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The Journal of Dermatological Treatment Apr 2015Topical antibiotics are not indicated for postsurgical wound infection prophylaxis in clean and clean-contaminated dermatologic surgeries, yet many dermatologists... (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
Topical antibiotics are not indicated for postsurgical wound infection prophylaxis in clean and clean-contaminated dermatologic surgeries, yet many dermatologists continue to prescribe them. The objective of our systematic review and meta-analysis was to critically assess the efficacy of topical antibiotics in terms of preventing postsurgical wound infections in the dermatology outpatient setting.
METHODS
PubMed, Embase, MD Consult, Science Direct, Springer Link, DynaMed and Cochrane online medical databases were searched from 1980 to 2013.
RESULTS
Using random effects modeling, the pooled odds ratio of developing a postsurgical wound infection was 0.71 (95% CI, 0.42-1.19).
DISCUSSION
Pooled data of the four trials in the meta-analysis did not show a statistically significant difference in incidence of postsurgical wound infections between topical antibiotics and petrolatum/paraffin. In the setting of moist occlusive dressings, there is no statistically significant difference in prophylactic efficacy between applying and not applying ointment to surgical wounds. Wounds at increased risk of developing surgical site infections include wounds in diabetics, wounds located in certain anatomic regions, and wounds created by some surgical procedures.
CONCLUSIONS
Petrolatum should be used instead of topical antibiotics as a prophylactic measure to prevent postsurgical wound infections in the outpatient dermatologic setting.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Dermatologic Surgical Procedures; Humans; Occlusive Dressings; Surgical Wound Infection
PubMed: 24646178
DOI: 10.3109/09546634.2014.906547 -
BMJ Clinical Evidence Oct 2013Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but the majority grow out of the problem. (Review)
Review
INTRODUCTION
Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but the majority grow out of the problem.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for recurrent idiopathic epistaxis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 5 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiseptic cream (containing chlorhexidine hydrochloride, neomycin sulfate, or both), petroleum jelly, and silver nitrate cautery.
Topics: Anti-Infective Agents, Local; Cautery; Child; Chlorhexidine; Epistaxis; Humans; Neomycin; Petrolatum; Remission Induction; Silver Nitrate
PubMed: 24172703
DOI: No ID Found -
The Cochrane Database of Systematic... Sep 2012Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified.... (Review)
Review
BACKGROUND
Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition.
OBJECTIVES
To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children.
SEARCH METHODS
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 March 2012.
SELECTION CRITERIA
We identified all randomised controlled trials (RCTs) (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The two authors reviewed the full-text articles of all retrieved trials of possible relevance and applied the inclusion criteria independently.
DATA COLLECTION AND ANALYSIS
We graded trials for risk of bias using the Cochrane approach. One author performed data extraction in a standardised manner and this was rechecked by the other author. Where necessary we contacted investigators to obtain missing information. We did not undertake a meta-analysis because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented.
MAIN RESULTS
Five studies (four RCTs and one quasi-randomised controlled trial) involving 468 participants satisfied the inclusion criteria. The identified RCTs compared 0.5% neomycin + 0.1% chlorhexidine (Naseptin®) cream with no treatment, Vaseline® petroleum jelly with no treatment, 75% with 95% silver nitrate nasal cautery, and silver nitrate cautery combined with Naseptin® against Naseptin® alone; the quasi-randomised controlled trial compared Naseptin® antiseptic cream with silver nitrate cautery. Overall results were inconclusive, with no statistically significant difference found between the compared treatments upon completion of the trials, however 75% silver nitrate was more effective than 95% silver nitrate at two weeks following application. The group treated with 75% silver nitrate had 88% complete resolution of epistaxis compared to 65% in the group treated with 95% silver nitrate (P = 0.01). No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic). The pain scores were significantly less in those treated with 75% silver nitrate, the mean score being 1 compared to a mean score of 5 in those treated with 95% silver nitrate; this was statistically significant (P = 0.001).We carried out a 'Risk of bias' assessment of each study according to the Cochrane methodology and judged that two randomised controlled trials had a low risk of bias, two had an unclear risk of bias and the quasi-randomised controlled trial had a high risk of bias.
AUTHORS' CONCLUSIONS
The optimal management of children with recurrent idiopathic epistaxis is unknown, however if silver nitrate nasal cautery is undertaken 75% is preferable to 95% as it is more effective in the short term and causes less pain. High-quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow-up period of at least a year, are needed to assess the relative merits of the various treatments currently in use.
Topics: Administration, Intranasal; Adolescent; Child; Child, Preschool; Chlorhexidine; Drug Combinations; Emollients; Epistaxis; Humans; Infant; Neomycin; Petrolatum; Randomized Controlled Trials as Topic; Recurrence; Silver Nitrate
PubMed: 22972071
DOI: 10.1002/14651858.CD004461.pub3 -
The Cochrane Database of Systematic... Jul 2012Constipation within childhood is an extremely common problem. Despite the widespread use of osmotic and stimulant laxatives by health professionals to manage... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Constipation within childhood is an extremely common problem. Despite the widespread use of osmotic and stimulant laxatives by health professionals to manage constipation in children, there has been a long standing paucity of high quality evidence to support this practice.
OBJECTIVES
We set out to evaluate the efficacy and safety of osmotic and stimulant laxatives used to treat functional childhood constipation.
SEARCH METHODS
The search (inception to May 7, 2012) was standardised and not limited by language and included electronic searching (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register), reference searching of all included studies, personal contacts and drug companies.
SELECTION CRITERIA
Randomised controlled trials (RCTs) which compared osmotic or stimulant laxatives with either placebo or another intervention, with patients aged 0 to 18 years old were considered for inclusion. The primary outcome was frequency of defecation. Secondary endpoints included faecal incontinence, disimpaction, need for additional therapies and adverse events.
DATA COLLECTION AND ANALYSIS
Relevant papers were identified and the authors independently assessed the eligibility of trials. Methodological quality was assessed using the Cochrane risk of bias tool.The Cochrane RevMan software was used for analyses. Patients with final missing outcomes were assumed to have relapsed. For continuous outcomes we calculated a mean difference (MD) and 95% confidence interval (CI) using a fixed-effect model. For dichotomous outcomes we calculated an odds ratio (OR) and 95% confidence intervals (95% CI) using a fixed-effect model. The chi square and I(2) statistics were used to assess statistical heterogeneity. A random-effects model was used in situations of unexplained heterogeneity
MAIN RESULTS
Eighteen RCTs (1643 patients) were included in the review. Nine studies were judged to be at high risk of bias due to lack of blinding, incomplete outcome data and selective reporting. Meta-analysis of two studies (101 patients) comparing polyethylene glycol (PEG) with placebo showed a significantly increased number of stools per week with PEG (MD 2.61 stools per week, 95% CI 1.15 to 4.08). Common adverse events in the placebo-controlled studies included flatulence, abdominal pain, nausea, diarrhoea and headache. Meta-analysis of 4 studies with 338 participants comparing PEG with lactulose showed significantly greater stools per week with PEG (MD 0.95 stools per week, 95% CI 0.46 to 1.44), although follow up was short. Patients who received PEG were significantly less likely to require additional laxative therapies. Eighteen per cent of PEG patients required additional therapies compared to 30% of lactulose patients (OR 0.49, 95% CI 0.27 to 0.89). No serious adverse events were reported with either agent. Common adverse events in these studies included diarrhoea, abdominal pain, nausea, vomiting and pruritis ani. Meta-analysis of 3 studies with 211 participants comparing PEG with milk of magnesia showed that the stools/wk was significantly greater with PEG (MD 0.69 stools per week, 95% CI 0.48 to 0.89). However, the magnitude of this difference is quite small and may not be clinically significant. One child was noted to be allergic to PEG, but there were no other serious adverse events reported. Meta-analysis of 2 studies with 287 patients comparing liquid paraffin (mineral oil) with lactulose revealed a relatively large statistically significant difference in the number of stools per week favouring paraffin (MD 4.94 stools per week, 95% CI 4.28 to 5.61). No serious adverse events were reported. Adverse events included abdominal pain, distention and watery stools. No statistically significant differences in the number of stools per week were found between PEG and enemas (1 study, 90 patients, MD 1.00, 95% CI -1.58 to 3.58), dietary fibre mix and lactulose (1 study, 125 patients, P = 0.481), senna and lactulose (1 study, 21 patients, P > 0.05), lactitol and lactulose (1 study, 51 patients, MD -0.80, 95% CI -2.63 to 1.03), and PEG and liquid paraffin (1 study, 158 patients, MD 0.70, 95% CI -0.38 to 1.78).
AUTHORS' CONCLUSIONS
The pooled analyses suggest that PEG preparations may be superior to placebo, lactulose and milk of magnesia for childhood constipation. GRADE analyses indicated that the overall quality of the evidence for the primary outcome (number of stools per week) was low or very low due to sparse data, inconsistency (heterogeneity), and high risk of bias in the studies in the pooled analyses. Thus, the results of the pooled analyses should be interpreted with caution because of quality and methodological concerns, as well as clinical heterogeneity, and short follow up. However, PEG appears safe and well tolerated. There is also evidence suggesting the efficacy of liquid paraffin (mineral oil), which was also well tolerated.There is no evidence to demonstrate the superiority of lactulose when compared to the other agents studied, although there is a lack of placebo controlled studies. Further research is needed to investigate the long term use of PEG for childhood constipation, as well as the role of liquid paraffin.
Topics: Adolescent; Child; Child, Preschool; Constipation; Defecation; Dietary Fiber; Humans; Infant; Lactulose; Laxatives; Magnesium Hydroxide; Mineral Oil; Osmosis; Polyethylene Glycols; Randomized Controlled Trials as Topic; Sugar Alcohols
PubMed: 22786523
DOI: 10.1002/14651858.CD009118.pub2 -
BMJ Clinical Evidence Jan 2011Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem. (Review)
Review
INTRODUCTION
Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for recurrent idiopathic epistaxis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 5 RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiseptic cream, petroleum jelly, and silver nitrate cautery.
Topics: Administration, Intranasal; Anti-Infective Agents, Local; Caffeine; Cautery; Child; Epistaxis; Humans; Petrolatum; Remission Induction; Silver Nitrate
PubMed: 21477398
DOI: No ID Found -
Journal of Wound, Ostomy, and... 2008Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple... (Review)
Review
BACKGROUND
Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound.
OBJECTIVES
We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing.
SEARCH STRATEGY
A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included.
RESULTS
Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea-based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing.
IMPLICATIONS FOR PRACTICE
Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.
Topics: Administration, Cutaneous; Autolysis; Bandages; Chronic Disease; Clinical Nursing Research; Collagenases; Debridement; Evidence-Based Medicine; Humans; Necrosis; Papain; Patient Selection; Practice Guidelines as Topic; Research Design; Skin Care; Treatment Outcome; Urea; Wound Healing; Wounds and Injuries
PubMed: 18496083
DOI: 10.1097/01.WON.0000319125.21854.78 -
BMJ Clinical Evidence May 2008Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem. (Review)
Review
INTRODUCTION
Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for recurrent idiopathic epistaxis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found six systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiseptic cream, cautery, petroleum jelly.
Topics: Administration, Intranasal; Administration, Topical; Anti-Infective Agents, Local; Cautery; Child; Databases, Factual; Epistaxis; Humans; Petrolatum; Remission Induction
PubMed: 19450311
DOI: No ID Found -
The Cochrane Database of Systematic... 2004Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified.... (Review)
Review
BACKGROUND
Recurrent idiopathic epistaxis (nosebleeds) in children is repeated nasal bleeding in patients up to the age of 16 for which no specific cause has been identified. Although nosebleeds are very common in children, and most cases are self-limiting or settle with simple measures (such as pinching the nose), more severe recurrent cases can require treatment from a healthcare professional. However, there is no consensus on the effectiveness of the different clinical interventions currently used in managing this condition.
OBJECTIVES
To assess the effects of different interventions for the management of recurrent idiopathic epistaxis in children.
SEARCH STRATEGY
We searched the Cochrane ENT Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3, 2003), MEDLINE (January 1966 to August 2003), EMBASE (January 1980 to August 2003), CINAHL (January 1982 to August 2003), and reference lists of relevant articles.
SELECTION CRITERIA
We identified all randomised controlled trials (with or without blinding) in which any surgical or medical intervention for the treatment of recurrent idiopathic epistaxis in children was evaluated in comparison with either no treatment, a placebo, or another intervention, and in which the frequency and severity of episodes of nasal bleeding following treatment was stated or calculable. The full text articles of all the retrieved trials of possible relevance were reviewed by the two reviewers and the inclusion criteria applied independently.
DATA COLLECTION AND ANALYSIS
Trials were graded for methodological quality using the Cochrane approach. Data extraction was performed in a standardised manner by one reviewer and rechecked by the other, and where necessary investigators were contacted to obtain missing information. A meta-analysis was not undertaken because of the heterogeneity of the treatments, procedures and quality of the included trials. A narrative overview of the results is therefore presented.
MAIN RESULTS
Three studies - two randomised controlled trials (RCTs) and one controlled clinical trial (CCT) - involving 256 participants satisfied the inclusion criteria. One RCT compared Naseptin antiseptic cream with no treatment, the second RCT compared Vaseline(R) petroleum jelly with no treatment, and the CCT compared Naseptin antiseptic cream with silver nitrate cautery. Overall, results were inconclusive, with no statistically significant difference found between the compared treatments. No serious adverse effects were reported from any of the interventions, although children receiving silver nitrate cautery reported that it was a painful experience (despite the use of local anaesthetic).
REVIEWER'S CONCLUSIONS
The optimal management of children with recurrent idiopathic epistaxis is unknown. High quality randomised controlled trials comparing interventions either with placebo or no treatment, and with a follow-up period of at least a year, are needed to assess the relative merits of the various treatments currently in use.
Topics: Administration, Intranasal; Adolescent; Child; Child, Preschool; Chlorhexidine; Drug Combinations; Emollients; Epistaxis; Humans; Infant; Neomycin; Petrolatum; Randomized Controlled Trials as Topic; Recurrence
PubMed: 14974069
DOI: 10.1002/14651858.CD004461.pub2