Monday, January 18, 2010

entre pañales y superheroes... o super heroes en pañales?

english version at the end
me acuesto con la ilusion de dormir y descansar sin recordar que tengo a mi lado un pedacito de carne a quien alimentar y que espera mi calor para recordar viejos tiempos en que compartiamos un mismo espacio. despierto chueca, torcida, con olor a leche agria, semidesnuda, vulnerable, pero a mi lado una carita hinchada con el cabello revuelto y una sonrisa sin dientes que derrite hasta al mas duro.
me levanto y lo primero que hago es visitar al super heroe, al vecino de junto que comunmente esta desparramado en su camita, con la cabeza colgando y las cobijas en el suelo. le doy un beso y le empiezo a cosquillar y hablarle bajito, se despierta con una sonrisa y retorciendose como gusano con sal.
cambio pañales, huelo a bebe, a super heroe, mis pechos irritados de tanta friccion, testigos del furor con que mi cachorra succiona, adoloridos de abrazos apretados, pero llenos de amor, mi espalda cansada de cargar a cuestas 6 kilos de puro amor concentrado.
jugando a ser grande, a echar carreras, a ser superheroe, practicando letras y preparandonos para el primer dia de escuela, platicando con fantasmas amigables, corriendo para ir a saltar y maromear en gimnasia, haciendo preguntas tan sabias, analizando el mundo y nuestra existencia..mami, porque estamos aqui? donde viviamos antes de nacer? a donde nos vamos cuando nos morimos? mami que te gusta hacer a ti?... recordandome a cada instante lo realmente importante.
daria lo que fuera por estos dos seres que iluminan mi vida, me entrego cada dia con amor sin condicion, intentando guiarlos en su propio camino pero dejandolos que lo recorran ellos mismos con libertad; no quiero nada a cambio, me doy por bien pagada con una sonrisa, un suspiro despues de comer, una leche desparramada por las comisuras, un abrazo en la noche y un "gracias mami por todo"
el mejor empleo del mundo? limpiar colitas, mocos, lagrimas, responder preguntas, jugar, arrullar, cantar, besar, cargar, reir, amar
la mejor de las misiones? ayudar a que sigan su propia mision, recordarselas dia a dia, recordarles que sean felices, que se amen, que son importantes como todos en este mundo. que sigan sus sueños, que todos son posibles de alcanzar...cualquiera que este sea.
mejor paga? sonrisitas chimuelas, abrazos con todas sus fuerzas que apenas te aprietan, sonrisas francas, desde adentro, caras de asombro, creyendo todo lo que escuchan, entregas totales.
esos son mis SUPERHEROES EN PAÑALES!!
Emiliano 5 años. Dharma Valentina 3 meses

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english version
among diapers and superheroes ... or super heroes in diapers?
I lie wishing get some sleep and rest without recalling the bit of meat by my side that demands to be fed and whose waiting for my warm approach to remember old times when we shared the same space.
I awake crooked, twisted, with a sour milk smelling, half-naked, vulnerable, but by my side a little swollen face with unkempt hair and toothless smile that melts even the hardest.
I get out of bed and the first thing I do is visit the super hero, the neighbor next door that is usually scattered on his bed, his head hanging down and the blankets on the floor. I give him a kiss and begin to tickle him and talk softly; he awakes with a smile and squirming like a worm with salt.
I change diapers, I smell like a baby, like super hero; my breasts are sore of so much friction, witnesses of the fury with which my cub sucks, sore of tight hugs full of love, my back tired of carrying on six kilos of pure concentrated love .
playing pretending to be grown up, running races, being superhero, practicing letters and getting ready for the first day of school, chatting with friendly ghosts, rushing to get to gymnastics to jump and somersault, trying to answer wise questions, analyzing the world and our existence .. mom, why we are here? where we lived before birth? where we go when we die? Mommy what do you like to do? ... reminding me at every moment what is really important.
I would give anything for these two beings that light my life, I surrender every day with love without condition, trying to guide them in their own way but letting them travel freely. I don't want anything back for me, I'm well-paid with a smile, a sigh after eating, with milk spilled over the mouth edges, a hug at night and a "thank you mommy for everything"
the best job in the world? change diapers, wipe noses, tears, answer questions, play, cuddle, sing, kiss, carry, laugh,love.
the best mission? help them to follow their own mission, remind them to be happy, to love, that they are important as everyone in this world. pursue their dreams, they are all attainable ... whatever they are. better pay? toothless smiles, hugs with all his strength that barely squeeze you, frank smiles from the inside, faces of astonishment, believing everything they hear, total surrenders. these are my SUPERHEROES IN DIAPERS!
Emiliano 5 y/o. Dharma Valentina 3 m/o

Carencia de maternaje y organización de dinámicas violentas

Personalmente creo que todas las formas de violencia, pasivas o activas, concretas o sutiles, se generan a partir de la falta de maternaje, es decir, a partir de la falta en la calidad de atención, calidez, amor, brazos, altruismo, generosidad, paciencia, comprensión, leche, cuerpo, mirada y sostén....recibidos –o no- desde el nacimiento y durante toda la infancia.

Desde el punto de vista del bebé, toda experiencia sin suficiente apoyo y sostén, es violenta. Porque actúa en detrimento de las necesidades básicas.

Sencillamente, un bebé pequeñito llega al mundo sin ninguna autonomía. Recién adquiere la capacidad de desplazarse por sus propios medios alrededor de los nueves meses, gracias al gateo. Y necesita alrededor de dos años para tener conciencia de su ser separado. Y luego precisará varios años para que pueda salir solo a la selva urbana. Necesita del adulto para sobrevivir. Por supuesto que requiere que se le procure alimento, higiene, calma y silencio para dormir. También sabemos que el niño necesita contención, calor, cercanía de otro cuerpo, leche, mirada, palabras y sobre todo alguien que haga de mediador entre él y el mundo externo. Si no recibe una calidad de atención acorde con sus necesidades básicas, esa falta la vive como violenta. Es la violencia del desamparo.

La realidad es que la mayoría de los bebés llegan al mundo sin una mamá o persona maternante capaces de sostener y fundirse en la inmensa necesidad de ser sostenidos y acariciados en forma permanente. En la actualidad, los bebes no reciben incondicionalmente lo que piden, porque siempre hay un adulto cerca para no estar de acuerdo y para tener una opinión al respecto.

Generalmente se trata de las mismas madres amorosas que entramos en contradicción con nuestros propios pensamientos. El asunto es que no es un período para pensar. Es un período para entrar en fusión emocional. No hay que buscar razones, ni elegir concienzudamente la mejor opción. No hay reglas a seguir ni consejos aplicables. En estos casos los niños quedan prisioneros de lógicas incomprensibles, alejados de los brazos de sus madres y solos.

Los bebés unánimemente explican una y otra vez a través de sus interminables y prístinos llantos, dónde está su lugar. El bebé que no está en contacto con el cuerpo de su madre, experimenta un inhóspito universo vacío que lo va alejando de su anhelo de bienestar que traía consigo desde el período en que vivía dentro del vientre amoroso de su madre. El bebé recién nacido no está preparado para un salto a la nada: a una cuna sin movimiento, sin olor, sin sonido, sin sensación de vida. Esta violenta separación de la díada causa más sufrimientos de lo que podemos imaginar y establece un sin sentido en el vínculo madre-niño. Cuando las expectativas naturales que traía el pequeño son traicionadas, aparece el desencanto, junto al miedo de ser nuevamente herido. Y después de muchas experiencias similares, brota algo tan doloroso para el alma como es el enojo, el miedo y la resignación.

Cuando ese ser tan pequeñito no se siente valioso ni bienvenido, se convertirá necesariamente en un ser humano sin confianza, sin espontaneidad y sin arraigo emocional. Todos los bebés son valiosos, pero sólo pueden saberlo por el modo en que son tratados. En los países “desarrollados”, las madres compramos libros con indicaciones sobre cómo atender a nuestros hijos, sobre cómo dejarlos llorar hasta que se duerman y cómo abandonarlos en el vacío emocional sin siquiera tocarlos. Las madres jóvenes desconfiamos de nuestra capacidad innata de criar a nuestros hijos, y desoímos los “motivos” que tienen los bebés para transmitir señales que son inconfundiblemente claras.

La noche en particular puede ser terrorífica para los niños al no percibir ningún movimiento. El “tiempo” aparece como un hecho doloroso y desgarrador si la madre no acude, a diferencia de las vivencias dentro del útero donde toda necesidad era satisfecha instantáneamente. Ahora la espera, duele. De hecho, los niños lloran hasta dormirse. Al despertar, finalmente encuentran confort en brazos de sus madres. Pero ya no confían, están atentos y se aferran con vigor a los pechos calientes. Los muerden, los lastiman. Tienen miedo. Y así, una y otra vez hasta que abandonan. El miedo los acompañará siempre, incluso en esos momentos en que están reconfortados. Porque saben que el silencio volverá en cualquier momento a devorarlos. Nunca más dejarán de estar alertas. No cuentan con nadie y el mundo es hostil.

Cuando nuestros hijos lloran o reclaman “más de lo normal”, creemos que se han constituido en enemigos que las madres debemos vencer. La idea básica alrededor de esta moda estima que satisfacer las necesidades de un bebé o niño pequeño los convierte en “malcriados”, aunque paradójicamente, obtenemos una y otra vez el resultado opuesto al esperado. De hecho, los bebés siguen siendo “demandantes”, se enferman, se accidentan y nos traen muchos dolores de cabeza.

En la medida que van creciendo, la psique se organiza adquiriendo ciertos mecanismos de supervivencia, para sufrir lo menos posible. Algunos de esos mecanismos son visibles, como los niños que pegan o muerden para sentirse valiosos; otros son invisibles, como los niños que suelen ser víctimas de otros niños, o los que se deprimen o pasan desapercibidos, o bien los que se enferman con demasiada frecuencia, logrando de ese modo obtener la mirada y la atención que siempre necesitaron.

En la medida que no estemos dispuestos a atender y satisfacer las necesidades naturales y legítimas de los niños pequeños, estamos induciendo a perpetuar las dinámicas violentas. Porque un niño no satisfecho, es un niño que insistirá por diferentes medios conquistar lo que necesitó genuinamente. Así crecerá, se convertirá en adolescente, en joven y en adulto: como un ser necesitado. Entonces golpeará a otros, robará, manipulará situaciones, se convertirá en víctima de otros, luchará por obtener lo que creerá imprescindible para su supervivencia emocional. Aunque habrá olvidado lo que siempre quiso pero no podrá conseguir, por más fuerte y poderoso que devenga: no podrá obtener más mamá.

Todas las formas de violencia que tanto nos preocupan, tienen un común denominador: la necesidad primaria no satisfecha. Cuando algo vital para la supervivencia emocional, no lo podemos incorporar, nos desesperamos. Y la desesperación por vivir, nos obliga a buscar modos de apropiarnos de lo que sea. Puede ser el deseo del otro, el cuerpo del otro, el prestigio del otro, o lo que sea que la conciencia perciba como alimento espiritual.

Por eso, si reconocemos nuestras propias limitaciones afectivas, nuestras incapacidades para reconocer el deseo del niño que es diferente al nuestro (y justamente por eso no lo toleramos); veremos que la dedicación, el altruismo y el tiempo de dedicación exclusiva hacia los niños pequeños, constituye la verdadera prevención contra todo tipo de violencias.

Los niños sostenidos, acariciados y respetados están en paz consigo mismos. No necesitan luchar por un territorio emocional, porque les sobra. No hay guerra interna o externa para librar. No les incumben las peleas. Los niños amparados y fusionados saben que obtendrán lo que necesitan. Esa es la experiencia cotidiana que repiten a cada instante y que conforman una rutina sin sobresaltos. Así se establece la seguridad interior y posiblemente ya no se mueva nunca más de las entrañas de esos seres. Sentirse seguros, amados, tenidos en cuenta, estables y con total confianza en ellos mismos y en los demás...será obviamente el tesoro más preciado para el despliegue de sus vidas.

Laura Gutman

La guerra de deseos

Si cuando hemos sido bebés, no hemos recibido el apoyo, la presencia, la mirada, la leche y los brazos constantes de una persona maternante, es posible que hayamos aprendido muy tempranamente, que para sobrevivir había que luchar. Cuando nuestra madre nos dejaba solos durante noches enteras sumidos en el miedo y la oscuridad, era obvio que ganaba su deseo en detrimento del nuestro. Por lo tanto, comprendimos que era necesario ganar terreno e imponer de algún modo nuestra imperiosa necesidad de ser sostenidos y protegidos, a través de diversos mecanismos. Enfermarnos puede haber sido un modo eficaz. Con lo cual posiblemente nuestra madre sentía que destruíamos la poca cordura que la sostenía. Una vez que sanábamos, estaba dispuesta a volver a abandonarnos, recuperando así el terreno perdido.

Así fuimos creciendo, sabiendo por propia experiencia que había que luchar esforzadamente para obtener un lugar dentro del vínculo con nuestra madre o persona maternante. Comprendimos que dentro de ese territorio emocional había lugar sólo para uno. Que no podían convivir dos deseos.

Según nuestra personalidad, fuimos adquiriendo herramientas para echar al otro, -sea quien fuera ese otro- de ese territorio de intercambio emocional. Hicimos todo lo que fuimos capaces de hacer. Algunos de nosotros devenimos agresivos, tal vez desde pequeños mordimos o peleamos o gritamos para dejar bien en claro nuestro poder y así hemos organizado a posteriori la totalidad de nuestras relaciones hasta nuestra vida adulta. Otros nos hemos convertido en víctimas eternas, comprendiendo que podíamos tener un lugar en el mundo sólo en la medida en que otro nos lastime, nos hiera, nos humille o nos desprecie. Algunos de nosotros sólo pudimos debilitarnos para obtener amor a través de las enfermedades, cosa que seguramente hemos logrado desde niños y posiblemente hayamos aceitado ese mecanismo en nuestra adultez. Y otros individuos, frente a la falta de cobijo y mirada, hemos intentado introducir cualquier cosa con tal de llenarnos de “madre”. Siendo niños tal vez nos hemos atiborrado de dulces y azúcar, luego nos hemos llenado de programas de televisión o de jueguitos electrónicos, luego nos hemos llenado de comida y de actividades, y en la adolescencia hemos incorporado desesperadamente alcohol o tabaco. Así hemos llegado finalmente a la adultez, tratando de llenarnos la barriga, sin saber que en realidad no lograremos incorporar “mamá”. Pero nuestra falta emocional es tan grande, que sólo nos importa llenarnos, y en esa desesperación, por supuesto que no hay lugar para mirar las necesidades de otros, ya que sentimos que somos los seres más necesitados del planeta. Una vez más, no hay lugar para varios dentro del intercambio emocional. Aún dentro de una relación amorosa, las necesidades personales son prioritarias. En todos los casos, hemos aprendido desde bebés, que hay que ganar para sobrevivir.

Resulta que un día devenimos madres o padres con las mejores intenciones de criar a nuestros hijos con amor y dedicación. Los niños llegan al mundo con un inmenso abanico de necesidades básicas impostergables. Y aquí se hace evidente el problema. Es aquí donde va a aparecer la lucha por ganar el espacio emocional. Porque si somos una madre o un padre que necesita primero llenarse la barriga -en términos emocionales- no estaremos tan dispuestos a dar prioridad a las necesidades del bebé, que además son inmensas e incomprensibles.

Deseamos ser madres amorosas, pero nos sentimos invadidas por el bebé que llora, que quiere el pecho constantemente, que reclama brazos tanto de día como de noche. No estamos acostumbradas a que alguien “gane” irrumpiendo en todo el territorio, sólo porque es capaz de llorar toda la noche sin cesar. Sentimos que el bebé ocupa todo el espacio emocional y que si él lo invade, nosotras desaparecemos. Para colmo nos damos cuenta que los momentos de descanso son efímeros, y que el “tiempo para una misma” quedó en el olvido. La sensación permanente suele ser que es menester “ganarle” al deseo del niño, de lo contrario él nos va a devorar. Si provenimos de historias de carencia emocional, aunque no tengamos conciencia de ello, posiblemente sentiremos que el niño tiene demandas excesivas, y que de alguna manera habrá que ponerle límites. Creemos que esos límites que en cuanto adultos impondremos, nos salvarán y que de ese modo no “perderemos” la batalla.

Vale la pena saber que esto no es real. Sólo es real para la vivencia de nuestra “niña interior”. Si éste es el sentimiento que nos inunda, tendremos que hacernos preguntas fundamentales y comprender cuál ha sido nuestra historia cuando fuimos bebés, para darnos cuenta con qué contamos y qué capacidad altruista podremos desplegar en la crianza de nuestros hijos. Porque posiblemente el niño no pide demasiado, sino que estamos cansadas de librar tantas batallas, sin saberlo. Y en ese caso, merecemos pedir ayuda, porque el niño tiene derecho a recibir lo que necesita, y nosotras tenemos la obligación de tomar conciencia sobre nuestras capacidades y discapacidades a la hora de maternar.

Laura Gutman

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.

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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.