in clinical practice. DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp). METHODS: We included all Cochrane reviews on any probiotics when they were used as preventive interventions and compared with no intervention, placebo or any other pharmacological or non-pharmacological intervention. RESULTS: 17 Cochrane systematic reviews fulfilled our inclusion criteria and were summarized in this report. None of the reviews included in the present study provided high-quality evidence for any outcome. The benefits from use of probiotics included decreased incidence of antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea; decreased incidence of upper respiratory tract infections and duration of episodes; decreased need for antibiotics and absences from school due to colds; and decreased incidence of ventilator-associated pneumonia. Probiotics seem to decrease the incidence of gestational diabetes mellitus, birthweight, risk of vaginal infection and incidence of eczema. CONCLUSION: Despite the marketing and the benefits associated with probiotics, there is little scientific evidence supporting the use of probiotics. None of the reviews provided any high-quality evidence for prevention of illnesses through use of probiotics. More trials are needed to gain better knowledge of probiotics and to confirm when their use is beneficial and cost-effective.
ABSTRACT CONTEXT AND OBJECTIVE: Despite the high prevalence of vitamin D supplementation, its use remains controversial. The objective of this review was to identify and summarize the evidence from Cochrane systematic reviews regarding vitamin D supplementation for preventing ortreating any clinical condition. DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: A search was conducted to identify all Cochrane systematic reviews that fulfilled the inclusion criteria. Titles and abstracts were screened by two authors. RESULTS: We included 27 Cochrane systematic reviews: 10 assessing use of vitamin D for prevention and 17 for treatment. The reviews found moderate to high quality of evidence regarding the benefit of vitamin D for pregnant women (prevention of adverse events: preterm birth risk [rate ratio, RR 0.36; 95% confidence interval, CI 0.14 to 0.93] and low birthweight risk [RR 0.40; 95% CI 0.24 to 0.67]) and for asthma patients (reduction of severe exacerbations [RR 0.63; 95% CI 0.45 to 0.88]). No benefit was found regarding vitamin D supplementation alone (without calcium) for preventing hip or any new fracture. For all other outcomes assessed under various conditions, the current quality of evidence is low or unknown, and therefore insufficient for any recommendation. CONCLUSION: Based on moderate to high quality of evidence, the Cochrane systematic reviews included here showed that there were some benefits from vitamin D supplementation for pregnant women and asthma patients and no benefits for preventing fractures.
ABSTRACT CONTEXT AND OBJECTIVE: The purpose of screening tests for cancer is to detect it at an early stage in order to increase the chances of treatment. However, their unrestrained use may lead to unnecessary examinations, overdiagnosis and higher costs. It is thus necessary to evaluate their clinical effects in terms of benefits and harm. DESIGN AND SETTING: Review of Cochrane systematic reviews, carried out in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: Cochrane reviews on the clinical effectiveness of cancer screening procedures were included. Study titles and abstracts were independently assessed by two authors. Conflicts were resolved by another two authors. Findings were summarized and discussed. RESULTS: Seventeen reviews were selected: fifteen on screening for specific cancers (bladder, breast, colorectal, hepatic, lung, nasopharyngeal, esophageal, oral, prostate, testicular and uterine) and two others on cancer in general. The quality of evidence of the findings varied among the reviews. Only two reviews resulted in high-quality evidence: screening using low-dose computed tomography scans for high-risk individuals seems to reduce lung cancer mortality; and screening using flexible sigmoidoscopy and fecal occult blood tests seems to reduce colorectal cancer mortality. CONCLUSION: The evidence found through Cochrane reviews did not support most of the commonly used screening tests for cancer. It is recommended that patients should be informed of the possibilities of false positives and false negatives before they undergo the tests. Further studies to fully assess the effectiveness of cancer screening tests and adverse outcomes are required.
RESUMO CONTEXTO E OBJETIVO: O objetivo do teste de rastreamento para o câncer é detectá-lo em um estágio inicial, a fim de aumentar as chances de cura. Contudo, seu uso descomedido pode levar a exames desnecessários, sobrediagnóstico e aumento de custos. Portanto, é necessário que se avalie a repercussão clínica do rastreamento em termos de benefícios e riscos. TIPO DE ESTUDO E LOCAL: Revisão de revisões sistemáticas Cochrane realizada na Disciplina de Medicina Baseada em Evidências da Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). MÉTODOS: Foram incluídas revisões sobre efetividade clínica de testes de rastreamento para câncer. Os títulos e resumos foram avaliados independentemente por dois autores e divergências foram resolvidas por outros dois. Os achados foram resumidos e discutidos. RESULTADOS: 17 revisões sistemáticas foram incluídas: 15 sobre rastreamento para cânceres específicos (vesical, mamário, colorretal, hepático, pulmonar, nasofaríngeo, esofágico, oral, prostático, testicular, uterino) e duas para câncer em geral. A qualidade das evidências encontradas pelas revisões variou muito. Duas revisões encontraram evidências de alta qualidade: o rastreamento com tomografia em dose baixa em pacientes de alto risco parece reduzir a mortalidade por câncer pulmonar; e rastreamento com sigmoidoscopia flexível e pesquisa de sangue oculto nas fezes parece reduzir a mortalidade por câncer colorretal. CONCLUSÃO: As evidências de revisões sistemáticas Cochrane não indicam a realização dos testes mais usados para rastreamento de câncer. Recomenda-se que os pacientes sejam informados sobre as possibilidades de falsos positivos e de falsos negativos antes de serem submetidos aos testes. Estudos adicionais para avaliar melhor a eficácia de testes de rastreamento para o câncer e os eventos adversos são necessários.
ABSTRACT BACKGROUND: Dementia is a highly prevalent condition worldwide. Its chronic and progressive presentation has an impact on physical and psychosocial characteristics and on public healthcare. Our aim was to summarize evidence from Cochrane reviews on non-pharmacological treatments for cognitive disorders and dementia. DESIGN AND SETTING: Review of systematic reviews, conducted in the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: Cochrane reviews on non-pharmacological interventions for cognitive dysfunctions and/or type of dementia were included. For this, independent assessments were made by two authors. RESULTS: Twenty-four reviews were included. These showed that carbohydrate intake and validation therapy may be beneficial for cognitive disorders. For dementia, there is a potential benefit from physical activity programs, cognitive training, psychological treatments, aromatherapy, light therapy, cognitive rehabilitation, cognitive stimulation, hyperbaric oxygen therapy in association with donepezil, functional analysis, reminiscence therapy, transcutaneous electrical stimulation, structured decision-making on feeding options, case management approaches, interventions by non-specialist healthcare workers and specialized care units. No benefits were found in relation to enteral tube feeding, acupuncture, Snoezelen stimulation, respite care, palliative care team and interventions to prevent wandering behavior. CONCLUSION: Many non-pharmacological interventions for patients with cognitive impairment and dementia have been studied and potential benefits have been shown. However, the strength of evidence derived from these studies was considered low overall, due to the methodological limitations of the primary studies.
RESUMO INTRODUÇÃO: Demência é uma condição com alta prevalência e incidência global. Sua característica crônica e progressiva tem impacto em aspectos físicos, psicossociais e na saúde pública. Nosso objetivo foi resumir evidências de revisões Cochrane sobre intervenções não farmacológicas para distúrbios cognitivos e demências. TIPO DE ESTUDO E LOCAL: Revisão de revisões sistemáticas conduzida na Disciplina de Medicina Baseada em Evidências da Escola Paulista de Medicina, Universidade Federal de São Paulo. MÉTODOS: Foram incluídas revisões Cochrane sobre intervenções não farmacológicas para disfunções cognitivas e/ou qualquer tipo de demência, após a avaliação realizada de forma independente por dois autores. RESULTADOS: Vinte e quatro revisões foram incluídas. As revisões mostraram que ingestão de carboidratos e a terapia de validação podem ser benéficas para distúrbios cognitivos. Para demência, existe benefício potencial de programas de atividade física, treino cognitivo, tratamentos psicológicos, aromaterapia, terapia com luz, reabilitação cognitiva, estimulação cognitiva, oxigenoterapia hiperbárica associada a donepezila, análise funcional, terapia de reminiscência, estimulação elétrica transcutânea, decisão estruturada em opções de alimentação, abordagem de gestão de casos e intervenções aplicadas por trabalhadores na área de saúde não especialistas e por unidades de cuidado especializado. Não foram encontrados benefícios para alimentação por sonda entérica, acupuntura, estimulação de Snoezelen, cuidados de repouso, equipe de cuidados paliativos e intervenções para prevenir comportamento de perambulação. CONCLUSÃO: Várias intervenções não farmacológicas para pacientes com comprometimento cognitivo e demência têm sido estudadas, mostrando benefícios potenciais. Entretanto, a força de evidência derivada desses estudos é em geral considerada baixa, devido às limitações metodológicas dos estudos primários.
ABSTRACT CONTEXT AND OBJECTIVE: Autism spectrum disorders (ASDs) include autistic disorder, Asperger’s disorder and pervasive developmental disorder. The manifestations of ASDs can have an important impact on learning and social functioning that may persist during adulthood. The aim here was to summarize the evidence from Cochrane systematic reviews on interventions for ASDs. DESIGN AND SETTING: Review of systematic reviews, conducted within the Discipline of Evidence-Based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo. METHODS: We included and summarized the results from Cochrane systematic reviews on interventions for ASDs. RESULTS: Seventeen reviews were included. These found weak evidence of benefits from acupuncture, gluten and casein-free diets, early intensive behavioral interventions, music therapy, parent-mediated early interventions, social skill groups, Theory of Mind cognitive model, aripiprazole, risperidone, tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI); this last only for adults. No benefits were found for sound therapies, chelating agents, hyperbaric oxygen therapy, omega-3, secretin, vitamin B6/magnesium and SSRI for children. CONCLUSION: Acupuncture, gluten and casein-free diets, early intensive behavioral interventions, music therapy, parent-mediated early interventions, social skill groups and the Theory of Mind cognitive model seem to have benefits for patients with autism spectrum disorders (very low to low-quality evidence). Aripiprazole, risperidone, tricyclic antidepressants and SSRI (this last only for adults) also showed some benefits, although associated with higher risk of adverse events. Experimental studies to confirm a link between probable therapies and the disease, and then high-quality long-term clinical trials, are needed.
RESUMO CONTEXTO E OBJETIVO: Os transtornos do espectro autista (TEA) incluem autismo, doença de Asperger e transtorno global do desenvolvimento. As manifestações dos TEA podem ter importante impacto na aprendizagem e funcionamento social, que pode persistir durante a fase adulta. O objetivo foi resumir as evidências de revisões sistemáticas Cochrane sobre intervenções para TEA. TIPO DE ESTUDO E LOCAL: Revisão de revisões sistemáticas conduzida na Disciplina de Medicina Baseada em Evidências da Escola Paulista de Medicina, Universidade Federal de São Paulo. MÉTODOS: Nós incluímos e resumimos os resultados de revisões sistemáticas Cochrane sobre intervenções para TEA. RESULTADOS: Foram incluídas 17 revisões que encontraram evidências fracas de benefícios da acupuntura, dietas isentas de glúten e caseína, intervenção comportamental intensiva precoce, musicoterapia, intervenção precoce mediada pelos pais, grupos de habilidades sociais, modelo cognitivo de Teoria da Mente, aripiprazol, risperidona, antidepressivos tricíclicos, inibidores seletivos da recaptação da serotonina (ISRS); o último apenas para adultos. Nenhum benefício foi encontrado com terapias sonoras, agentes quelantes, oxigenoterapia hiperbárica, ômega-3, secretina, vitamina B6/magnésio e ISRS para crianças. CONCLUSÃO: Acupuntura, dietas sem glúten e caseína, intervenção comportamental intensiva precoce, musicoterapia, intervenção precoce mediada pelos pais, grupos de habilidades sociais e modelo cognitivo de Teoria da Mente parecem ter benefícios para pacientes com TEA (evidência de qualidade muito baixa a baixa). Aripiprazol, risperidona, antidepressivos tricíclicos e ISRS (o último apenas para adultos) também apresentam algum benefício, embora estejam associados a maior risco de eventos adversos. Estudos experimentais confirmando a relação entre prováveis terapias e a doença, e então ensaios clínicos de alta qualidade e de longo seguimento, são necessários.
ABSTRACT CONTEXT AND OBJECTIVE: Diabetic retinopathy is a disease caused by increased permeability of retinal vessels. Its incidence and prevalence have been increasing due to urbanization, greater life expectancy and the habits of modern life. Its onset is insidious and it may lead to blindness in 75% of individuals who have been diabetic for more than 20 years. The aim here was to evaluate the evidence from Cochrane systematic reviews on interventions relating to diabetic retinopathy. DESIGN AND SETTING: Review of systematic reviews, conducted at Cochrane Brazil. METHODS: We included Cochrane systematic reviews on interventions relating to diabetic retinopathy. Two researchers evaluated the inclusion criteria, summarized the reviews and presented the results narratively. RESULTS: Ten reviews met the inclusion criteria. They showed some evidence of benefits from: (a) photocoagulation for diabetic retinopathy; (b) strict glucose and pressure control for postponing the onset of retinopathy; (c) antiangiogenic drugs for macular edema (high-quality evidence); (d) anti-vascular endothelial growth factor agents for proliferative diabetic retinopathy (very low to low-quality evidence); and (e) intravitreal injection or surgical implantation for treating persistent or refractory macular edema. However, blood pressure control seems to have no benefit after the onset of retinopathy. CONCLUSION: Only a few options are likely to be effective for treating diabetic retinopathy. These include photocoagulation and anti-vascular endothelial growth factor agents. Strict glucose and pressure control seem to postpone the onset of retinopathy. For macular edema, antiangiogenic drugs, intravitreal injection and surgical implantation seem to have some benefit.
RESUMO CONTEXTO: A retinopatia diabética é uma doença causada pelo aumento da permeabilidade dos vasos da retina. Sua incidência e prevalência vêm aumentando devido à urbanização, maior expectativa de vida e hábitos de vida modernos. Seu início é insidioso e pode levar à cegueira em 75% dos pacientes diabéticos com mais de 20 anos de doença. O objetivo foi avaliar a evidência das revisões sistemáticas Cochrane sobre intervenções para retinopatia diabética. TIPO DE ESTUDO E LOCAL: Revisão de revisões sistemáticas conduzida no Centro Cochrane do Brasil. MÉTODOS: Nós incluímos revisões sistemáticas Cochrane sobre intervenções para retinopatia diabética. Dois pesquisadores avaliaram os critérios de inclusão, resumiram as revisões e apresentaram os resultados narrativamente. RESULTADOS: Dez revisões preencheram os critérios de inclusão e mostraram benefícios com: (a) fotocoagulação para retinopatia diabética; (b) controle rigoroso da glicose e da pressão para adiar o início da retinopatia; (c) fármacos antiangiogênicos para edema macular (evidência de alta qualidade); (d) agentes antifator de crescimento do endotélio vascular para retinopatia diabética proliferativa (evidência de qualidade muito baixa a baixa); (e) injeção intravítrea ou implante cirúrgico para o tratamento do edema macular persistente ou refratário. No entanto, o controle da pressão arterial parece não ter benefício após o início da retinopatia. CONCLUSÃO: Existem poucas opções provavelmente efetivas para o tratamento da retinopatia diabética. Estas incluem fotocoagulação e agentes antifator de crescimento do endotélio vascular. O controle rigoroso da glicose e da pressão parecem adiar o início da retinopatia. Para o edema macular, fármacos antiangiogênicos, injeção intravítrea e implante cirúrgico parecem ter algum benefício.
ABSTRACT BACKGROUND: Approximately 50% of patients with newly diagnosed non-small cell lung cancer (NSCLC) are over 70 years of age at diagnosis. Despite this fact, these patients are underrepresented in randomized controlled trials (RCTs). As a consequence, the most appropriate regimens for these patients are controversial, and the role of single-agent or combination therapy is unclear. In this setting, a critical systematic review of RCTs in this group of patients is warranted. OBJECTIVES: To assess the effectiveness and safety of different cytotoxic chemotherapy regimens for previously untreated elderly patients with advanced (stage IIIB and IV) NSCLC. To also assess the impact of cytotoxic chemotherapy on quality of life. METHODS: Search methods: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (1966 to 31 October 2014), EMBASE (1974 to 31 October 2014), and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to 31 October 2014). In addition, we handsearched the proceedings of major conferences, reference lists from relevant resources, and the ClinicalTrial.gov database. Selection criteria: We included only RCTs that compared non-platinum single-agent therapy versus non-platinum combination therapy, or non-platinum therapy versus platinum combination therapy in patients over 70 years of age with advanced NSCLC. We allowed inclusion of RCTs specifically designed for the elderly population and those designed for elderly subgroup analyses. Data collection and analysis: Two review authors independently assessed search results, and a third review author resolved disagreements. We analyzed the following endpoints: overall survival (OS), one-year survival rate (1yOS), progression-free survival (PFS), objective response rate (ORR), major adverse events, and quality of life (QoL). MAIN RESULTS: We included 51 trials in the review: non-platinum single-agent therapy versus non-platinum combination therapy (seven trials) and non-platinum combination therapy versus platinum combination therapy (44 trials). Non-platinum single-agent versus non-platinum combination therapy Low-quality evidence suggests that these treatments have similar effects on overall survival (hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.72 to 1.17; participants = 1062; five RCTs), 1yOS (risk ratio (RR) 0.88, 95% CI 0.73 to 1.07; participants = 992; four RCTs), and PFS (HR 0.94, 95% CI 0.83 to 1.07; participants = 942; four RCTs). Non-platinum combination therapy may better improve ORR compared with non-platinum single-agent therapy (RR 1.79, 95% CI 1.41 to 2.26; participants = 1014; five RCTs; low-quality evidence). Differences in effects on major adverse events between treatment groups were as follows: anemia: RR 1.10, 95% 0.53 to 2.31; participants = 983; four RCTs; very low-quality evidence; neutropenia: RR 1.26, 95% CI 0.96 to 1.65; participants = 983; four RCTs; low-quality evidence; and thrombocytopenia: RR 1.45, 95% CI 0.73 to 2.89; participants = 914; three RCTs; very low-quality evidence. Only two RCTs assessed quality of life; however, we were unable to perform a meta-analysis because of the paucity of available data. Non-platinum therapy versus platinum combination therapy Platinum combination therapy probably improves OS (HR 0.76, 95% CI 0.69 to 0.85; participants = 1705; 13 RCTs; moderate-quality evidence), 1yOS (RR 0.89, 95% CI 0.82 to 0.96; participants = 813; 13 RCTs; moderate-quality evidence), and ORR (RR 1.57, 95% CI 1.32 to 1.85; participants = 1432; 11 RCTs; moderate-quality evidence) compared with non-platinum therapies. Platinum combination therapy may also improve PFS, although our confidence in this finding is limited because the quality of evidence was low (HR 0.76, 95% CI 0.61 to 0.93; participants = 1273; nine RCTs). Effects on major adverse events between treatment groups were as follows: anemia: RR 2.53, 95% CI 1.70 to 3.76; participants = 1437; 11 RCTs; low-quality evidence; thrombocytopenia: RR 3.59, 95% CI 2.22 to 5.82; participants = 1260; nine RCTs; low-quality evidence; fatigue: RR 1.56, 95% CI 1.02 to 2.38; participants = 1150; seven RCTs; emesis: RR 3.64, 95% CI 1.82 to 7.29; participants = 1193; eight RCTs; and peripheral neuropathy: RR 7.02, 95% CI 2.42 to 20.41; participants = 776; five RCTs; low-quality evidence. Only five RCTs assessed QoL; however, we were unable to perform a meta-analysis because of the paucity of available data. AUTHORS' CONCLUSIONS: In people over the age of 70 with advanced NSCLC who do not have significant co-morbidities, increased survival with platinum combination therapy needs to be balanced against higher risk of major adverse events when compared with non-platinum therapy. For people who are not suitable candidates for platinum treatment, we have found low-quality evidence suggesting that non-platinum combination and single-agent therapy regimens have similar effects on survival. We are uncertain as to the comparability of their adverse event profiles. Additional evidence on quality of life gathered from additional studies is needed to help inform decision making