Monday, January 18, 2010

Delayed cord clamping

The Cochrane Library

… the best single source of reliable evidence

about the effects of health care

Strictly Embargoed until 00:01 hours (BST), 16th April 2008

This alert highlights some of the key health care conclusions and their implications for practice as published next week in The Cochrane Library, 2008, Issue 2.

To receive a full copy of the Reviews highlighted in this newsletter, or to arrange an interview with an author, contact Jennifer Beal on +44 (0)1243 770633 / +44 (0) 7802 468863 or by email, jbeal@wiley.com.

Reviews highlighted in this newsletter:

· Delayed cord clamping: no increase in excessive bleeding for the mother and may increase infant’s iron in first 6 months

Should you clamp the umbilical cord within a minute of birth or wait two or three minutes? A Cochrane Systematic Review considered data from 11 trials that included a total of 2,989 mothers and their babies and concluded that early or late clamping caused no differences for the mother in terms of greater risk of blood loss.

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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No evidence that antioxidant supplements prolong life

Many people take antioxidants in the belief that they will prolong their life expectancy. However, data from 67 randomised trials that involved just under a quarter of a million people failed to support this idea, a Cochrane Systematic Review has discovered.

“We could find no evidence to support taking antioxidant supplements to reduce the risk of dying earlier in healthy people or patients with various diseases,” says Goran Bjelakovic, visiting researcher, who performed the systematic review at the Copenhagen Trial Unit at the Copenhagen University Hospital in Denmark.

The idea that antioxidants can extend life comes from human and animal laboratory research and has been boosted by some observational clinical studies. But other studies have indicated neutral or even harmful effects.

Cochrane reviews are based on peer reviewed published protocols that aim to identify randomised, published and unpublished, trials. Following Cochrane methodology, relevant data are extracted and pooled together from the identified trials, which are also assessed and subdivided into unbiased and biased in terms of methodology of their conductance, so that unbiased assessments of intervention effects can be conducted.

“The findings of our review show that if anything, people in trial groups given the antioxidants beta-carotene, vitamin A, and vitamin E showed increased rates of mortality. There was no indication that vitamin C and selenium may have positive or negative effects. So regarding these antioxidants we need more data from randomised trials,” says Bjelakovic. “The bottom line is that current evidence does not support the use of antioxidant supplements in the general healthy population or in patients with certain diseases.”

Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007176. DOI:10.1002/14651858.CD007176.

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Delayed cord clamping: no increase in excessive bleeding for the mother and may increase infant’s iron in first 6 months

Should you clamp the umbilical cord within a minute of birth or wait two or three minutes?

A Cochrane Systematic Review considered data from 11 trials that included a total of 2,989 mothers and their babies. The review sought to establish whether the timing of clamping of the umbilical cord was significant in reducing the risk of excessive postpartum bleeding in the mother (postpartum haemorrhage) or had any advantages or disadvantages for the health of the infant

It found that early or late clamping caused no differences for the mother in terms of greater risk of blood loss.

Delaying cord clamping for 2-3 minutes after the birth gives the infant increased amounts of haemoglobin in their first months of life, but may increase the risk of needing phototherapy to treat jaundice. Sometimes a newborn’s liver is slow to break down all of the red cells they had in the womb, particularly if they are left with more fetal blood from delayed cord clamping and phototherapy helps to speed the break down.

Although studies looking at the longer term health of infants are required, the current evidence suggests that there is no disadvantage to the amount of blood loss a mother experiences at the time of birth and there are advantages for babies.

“If there is access to phototherapy treatment, there would appear to be no additional risk in delaying clamping the cord in healthy term infants, particularly as this appears to boost the infant’s stores of iron. This may be of particular benefit for babies with poor nutrition,” says lead researcher Dr Susan McDonald Professor of Midwifery at La Trobe University who also works at Mercy Hospital for Women in Heidelberg, Victoria, Australia.

McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2.

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Chinese club moss extract (Huperzine A) may improve cognition in Alzheimer’s disease

Existing evidence suggests that patients with Alzheimer’s disease who have taken Huperzine A have improved general cognitive function, global clinical status, functional performance and reduced behavioural disturbance compared to patients taking placebos.

The research team came to this conclusion after studying data in six trials that involve a total of 454 patients.

Part of the damage involved in Alzheimer’s disease is a loss of acetylcholine-containing neurons in the basal forebrain. This suggests that drugs that could inhibit cholinesterase, which breaks down acetylcholine, could increase the ability of remaining cholinergic neurons.

Scientists know that Huperzine A can block acetyl cholinesterase and that it can work both in the peripheral and central nervous systems. This makes it a promising agent for treating various forms of dementia including Alzheimer’s disease.

“These findings are based on small number of trials, but the data indicate that it would be well worth setting up some more high quality assessments of this interesting drug,” says Associate Professor Hongmei Wu, who led this research and works in the Department of Geriatrics at the West China Hospital of Sichuan University in Chengdu, Sichuan, China.

Li J, Wu HM, Zhou RL, Liu GJ, Dong BR. Huperzine A for Alzheimer’s disease. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005592. DOI: 10.1002/14651858.CD005592.pub2.

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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After heart complaints, heparin reduces heart attacks but increases minor bleeding

Compared with those on placebos, giving heparin to people who have heart conditions like unstable angina and some forms of heart attack reduces the risk of having another heart attack, concluded a Cochrane Systematic Review. However, heparin also increases the chance of suffering from minor bleeding. In each study the agents were given within 24 to 72 hours of the first symptoms, and were given for between two and eight days.

Taking heparin does not, however, decrease the overall risk of dying or reduce the chance of having further bouts of angina.

These conclusions were drawn after Cochrane Researchers considered the data within eight studies that included 3118 participants, comparing the effects of giving patients either heparin or a placebo.

Heparin effectively thins blood clotting by interfering with its clotting mechanism.

“Our research supports the use of heparins in the early treatment of acute coronary syndromes,” says lead researcher Dr Kirk Magee who works in the Department of Emergency Medicine at Dalhousie University in Halifax, Nova Scotia.

Magee KD, Campbell SG, Moher D, Rowe BH. Heparin versus placebo for acute coronary syndromes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003462. DOI: 10.1002/14651858.CD003462.pub2.

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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Dopamine agonists reduce motor complications in Parkinson’s disease, but increase other side-effects

Dopamine agonists are increasingly used to treat people with Parkinson’s disease, but there is a debate about how well they work. A review of current data indicates that there is less risk of developing motor complications with these drugs. However, the review revealed that dopamine agonists can also lead to a range of other side-effects, including oedema, sleepiness, constipation, dizziness, hallucinations and nausea.

This is the first review that assesses dopamine agonists as a class. The researchers found 29 eligible trials that included a total of 5247 participants.

“When you consider costs, benefits and side-effects, the old drug levodopa is probably still the best option, although we can’t be sure because few studies asked patients how the drugs affected their overall quality of life,” says lead researcher Dr Rebecca Stowe who works at the University of Birmingham Clinical Trials Unit, in Edgbaston, Birmingham.

“To clarify the balance of risks and benefits, we’re running a large study called PD MED that is assessing patient-rated quality of life and economic measures,” says Stowe.

Stowe R L, Ives N J, Clarke C, van Hilten J, Ferreira J, Hawker R J, Shah L, Wheatley K, Gray R. Dopamine agonist therapy in early Parkinson’s disease. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006564. DOI: 10.1002/14651858.CD006564.pub2.

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Naftidrofuryl can reduce leg pain (intermittent claudication)

Patients with pain caused by narrowed arteries in their legs have 37% more pain-free walking if they take naftidrofuryl (200mg three times a day) than those taking placebos, a Cochrane Review has found. In addition, 55% of patients taking naftidrofuryl improved, while only 30% of people on placebo treatments improved. Naftidrofuryl is used to treat circulatory problems.

Cochrane Researchers came to this conclusion after identifying seven studies in which a total of 1266 patient had been treated for at least three months. They analysed the data by retrieving and pooling the original patient data.

The symptoms of intermittent claudication are pain, cramp or a sense of fatigue in leg muscles that increases on exercise such as walking, but goes away when the person rests. The condition affects less than 1% of people below the age of 49, but increases to over 5% of those aged 70 and older. The problem is that the arteries supplying the legs have hardened and narrowed due to fatty deposits. This makes it less easy for blood to carry oxygen and nutrients to the muscles or clear waste products away.

While stopping smoking and gently increasing exercise can reduce symptoms, interest has also been focused on some pharmaceutical products. Naftidrofuryl has been on the market since 1968 and has a good safety record. Its patent has expired, so there are many generic options in most countries.

“It would make sense to give naftidrofuryl alongside recommending lifestyle changes such as stopping smoking, physical exercise and also prescribing anti-platelet drugs and statins” says lead researcher Dr Tine de Backer who works at the Heymans Institute of Pharmacology in Gent, Belgium.

TLM De Backer, R Vander Stichele, P Lehert, L Van Bortel. Naftidrofuryl for intermittent claudication. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001368. DOI: 10.1002/14651858.CD001368.pub3.

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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5-alpha-reductase inhibitors and reduced prostate cancer risk: a mixed set of results

Compared to placebo treatment, taking 5-alpha-reductase inhibitors (5-ARIs) can reduce a man’s risk of being diagnosed with prostate cancer from around 5–9% to around 4-6% during up to 7 years of treatment, according to a new Cochrane Review. However, those who are diagnosed with prostate cancer may be at a slightly increased risk of having a more dangerous (high grade) tumour. Additionally, the vast majority of cancers detected in these studies were very small and unlikely to cause any clinical problems during a man’s lifetime.

Prostate cancer affects around 220,000 men each year in the USA alone, killing about 27,000 of them. Men over the age of 65 are at greatest risk. Safe and effective methods to prevent prostate cancer would be beneficial.

The hormone testosterone is one of the factors that may encourage these tumours to grow. There is now a range of 5-alpha-reductase inhibitors that disrupt the biochemical pathway that generates testosterone, therefore potentially reducing the incidence of prostate cancer development.

A group of Cochrane Researchers searched existing literature for trials that looked at the effects of these drugs in men. They found good and bad results.

On the positive side, the drugs led to slight decreases in the incidence of prostate cancer and can improve common benign lower urinary tract symptoms such as hesitancy, straining, frequency and night time urination.

On the negative side, when cancer was detected it was more likely to be of a high grade in men receiving 5 alpha reductase inhibitors. The reason for this is uncertain, and could be because the drugs alter the way that the tumour cells grow. However, it could be that these drugs just alter the way the cells look under the microscope rather than affecting their clinical prognosis. In addition there was evidence with one 5-ARI (finasteride) that it has a tendency to impair sexual or erectile function.

“There is a lot we still don’t know and future research must determine whether 5-ARIs reduce the overall risk of dying from prostate cancer, whether any of the different 5-ARIs on the market does a better job than the others and whether the potential benefits outweigh the risks,” says lead researcher Dr Timothy Wilt, Coordinating Editor of the Cochrane Prostatic Disease and Urologic Cancers group based at Veterans Affairs Medical Centre in Minneapolis, Minnesota, USA.

Wilt TJ, MacDonald R, Hagerty K, Schellhammer P, Kramer BS. Five-alpha-reductase Inhibitors for prostate cancer prevention. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007091. DOI: 10.1002/14651858.CD007091.

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Youth gangs - a big issue with many theories but poor research

Youth gangs cause considerable personal and social damage worldwide, yet while there are many theories about how they form and how to prevent young people becoming involved, there is no evidence to back two of the key theories, according to the results of two Cochrane Systematic Reviews.

One review (CD007002) looked to see whether providing opportunities such as after-school clubs prevented gang membership. The other (CD007008) tried to find out if cognitive-behavioural interventions can prevent young people aged between 7 and 16 from joining gangs. Despite studying 2,696 publications relating to youth gangs, the Cochrane Reviewers were unable to find any randomised controlled trials or quasi-randomised controlled trials that studied these issues.

Current estimates suggest that in the USA alone there are currently 24,000 gangs with 760,000 members, and internationally street gangs have been identified in developed and developing countries in South America, Europe, Asia and Africa.

“This lack of research is surprising given the scale of the problem,” says lead researcher Dr Paul Montgomery who works at the Centre for Evidence-based Intervention at the University of Oxford, UK.

“There is an urgent need to rigorously evaluate the various gang prevention strategies that people suggest and try to implement, if we are going to be able to direct resources well and build future gang prevention programmes that have a good chance of working,” says Montgomery.

Fisher H, Montgomery P, Gardner FEM. Opportunities provision for preventing youth gang involvement for children and young people (7-16). Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007002. DOI: 10.1002/14651858.CD007002.pub2.

Fisher, H, Gardner FEM, Montgomery P. Cognitive-behavioural interventions for preventing youth gang involvement for children and young people (7-16). Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007008. DOI: 10.1002/14651858.CD007008.pub2.

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Extracts from a selection of other Cochrane Systematic Reviews

This section contains extracts from 11 selected new or updated reviews also publishing in The Cochrane Library 2008, Issue 2. These extracts have been divided into headings of:

Asthma

Cancer

Drug efficacy?

Parenting

Policy

To receive a full copy of the results from this selection, or to arrange an interview with an author, contact Jennifer Beal on +44 (0)1243 770633 / +44 (0) 7802 468863 or by email, jbeal@wiley.com.

Asthma

“Ciclesonide versus placebo for chronic asthma in adults and children"

(CD006217) by Manning et al

Background

Inhaled corticosteroids are an integral part of asthma management, and act as an anti-inflammatory agent in the airways of the lung. These agents confer significant benefit in terms of symptom management and improvement in lung function, but may also cause harm in terms of local and systemic side-effects. Ciclesonide is a novel steroid that has efficient distribution and release properties that mean it can be taken once daily, making it potentially useful in ongoing asthma management.

Extract from the Implications for Practice findings

The results of this review clearly show a short-term benefit of ciclesonide compared to placebo, in terms of lung function, symptoms and rescue inhaler use. The results have not identified an apparent dose-response effect of ciclesonide across a wide range of doses.

"Ciclesonide versus other inhaled steroids for chronic asthma in children and adults"

(CD007031) by Manning et al

Background

Inhaled corticosteroids (ICS) are an integral part of asthma management, and act as an anti-inflammatory agent in the airways of the lung. These agents confer both significant benefit in terms of symptom management and improvement in lung function, but may also cause harm in terms of local and systemic side-effects. Ciclesonide is a novel steroid that is metabolised to its active component in the lung, making it a potentially useful for reducing local side effects.

Extract from the Implications for Practice findings

The results of this review provide evidence that ciclesonide is equivalent to BDP/BUD in terms of peak flow at dose ratios of 1:1, but the effect in terms of FEV1 was more inconsistent. When compared with FP, ciclesonide demonstrated equivalence in FEV1 and peak flow at dose ratios of 1:1. The patients recruited to the studies of this review were generally mild to moderate as measured by the stipulation for low doses of maintenance treatment and moderate airway obstruction. We could not establish that the use of ciclesonide provided equivalent or superior tolerability at the same doses since the confidence intervals indicated imprecise findings. The finding of lower oral candidiasis with ciclesonide compared to FP may be important for those who find this side effect troublesome. How confirmation of oral thrush was obtained was not reported across the studies, and future studies should provide better descriptions as to how and whether such procedures were undertaken.

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Cancer

"Psychotherapy for depression among incurable cancer patients"

(CD005537) by Akechi et al

Background

The most common psychiatric diagnosis among cancer patients is depression; this diagnosis is even more common among patients with advanced cancer. Psychotherapy is a patient-preferred and promising strategy for treating depression among cancer patients. Several systematic reviews have investigated the effectiveness of psychological treatment for depression among cancer patients. However, the findings are conflicting, and no review has focused on depression among patients with incurable cancer.

Extract from the Implications for Practice findings

Evidence from RCTs of moderate quality suggests that psychotherapy is useful for treating depressive states in advanced cancer patients although little evidence supports the effectiveness of psychotherapy for patients with clinically diagnosed depression including major depressive disorder. The effects of psychotherapy are almost comparable to those observed in antidepressant pharmacotherapy studies of major depressive disorders in general psychiatry settings.

"Exercise for the management of cancer-related fatigue in adults"

(CD006145) by Cramp et al

Background

Cancer-related fatigue is now recognised as an important symptom associated with cancer and its treatment. A number of studies have investigated the effects of physical activity in reducing cancer-related fatigue with no definitive conclusions regarding its effectiveness. Extract from the Implications for Practice findings

Exercise appears to have some benefit in the management of fatigue both during and after cancer treatment. Therefore it should be considered as one component of the management strategy for fatigue that may include a range of other interventions and education.

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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Drug efficacy?

"Chemoprophylaxis and intermittent treatment for preventing malaria in children"

(CD003756) by Meremikwu et al

Background

Malaria causes repeated illness in children living in endemic areas. Policies of giving antimalarial drugs at regular intervals (prophylaxis or intermittent treatment) are being considered for preschool children.

Extract from the Implications for Practice findings

Giving antimalarial drugs at regular intervals (prophylaxis or intermittent treatment) reduces clinical malaria, severe anaemia, and hospital admissions. There are insufficient data to know whether such preventive interventions impact on mortality or if there are any detrimental impacts on health when the prophylaxis or intermittent treatment is stopped. Intermittent preventive treatment of infants (IPTi) along with routine childhood immunization is a potentially beneficial public health intervention, but decisions to promote its use on a wide scale should await the result of long-term follow-up studies to resolve uncertainties about long-term safety. There are some large trials in progress evaluating intermittent treatment that will help inform policy.

"Recombinant interferon beta or glatiramer acetate for delaying conversion of the first demyelinating event to multiple sclerosis"

(CD005278) by Clerico et al

Background

Immunomodulatory drugs have been shown to be only modestly effective in clinically definite relapsing remitting multiple sclerosis (RRMS). It has been hypothesized that their efficacy could be higher if used at the first appearance of symptoms, that is in the clinically isolated syndromes (CIS) suggestive of demyelinating events, a pathology which carries a high risk to convert to clinically definite MS (CDMS).

Extract from the Implications for Practice findings

Our study showed that early IFN beta treatment delays a second attack over 2 years of follow-up in the two trials where the analysis was possible. Some limitations in the interpretation of the results are implied by the analysis of the quality of the studies: in the ETOMS trial no clear information about the blindness of the treating and evaluating investigators is provided; the number of patients lost to follow-up during the second year of the CHAMPS study is quite high (around 40%) due to the early trial termination.

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Parenting

"Routine perineal shaving on admission in labour"

(CD001236) by Basevi et al

Background

Pubic or perineal shaving is a procedure performed before birth in order to lessen the risk of infection if there is a spontaneous perineal tear or if an episiotomy is performed.

Extract from the Implications for Practice findings

There is sufficient evidence that avoiding routine perineal shaving for women prior to labour is safe. The clinical significance of the difference in women having gram negative bacteria is uncertain. Furthermore, the potential for side-effects suggests that shaving should not be part of routine clinical practice. All three trials identified included the clipping of long hairs in their control groups to aid in operative procedures. This process is carried out for practical reasons, i.e. when performing instrumental deliveries or carrying out perineal repairs.

"Interventions for treating wrist fractures in children"

(CD004576) by Abraham al

Background

Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.

Extract from the Implications for Practice findings

The limited evidence available from randomised controlled trials supports the use of removable splintage or supports for buckle fractures with the option of clinical review rather than plaster cast for three weeks requiring a return for removal and assessment. However, the best type of splintage is not established. For children whose displaced fractures have been reduced, there is some preliminary evidence suggesting that below-elbow casts do not increase, and may in fact reduce, the risk of redisplacement compared with above-elbow casts.

"Anti-histamines for prolonged non-specific cough in children"

(CD005604) by Chang et al

Background

Non-specific cough is defined as non-productive cough in the absence of identifiable respiratory disease or known aetiology. It is commonly seen in paediatric practice. These children are treated with a variety of therapies including anti-histamines. Also, anti-histamines are advocated as an empirical treatment in adults with chronic cough.

Extract from the Implications for Practice findings

With the lack of evidence, the routine use of anti-histamines in treating children with non-specific cough cannot be recommended and is arguably contra-indicated in young children because of its side effects. If anti-histamines are to be trialled in these children, current data suggest a clinical response (time to response) occurs within two weeks of therapy. However the use of anti-histamines in children with non-specific cough has to be balanced against the well known risk of adverse events especially in very young children.

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Policy

"Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence"

(CD002207) by Mattick et al

Background

Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review.

Extract from the Implications for Practice findings

The implication of the results of the meta-analytic review conducted and reported herein are clear for clinical practice. Despite the results showing that buprenorphine is an effective treatment for heroin use in a maintenance therapy when compared with placebo, methadone maintenance treatment at high dose or flexible doses is associated with better suppression of heroin use than buprenorphine maintenance treatment. Buprenorphine maintenance should be supported as a maintenance treatment, where higher doses of methadone cannot be administered or methadone is not tolerated.

"Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries"

(CD006358) by Lucas et al

Background

A strong and consistent relationship has been observed between relative poverty and poor child health and wellbeing even among rich nations. This review set out to examine evidence that additional monies provided to poor or disadvantaged families may benefit children by reducing relative poverty and thereby improving children's health, well-being and educational attainment.

Extract from the Implications for Practice findings

The association between low income and poor outcome in all dimensions of child health is strong and consistent across countries and time. On the basis of current evidence we have not been able to establish that direct financial benefits delivered as an intervention are effective in redressing this balance in the short term. It is plausible that studies reviewed here did not offer a significant 'dose' (an interventions of larger value or longer duration).

***SEE WWW.COCHRANE.ORG/PODCASTS FOR A PODCAST BY THE AUTHOR OF THIS REVIEW, AVAILABLE FROM WEDNESDAY 16th APRIL 2008***

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- Ends -

Notes for editors

1. The Cochrane Library contains high quality health care information, including Systematic Reviews from The Cochrane Collaboration. These Reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions. The Cochrane Collaboration (http://www.cochrane.org) is a UK registered international charity and the world's leading producer of systematic Reviews. It has been demonstrated that Cochrane Systematic Reviews are of comparable or better quality and are updated more often than the Reviews published in print journalsª.

2. The Cochrane Library can be accessed at http://www.thecochranelibrary.com. Guest users may access abstracts for all Reviews in the database, and members of the media may request full access to the contents of the Library. For further information, see contact details below.

A number of countries have national provisions by which some or all of their residents are able to access The Cochrane Library for free. These include:

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Ireland http://www.thecochranelibrary.com

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New Zealand http://www.moh.govt.nz/cochranelibrary or http://www.nzgg.org.nz/ or http://www.cochrane.org.nz/

Norway http://www.cochrane.no

Poland http://www.aotm.gov.pl

Scotland http://www.nes.scot.nhs.uk

Spain http://www.update-software.com/Clibplus/ClibPlus.asp

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The Canadian Province of New Brunswick http://www.gnb.ca/0003

The Canadian Northwest Territories, Nunavut, Yukon http://www.thecochranelibrary.com

The Canadian Province of Saskatchewan http://www.thecochranelibrary.com

The Canadian Province of Nova Scotia http://www.library.dal.ca/kellogg/ahkp/cochrane.htm

The US State of Wyoming http://wyld.state.wy.us/dbloginform.html

3. The Cochrane Library is available with free one-click access to all residents of countries in the World Bank’s list of low-income economies (countries with a gross national income (GNI) per capita of less that $1000). Access to The Cochrane Library for low-income countries is via Wiley-Blackwell IP recognition, a system which recognises the country a user is in.

There are also several programmes, such as the Health InterNetwork Access to Research Initiative (HINARI) and the International Network for the Availability of Scientific Publications (INASP) that provide access in developing countries. To find out whether your country is included in any of these programmes/provisions, or to learn how to get access if you don’t already have it, please visit: http://www.thecochranelibrary.com.

4. A new feature from The Cochrane Library for 2008: a collection of podcasts on a selection of Cochrane Reviews by the authors will be available from http://www.cochrane.org/podcasts from Wednesday 16th April 2008.

For Issue 2, 2008, the podcasts are from reviewers from Australia, China, Pakistan, The Netherlands, Germany, UK, Canada and Brazil and include the following topics:

o Aerobic exercise can increase mental fitness in older people

o Chinese club moss extract (Huperzine A) may improve cognition in Alzheimer’s disease

o Interventions for enhancing medication adherence

o House dust mite control measures for asthma

o Exercise for the management of cancer-related fatigue in adults

o Interventions for alopecia areata

o Financial benefits for child health and well-being in low income or socially disadvantaged families in developed world countries

o Naftidrofuryl can reduce leg pain (intermittent claudication)

o After heart complaints, heparin reduces heart attacks but increases minor bleeding

o Antiepileptic drugs for preventing seizures in people with brain tumors

5. The Cochrane Library has undergone some functional improvements:

o Improved Status Flags: The Update flag no longer exists and instead has been replaced with the more accurate flags NewSearch ConclusionChanged and MajorChange.

o Changes to the way Reviews are displayed: Starting with Issue 2, 2008 The Cochrane Library, Cochrane Reviews will progressively be enhanced with the following additional features:

§ Author Affiliations and Contact details are now displayed

§ WHAT’S NEW? Section added

§ Introduction of SUMMARY OF FINDINGS TABLE

§ Introduction of RISK OF BIAS TABLE

o For full details of the changes, go to www.thecochranelibrary.com and select ‘Important changes to The Cochrane Library’ under ‘What’s New in Issue 2, 2008’

If you would like to see a full list of Reviews published in the new issue of The Cochrane Library, or would like to request full access to the contents of The Cochrane Library, please contact:

Contact: Jennifer Beal

Direct line: +44 (0)1243 770633

Mobile: +44 (0) 7802468863

Email: jbeal@wiley.com

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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