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The Cochrane Reviews in this Evidence Aid Special Collection are free to access.
This Special Collection includes Cochrane Reviews of healthcare topics that are important in the aftermath of a major earthquake. The reviews' conclusions are presented, and there are signposts to systematic reviews that might be helpful to decision-makers.
This collection has been developed in collaboration with Evidence Aid (www.evidenceaid.org).
Topics covered: diarrhoea prevention and treatment; wound management; fracture management; physical trauma (excluding fractures); sepsis; anaesthesia; renal; chest infections; diseases caused by water-based insect vectors; mental health; neonatal health; child health and nutrition and human resources for health
Translations: a Japanese translation is maintained by Kyoto University School of Public Health. All countries in Latin America and the Caribbean can access the Cochrane Library in English, Spanish or Portuguese via the Virtual Health Library BIREME interface.
The World Health Organization (WHO) has published guidelines for drug donations following disasters (in English and Russian) and details an interagency emergency health kit (in English, French, and Spanish).
See Cochrane & Evidence Aid: resources for flooding and poor water sanitation
There is no evidence that using tap water to cleanse acute wounds in adults increases infection, and there is some evidence that it reduces infection. However, there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.
Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use. The objective of this review was to assess the effects of water compared with other solutions for wound cleansing. [Resumen en español]
Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention
Evidence for the effectiveness of negative pressure wound therapy (NPWT) for complete healing of acute wounds remains unclear, as does the effect of NPWT on time to complete healing. Rates of graft loss may lower when NPWT is used, but hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established.
Indications for the use of NPWT are broadening, with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. This review assessed the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention.
Aloe vera for treating acute and chronic wounds
There is currently an absence of high-quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds.
Aloe vera is a cactus-like perennial succulent belonging to the Liliaceae family, commonly grown in tropical climates. Animal studies have suggested that Aloe vera may help accelerate the wound healing process. There is currently insufficient clinical trial evidence available regarding the effects of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds. This is primarily due to the lack of high-quality trials with adequate methodology.
Tissue adhesives for closure of surgical incisions
There is evidence to support the use of sutures over tissue adhesives for minimising dehiscence.
Sutures, staples and adhesive tapes are often used in wound closure however; each method has some advantages and disadvantages. The aim of the review was to determine the relative effects of tissue adhesives and conventional skin closure techniques on the healing of surgical wounds.
Debridement for surgical wounds
There is insufficient evidence on the efficacy of various methods of debridement on wound healing and the rate of debridement to guide clinical practice. There are very few large high quality trials evaluating the efficacy of various methods of debridement that have been conducted after 1990. Studies recently conducted by manufacturers of new and existing wound debridement products have used controlled trials methods, retrospective analysis of patient case notes and case studies as evidence of effectiveness therefore more high quality randomised controlled trials are needed.
There is a common belief that debridement of infected surgical wounds helps to increase wound healing. However, there is no consensus on the best method for debridement. The aim of the review was to assess the effectiveness of various methods of debridement on wound healing and rate of debridement.
Evidence on the effectiveness of early dressing removal compared with dressing surgical wounds beyond 48 hours post-surgery is based on very low quality evidence from only three randomised controlled trials.
There is contradictory evidence on the importance of dressing surgical wounds beyond 48 hours post-surgery. The aim of the review was to evaluate the effectiveness of removing a dressing covering a closed surgical incision site within 48 hours permanently or beyond 48 hours of surgery permanently with interim dressing changes allowed on surgical site infection.
Bone grafts and bone substitutes for treating distal radial fractures in adults
Bone scaffolding may improve anatomical outcome compared with plaster cast alone but there is insufficient evidence to conclude on functional outcome and safety; or for other comparisons.
Surgical treatment of fractures of the distal radius can involve the implantation of bone scaffolding materials (bone grafts and substitutes) into bony defects that frequently arise after fracture reduction. This review assesses the evidence from randomised controlled trials evaluating the implanting of bone scaffolding materials for treating distal radial fractures in adults. [Resumen en español]
Pre-operative traction for hip fractures in adults
From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use. Given the continued lack of evidence for the use of pre-operative traction, the onus should now be on clinicians who persist in using pre-operative traction to either stop using it or to use it only in the context of a well-designed randomised controlled trial.
Following a hip fracture, traction may be applied to the injured limb before surgery. This review evaluates the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered.
Percutaneous pinning for treating distal radial fractures in adults
There is some evidence to support the use of percutaneous pinning, its precise role and methods are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use.
A key method of surgical fixation for distal radial fractures is percutaneous pinning, involving the insertion of wires through the skin to stabilise the fracture. This review evaluates the evidence from randomised controlled trials for the use of percutaneous pinning for fractures of the distal radius in adults. [Resumen en español]
Interventions for treating proximal humeral fractures in adults
Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long-term outcomes. There is insufficient evidence to establish what is the best method of surgical treatment or when to start mobilisation after either surgical fixation or hemiarthroplasty.
Shoulder fractures are common in older people. The management (including surgery) of fractures of the proximal humerus fractures varies widely. This review assessed the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.
Interventions for isolated diaphyseal fractures of the ulna in adults
Overall, there is insufficient evidence to determine which method of treatment (randomised trials assessed four treatment options) is the most appropriate for the treatment of isolated fractures of the ulnar shaft in adults. However, there is weak evidence (all trials were methodologically flawed and potentially biased) that in people with minimally displaced isolated fracture of the ulna, cast immobilisation of the elbow may offer no short-term advantage in respect of pain relief or fracture union, and may be associated with longer delay in return to work, when compared with the use of a cast or brace that immobilises only the forearm. This summary does not imply that practitioners should use cast immobilisation of the elbow.
Isolated fractures of the shaft of the ulna are often sustained when the forearm is raised to shield against a blow. This review assesses the effects of various forms of treatment for isolated fractures of the ulnar shaft in adults.
External fixation versus conservative treatment for distal radial fractures in adults
There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.
Fracture of the distal radius ('broken wrist') can be treated conservatively, usually involving wrist immobilisation in a plaster cast, or surgically. A key method of surgical fixation is external fixation. This review evaluates the evidence from randomised controlled trials comparing external fixation with conservative treatment for fractures of the distal radius in adults. [Resumen en español]
Conservative versus operative treatment for hip fractures in adults
Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common.
Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest. This review compares conservative with operative treatment for fractures of the proximal femur (hip) in adults. [Resumen en español]
Conservative interventions for treating distal radial fractures in adults
There remains insufficient evidence from randomised controlled trials to determine which methods of conservative treatment are the most appropriate for the more common types of distal radial fractures in adults. Therefore, at present, practitioners applying conservative management should use an accepted technique with which they are familiar, and which is cost-effective from the perspective of their provider unit. Patient preferences and circumstances, and the risk of complications should also be considered.
Fracture of the distal radius is a common clinical problem particularly in elderly white women with osteoporosis. This review aims to determine the most appropriate conservative treatment for fractures of the distal radius in adults [Resumen en español]
Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures
Antibiotic prophylaxis for closed fracture surgery is an effective intervention. Single dose intravenous prophylaxis is effective if the agent used provides tissue levels exceeding the minimum inhibitory concentration over a 12-hour period. If the antibiotic chosen has a short half-life which may not allow minimum inhibitory concentrations to be exceeded throughout the period from incision to wound closure, the use of multiple dose regimens using a 12-hour dosage schedule is a satisfactory alternative.
Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections. The aim of this review is to determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.
Intramedullary nailing for tibial shaft fractures in adults
There are a variety of intramedullary nails and associated techniques available and widely used, but it is not clear which is the best method since there is insufficient evidence to draw definitive conclusions.
Fractures of the tibial shaft (breaks in the bone situated in the long middle section of the tibia or shin bone) are mostly caused by high-energy trauma. These fractures are major injuries and can result in severe permanent disability. Other serious complications include infection and compartment syndrome, where a dangerous build-up of pressure from internal bleeding restricts or cuts off the blood supply to the surrounding tissues. Intramedullary nailing is commonly used for treating these types of fractures. This review assesses the effects (benefits and harms) of different methods and types of intramedullary nailing for treating tibial shaft fractures in adults.
Surgical versus non-surgical interventions for treating humeral shaft fractures in adults
There is no evidence available from randomised controlled trials to ascertain whether surgical intervention of humeral shaft fractures gives a better or worse outcome than no surgery.
Fractures of the shaft of the humerus account for 1% to 3% of all fractures in adults. The management of these fractures, including surgical and non-surgical interventions, varies widely. This review assesses and compare the effects of surgical versus non-surgical intervention for non-pathological fractures of the humeral shaft in adults.
Ultrasound and shockwave therapy for acute fractures in adults
This review highlights the limitations of the available evidence on therapeutic ultrasound for acute fractures in adults. Currently, the best assessment of the clinical effectiveness of low intensity ultrasound (LIPUS) for complete or stress fractures in adults does not support the routine use of this intervention in clinical practice.
The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a patient's recovery after a fracture. This review assesses the effects of LIPUS, high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults. The studies included in the review generally assessed upper limb fractures (the tibia being the most investigated bone).
Surgical versus conservative interventions for treating ankle fractures in adults
There is insufficient evidence to conclude whether surgical or conservative treatment produces superior long-term outcomes for ankle fractures in adults.
Ankle fractures usually affect young men and older women and the question of whether surgery or conservative treatment should be used for ankle fractures remains controversial. This review assessed the effects of surgical versus conservative interventions for treating ankle fractures in adults.
Surgical versus conservative interventions for displaced intra-articular calcaneal fractures
There is insufficient high quality evidence to establish whether surgical or conservative treatment is better for adults with displaced intra-articular calcaneal (heel bone) fracture.
Fractures of the calcaneus (heel bone) comprise up to 2% of all fractures, and are mostly caused by a fall from a height, and common in younger adults. Treatment can be surgical or non-surgical. However, there is clinical uncertainty over optimal management. This review assessed the effects of surgical compared with conservative treatment of displaced intra-articular calcaneal fractures in adults.
Surgical interventions for treating distal humeral fractures in adults
There is insufficient evidence to determine whether surgery is, and which surgical interventions are, the most appropriate for the management of different types of distal humerus fractures.
Distal humeral fractures in adults are relatively uncommon injuries that require surgical intervention in most cases. There is a lack of consensus regarding the best management of distal humeral fractures in adults, including the role of conservative treatment, appropriate surgical approach, fixation strategies, the role of total elbow arthroplasty and handling of nerves such as the ulnar nerve. This review assessed the effects (benefits and harms) of surgical interventions for distal humeral fractures in adults.
Early mobilisation for elbow fractures in adults
There is a lack of evidence to inform on the timing of mobilisation, and specifically on the use of early mobilisation, after non-surgical or surgical treatment for adults with elbow fractures.
Falling on the outstretched arm can result in an elbow fracture. Loss of elbow function is a common problem with these fractures and can have major implications for functional capabilities. This review assessed the effects (benefits and harms) of early mobilisation versus delayed mobilisation of the elbow after elbow fractures in adults.
Condylocephalic nails versus extramedullary implants for extracapsular hip fractures
The use of condylocephalic nails (in particular Ender nails), for trochanteric fracture is no longer appropriate. Any advantages in intra-operative outcomes of condylocephalic nails are outweighed by the increase in fracture healing complications, reoperation rate, residual pain and limb deformity when compared with an extramedullary implant, particularly a sliding hip screw.
Two types of implants used for the surgical fixation of extracapsular hip fractures are condylocephalic nails (intramedullary nails that are inserted up through the femoral canal from above the knee and across the fracture) and extramedullary implants. This review assessed condylocephalic nails (e.g. Ender and Harris nails) compared to extramedullary implants (e.g. fixed nail plates and sliding hip screws) for the treatment of extracapsular (trochanteric and subtrochanteric) hip fracture in adults.
Perioperative fluid volume optimization following proximal femoral fracture
Limited low quality and weak evidence from randomised controlled trials to support the use of advanced haemodynamic monitoring compared to protocol using standard measures such as CVP for perioperative fluid volume optimisation for patients with proximal femoral fracture exists. Research findings to this point are insufficient to show how one can best optimize fluid levels in the large number of people around the world suffering from hip fracture.
Proximal femoral fracture (PFF) is often managed by early surgical fixation with the main aim of reducing associated complications. The aim of the review was to assess the safety and effectiveness of various methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture.
Intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There is not enough evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.
Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. This review compared compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults.
Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults
Sliding Hip Screws (SHS) appear to be preferable for fixation of hip fractures in adults, given the markedly increased fixation failure rate of fixed nail plates.
Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This review compared different types of extramedullary fixation implants and external fixators for fixing extracapsular hip fracture in adults.
Internal fixation implants for intracapsular hip fractures in adults
There were no major differences in patient survival or complications related to the operation, using different implants for internal fixation of intracapsular hip fractures, from the available evidence within randomised trials.
Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular (close to the hip joint) hip fractures. Implants are used to stabilise the bone during healing thereby reducing the chance of the bones slipping out of line. They consist of either screws or pins and may have an additional side plate attached, which is fixed to the bone. This review aimed to determine which implant is superior for the internal fixation of intracapsular proximal femoral fractures.
There is insufficient evidence on the effectiveness of osteotomy for internal fixation of trochanteric hip fractures. Additionally, there was inadequate evidence on the use of compression of the fracture, reaming of the femur, cement augmentation and hydroxyapatite coating of the lag screw.
Many different technical aspects of surgical fixation exist. In addition, substances have been used, either inserted at the fracture site or coated on the implant, to enhance the fixation of the fracture. The review aimed to investigate the effectiveness of new and existing interventions used for internal fixation of extracapsular hip fractures in adults.
Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults
There is still a lack of evidence on the effectiveness of replacement arthroplasty compared to internal fixation for extracapsular hip fractures in adults.
Internal fixation of extracapsular fractures, using extramedullary or intramedullary devices, has been developed over the last 50 years. Internal fixation may fail, particularly in unstable fractures. This has led some surgeons to try replacing the proximal femur with an arthroplasty in the treatment of an extracapsular femoral fracture. This review aimed to compare the relative effects (benefits and harms) of replacement arthroplasty versus internal fixation for the treatment of extracapsular hip fractures in adults.
There is little data from RCTs on the relative efficacy of open versus closed reduction of intracapsular fractures. Additionally, there was insufficient evidence on the efficacy of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.
Various surgical tactics, implants and ancillary manoeuvres are used in the fixation of intracapsular hip fractures to reduce the frequency of non-union and aseptic necrosis of the femoral head. This review aimed to compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures in adults.
Surgical interventions for diaphyseal fractures of the radius and ulna in children
There is insufficient evidence from RCTs on the type of surgery most effective in treating fractures of the radius and ulna in children. Also, there is lack of evidence on when surgery is a prerequisite.
Diaphyseal fractures of the radius and ulna are common in children particularly, from falls. The treatment modalities include surgical and non-surgical. This review aimed to assess the clinical effectiveness of surgical versus non-surgical interventions in addition to the different surgical interventions for the fixation of diaphyseal fractures of the radius and ulna in children.
Closed reduction methods for treating distal radial fractures in adults
There was insufficient evidence to establish the relative effectiveness of different methods of closed reduction used in the treatment of displaced fractures of the distal radius in adults. The three included randomised controlled trials did not assess functional outcome and only one reported on complications.
Fracture of the distal radius is a common injury in adults. Displaced fractures are usually reduced using closed reduction methods, which are non-surgical and generally comprise traction and manipulation. The resulting position is then stabilised, typically by plaster cast immobilisation. This review assessed the evidence for the relative effectiveness of different methods of closed reduction for displaced fractures of the distal radius in adults.
Different methods of external fixation for treating distal radial fractures in adults
There was insufficient evidence to determine the relative effects of different methods of external fixation for treating distal radial fractures in adults.
Fracture of the distal radius is a common injury. A surgical treatment is external fixation, where metal pins inserted into bone on either side of the fracture are then fixed to an external frame. The external component holds the bony fragments in position while the bone heals. Most of the differences between methods of external fixation are in the characteristics and design of the external component and in the placement of pins. This review assessed randomised controlled trials comparing different methods of external fixation for distal radial fractures in adults.
There is insufficient evidence on the effectiveness of surgical versus conservative treatments for acute middle third clavicle fractures. Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.
The majority of clavicle fractures are treated with non-surgical interventions, however, displaced clavicle fractures maybe considered for surgical therapy. The aim of the systematic review was to assess the effectiveness (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures.
Antibiotics for preventing infection in open limb fractures
There is evidence that antibiotics reduce the incidence of early infections in open fractures of the limbs.
Antibiotics are routinely used in clinical practice as an adjunct to other treatment and management interventions in the prevention of infections resulting from open limb fractures. The aim of the review was to identify any evidence for the effectiveness of antibiotics in the initial treatment of open fractures of the limb.
Nerve blocks for initial pain management of femoral fractures in children
Low quality evidence from one small trial suggests that fascia iliaca compartment block (FICB) provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks with systemic analgesia are required to confirm this result.
Fractures (breaks) of the thigh bone can be very painful. Often children arriving at hospital emergency departments are moved several times during their assessments and therefore prompt pain relief is essential. This review investigated whether a nerve block, involving the injection of a freezing/numbing medication (FICB) at the top of the thigh, would provide more effective pain relief than pain medicine given by mouth or into a vein (e.g. morphine).
Interventions for treating femoral shaft fractures in children and adolescents
There is insufficient evidence on the benefits and harms from the independent comparisons of surgical and non-surgical interventions for treating femoral shaft fractures. Furthermore, there is insufficient evidence on whether long term function as an outcome differs between the surgical and conservative interventions of thigh bone fractures in children and adolescents. However, evidence from the comparison between surgical and conservative treatment shows that surgery resulted in low rates of malunion although it may be associated with serious adverse events. Similarly, internal nailing may help speed up recovery.
Femoral shaft fracture, although uncommon, are serious injuries that affect the quality of life of both the children and their carers which may result in long term morbidity. The treatment, often in-hospital care, of the femoral shaft fractures range from surgical fixations to conservative treatment associated with prolonged immobilisation. The aim of this review was to assess the benefits and harms of interventions for treating femoral shaft fractures in children and adolescents.
Pin site care for preventing infections associated with external bone fixators and pins
There is insufficient evidence from eleven randomised controlled trials to determine if any one technique of caring for pin sites was better than any other for reducing the chance of infection and other complications. Methods identified included: cleaning around pins; applying different dressings; removal of scabs or not; and massage to drain accumulated fluids.
Metal pins are used in the management of orthopaedic fractures. The pins protrude through the skin, and the way the pin sites are cared for may have an impact on the likelihood of developing an infection. The review aimed to summarise the evidence of pin site care on infection rates.
Colloids versus crystalloids for fluid resuscitation in critically ill patients
There is no evidence from randomised trials that resuscitation with colloids reduces the risk of death, compared with resuscitation with crystalloids, in patients with trauma or burns, or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of randomised trials.
Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. This review assesses the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. [Resumen en español]
Antifibrinolytic drugs for acute traumatic injury
Tranexamic acid safely reduces mortality in bleeding trauma patients without increasing the risk of adverse events. Tranexamic acid should be given as early as possible and within three hours of injury, as treatment later than this is unlikely to be effective.
Uncontrolled bleeding is an important cause of death in trauma victims. Antifibrinolytic treatment has been shown to reduce blood loss following surgery and may also be effective in reducing blood loss following trauma. This review quantified the effects of antifibrinolytic drugs on mortality, vascular occlusive events, surgical intervention and receipt of blood transfusion after acute traumatic injury. [Listen to podcast]
There is no randomised controlled trial evidence to suggest the best timing for closure of traumatic wounds within clinical practice.
Traumatic wounds presenting within six hours of injury and considered 'clean' by the attending surgeon have traditionally undergone primary closure (closure soon after patient arrives at health facilities) with the rest undergoing delayed closure as a means of controlling potential infection. This review assessed the impact of time to wound healing and adverse effects of primary versus delayed closure in acute non-bite traumatic wounds presenting within 24 hours post injury.
Tissue adhesives for traumatic lacerations in children and adults
There is evidence to suggest that tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. Additionally, the tissue adhesives are helpful in terms of reducing pain, ease of use, and procedure time.
The use of tissue adhesives to close simple lacerations has been widespread as an alternative to standard wound closure procedures. This review aimed to identify the best available evidence on the effectiveness of tissue adhesives on the healing of traumatic lacerations in children and adults.
Steroids for acute spinal cord injury
Methylprednisolone has been shown to enhance sustained neurologic recovery in a phase III randomised trial; findings replicated in a second trial. Therapy must be started within 8 hours of injury using an initial bolus of 30 mg/kg by IV for 15 minutes followed 45 minutes later by a continuous infusion of 5.4 mg/kg/hour for 24 hours. Further improvement in motor function recovery has been shown to occur when the maintenance therapy is extended for 48 hours. This is particularly evident when the initial bolus dose could only be administered 3 to 8 hours after injury.
Steroid treatment in the early hours after acute spinal cord injury (SCI) is aimed at reducing the extent of permanent paralysis during the rest of the patient's life. This review assessed randomised trials of steroids for human acute SCI.
Gangliosides for acute spinal cord injury
The evidence available does not support the use of ganglioside treatment to reduce the death rate in spinal cord injury (SCI) patients. No evidence has yet emerged that ganglioside treatment improves recovery or quality of life in survivors.
SCI results in loss of feeling and movement. Care for people with SCI has improved, leading to an increase in survival rates. Attempts to improve patients' feeling and movement have involved the use of a wide range of treatments. Laboratory studies have suggested that gangliosides may have protective effects on nerves and even help them to re-grow. Clinical trials have taken place using gangliosides (usually GM1 ganglioside) for a number of neurological conditions. The aim of this review is to quantify the evidence for the effectiveness and safety of gangliosides when used to treat acute SCI.
Spinal fixation surgery for acute traumatic spinal cord injury
There is insufficient evidence to assess the benefits and harms associated with spinal fixation surgery in patients with traumatic spinal cord injuries.
Spinal fixation surgery is aimed at preventing re-injury by ensuring the spinal cord is fixed in a vertical position. If the spine is unstable following traumatic spinal cord injury (SCI), surgical fusion and bracing may be necessary to obtain vertical stability and prevent re-injury of the spinal cord from repeated movement of the unstable bony elements. This review assessed the differences in functional outcome and other commonly measured outcomes between people who have a spinal cord injury and have had spinal fixation surgery and those who have not.
Spinal immobilisation for trauma patients
There is no evidence from randomised controlled trials (RCTs) on the effectiveness of spinal mobilisations on neurological injury, spinal stability, mortality and adverse effects in trauma patients.
Spinal immobilisation encompasses the use of various devices and strategies aimed at stabilising the spinal cord following trauma with the aim of preventing damage to the spinal cord. This review assessed the effectiveness of various spinal cord immobilisations (including no immobilisation as a comparator) on patient outcomes such as neurological injury, spinal stability, mortality and adverse effects.
Spinal injuries centres (SICs) for acute traumatic spinal cord injury
There is insufficient evidence on the benefits or disadvantages of immediate referral versus late referral to spinal injuries centres in patients with acute traumatic spinal cord injury.
The majority of acute traumatic spinal cord injuries related complications occur within the first 24 hours and, therefore, spinal injuries centres (SICs) are thought to impact on the pre-transfer care of patients with spinal cord injuries. However, the majority of patients do not have access to such specialist centres. This review assessed whether immediate referral to an SIC results in better patient outcomes compared to delayed referral.
Mannitol for acute traumatic brain injury
Mannitol therapy for raised intracranial pressure (ICP) may have a beneficial effect on mortality when compared with pentobarbital treatment, but it may have a detrimental effect on mortality compared with hypertonic saline. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators.
Mannitol is sometimes effective in reversing acute brain swelling, but its effectiveness in the ongoing management of severe head injury remains unclear. There is evidence that, in prolonged dosage, mannitol may pass from the blood into the brain, where it might cause increased ICP. This review assesses the effects of different mannitol therapy regimens, of mannitol compared with other ICP-lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury. [Resumen en español]
Hypothermia for traumatic head injury
There is no evidence that hypothermia is beneficial in the treatment of head injury. Hypothermia should not be used except in the context of a high-quality randomised controlled trial with good allocation concealment.
Hypothermia has been used in the treatment of head injury for many years. This review assesses the effect of mild hypothermia for traumatic head injury on mortality and long-term functional outcome complications. [Resumen en español]
Corticosteroids for acute traumatic brain injury
The increase in mortality with steroids in one trial suggest that steroids should no longer be routinely used in people with traumatic head injury (TBI).
TBI is a leading cause of death and disability. Corticosteroids have been widely used in treating people with TBI. This review quantifies the effectiveness and safety of corticosteroids in the treatment of acute TBI.
Psychological treatment for anxiety in people with traumatic brain injury
There is some evidence for the effectiveness of cognitive behavioural therapy (CBT) for treating acute stress disorder following mild traumatic brain injury (TBI) and of CBT combined with neurorehabilitation for targeting general anxiety symptomatology in people with mild-to-moderate TBI.
Psychological treatments are commonly used in the management of anxiety. Certain types of psychological treatments are well suited to needs of people with TBI. This review assesses the effects of psychological treatments for anxiety in people with TBI. [Resumen en español]
Psychosocial interventions for the prevention of disability following traumatic physical injury
There is no convincing evidence from RCTs for the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury. More RCTs with large sample sizes are needed.
The impact of traumatic physical injury is associated with various disabilities including physical, social functioning and mental health issues. The review assessed the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury.
Interventions for treating acute elbow dislocations in adults
Overall, there is a lack of evidence to inform clinical decisions for treating acute simple elbow dislocations in adults. Nonetheless, it should be noted that, while weak and inconclusive, the available evidence from a trial comparing surgery versus conservative treatment did not suggest that the surgical repair of elbow ligaments for simple elbow dislocation improved long-term function.
Dislocation of the elbow joint is a relatively uncommon injury and this review assessed the effects of various forms of treatment for acute simple elbow dislocations in adults.
Surgical versus non-surgical treatment for acute anterior shoulder dislocation
Limited evidence supports primary surgery for young people engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine which treatment is better for other patient groups.
Acute anterior shoulder dislocation occurs where the top end of the humerus (the upper arm bone) is pushed out of the joint socket in a forward direction, usually as a result of an accident such as a fall and it is the commonest type of shoulder dislocation. Subsequently, the shoulder is less stable and more susceptible to redislocation, especially in active young adults. This review compared surgical versus non-surgical treatment for acute anterior dislocation of the shoulder.
Damage control surgery for abdominal trauma
Evidence that supports the efficacy of damage control surgery (DCS) with respect to traditional laparotomy in patients with major abdominal trauma is limited and its benefit cannot be established. Patients with major trauma are usually unstable and are at risk of complications including bleeding, acidosis, hypothermia, and coagulopathy.
Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, DCS avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. This review assessed the effects of DCS compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma.
Helicopter emergency medical services for adults with major trauma
An accurate composite estimate of the benefit of helicopter emergency medical services (HEMS) could not be determined using the evidence identified in this review. The question of which elements of HEMS are most beneficial for patients has not been fully answered, and any HEMS-associated benefit could be the result of some combination of crew expertise, decreased prehospital time, and the fact that HEMS are an integral part of organized trauma systems in many developed countries. HEMS-associated benefits may include physician adjudicated launching criteria based on severity injury and mechanism, centrally coordinated launching algorithms with selected HEMS deployment, trauma volumes at receiving trauma centres, and the ability of the helicopter to transport patients in areas inaccessible by ground vehicles or prohibitively distant from trauma centres. This review stresses the importance of triage criteria since the benefits of HEMS may be greatest for patients with serious but potentially survivable injuries. Ideal dispatch criteria and triage guidelines to ensure the efficient use of helicopters remain elusive.
Although helicopter emergency medical services (HEMS) transport are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit. This review assessed whether helicopter emergency medical services transport (HEMS) was associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma.
Tranexamic acid for reducing mortality in emergency and urgent surgery
There is evidence that tranexamic acid reduces blood transfusion in patients undergoing emergency or urgent surgery.
Emergency or urgent surgery, which can be defined as surgery which must be done promptly to save life, limb, or functional capacity, is associated with a high risk of bleeding and death. Antifibrinolytic agents, such as tranexamic acid, inhibit blood clot breakdown (fibrinolysis) and can reduce perioperative bleeding. Tranexamic acid has been shown to reduce the need for a blood transfusion in adult patients undergoing elective surgery but its effects in patients undergoing emergency or urgent surgery is unclear. This review assesses the effects of tranexamic acid on mortality, blood transfusion and thromboembolic events in adults undergoing emergency or urgent surgery.
Surgical versus non-surgical management of abdominal injury
There is a lack of evidence from randomised controlled trials (RCTs) for the use of surgical over non-surgical interventions such as observation for the management of people with abdominal trauma.
There is uncertainty about the best management approach (surgical and non-surgical) for abdominal injuries. The aim of the review was to assess the effects of surgical and non-surgical interventions in the management of abdominal trauma.
Prophylactic antibiotics for penetrating abdominal trauma
There is no evidence from randomised controlled trials on the benefits and harms for the use of antibiotics for abdominal trauma. Due to the lack of randomised controlled trials on the effectiveness of antibiotics for abdominal injuries, future research should focus on designing a randomised controlled trial to assess the relative effectiveness.
The use of antibiotics for penetrating abdominal trauma is based on expert opinion rather than evidence from randomised controlled trials. Studies with 33% to 57% infection rate with intra-operative antibiotic administration and 30% to 70% infection rate with only post-operative antibiotic administration have been reported. The aim of the review was to assess the effectiveness (benefits and harms) of prophylactic antibiotics for penetrating abdominal injuries.
The addition of an aminoglycoside to a beta lactam does not improve the clinical efficacy achieved with the beta lactam alone. However, the combination therapy of an aminoglycoside and a beta lactam was associated with an increased risk of renal damage and high cost in resource poor setting therefore should be discouraged.
Infections caused by bacteria and requiring hospitalization are a leading cause of preventable death. The beta lactam antibiotics and the aminoglycosides kill bacteria by different means, therefore there combination maybe a more effective treatment. This review aimed to compared intravenous treatment with a beta lactam versus treatment with a beta lactam plus an aminoglycoside, to establish effectiveness and safety.
Anaesthesia for hip fracture surgery in adults
There was insufficient evidence available from trials comparing regional versus general anaesthesia for surgical repair of hip fractures in adults to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.
The majority of people with hip fracture are elderly and are treated surgically, requiring anaesthesia. The most common types of anaesthesia are 'general' and 'spinal'. This review assessed different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.
Anaesthesia for treating distal radial fracture in adults
There was insufficient evidence to establish the relative effectiveness of different methods of anaesthesia, different associated physical techniques or the use of drug adjuncts in the treatment of distal radial fractures. There is, however, some indication that haematoma block provides poorer analgesia than intravenous regional anaesthesia (IVRA), and can compromise reduction.
Fracture of the distal radius (wrist) is a common clinical problem, particularly in women with osteoporosis. Anaesthesia is usually provided during manipulation of displaced fractures or during surgical treatment. This review asssessed the evidence for the relative effectiveness of the main methods of anaesthesia (haematoma block, intravenous regional anaesthesia (IVRA), regional nerve blocks, sedation and general anaesthesia) as well as associated physical techniques and drug adjuncts used during the management of distal radial fractures in adults.
There is evidence that multiple injection techniques using nerve stimulation for axillary plexus block produce more effective anaesthesia than either double or single injection techniques. There is insufficient evidence for a significant difference in other outcomes, including safety.
Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. Successful blocking of the nerves produces a numb and limp arm that enables pain-free surgery. This review compared the relative effects of single, double or multiple injections for axillary block of the brachial plexus for distal upper limb surgery.
Topical anaesthetics for repair of dermal laceration
There is still insufficient evidence from RCTs on the efficacy and safety of topical anaesthetics for repair of dermal laceration. Topical anaesthetics are, however, possibly an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations.
Topical local anaesthetics are used in providing effective analgesia in several superficial surgeries such as repair of dermal lacerations. The aim of this review was to compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for the repair of dermal lacerations. Additionally, to assess the efficacy and safety of several single or multi-component topical anaesthetics to identify cocaine-free topically applied anaesthetics that may provide equivalent analgesia to those containing cocaine.
Pulse oximetry for perioperative monitoring
There is evidence to support use of pulse oximetry for detecting hypoxaemia and other related events. However, there is no evidence to suggest that oximetry affects patient related outcomes.
The use of pulse oximetry in perioperative monitoring is very common in routine clinical practice. The aim of the review was to assess the effects of perioperative monitoring with pulse oximetry and to identify the adverse outcomes that might be prevented or improved by the use of pulse oximetry.
Single dose oral analgesics for acute postoperative pain in adults
There is a large amount of evidence available from thirty-five reviews on the efficacy of single dose oral analgesics for acute postoperative pain in adults. Additionally, this overview of reviews found a wealth of information on drugs that had no data, inadequate data or unreliable results as a result of publication bias.
Oral analgesics are used for acute pain relief in adults following surgery. The aim of this overview of Cochrane Reviews was to summarise all available data (from existing reviews) on the efficacy (including benefits and harms) of single dose oral analgesics in acute postoperative pain.
Emergency interventions for hyperkalaemia
Nebulised or inhaled salbutamol, or IV insulin-and-glucose are the first-line therapies for the management of emergency hyperkalaemia that are best supported by the evidence. Their combination may be more effective than either alone, and should be considered when hyperkalaemia is severe. When arrhythmias are present, a wealth of anecdotal and animal data suggests that IV calcium is effective in treating arrhythmia.
Hyperkalaemia occurs in outpatients and in between 1% and 10% of hospitalised patients. When severe, consequences include arrhythmia and death. This review evaluates evidence from randomised trials informing the emergency management of hyperkalaemia. [Resumen en español]
Tidal versus other forms of peritoneal dialysis for acute kidney injury
There is insufficient evidence to determine whether tidal peritoneal dialysis is superior to any other mode of peritoneal dialysis for the treatment of patients with acute kidney injury.
Acute kidney injury is associated with substantial morbidity and mortality. Recent studies have shown that dialysis dose was a major factor associated with patient survival. Unresolved questions persist about which mode of peritoneal dialysis should be used for most patients with acute kidney injury. The one RCT identified by this review evaluated tidal peritoneal dialysis for the treatment of patients with acute kidney injury and was not designed to enable assessment of clinical outcome measures of efficacy.
Interventions for protecting renal function in the perioperative period
There is inconclusive evidence for benefits or increased harm on the use of various interventions (including dopamine and analogues, diuretics, ACE inhibitors, erythropoietin, intravenous fluid and atrial natriuretic peptide) for protecting renal function in the perioperative period for patients undergoing surgery. Also, many criteria used to diagnose acute renal damage suffered from low methodological quality.
There are various interventions used for protection of kidney function in persons undergoing surgery. The aim of the review was to determine the effectiveness of various interventions for protection of kidney function during the perioperative phase.
Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults
Xpert® MTB/RIF used as initial diagnostic test for TB detection in patients suspected of having TB, MDR-TR or HIV-associated TB is sensitive and specific. Compared with smear microscopy, Xpert® MTB/RIF substantially increases TB detection among culture-confirmed cases. Xpert® MTB/RIF may also be valuable as an add-on test following microscopy for patients who have previously been found to be smear-negative. For rifampicin resistance detection, Xpert® MTB/RIF provides accurate results and can allow rapid initiation of MDR-TB treatment.
Accurate and rapid detection of tuberculosis (TB) and drug resistance are critical for improving patient care and decreasing the spread of TB. Xpert® MTB/RIF assay (Xpert) is a rapid, automated test that can detect both TB and rifampicin resistance, within two hours after starting the test, with minimal hands-on technical time, but is more expensive than conventional sputum microscopy. This review assessed the diagnostic accuracy of Xpert for pulmonary TB (TB detection), both where Xpert was used as an initial test replacing microscopy, and where Xpert was used as an add-on test following a negative smear microscopy result. It also assessed the diagnostic accuracy of Xpert for rifampicin resistance detection where Xpert was used as the initial test, replacing conventional culture-based drug susceptibility testing. The assessment was made in the adult population suspected of having pulmonary TB or multidrug-resistant TB (MDR-TB), with or without HIV infection. Most studies were performed in high TB burden countries.
Antibiotics for community-acquired pneumonia in adult outpatients
There is insufficient evidence from randomised controlled trials (RCTs) on the efficacy of various antibiotic treatments in patients who are older than 12 years of age with a diagnosis of community-acquired pneumonia (CAP).
CAP is associated with very high mortality and morbidity rates, particularly in the elderly population. Antibiotic treatment is one of the most common methods of treatment for CAP although it is often associated with increased antibacterial resistance and adverse effects. The aim of this review was to summarise all available evidence from RCTs on the efficacy of various antibacterial treatments for CAP in participants older than 12 years.
Antibiotics for community acquired pneumonia in children
The evidence from RCTs on the effectiveness of various antibiotics for community-acquired pneumonia (CAP) in children varies. For the treatment of patients with CAP in ambulatory setting, amoxycillin can be used as an alternative to co-trimoxazole. The limited data available on other antibiotics suggest that co-amoxyclavulanic acid and cefpodoxime may be used as alternatives in second-line therapy. Children with severe pneumonia but without hypoxaemia may be treated with oral amoxycillin in ambulatory settings. Additionally, children hospitalised with severe or very severe pneumonia may be given penicillin/ampicillin plus gentamycin as the preferred choice to chloramphenicol. Other alternative antibiotics for severe and very severe pneumonia are co-amoxyclavulanic acid and cefuroxime that may be used as second-line therapies.
Pneumonia in children is associated with high mortality rates, particularly in low income settings or countries. Early administration of antibiotics is associated with improved health outcomes. The aim of this review was to identify effective antibiotic drug therapies for community acquired pneumonia (CAP) of varying severity in children through a comparison of various antibiotics.
There is still insufficient evidence on efficacy and safety of corticosteroids in patients with pneumonia. The current available evidence suggests that corticosteroids in patients with pneumonia are usually helpful in accelerating the time to symptom resolution.
The use of corticosteroids is associated with improved immune regulation, stress response, electrolyte balance, carbohydrate and protein catabolism, however, their benefit in patients with pneumonia is still unclear. The aim of this review was to assess the efficacy and safety of corticosteroids in the treatment of pneumonia.
There is insufficient evidence from randomised controlled trials (RCTs) to support the use of zinc as an adjunct to antibiotics in the treatment of pneumonia in children aged between 2 and 59 months.
Acute respiratory infections particularly pneumonia, are responsible for high mortality in low income countries among children aged between 2 and 59 months. The evidence for the use of zinc as an adjunct to antibiotics in the treatment of pneumonia is rather varied. The aim of the systematic review was to evaluate zinc supplementation as an adjunct to antibiotics in the treatment of (clinical recovery) pneumonia in children aged between 2 and 59 months.
Physical interventions to interrupt or reduce the spread of respiratory viruses
There is some evidence to suggest that some low cost and simple interventions such as hand washing would be useful in helping to reduce the transmission of epidemic respiratory viruses. Implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. However, the long term implementation of these interventions poses a challenge where no threat of epidemic is detected.
Viral pandemics and epidemics of acute respiratory infections like influenza or severe acute respiratory syndrome are a global threat. The use of vaccinations and antiviral medications may not necessarily stop the transmission of viruses. The aim of the review was to examine the effectiveness (harms and benefits) of physical interventions to interrupt and reduce the spread of respiratory viruses.
Intermittent versus daily therapy for treating tuberculosis in children
Evidence from four randomised trials was insufficient to determine that the use of daily drug treatment was more effective than intermittent (twice- or thrice-weekly) treatment for children with tuberculosis.
Childhood tuberculosis is a neglected global public health problem. Rifampicin-containing drugs given daily for six months cure over 90% of infected children, but poor adherence and supervision reduces treatment success. The aim of the review was to establish if daily anti-tuberculosis treatments were better than intermittent treatments.
There is insufficient evidence from clinical trials on the effectiveness (efficacy and safety) of antibiotics in reducing the risk of otitis or pneumonia in children aged between two and 59 months with undifferentiated acute respiratory infections (ARIs).
ARIs are a group of infections affecting the upper part of the respiratory system lasting up to seven days. The infections are most common in pre-school children residing in low income countries. About 75% of the total amount of prescribed antibiotics in high-income countries is attributable to ARIs. The aim of this review was to assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.
Mass drug administration for malaria
Administration of antimalarial drugs to whole populations (mass drug administration) can reduce the initial (6 month) risk of malaria-specific outcomes, but few studies found that this effect was sustained. However, adverse events were inadequately addressed in these studies.
Malaria is the most important mosquito-borne disease caused by a parasite, accounting for an estimated 660,000 deaths annually. Fortunately, malaria is both preventable and treatable. The review aimed to assess the potential for mass drug administration to reduce malaria burden and transmission, and to identify gaps in our understanding. It highlighted that such reviews are a challenge due to the heterogeneity of the study methods employed.
Chlorpromazine versus placebo for schizophrenia
55 studies of predominantly low quality suggest that chlorpromazine reduces relapse and improves mental health, symptoms and functioning in patients with schizophrenia. However, there are side effects of chlorpromazine associated with its use and its use should be judicious.
The main treatment for the symptoms of schizophrenia is antipsychotic drugs. Chlorpromazine was one of the first drugs discovered to be effective in the treatment of schizophrenia. It remains one of the most commonly used and inexpensive treatments, however it also has serious side effects. The aim of this review was to perform an update and further establish the effects of chlorpromazine compared with placebo, for the treatment of schizophrenia.
Nasal versus oral route for placing feeding tubes in preterm or low birth weight infants
There is insufficient evidence on the effect of nasal versus oral replacement of enteral feeding tubes on growth and development, food tolerance, or incidence of adverse events in low birth weight or preterm babies. One small trial found no evidence of an effect on the time taken to establish enteral feeding or the time taken to regain birth weight, however the trial may have been too small to detect modest effect sizes. Another small trial found no statistically significant effects on incidence of apnoea, desaturation, and bradycardia during the study period.
In preterm or low birth weight infants, enteral feeding is a preferred method of nutrition. The enteral tubes can either be used orally (mouth) or inserted in to the nose. However, both methods of placement are associated with adverse events. For example, nasal placement is associated with restrictions in respiration whereas, oral tubes are associated with vagal stimulation, localised irritation and are often prone to displacement. The aim of this review was to determine the effect of nasal versus oral placement of enteral feeding tubes on food tolerance, growth and development and the incidence of adverse events in preterm or low birth weight infants.
There is evidence from randomised controlled trials (RCTs) suggesting that delayed introduction of progressive feeding beyond four days after birth is not associated with increased risk of developing necrotising enterocolitis in very preterm, very low birth weight infants and growth restricted infants. However, delaying the introduction of progressive enteral feeds results in the delay of establishing full enteral feeds although the clinical importance of this is still uncertain.
The introduction of enteral feeds for very preterm (< 32 weeks) or very low birth weight (< 1500 g) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis. However, delayed enteral feeding may be associated with diminished gastrointestinal functional adaptation thus increasing the need for prolonged parenteral feeding with its health associated problems. The aim of this review was to determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very preterm or very low birth weight infants.
Dilute versus full strength formula in exclusively formula-fed preterm or low birth weight infants
The available evidence on the reduction in time taken for infants to attain an adequate energy intake as a result of use of dilute formula is based on three small low quality studies. No evidence was reported on outcomes such as gastrointestinal problems. Also, on the outcome of feeding intolerance, no evidence of important differences between the dilute and full strength formulae was found.
The aim of the review was to assess the effects of dilute versus full strength formulae on the incidence of necrotising enterocolitis, feeding intolerance, weight gain, length of stay and time to achieve full calorie intake in exclusively formula-fed preterm or low birth weight infants. Additionally, it aimed to assess the effects of different dilution strategies.
Kangaroo mother care to reduce morbidity and mortality in low birth weight infants
There is evidence to support the use of Kangaroo Mother Care (KMC) as an alternative to neonatal care in low-birth weight infants particularly, in resource limited settings in the reduction of mortality and morbidity rates. However, more evidence to assess efficacy and safety of early onset continuous KMC in unstabilized or relatively stabilized Low Birth Weight (LBW) infants, long term neurodevelopmental outcomes, and costs of care is needed.
Kangaroo mother care (KMC), promotes skin to skin contact between a mother and her new-born and has been proposed as an alternative to the conventional neonatal care of LBW infants which is often associated with high health care costs due to the need for highly skilled personnel and logistic support. The aim of this review was to determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care.
Combined and alternating paracetamol and ibuprofen therapy for febrile children
There is some evidence to support the use of alternating and combination therapy compared with monotherapy alone at reducing temperatures in children with a fever. However, on the outcome of child discomfort, the evidence still remains unsatisfactory. Furthermore, there is insufficient evidence to ascertain which combination or alternative therapy would be more useful at treating fevers in children.There were no serious adverse events reported that were directly attributed to the medications used.
There is inconsistent evidence on the effects of using monotherapy compared to combination therapies for the treatment of fever in children. The aim of the review was to assess the safety and effectiveness of combining paracetamol and ibuprofen or alternating them as consecutive treatments compared with monotherapy for treating fever in children.
There is insufficient evidence from clinical trials on the effectiveness of home-based ready to use therapeutic food (RTUF) in comparison to the standard diet on clinical outcomes of recovery, relapse and mortality in children with severe acute malnutrition. Either RUTF or flour porridge can be used to treat children at home depending on availability, affordability and practicality. Pragmatic randomised controlled trials of HIV-uninfected and HIV-infected children with severe acute malnutrition are needed.
Malnutrition is associated with increased mortality rates and health associated illnesses. The aim of the systematic review was to assess the effectiveness (benefits and harms) of home-based ready to use therapeutic food (RTUF) on recovery, relapse and mortality in children with severe acute malnutrition.
There is moderate to high quality evidence on the effectiveness of lipid-based nutrient supplements and blended foods for treating children with moderate acute malnutrition. Although, lipid-based foods were associated with increased recovery rates compared with blended foods; lipid-based foods did not reduce mortality rates or the risk of progression to severe acute malnutrition. There is scarcity of data from Asia despite the high prevalence of moderate acute malnutrition.
Various treatment approaches for children with moderate malnutrition in low and middle income countries exist. However, there is no consensus on the most effective treatment approach. The aim of the systematic review was to assess the effectiveness (benefits and harms) of various specially formulated foods for children with moderate acute malnutrition in low and middle income settings, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective.
There is evidence to suggest that intermittent iron supplementation when compared to placebo or no intervention, is effective in reducing the risk of anaemia in children ≤12 years of age. However, daily supplementation is more effective than intermittent iron supplementation in preventing and controlling anaemia. Intermittent iron supplementation maybe used in settings where daily supplementation cannot be applied.
The use of daily iron supplements in children ≤12 years of age has been associated with several side effects. The use of intermittent supplementation has been proposed as an effective and safe alternative. The aim of the review was to assess the effects of intermittent supplementation alone or in combination with other vitamins and minerals on nutritional and developmental outcomes in children ≤12 years of age compared with placebo, no intervention or daily intervention.
There is insufficient evidence to support the community-based supplementary feeding for promoting the growth of children under 5 years old in developing countries. This is because of the scarcity of available studies and their heterogeneity, which makes it difficult to reach any firm conclusions. Meanwhile, children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children.
The effectiveness of community supplementary feeding is still unclear due to the lack of evidence from large well conducted randomised controlled trials. The aim of the review was to evaluate the effectiveness of community based supplementary feeding for promoting the physical growth of children under five years of age in low- and middle-income countries (LMICs).
No evidence was found to investigate whether vitamin A can prevent blindness in children infected with measles.
Annually 500,000 children become blind worldwide, 75% of them living in low-income countries. Measles infection in children has been associated with vitamin A deficiency and blindness. This review aimed to assess whether vitamin A could prevent blindness in children infected with measles.
There is some evidence to support the effectiveness of preventative zinc supplementation particularly, where the risk of zinc deficiency is high. However, more evidence on optimal intervention characteristics such as supplement dose is needed.
Zinc deficiency is responsible for significant morbidity and mortality rates associated with diarrhoea, malaria and pneumonia in children aged six months to 12 years. The aim of the review was to assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged six months to 12 years of age.
Lay health workers may provide benefits in promoting immunisation uptake and breastfeeding, improving tuberculosis cure rates, and child health when compared to usual care. There is insufficient evidence to draw any conclusions for other health issues.
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues, however, little is known about the effectiveness of LHW interventions. This review assesses the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases. The evidence had considerable diversity with regards to country, targeted health issue and aims.
Image credit: Will and Deni Mcintyre/Science Photo Library
Date published: 10 March 2010; updated 21 December 2010, 25 October 2011, 9 December 2011, 20 December 2012, 1 February 2013, 14 February 2013, 21 May 2013, 14 June 2013, 29 July 2013, 02 August 2013, 09 September 2013, 06 November 2013, 03 January 2014, 08 May 2014, and 13 October 2014. Last updated 12 December 2014 to include one new review.
Contact: Cochrane Editorial Unit (firstname.lastname@example.com) for suggestions for additions or changes to this Special Collection or queries about the included Cochrane Reviews; and Evidence Aid (email@example.com) for information about this initiative.


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Peter Kun Frary's 'Makeup Girl' is very confusing. It looks like an oil painting, but it's actually a photograph of a model in body paint. What a twist!
Peter Kun Frary's 'Makeup Girl' was snapped outside of a MAC cosmetics store in Hawaii. This is an amazing advertisement. This almost-nude body painted model had to be a show-stopper. Way to go MAC, you've done it again. Now lower the prices on your cosmetics and we'll talk business.

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(Updates with government comments from seventh paragraph.)
Oct. 25 (Bloomberg) -- Hong Kong's exports declined in September for the first time in almost two years and the government warned the outlook is "bleak," adding to the risks the city will enter a recession.
Overseas shipments fell 3 percent from a year earlier to HK$271.8 billion ($35 billion), the government said on its website today. That compared with a 6.8 percent gain in August. Exports last dropped in October 2009.
Elevated unemployment in the U.S. and Europe's debt crisis are damping economic expansion in the city by weakening overseas demand, Financial Secretary John Tsang said Oct. 16. Trade through Hong Kong is also being hurt by moderating growth in China, the world's biggest exporting nation.
"A prolonged period of low growth in the West, together with a soft landing in China, could mean further downside risk to export growth in the coming months," Kelvin Lau, an economist at Standard Chartered Plc in Hong Kong, said before today's report. "This should translate into a bigger drag on overall economic growth."
The median estimate of 10 economists in a Bloomberg News survey was for a 6.5 percent increase in exports. None of the economists forecast a decline.
Imports increased 2.3 percent in September from a year earlier, the smallest gain since growth resumed in November 2009 after a yearlong decline during the financial crisis. September's trade deficit was HK$40 billion, the government said.
'Bleak' Outlook
The outlook for overseas shipments in coming months is "bleak," the government said in today's release, citing the deepening sovereign debt crisis in the euro area and a stalling recovery in advanced economies.
"Although some Asian markets still held up relatively well, the impact of weaker demand from the West on regional trade flows has turned more evident of late," it said.
Exports to China, the biggest destination for shipments through Hong Kong, fell 7.3 percent last month from a year earlier, while sales to the U.S., the city's second-largest market, slid 8.9 percent, the fifth straight monthly decline, it said.
China's gross domestic product expanded 9.1 percent in the third quarter from a year earlier, the slowest pace in two years. Goldman Sachs Group Inc. this month reduced its global growth estimates for 2011 and 2012, predicting recessions in Germany and France as the European economy stalls and an increasing risk of a contraction in the U.S.
Third-Quarter Recession
European services and manufacturing output contracted at the fastest pace in more than two years in October, London-based Markit Economics said yesterday in an initial estimate based on a survey of purchasing managers.
Hong Kong's exports of electronic appliances and electrical parts fell 16 percent in September from a year earlier and apparel dropped 8 percent, the government said.
Morgan Stanley and Daiwa Capital Markets Co. say Hong Kong may have tipped into recession in the third quarter, after the economy shrank 0.5 percent in the April-to-June period from the previous quarter.
--With assistance from Michael Munoz in Hong Kong and Ken McCallum in Tokyo. Editors: Nerys Avery, Shamim Adam
To contact the reporter on this story: Sophie Leung in Hong Kong at firstname.lastname@example.com
To contact the editor responsible for this story: Ken McCallum in Tokyo at email@example.com


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You know LivingSocial as the marketplace to buy and share the best things to do in your city and beyond. And while we're bringing excitement and value to our merchants and consumers, we're also committed to creating a world-class environment for our employees. Our talented
1/17/2015 Chicago, IL Save This JobSales New York, NY Build software. Reach 500 million users. Change lives. That?s what we?re doing at Lithium. And you can do it, too. If you want to put your stamp on the digital customer space and enjoy yourself along the way, come join the team. We?re looking for seriously
11/26/2014 New York, NY Save This JobBuild software. Reach 500 million users. Change lives. That?s what we?re doing at Lithium. And you can do it, too. If you want to put your stamp on the digital customer space and enjoy yourself along the way, come join the team. We?re looking for seriously passionate, fun,
11/26/2014 Boston, MA Save This JobQuantcast, a revolutionary audience intelligence and addressable advertising service, has aggressive plans for expanding its field sales team. This individual will be responsible for calling on and working with top-tier agencies and their online adve
1/17/2015 New York, NY Save This JobON24 is a Silicon Valley-based software company and the global leader in webcasting and virtual events. Our solutions are used by some of the biggest companies in the world for initiatives like product launches, training, internal communications, conferences, demand generation,
12/6/2014 Charlotte, NC Save This JobDept: Sales As the leader in the Social Intelligence space Visible Technologies is looking for a Sales Executives to join our growing team on the East Coast. With a track record of success, loyal customer base, and innovative Social Intelligence platform Visible Technologies is
11/30/2014 Bellevue, WA Save This JobTHE POSITION This position requires expertise in all aspects of the agency sales process, from intensive prospecting, accurate forecasting, solution selling and strong closing abilities, to superior relationship building with customers through a detailed understanding of the
12/5/2014 New York, NY Save This JobJob Description The Regional Vice President of Sales must generate revenue within SAVO by closing sales. This person will sell products and services directly to end users, primarily via face-to-face contact. Duties also include a high level of travel. Target location is East
11/30/2014 Chicago, IL Save This JobSilicon Valley tech company coming to uptown Charlotte! It's official, we will be opening the doors to our East Coast sales hub in 2015 right in the heart of the city. We?re looking for experienced Senior Account Executives that thrive in a fast-paced, cutting-edge,
12/8/2014 Charlotte, NC Save This JobJob Number:001083 Job Title:Software Project Manager, Sales & Operational Planning, Supply Chain Management Number of Openings:1 Job Type (Employment Type):Direct Hire Country:United States State/Province:California City:East Coast Salary Interval:Per Year Job Schedule:Full
12/16/2014 Pleasanton, CA Save This JobThe North America Director of Pre-Sales will help build and manage (as a player/coach) a dynamic team of pre-sales engineers, as well as work collaboratively with the Global Pre-sales team(s) inside the New Business Organization as well as in the Technology Solutions groups and
12/8/2014 Conshohocken, PA Save This JobWe?re the world?s largest content discovery platform, delighting audiences with engaging, personalized content recommendations while serving as the primary native monetization partner and platform for the world?s top digital media companies. Outbrain is seeking a highly
12/26/2014 New York, NY Save This Job


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Hawkeyes origin isn't really anything new, but this time the "inspired hotshot" actually tries to be a hero! And...fails badly. Well, actually only as much as Spiderman does, sometimes. Then, he meets the Black Widow, and...somehow falls so deeply for her, that he immediately commits crimes to her bidding. Okay? I might be lacking a romantic heart, but this is one of the uses "love" in fiction I absolutely can't stand.
Still, solid first appearance of Hawkeye, one of my favorite Avengers ever.


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Startup Pitch NightStartup Pitch Night and related entrepreneural iniatives are serving a highly targeted audience of founders and co-founders, designers and developers, management consultants, legal and finance professionals, etc. Our communities are growing with interest in what we're doing and with new members joining every single day. We have traveled across the globe (and are ramping up the team this year) organizing and running events, and educating and mentoring startups on how to pitch to investors, etc. The response has been overwhelming positive as a resource. Traction is evidence of the effectiveness - some members join multiple communities and attend multiple city events on a regular basis. We are focused primarily on key startup cities. If you'd like to sponsor a particular city or a series of events in multiple cities, consider sponsoring us and increasing awareness of your brand before and/or during those events.Sponsorship ProgramsWe're looking for sponsors to propel our growth in targeted ways. We're also looking for suppport for some cities in the areas of venue space, event prizes, and food and beverages. Please contact us to start the discussion and to provide your sponsorship proposal for consideration. We look forward to working with you as a new sponsor. |


text: Epilepsy Awareness Month 10/29/2013 06:40 PM 10/29/2013 06:58 PM Linsdie Burk joins Trends and Friends to talk about this Saturday's upcoming conference. Lindsie Burk with the Lubbock Epilepsy Foundation visits Trends and Friends to talk about the upcoming Epilepsy Awareness Month, along with the upcoming conference. The Epilepsy Conference is being held this weekend on Saturday, November 2nd from 8:30-Noon at the Knipling Center at Covenant. The Conference is FREE to all those who attend. Snacks and drinks will be provided. Copyright 2013 Nexstar Broadcasting, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. Page: [[$index + 1]]


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I run many experiements in order to find the exact fit or. Currently I am working on Intern.ly and Jobisoft.com to help companies find interns and interns to find internship opportunities. Check it out at www.intern.ly
If you need an entry level job or an internship position, apply to numerous openings via Intern.ly
If you need software developers then Jobisoft.com can be used to post vacancies or apply for software development jobs.
Veronica Belmont - about.me user since 2010
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Date of Liquidation: 11/22/2011
Date of Policy Cancellation: 12/23/2011
Claims Filing Deadline:
11/01/2012 (.doc)
Minnesota Surety and Trust Liquidation Order
Find documents and additional information on Minnesota Surety and Trust liquidation.
Copyright © 2014 Minnesota Department of Commerce. All Rights Reserved.
Minnesota Department of Commerce + 85 Seventh Place East + Saint Paul, MN 55101


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This development in Seattle, Wash. designed by Eggleston Farkas offers an alternative to typical townhomes in the area, placing duplex units on the street with three wider units in the back of each building. The modern design in concrete and wood features generous glazing to give the units plenty of natural light.
Seattle is also home to Pb Elemental, who have designed a number of multi-family projects — some "twins" with the same or similar plans mirrored on either side of a walkway or shared wall.
The second-floor volumes here articulate the openings differently to give each residence its own identity, while still making it clear that they are part of one project.
The second-floor volumes here articulate the openings differently to give each residence its own identity, while still making it clear that they are part of one project.
These townhomes, also designed by Pb Elemental, appears to be situated next to smaller houses. Turned 90 degrees to the street, with a driveway on the side, the project fits a somewhat narrow lot and comes closer in scale to its neighbors. The modern design in wood is certainly pleasing.
A last Pb Elemental project includes three live/work units with ground floor retail space. Pictured are two units in the rear, removed from the street by the front building and an area for parking. Note the porous paving for part of the parking.
Here is a development with four townhomes, also in Seattle, that is more traditional in appearance, pitched roofs and all. Collective living need not mean stylistic antagonism; it can take cues from the local style while offering a lower ecological footprint and other 21st-century advantages.
Another Seattle development incorporates balconies and courtyards oriented to gardens and a water feature. The latter is a key draw to the project while creating a strong sense of entry via bridges over it on the way home.
This duplex project in Vancouver, British Columbia includes generous balconies facing the street and a rooftop deck. There is something striking and appealing about the yellow wood that makes up this elevation.
As mentioned earlier, a common way of designing multiple units is to mirror duplicate or similar plans. Here that is evident in the entrance to a couple units of a three-unit project. But seen overall ...
The whole project isn't as symmetrical as the entry in the previous photo would have us believe. The third unit gives it an asymmetrical form that almost makes it look like a large house — if it weren't for the three garages under the balconies.
Here is a duplex in Austin, Texas that also appears to be a large single-family residence from the street. One unit faces the front, and the second one is tucked in the back, reached via the side driveway.
This duplex in San Francisco, Calif. projects one in front of the other to give each its own character behind the identical garages. The rear yard condition ...
... shows how the terraced backyard, shared by both units, gives privacy to each if desired. Multi-family housing does require a certain social negotiation when it comes to green space, but it is usually worth it.
The quality of the spaces created through multi-family housing is certainly important. This large project in San Francisco about a block from the love-it-or-hate-it Federal Building by Morphosis) features units facing the streets to the east and west, while half of the units face the bamboo courtyard pictured here. A view from down on the walkway ...
Shows this space to be much softer than the street fronts. I could see the courtyard units being more desirable — and expensive — than the units on the streets.
This development of townhomes is located on a triangular site in Santa Barbara, California. The residences are oriented to this thoughtfully designed alleyway that looks like it could be a place for block parties and other social gatherings with the neighbors. Whatever the case, it is an amenity that arises from the density that is part of the development.
This last example, by Rhodes Architecture + Light, illustrates that even single-family houses can be created in developments to bring their benefits closer to those of multi-family buildings.
Anderson Gardens features four houses (three new, one renovated) that surround a large garden. Formerly a farmhouse, the land is now home to a few more houses than another suburban context might support.
More inspiring architecture
Anderson Gardens features four houses (three new, one renovated) that surround a large garden. Formerly a farmhouse, the land is now home to a few more houses than another suburban context might support.
More inspiring architecture


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When the lights flicker on and off at The Gourmet Detective, there's no cause for alarm?it's all just part of the show. The interactive murder mystery dinner theatre injects a three-course meal with whimsical performers who blend comedy and drama into a vintage whodunnit. Each show transports its captive audience to the era of film noir, wrapping them into a dark, twisting narrative scored with live music from a lounge singer. The scene is set as guests mingle with the characters at a pre-show cocktail hour, then step into the seedy restaurant those characters run. When the first players are bumped off at the start of the meal, everyone in the crowd becomes equally gumshoe, witness, and suspect. Throughout the dinner, guests can either sit back and enjoy the show or gather clues by talking with the characters who serve each course between the scenes. The evening culminates in a reveal of the real culprit, as well as the audience's most inaccurate guesses.
Arthur Murray Dance Studio has been a leading name in franchise dance since 1912, when the entrepreneur began selling mail-order dance lessons. Expanding his reach, he enlisted teachers to spread his signature dance lessons on first-class steamships and skyrocketed to fame in the '30s after introducing the public to such dances as the Lambeth Walk and the Big Apple. By the 1950s, Arthur and his wife, Kathryn, were hosting their own highly popular TV show on ABC, the Arthur Murray Dance Party, which ran for 12 years. Today, Arthur Murray's team prepares students for rug cutting at special events and weekend nightclub jaunts. Clients who arrive to lessons partnerless will be paired up with an instructor as the teachers assess their current skill level and make recommendations on the most appropriate program. Throughout lessons, instructors teach the foundations of two to four dances from a long list of styles that range from Latin to country-western, helping students to learn basic step patterns, timing, and the ability to lead or follow.
Dancemeister David Vanderzell transforms his lifelong passion for ballroom dance into a living through both the lessons and facilities at D&D's Dance Center. He and his cast of instructors aid beginners and aspiring professionals in lightening their feet within one of the establishment's four ballrooms, the largest of which measures a whopping 2,500 square feet, the size of a three- to four-bedroom house or the cramped dorm room of a gray whale. This grand ballroom also boasts a DJ booth, a full light and sound system, and a stage for live bands. A dance-supply store inhabits one of the building's many chambers, dealing in everything from championship costume design to emergency pairs of shoes for sudden danceoffs to determine to the fate of the nations.
UltraStar Cinemas cossets moviegoers in cushy seating as they enjoy Hollywood hits alongside buttery servings of popcorn. Film buffs can peruse the current showtimes to handpick an action-packed flick, romantic comedy, or chilling thriller featuring inexplicably aggressive hamsters. The concession stand outfits moviegoers with snacks, drinks, and buckets filled with warm kernels, keeping stomach grumblings to a minimum during showings and providing crunchy projectiles in case of sudden younger-sibling attacks.