A common consequence for people who have a stroke is a reduction in their arm function. Various approaches are available to try to help and, in September 2018, the Cochrane Review for one of these, electromechanical and robot‐assisted arm training, was updated by a team of researchers from Germany. We asked lead author, Jan Mehrholz from Dresden Medical School, to tell us about the latest findings in this podcast.
"More than two‐thirds of people who have had a stroke have difficulties with reduced arm function. This can limit their ability to perform everyday activities and electromechanical and robot‐assisted arm training might help by using specialised machines to support shoulder, elbow and hand movements. Our review looks at the effects on arm function and muscle strength, and whether patients find it acceptable.
We identified 45 trials, involving a total of approximately 1600 participants; ranging from a trial with just eight participants to a US study with nearly 130. The trials assessed 24 different electromechanical devices, which were tested for between two and 12 weeks, and compared to a variety of other interventions.
Although the trials also used a variety of outcome measures, we can say that, on average, electromechanical and robot‐assisted arm training improves daily living for people after stroke, and improves the function and muscle strength of the affected arm. However, the effects were relatively small and might not be big enough to be seen as clinically important. Adverse events, such as injuries and pain, were seldom described, and so it does seem reasonable to include these devices in the rehabilitation of patients after a stroke but with some uncertainty about when and how often they should be used.
In summary, people who receive electromechanical and robot‐assisted arm training after a stroke might improve their activities of daily living, arm function, and arm muscle strength. However, although the quality of the evidence was high, we still need to be cautious because the benefits are small and there were substantial differences between the trials in the intensity, duration, and amount of training; and the types of treatment, participants and outcomes measurements used."
Omega-3 fats are the subject of more than two dozen Cochrane Reviews for conditions including cardiovascular health, dementia and gastrointestinal problems. In November 2018, the review on the effects on preterm birth when these are taken by pregnant women was updated. The review was led by Associate Professor Philippa Middleton and Professor Maria Makrides, from the Healthy Mothers Babies and Children theme at the South Australian Health and Medical Research Institute. Professor Makrides tells us about the latest evidence.
"In Australia, about 1 in 12 babies are born prematurely, this means that they are born more than three weeks before the usual 40 weeks of pregnancy. This is a problem because premature birth is responsible for around 85% of all health complications in early life and is the leading cause of death in children under 5.
There are very few strategies to prevent women from going into early labour and delivering a premature baby. However, one of the things that our research team has been studying is whether the omega-3 long-chain fatty acids, such as DHA and EPA that are found in fish and fish oils, can extend the length of pregnancy.
We have now completed our Cochrane systematic review that brings together all the published randomised trials that test the effects of these long chain omega-3 fats during pregnancy on the health of mothers and their babies. We included 70 studies, which contained more than 19,000 women in the trials. The review shows that there is high-quality evidence that supplementation with long-chain omega-3 fats during pregnancy, particularly with DHA, reduced the risk of having a premature baby by 11% and it also reduced the risk of having a very premature baby, born before 34 weeks, by 42%.
Based on these findings, we suggest that pregnant women with one baby take between 500 and 1000mg of long-chain omega-3s every day from the 12th week of pregnancy. It’s best if these supplements contain at least 500mg of DHA per day. As a result of the review, we are revising clinical practice guidelines for health professionals who are working in pregnancy care to try and encourage pregnant women to supplement their diets with omega-3s, to increase their chances of having a healthy full-length pregnancy."
The call for ‘Expressions of Interest’ to join the Cochrane US Network is now open. This call invites US-based organizations and institutions of different kinds to indicate their interest to support and/or join and become part of a new Cochrane US Network. The deadline for submitting an Expression of Interest is January 31, 2019.
This recently published Cochrane Review assessed which long-acting inhalers are the most effective and safest for people with advanced chronic obstructive pulmonary disease (COPD.)
Chronic obstructive lung disease (COPD) is usually caused by smoking or other airway irritants. COPD damages the lungs and causes airways to narrow which makes it difficult to breathe. The disease accounts for more than three million deaths annually and is the third leading cause of death world-wide, it is also a major cause of disability and hospitalisation. Quality of life can be poor as people find it hard to carry out everyday tasks
There are two types of inhalers for COPD: rescue and maintenance. A rescue inhaler is short- and fast-acting, and used as needed for quick relief of symptoms, whereas a maintenance inhaler is long-acting and used on a daily basis to relieve daily symptoms and reduce flare-ups. The long-acting inhalers are usually reserved for more advanced COPD.
Does it matter which long-acting inhaler is used in people with advanced COPD?
Commonly used maintenance inhalers are grouped into four different groups: long-acting beta2-agonists (LABAs); long-acting muscarinic antagonists (LAMAs); LABA/inhaled corticosteroid (ICS) combinations; and LABA/LAMA combinations. Combination inhalers are usually reserved for individuals whose single-maintenance inhaler, such as LAMA or LABA fails.
There are not many head-to-head comparisons to determine which treatment group or individual inhaler is better compared to the others. Preventing severe flare-ups and hospital admissions is especially important to people with COPD, healthcare providers, policy makers and society.
How did the review group answer the question?
We collected and analysed data from 99 studies, including a total of 101,311 participants with advanced COPD, using a special method called network meta-analysis, which enabled us to simultaneously compare the four inhaler groups and 28 individual inhalers.
What did it find?
- The LABA/LAMA combination was the best treatment, followed by LAMA, in preventing flare-ups although there was some uncertainty in the results.
- Combination inhalers (LABA/LAMA and LABA/ICS), are more effective for controlling symptoms than single-agent therapies (LAMA and LABA), in general.
- The LABA/LAMA combination was better than LABA/ICS combination, especially in people with a prior episode of flare-ups.
- The LABA/ICS combination had a higher incidence of severe pneumonia compared to the others.
- oWe did not find a difference in benefits and harms, including side effects, among individual inhalers within the same treatment groups.
The LABA/LAMA combination is likely the best treatment in preventing COPD flare-ups. LAMA-containing inhalers appear to have an advantage over those without LAMA for preventing flare-ups.
Combination inhalers (LABA/LAMA and LABA/ICS), appear more effective for controlling symptoms than single-agent therapies (LAMA and LABA). Inhaled steroids carry an increased risk of pneumonia.
Yuji Oba, lead author of this Cochrane review said, “ There are a range of different treatments for COPD, and this review provides a comprehensive assessment of how effective they are at preventing flare ups of COPD, managing symptoms and improving quality of life, but it also looks at important harms including the risk of pneumonia. The findings of the network meta-analysis feed in to guidelines published by NICE and are testament to a strong collaboration between Cochrane Airways group and the guideline group who have developed guidance on managing COPD.”
Cochrane Airways have published its biggest ever Cochrane Review. The meta-analysis review assesses which long-acting inhalers are the most effective and safest for people with advanced chronic obstructive pulmonary disease (COPD) and supports a recently published NICE guideline.
The logistics of getting such a large review done with time tight timescales have been an enormous challenge for the review team. We asked Rebecca Normansell, Joint Co-ordinating Editor and Emma Dennett, Managing Editor, Cochrane Airways, how this review came about and its potential impact.
How did the review come about?
We received a review proposal towards the end of 2015 from a chest physician in the USA, Yuji Oba, who had identified from his own practice an important clinical question about inhalers for COPD. He had already reviewed the literature and published on the subject, but was aware of new data and was interested in producing a Cochrane Review. He had assembled a team including a UK-based expert in network meta-analysis (NMA), Sofia Dias, with whom we had worked before. We agreed it was an important question, but needed to refine the comparisons in the NMA to minimise overlap with an existing Airways NMA and other reviews. After a bit of back and forth between the editorial base and the authors, we registered the title and the protocol was published in March 2017.
This is the biggest the airways group has done - how many people were involved, did it 'draw' on the team in a unique way?
The review was the biggest review we have ever done. Not only did it have 99 studies, but there were six pairwise comparisons, each with multiple outcomes, and network meta-analyses of multiple outcomes in both high and low risk COPD populations – a vast amount of data!
One of the challenges for the editorial team was the sheer volume of material to edit. We felt overwhelmed at times and making sure the review met the standards and all the data matched up throughout the review and the summary versions was time-consuming. Denise Mitchell, UK-based copy-editor, spent two weeks on it - copy editors are some of the unsung heroes in Cochrane!
While the payoff from working to get the review finished for the NICE guideline has been great, it was quite nerve-wracking. We are essentially trusting an author team to do what they said they will do, but without the control you would have of someone you are employing or paying to deliver a service. Yuji and Sofia were brilliant at keeping in touch with us and doing what they said they would in the timeframe.
What does the review mean? How will it inform policy or practice?
There is an overwhelming number of inhaled drugs licenced for use in COPD, and now multiple ‘fixed dose’ combined inhalers. Health care professionals and health services have to make difficult choices every day, balancing efficacy, safety, patient preference and cost. This huge review compared two single drug options – LABA or LAMA – to combined options – LAMA/LABA or LABA/ICS. The review found that one particular combination – LABA/LAMA – is probably the best treatment for reducing harmful flare-ups of COPD. LAMA containing inhalers (combined with LABA and on its own) are likely to have an advantage over those without a LAMA for preventing COPD flare-ups. Combined drugs appeared more effective than single drugs for improving symptom and quality-of-life scores. Importantly, ICS-containing inhalers were found to be associated with an increased risk of pneumonia – a potentially serious lung infection.
These are important findings that they give extra weight to the direction that most current guidelines are going – to favour LAMA-containing inhalers, especially for those having frequent flare-ups, and reserve ICS-containing inhalers for those who keep having flare-ups despite treatment, or have features suggestive of asthma. The next question is what are the risk and benefits of triple therapy, i.e. adding ICS to LAMA/LABA combinations? Cochrane Airways has just started a review update on this topic.
The other finding that may interest health care professionals and policy makers is that, in general, when the review authors looked at individual drugs within a class and at the class of drugs as a whole in the NMA, they found little difference. This suggests that drugs within a class are probably broadly equivalent, so perhaps other factors such as cost and patient preference can be considered when prescribing.
In terms of it appearing in guidelines, can you say a little about the history of this relationship? How does it build on what has happened before?
Back in 2016, we started the process of applying for a Cochrane Programme Grant, focussed on COPD. We were aware that NICE were working on a COPD guidelines update at the same time. We made contact with NICE to find out if there were sensible ways for us to work together and share resources. We had already had some contact with NICE in previous Programme Grants, and are registered stakeholders for their respiratory-related consultations.
We had a discussion and agreed that we would deliver one of our Programme Grant reviews, about long-term antibiotics for COPD, in time for the guideline and to share our data early – which we have done – the published review can be read here. But during the discussion, we also found out that NICE would be very interested in the findings of this NMA, which was about to be published as a protocol. We approached the author team to find out if they could deliver data and the finished review to the NICE deadline and we were delighted when they agreed to do their best. We kept in close contact with NICE and the author team over the following 18 months. We shared data from the NMA with NICE in January 2018 and were thrilled to be able to publish the finished review just a couple days before the guideline itself – phew!
The Cochrane Fertility Regulation Group (CFRG) is looking to appoint one or more new Co-ordinating Editor(s) to provide leadership of the Group. The CFRG is part of the Cochrane Children & Families Network. This is an important opportunity to lead and shape the future development of a strategically important area of Cochrane’s healthcare evidence coverage. The CFRG portfolio of reviews includes 81 active reviews and 13 protocols.
Applications are welcomed from individuals based in any country. We invite applications from within existing Cochrane Groups and beyond, and also individuals interested in a job share. Applicants should be aware of the following requirements:
1. The Co-ordinating Editor(s) must have:
- Experience of authoring Cochrane or alternative high quality systematic reviews
- Clinical expertise and standing in the field of contraception and abortion
- Methodology expertise in the field of evidence synthesis, including risk of bias and GRADE assessments
2. The following attributes are highly desirable
- Experience of editing Cochrane reviews or alternative high quality systematic reviews
- Advanced methodological skills and knowledge
3. The new Co-ordinating Editor(s) must work within the terms of the Collaboration Agreement that defines the responsibilities of Cochrane and the Cochrane Review Group.
Potential applicants should familiarise themselves with Cochrane’s commercial sponsorship and conflict of interest policy.
Individuals who are interested to explore this opportunity are welcome to speak with David Tovey, Editor-in-Chief (email@example.com).
To apply, please send a cover letter detailing the responses to the numbered bullet points above, and a short Curriculum Vitae to David Tovey.
For further information, please review the full role description.
Deadline for applications: 07 January 2019 (12 midnight GMT)
Details of interviews will be provided in the due courseWednesday, December 5, 2018 Category: Jobs
This Special Collection of Cochrane Systematic Reviews brings together a large body of research on the accuracy of tests used to diagnose skin cancer.
The suite of eleven reviews was led by Dr Jac Dinnes at the University of Birmingham and supported by the Cochrane Skin Group and a team of over 30 researchers and expert advisors, funded by the National Institute for Health Research (NIHR).
The reviews summarise research evidence assessing the accuracy of different diagnostic tests to support clinical and policy related decision making in the diagnosis of all types of skin cancer.
Dr Jac Dinnes, of the University of Birmingham’s Institute of Applied Health Research, said: “Early and accurate detection of all skin cancer types is essential to manage the disease and to improve survival rates in melanoma, especially given the rate of skin cancer world-wide is rising.
The visual nature of skin cancer means that it can be detected and treated in many different ways and by a number of different types of specialists, therefore the aim of these reviews is to provide the world’s best evidence for how this endemic type of cancer should be identified and treated."
“We have found that careful consideration should be given of the technologies that could be used to make sure that skin cancers are not missed, at the same time ensuring that inappropriate referrals for specialist assessment and inappropriate excision of benign skin lesions are kept to a minimum.”
Key findings of the Special Collection were:
- Visual inspection using the naked eye alone is not good enough and melanomas may be missed.
- Smartphone applications used by people with concerns about new or changing moles or other skin lesions have a high chance of missing melanomas.
- When used by specialists, dermoscopy - a technique using a handheld device to zoom in on a mole and the underlying skin - is better at diagnosing melanoma than visual inspection alone, and may also help in the diagnosis of BCCs.
- Dermoscopy might also help GPs to correctly identify people with suspicious lesions who need to be seen by a specialist.
- Dermoscopy is already widely used by dermatologists to diagnose melanoma but its use in primary care has not been widely evaluated therefore more specific research is needed.
- Checklists to help interpret dermoscopy might improve the accuracy of diagnosis for practitioners with less expertise and training.
- Teledermatology - remote specialist assessment of skin lesions using dermoscopic images and photographs - is likely to be a good way of helping GPs to decide which skin lesions need to be seen by a skin specialist but future research needs to be better designed.
- Artificial intelligence techniques, such as computer-assisted diagnosis (CAD), can identify more melanomas than doctors using dermoscopy images. However, CAD systems also produce far more false positive diagnoses than dermoscopy and could lead to considerable increases in unnecessary surgery.
- Further research is needed on the use of specialist tests such as reflectance confocal microscopy (RCM) – a non-invasive imaging technique, which allows a clinician to do a ‘virtual biopsy’ of the skin and obtain diagnostic clues while minimising unnecessary skin biopsies. RCM is not currently widely used in the UK but the evidence suggests that RCM may be better than dermoscopy for the diagnosis of melanoma in lesions that are difficult to diagnose.
- Other tests such as using high frequency ultrasound have some promise, particularly for the diagnosis of BCCs, but the evidence base is small and more work is needed.
Cochrane Skin founder Professor Hywel Williams, of the Centre of Evidence-Based Dermatology at the University of Nottingham, said: “Completing this broad suite of detailed reviews was a real marathon.
“Apart from a few exceptions, I was surprised by how poor the overall study designs were, especially in terms of accurately documenting where on the clinical pathway patients were tested.
“Although some useful conclusions have emerged, for example, on the role of dermoscopy, the greatest value of the research is to serve as a yardstick for designing future studies evaluating skin cancer diagnosis techniques on patients who are typically seen in GP and specialist settings.”
The research team said that future studies evaluating diagnostic skin cancer tests should recruit patients with suspicious skin lesions at the point on the clinical pathway where the test under evaluation will be used in practice. Further research is also needed to evaluate whether checklists to assist diagnosis by visual inspection alone can improve accuracy and to identify how much accuracy varies according to the level of expertise of the clinician carrying out the assessment. Well-designed studies of dermoscopy in primary care are needed, and the best ways of delivering dermoscopy training need to be identified.
The reviews have been shared with The National Institute for Health and Care Excellence (NICE) to inform a potential update of the NICE Melanoma guideline, which was last updated in 2015.
Are you living with Heart Disease and interested in helping Cochrane Heart focus on research relevant to your condition?
Cochrane Heart aims to prepare, maintain, and promote the access of systematic reviews of the effect of interventions for treating and preventing heart disease. Visit the Cochrane Heart website to find out more about their work.
The Cochrane Consumer Network describes the importance of including people who access health services in the work that Cochrane does. As someone with experience of heart disease, Cochrane Heart would welcome your perspective and input at all stages of the review process.
Perhaps you could help select new topics for reviews, or check that review protocols contain outcomes of relevance to patients and their families? All Cochrane reviews have Plain Language Summaries for a wider audience, and your input here would be really valuable in helping to get the review’s message across to everyone.
If this sounds like something you’d like to get involved with, please contact firstname.lastname@example.org for further information.
World AIDS Day takes place on the 1st December each year. It’s an opportunity for people worldwide to unite in the fight against HIV, to show support for people living with HIV, and to commemorate those who have died from an AIDS-related illness. Founded in 1988, World AIDS Day was the first ever global health day.
Cryptococcal meningitis causes an estimated 15% of all AIDS‐related deaths globally. The disease largely affects people with advanced HIV disease, mostly in low‐ and middle‐income countries. The high death rate in part relates to limited access to diagnostic tests for the disease and the high cost and limited availability of treatments. A new Cochrane Library editorial has been published on this important topic; 'Updating guidance for preventing and treating cryptococcal disease: how evidence and decisions interface'.
Saturday, December 1, 2018
Cochrane Colloquium, Santiago, Chile 22-25 October 2019
Cochrane Chile is delighted to be hosting the Colloquium next year. It will be a great opportunity to meet and network with the Cochrane community from Chile and Latin America, and to be surprised by the wide usage of Cochrane evidence in decision-making at all levels.
The theme of the next Colloquium is ‘Embracing Diversity’, and there is no better place to experience it. In 2018, Chile was recognized as the best country to visit by the prestigious Lonely planet travel guide. This long and narrow strip of land, isolated from the rest of the world by the soaring Andes to the east, and the vast Pacific Ocean to the west, acts as a catalogue of natural wonders, ranging from the unearthly scenery of the world’s driest desert in the north, to the world’s largest continental ice fields in the south. In between, countless unforgettable locations, including top-of-the-list wine growing regions, the clearest skies in the world, the impenetrable wilderness of Patagonia and the enigmatic Easter island, just to name a few. Chile is nature on a colossal scale, and travel is surprisingly safe and easy.
Accompanying Chile’s diverse geography is it’s multi-ethnic and diverse society. High-tech, early technology adopters, conforming what the media refers to as Chilecon Valley, coexist with writers that make Chile known as a country of poets, and nine indigenous peoples that have preserved their culture as a living heritage.
Registration is scheduled to open in February 2019 and abstract and workshop submission will launch in early January. Visit the website to get the latest information and key dates, with more details to be announced in the coming months.
Hashtag: #CochraneSantiagoWednesday, December 5, 2018
An enhanced Cochrane Library platform launch, huge increase in visits to Cochrane.org, and almost 1,300 contributors attend Cochrane’s Colloquium in Edinburgh, UK.
We are proud to present key highlights of Cochrane’s performance during July – September 2018 as part of our latest organizational Dashboard.
This important information consists of data on Strategy to 2020 target achievements, and key metrics around the Strategy’s four Goals, Producing evidence; Making our evidence accessible; Advocating for evidence; Building an effective sustainable organization.
This quarter, July- September 2018, saw the successful launch of the new Cochrane Library platform, redesigned with enhancements to improve user experience and functionality.
We are delighted to share other achievements across Cochrane during this period including:
An astonishing 22% increase in Cochrane.org web sessions since Quarter II 2018, that’s a 99% increase in Cochrane.org web sessions since a year ago.
Usage in some countries (Japan, Mexico, Brazil) showing even more significant growth
22% increase in Cochrane supporters since Quarter II
Major increases in year on year members of Cochrane Crowd (44%), users of Task Exchange (89%) and Covidence (65%)
Nearly 1,300 delegates attend a hugely successful Patients Included Cochrane Colloquium in Edinburgh, UK.
View Cochrane’s organizational performance in more detail in PDF formatIf you would like further information on Cochrane’s organizational data and information, please contact Sarah Darbyshire Evans (email@example.com)Friday, November 30, 2018
Cochrane reviews should help inform health decision making. As the producers of reviews, we cannot do this on our own. Strategic partnerships, at the organizational, regional, national, network and group levels, are essential. These partnerships can be very diverse, from working with local media or a local community organization, to global and national health policy makers, major research funders, as well as a wide variety of health practitioners.
This video highlights some of our partnerships with Patient-Centered Outcomes Research Institute (PCORI), Health Talk, Choosing Wisely, and Wikipedia. It demonstrates the variety of partners Cochrane engages with to ensure its reviews are relevant and responsive to the needs of users, and help inform health decisions people need to make.
Podcast: A review of activities to help healthcare professionals share decisions about care with their patients
It is widely recognised that more emphasis needs to be given to the role of the patient in making decisions about their health care. But what are the best ways to make this happen? Some of the answers are in the July 2018 update of a Cochrane Review on shared decision making and we asked the lead author, France Légaré from Université Laval in Québec Canada, to tell us why this is important and what they found.
"I have been practising family medicine since 1990, and training family physicians for many years. I have seen the many difficult decisions that patients face every day about everything from screening to treatment options, and have always suspected that family physicians could do things differently so they could better support their patients in making decisions. Often, the physician makes the decision for the patient, or the patients make it on their own. But this could be different. Physicians could change how they explain the scientific evidence to the patient. They could help patients discover what’s most important to them personally about the pros and cons of the available options. We call this process shared decision making, and I believe not only that physicians can learn to do it better, but that it’s the ethical thing to do. We did this review to find out about the best ways to encourage healthcare professionals to do this, and have several things to suggest.
This is the second update of our review of studies of interventions which include, among other things, training programs, audit and feedback, public campaigns, and patients decision aids. Our first review was published in 2010, when there were just 5 eligible studies. By 2014, 34 more studies were available for our first update, and we’ve now reached 87 studies. The number of studies more than doubled in just five years, probably because of the increased awareness of the importance of shared decision making in medical communities and governments.
It’s also encouraging to see that more than half the studies reported on the patient’s awareness of whether shared decision making occurred, showing that more and more researchers are interested in finding out what matters most to patients from the patients’ perspective. However, only one study took place in a low-income country, suggesting that shared decision making is still seen as something for the privileged one.
Studies had tested a great many different approaches, and many were found to be effective in increasing shared decision making, especially the use of decision aids. However, when applying Cochrane’s very strict rules about evidence quality we found that few studies met the high standards. For example, many didn’t give enough information to properly judge the quality of the evidence they produced. But, we can say that compared to no activity at all, it is clear that some interventions which aim to implement shared decision making in clinical practices slightly improve patients’ quality of life in terms of mental health, but make little difference to their quality of life in terms of physical health.
Having done this update and thinking about its meaning for me as a family physician, I will encourage my patients to use decision aids. And, as an educator, I will encourage health professionals to get training in how to use them. While, as a researcher, I will strongly encourage other researchers to design their studies so that the quality of evidence is better and to agree on a set of measures of shared decision making that would make it easier to compare studies."
In this Evidently Cochrane blog, Sarah Chapman looks at the Cochrane evidence for aspects of routine dental care. Something to smile about? Or are there big gaps…?
My grandmother used to tell the tale of when she was a schoolgirl, back in about 1920, and a school event to which parents were invited. Nan and her friend enjoyed a carefree afternoon without their mothers there, having avoided inviting them – the friend because her mother had white hair, and Nan because her mother had just had all her teeth taken out. There was trouble, she recalled, when they were rumbled by a write-up of the event.
Teenagers haven’t changed much in the hundred years since then, but thankfully the state of the nation’s teeth has. My great-grandmother would not have been unusual in having all her teeth removed, to be replaced by an easier-to-care-for set of dentures, and some women even received this as a 21st birthday present! This changed, thanks, in part, to free dental treatment through the NHS from its beginning in 1948, the fluoridation of toothpaste from 1959, improvements in diet and a new emphasis on good dental hygiene.
Today, we are commonly told we should have a dental check-up every six months, and a visit to the dental surgery often includes getting advice from a hygienist on how to care for our teeth and gums, and perhaps a ‘scale and polish’. This routine dental care is all so familiar we may not question it, but we should! What’s the evidence? Does it give us, and our dental health professionals, something to smile about?How often should you have a dental check-up?
As a child, I loved my regular visits to the dentist. As an infant, I delighted in the toy farm in the waiting room with, joy of joys, a ‘real’ well with a bucket you could wind up; while my teenage dental trips were always followed by a visit to the ice cream parlour (oh dear…)! But is there any evidence behind the common recommendation that we should go every six months? No there isn’t! The Cochrane Review addressing this found just one study with 185 people; insufficient evidence to support or refute that six-monthly recall. This is something that has been debated since the 1970s and we still lack evidence to guide practice!Oral hygiene advice
A newly published Cochrane Review aimed to address uncertainties about the impact of one-to-one oral hygiene advice (OHA), given by a dental care professional in a dental setting, on our oral health, attitudes and behaviour, by bringing together the best available evidence. Although the review includes 19 studies (randomised trials) with over 4000 people, there was so much variation that the team weren’t able to pool the data, and concluded that “there was insufficient high‐quality evidence to recommend any specific one‐to‐one OHA method as being effective in improving oral health or being more effective than any other method.”
That’s disappointing. So what about that ‘scale and polish’? Is the evidence any better?Routine scale and polish
Both hygienists and dentists provide scaling and polishing for their patients at regular intervals, even when those patients are at low risk of gum disease. There is uncertainty about whether this is useful and how often it should be done. Along with a sit-down and a chance to reflect on your guilt about not having flossed when you were told to, the ‘routine scale and polish’ offers you the removal of deposits of bacteria called plaque, and hardened plaque known as tartar or calculus, which is too hard for removal by toothbrushing by even the most diligent brushers (I’m looking at my husband, bafflingly motivated by the promise of a digital smiley face after two minutes, on a gadget linked to his toothbrush. He is 55…).
A Cochrane Review team looked for the evidence from randomised trials on routine scale and polish in healthy adults without severe gum disease and found surprisingly little – just three studies with 836 people. The authors note that “given the considerable resources involved in providing this treatment for adults in many countries it is disappointing that there is so little good quality, reliable research evidence available to inform clinical practice.”
This potentially relieves you of guilt if you’re not getting a scale and polish regularly, but it would be very good to have some decent evidence to guide practice, and there is work being done to try to do just this. A randomised trial, mentioned as ongoing in the Cochrane Review, has now been published and you can read about it here. We look forward to seeing this trial incorporated into the next update of the Cochrane Review. They found “no additional benefit from scheduling 6-monthly or 12-monthly PIs [scale and polish] or over not providing this treatment unless desired or recommended, and no difference between OHA delivery for gingival inflammation/bleeding and patient-centred outcomes. However, participants valued, and were willing to pay for, both interventions, with greater financial value placed on PI than on OHA.” This reminds us that patient preference and clinical judgement also play a role and along with evidence these are regarded as the three pillars of evidence-based decision-making.Flossing?
I have yet to meet a dental hygienist who didn’t advocate flossing, but I really can’t be bothered to do it, and I don’t want to find a reason to add yet another source of plastic to my environmental footprint. Need I feel guilty? There’s a Cochrane Review on flossing too, which includes 12 studies with 582 people, comparing flossing and toothbrushing with toothbrushing alone. All the studies looked at the effects on gum disease and plaque. Once again, there was so much variation between the studies that the data couldn’t be pooled. Whilst there is some evidence that flossing added to toothbrushing may reduce gum disease and plaque compared to just toothbrushing, it is unreliable. For adults, feel free to choose whether or not to floss your teeth, but it’s probably wise to steer clear of this year’s dance trend, or you risk being ridiculed for your flossing, like Jeremy Corbyn at the Pride of Britain Awards.Check your bathroom shelf
Finally, while good evidence on these elements of routine dental care is lacking, there is evidence to guide us on what we have at home, in those basics of toothbrushes and toothpaste. Something to smile about! A Cochrane Review found moderate-certainty evidence that powered toothbrushes probably reduce plaque compared with manual toothbrushes, in the short- and long-term. (If trialists want to explore the impact of a digital smiley face toothbrushing intervention, I will volunteer my husband.)
Another Cochrane Review has evidence you might want to consider when choosing your toothpaste. It finds that fluoride toothpaste containing triclosan and copolymer leads to a small reduction in tooth decay and is probably more effective at reducing plaque and gingivitis than fluoride toothpaste without those ingredients. As for chlorhexidine mouthwash, you can read all about the Cochrane evidence in this blog by dentist Bosun Hong.
Featured Review: Piperonyl butoxide (PBO) combined with pyrethroids in insecticide‐treated nets to prevent malaria in Africa
Review confirms that using pyrethroid-PBO treated nets to prevent malaria is more effective at killing mosquitoes in areas where there is a high level of resistance to pyrethroids.
The distribution of nets treated with pyrethroid insecticides has been very effective in reducing malaria transmission during the past two decades in Africa. However, there has been a rise in the number of mosquitoes developing resistance to pyrethroids, which is the only class of insecticides currently used to treat nets.
In a new Cochrane review, an independent team of review authors led by Katherine Gleave and Natalie Lissenden at the Liverpool School of Tropical Medicine (LSTM) assessed the efficacy of insecticide-treated nets (ITNs) with added piperonyl butoxide (PBO). This chemical works by blocking an enzyme in the mosquito that prevents pyrethroids from working, to overcome the problem of insecticide resistance.
LSTM’s Professor Hilary Ranson is senior author on the review. She said: “We have to find a way to maintain the efficacy of ITNs, which have been a cornerstone of vector control. While these nets are more expensive, the evidence shows that in areas where pyrethroid resistance is high, adding PBO to nets killed more mosquitoes, stopping them from feeding on people and probably reducing the levels of disease.”
The review author team looked at results from 15 included studies that compared pyrethroid-PBO nets to standard pyrethroid nets, with one study measuring the impact on malaria infection in humans and the others looking at the impact on the mosquito population. The results show that while there is little or no difference in areas where resistance to pyrethroid is low or moderate, the nets had an impact where resistance was high. One trial carried out in an area at high levels of resistance also showed an important reduction in the number of people developing malaria illness. As ITNs are washed throughout their use, the review team also looked at the impact of washing these pyrethroid-PBO nets. While there was still a decrease in mosquito blood feeding success, the effect on mosquito mortality was not so marked when nets were washed multiple times, which would be important when considering community-level protection.
Professor Ranson continued: “Researchers are working hard to reduce the impact of insecticide resistance, but our review is the first to look at ‘next generation nets’. While there is more research to be undertaken, we think that the results help show the value that these nets represent and supports the WHO’s recommendations for pyrethroid-PBO nets.” Jan Kolaczinski, Coordinator of Entomology and Vector Control at WHO’s Global Malaria Programme, supports this statement noting that “systematic reviews, such as the one on pyrethroid-PBO nets, provide a crucial underpinning of evidence-based WHO recommendations and guidelines. We greatly appreciate the important contribution to WHO’s work made by the Cochrane Infectious Diseases Group in this area.”
This Cochrane Review was co-ordinated by the Cochrane Infectious Diseases Group (CIDG), which has its editorial base at LSTM. The CIDG has been in operation since 1994 and consists of over 600 authors from 52 countries and is supported by UK aid from the UK Government for the benefit of low- and middle-income countries (project number 300342-104).
Gleave K, Lissenden N, Richardson M, Choi L, Ranson H. Piperonyl butoxide (PBO) combined with pyrethroids in insecticide-treated nets to prevent malaria in Africa. Cochrane Database of Systematic Reviews 2018, Issue 11 DOI: 10.1002/14651858.CD012776.pub2
This news article was first published on the LSTM website.
Specifications: Secondment/Fixed term contract/consultancy contract for a minimum of 12 weeks starting February 2019 up to three working days a week
Application Closing Date: 17th December 2018
Cochrane’s work is recognized as the international gold-standard for high quality, trusted information. We want to be the leading advocate for evidence-informed health care across the world.
Knowledge Translation (KT) is defined in Cochrane as the process of supporting the use of health evidence from our high quality, trusted Cochrane systematic reviews by those who need it to make health decisions. Knowledge Translation is essential in achieving Cochrane’s vision and maximizes the benefit of the work of our global contributors and members. The Cochrane Knowledge Translation Framework (KT Framework) provides more details on Strategy to 2020’s commitment to the dissemination, use and impact of Cochrane evidence. For many working in Cochrane, the focus on KT is a different way of thinking and uses concepts and terminology that may be unfamiliar.
This exciting role provides you with the opportunity to take the lead on the development and implementation of an introductory ‘What is Knowledge Translation in Cochrane?’ online learning module for people working across Cochrane’s Groups and global community.
The successful candidate will be responsible for developing the content of the module, supporting the creation and testing of the e-learning module and for launching the module in the Cochrane community. You will be working with Cochrane’s central KT Department, members of Cochrane’s KT Working Groups with expertise in KT, Cochrane Membership and Learning Services Department, and external contractors, to ensure a smooth delivery of the project.
We are looking for a self-motivated and highly organised individual who is able to work effectively and collaboratively with a diverse range of contacts across the world. The successful candidate will also have
- Experience of developing and delivering educational training materials.
- Experience of delivering Knowledge Translation projects.
- Good understanding of the Cochrane Knowledge Translation Framework and terminology.
- Understanding of the structure and function of Cochrane groups (Review Groups, Networks, Fields and Geographically Orientated Groups).
- Ability to work alongside varied teams in different cultural and linguistic settings.
- Good IT skills, including PowerPoint and Excel.
- Proven experience of quickly building productive working relationships, both internally and externally, in a geographically dispersed environment.
- Strong written and verbal communication skills.
- Willingness to work flexibly including outside normal working hours for occasional out-of-hours telephone conferences.
- Commitment to Cochrane’s mission and values.
Cochrane is a global, independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making vast amounts of research evidence useful for informing decisions about health. We do this by synthesizing research findings to produce the best available evidence on what can work, what might harm and where more research is needed. Our work is recognised as the international gold standard for high quality, trusted information.
If you would like to apply for this position, please send a CV along with a supporting statement to firstname.lastname@example.org with Knowledge Translation Learning Module Content Developer in the subject line. The supporting statement should indicate why you are applying for the post, and how far you meet the requirements for the post outlined in the job description using specific examples. List your experience, achievements, knowledge, personal qualities, and skills which you feel are relevant to the post.
For further information, please review the full job description.
Deadline for applications: 17 December 2018 (12 midnight GMT)
Interviews to be held on: (TBC)Thursday, November 29, 2018 Category: Jobs
Dear Cochrane Members,
If you haven’t voted yet in the current Governing Board elections, you’re still able to do so until 10 December 2018 at 12:00 GMT.
With 18 candidates standing for election this year, there’s a lot of information available for you to review before casting your votes. To support your choices, we’ve interviewed the candidates about their motivation to stand for election and their views on Cochrane’s key opportunities and challenges.
Visit elections.cochrane.org to read these interviews, view the full Candidate Statements, and cast your votes.
All members as defined by the Membership Terms & Conditions are entitled to vote in this election. To check your membership status, please see https://join.cochrane.org/your-membership. If you know of fellow members who aren’t receiving these emails but want to, you can ask them to check their communications preferences in their Cochrane Account. The Community Support Team will also be happy to assist you by email at email@example.com.
Questions about any aspects of the elections process can be raised with Lucie Binder, Senior Advisor to the CEO (Governance & Management) and Electoral Officer for this election.Wednesday, November 28, 2018
Podcast: Talking therapy for the management of mental health in low- and middle-income countries affected by mass human tragedy
Evidence Aid, an organisation dedicated to improving the use of evidence in humanitarian crises, highlights information from Cochrane and other systematic reviews of particular relevance to those involved in humanitarian assistance and, in July 2018, these were added to by a report on psychological therapies for the treatment of mental disorders in low- and middle-income countries. We asked one of the authors, Marianna Purgato from the University of Verona in Italy, to tell us about this new Cochrane Review.
"Whether a humanitarian crisis is triggered by natural hazards or other events, people affected by it in low- and middle-income countries are exposed to many stressors that make them more vulnerable to mental disorders, including post-traumatic stress disorder, major depression and anxiety. They are also more at risk of other negative psychological outcomes.
Various types of psychological therapy are available to try to manage these conditions, including different forms of cognitive-behavioural therapy, or CBT, including CBT with a trauma focus, Brief Behavioural Activation, narrative exposure therapy, the common elements treatment approach and several others. It’s important, therefore, to know how effective and acceptable these therapies are and we did our review to investigate this for people with mental disorders who are living in humanitarian crises in low- and middle-income countries.
We included 33 randomised trials, involving more than 3500 participants. The studies are from sub-Saharan Africa, the Middle East and North Africa, and Asia, and were implemented during armed conflicts and disasters triggered by natural hazards, as well as in other types of humanitarian crises. Together, the 33 studies assessed the effects of eight different psychological treatments, each of which was compared against a control group.
Most of the studies were limited to adults, but three included both older children and adults, and four just recruited children and adolescents between 5 and 18 years of age.
In adults, we found that psychological therapies may substantially reduce post-traumatic stress disorder symptoms by the end of the therapy, but the effect is smaller over the subsequent one to four months and at six months follow-up. There were similar findings for the effects of the therapies on depression, and we found that they may moderately reduce anxiety at the end of the therapy and at one to four months' follow-up.
The evidence was much less clear for children and adolescents. We found very low quality evidence for lower post-traumatic stress disorder symptoms scores after CBT compared to control conditions, and there was no randomised evidence on major depression or anxiety in children.
In summary, our review supports the approach of providing psychological therapies to populations affected by humanitarian crises, although none of the included studies looked at the effectiveness or acceptability of these therapies for depressive and anxiety symptoms beyond six months, and most of the data comes from research in adults. Only a small number of the trials studied children and adolescents, and these provided very low-quality evidence of benefit from the psychological treatments."
- Read the Cochrane Review
- Visit the Cochrane Common Mental Disorders website
- Listen to more Cochrane Podcasts
- Get Cochrane Podcasts on iTunes
Tuesday, November 27, 2018
2018 Colloquium Gala Dinner Raises £9,880 for Social Bite, a charity dedicated to tackling homelessness in Scotland
The Colloquium is Cochrane's annual flagship event, bringing people together from around the world to discuss research into important global health questions and to promote evidence-informed health care. This year, the Colloquium took place in Edinburgh, UK, in September and was hosted by Cochrane UK. Almost 1300 people from 57 countries attended. The theme was ‘Cochrane for all - better evidence for better health decisions.’ It was a Patients Included event, co-designed, co-produced and co-presented by healthcare consumers.
This year’s Colloquium gala dinner was held at the National Museum of Scotland. Guests enjoyed their meal in the Grand Gallery, followed by traditional Scottish music, a ceilidh and a disco.
In order to guarantee their place at the dinner, guests were asked to make a charitable donation at the time of registration. These donations were promised to Social Bite, a national Social Enterprise in Scotland dedicated to tackling homelessness. We are delighted to have raised £9,880 for this cause.
Social Bite invite their homeless customers into their chain of sandwich shops to enjoy homemade food and hot drinks throughout the day. Among other ventures, they also hold a series of ‘social supporter’ events in the evenings, including nights for refugees and ‘women’s only’ nights for homeless women. Social Bite have also secured 800 homes for their first Housing Initiative. This plans to take a minimum of 800 people out of homelessness and into a proper home with fully funded support over the next 18 months.
After learning of the donation raised from the gala dinner, Jamie Boyd, Head of Event Fundraising at Social Bite passed on this message:
“Your gift will make such a difference to the lives of the many homeless people we support. Thanks to the generosity of our supporters, like yourselves, we are able to distribute over 100,000 items of food and hot drinks every year to Scotland’s most vulnerable people… Support such as yours gives the small team at Social Bite great hope that together we can end homelessness and we thank you once again”.
To learn more about Social Bite watch this short video:Tuesday, November 27, 2018
Does very early and active mobilisation improve recovery after stroke?
Care in a stroke unit is recommended for people soon after a stroke, and results in an improved chance of surviving, returning home, and regaining independence. Very early mobilisation (helping people to get up out of bed very early, and more often after the onset of stroke symptoms) is performed in some stroke units, and is recommended in many acute stroke clinical guidelines. However, the impact of very early mobilisation on recovery after stroke is not clear.
This review identified nine trials (2958 participants), although one trial (2104 participants) provided most of the information. On average, very early mobilisation participants started mobilisation 18.5 hours after their stroke, compared with 33.3 hours in the usual care group.
Review author Prof. Julie Bernhardt said:
“Very early mobilisation did not increase the number of people who survived or made a good recovery after their stroke but there was a suggestion that very early mobilisation may reduce the length of stay in hospital by about one day.
“However the results raised the concern that starting intensive mobilisation within 24 hours of stroke may carry some increased risk, at least for some people with stroke and this potential risk needs to be clarified.”
Monday, November 26, 2018