Share of current unmet need for modern contraceptive methods attributed to past users of these methods in India.

Despite persistent efforts, unmet need for contraceptives in India has declined only slightly from 14% to 13% between 2005-06 and 2015-16. Many women using a family planning method discontinue it without switching to another method and continue to have unmet need. This study quantified the share of current unmet need for modern contraceptive methods attributed to past users of these methods in India. Data were drawn from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16. Using information on women with current unmet need, and whether they used any modern method in the past, the share of past users with current unmet need for modern methods was calculated. Bivariate and multivariate analyses were performed. Among 46 million women with unmet need, 11 million were past users of modern methods in 2015-16. The share of current unmet need attributed to past users of modern contraceptive methods declined from 27% in 2005-06 to 24% in 2015-16. Share of current unmet need attributed to past users was associated with reversible method use. This share rose with increased use of modern reversible methods. With the Indian family planning programme's focus on increasing modern reversible method use, the share of unmet need attributed to past users of modern methods is likely to increase in the future. The programme's emphasis on continuation of contraceptive use, along with bringing in new users, could be one of the key strategies for India to achieve the FP2020 goals.

SELF-REPORTED MORBIDITY AND BURDEN OF DISEASE IN UTTAR PRADESH, INDIA: EVIDENCE FROM A NATIONAL SAMPLE SURVEY AND THE MILLION DEATHS STUDY.

Uttar Pradesh is India's most populous state with a population of 200 million. Any change in its fertility and mortality is bound to bring change at the national level. This study analysed the burden of disease in the state by calculating the disability-adjusted life year (DALY) for infectious and non-communicable diseases. Data were from two rounds (52nd and 60th) of the National Sample Survey Organization (NSSO) survey conducted in 1995-96 and 2004, respectively, and the Million Deaths Study (MDS) of 2001-03. Descriptive and multivariate analyses were carried out to identify the determinants of different types of self-reported morbidity and DALY. The results show that in Uttar Pradesh the prevalence of all selected self-reported infectious and non-communicable diseases increased over the study period from 1995 to 2004, and in most cases by more than two times. The highest observed increase in prevalence was in non-communicable diseases excluding CVDs, which increased from 7% in 1995 to 19% in 2004. The prevalence was higher for those aged 60 and above, females, those who were illiterate and rich across the time period and for all selected morbidities. The results were significant at p<0.001. The estimation of the DALY revealed that the burden of infectious diseases was higher during infancy, noticeably among males than females in 2002. However, females aged 1-5 years were more likely to report infectious diseases than corresponding males. The age distribution of the DALY indicated that individuals aged below 5 years and above 60 years were more susceptible to ill health. The growing incidence of non-communicable diseases, especially among the older generation, puts an additional burden on the health system in the state. Uttar Pradesh has to grapple with the unresolved problem of preventable infectious diseases on the one hand and the growth in non-communicable disease on the other.

Human rights approach to maternal & child health: has India fared well?

BACKGROUND & OBJECTIVES: The objectives of the study were to examine: right to access maternal health; right to access child health; and right to access improved water and sanitation in India. METHODS: We used large-scale data sets like District Level Household Survey conducted in 2007-08 and National Family Health Surveys conducted during 1992-93, 1998-99, and 2005-06 to fulfil the objectives. The selection of the indicator variables was guided by the Human Rights' Framework for Health and Convention of the Rights of the Child- Articles 7, 24 and 27. We used univariate and bivariate analysis along with ratio of access among non-poor to access among poor to fulfil the objectives. RESULTS: Evidence clearly suggested gross violation of human rights starting from the birth of an individual. Even after 60 years of independence, significant proportions of women and children do not have access to basic services like improved drinking water and sanitation. INTERPRETATION & CONCLUSIONS: There were enormous socio-economic and residence related inequalities in maternal and child health indicators included in the study. These inequalities were mostly to the disadvantage of the poor. The fulfilment of the basic human rights of women and children is likely to pay dividends in many other domains related to overall population and health in India.

Factors Associated with Disposable Menstrual Absorbent Use Among Young Women in India.

CONTEXT: Hygienic use of absorbent products during menstruation is a challenge for young women in India, especially among the underprivileged, who lack knowledge and access to resources. Reuse of menstrual absorbents can be unhygienic and result in adverse health and other outcomes. METHODS: Data from the 2015-2016 National Family Health Survey-4 for 233,606 menstruating women aged 15-24 were used to examine levels and correlates of exclusive use of disposable absorbents during menstruation. Bivariate and logistic regression analyses were conducted to identify disparities in exclusive use by such characteristics as caste, mass media exposure and interaction with health workers. RESULTS: Exclusive use of disposable absorbents was low among young women overall (37%), and varied substantially by caste and other characteristics. Compared with women from general castes, those from scheduled castes, scheduled tribes and other backward classes had reduced odds of exclusive disposable absorbent use (odds ratios, 0.8-0.9). Disposable absorbent use was negatively associated with lower levels of education and household wealth, and rural residence. Compared with women who reported daily media exposure, those exposed less frequently had reduced odds of disposable absorbent use (0.7-0.9). Among those who recently met with a health worker, odds of use were lower if menstrual hygiene had not been discussed (0.9). CONCLUSIONS: Promoting awareness of proper menstrual hygiene-through education, media campaigns and discussion with reproductive health workers-and targeted interventions to disseminate and subsidize the purchase of disposable sanitary napkins should be pursued to address health disparities.

RESUMEN Contexto: El uso higiénico de productos absorbentes durante la menstruación es un reto para las mujeres jóvenes en India, especialmente entre las carentes de privilegios que no tienen el conocimiento y el acceso a recursos. Reusar los productos absorbentes del flujo menstrual puede ser antihigiénico y derivar en resultados adversos para la salud y de otro tipo. Métodos: Se utilizaron datos correspondientes a los años 2015-2016 de la Encuesta Nacional de Salud Familiar 4 de 233,606 mujeres menstruantes en edades de 15 a 24 años, para examinar niveles y correlatos del uso exclusivo de productos absorbentes desechables durante la menstruación. Se condujeron análisis de regresión bivariada y logística para identificar las disparidades en el uso exclusivo por características tales como la casta, la exposición a medios masivos y la interacción con trabajadores sanitarios. Resultados: El uso exclusivo de productos absorbentes desechables fue bajo en mujeres jóvenes en general (37%) y varió sustancialmente en función de la casta y otras características. En comparación con mujeres de castas generales, aquellas pertenecientes a castas y tribus oficialmente reconocidas y otras clases en desventaja, tuvieron reducidas probabilidades de un uso exclusivo de productos absorbentes desechables (razón de probabilidades, 0.8-0.9). El uso de productos absorbentes desechables se asoció negativamente con más bajos niveles educativos y de riqueza familiar, así como con el hecho de residir en zonas rurales. En comparación con las mujeres que reportaron tener exposición diaria a los medios, aquellas con una exposición menos frecuente tuvieron probabilidades reducidas de usar productos absorbentes desechables (0.7-0.9). Entre aquellas que tuvieron contacto reciente con un trabajador sanitario las probabilidades de uso exclusivo fueron menores si la higiene menstrual no había sido abordada durante la consulta (0.9). Conclusiones: Debe procurarse la promoción de la conciencia acerca de una apropiada higiene menstrual -a través de la educación, las campañas de medios y las conversaciones con trabajadores de la salud reproductiva- así como las intervenciones para diseminar y subsidiar la compra de toallas sanitarias desechables con el fin de hacer frente a las disparidades en salud.

RÉSUMÉ Contexte: L'utilisation hygiénique de produits absorbants pendant la menstruation pose un défi aux jeunes femmes d'Inde, en particulier celles défavorisées, qui manquent d'information et d'accès aux ressources. La réutilisation d'absorbants menstruels peut être contraire à l'hygiène et donner lieu à des résultats de santé et autres défavorables. Méthodes: Les données de l'Enquête nationale 2015-2016 sur la santé familiale-4 relatives à 233 606 femmes réglées âgées de 15 à 24 ans ont servi à examiner les niveaux et les corrélats de l'utilisation exclusive d'absorbants jetables pendant la menstruation. Les disparités en ont été identifiées par analyses de régression logistique et bivariée en fonction de caractéristiques telles que la caste, l'exposition aux médias et l'interaction avec les agents de santé. Résultats: L'utilisation exclusive d'absorbants jetables s'est révélée faible parmi les jeunes femmes dans leur ensemble (37%), avec une variation nette suivant la caste et d'autres caractéristiques. Par rapport aux femmes des castes générales, celles des castes et tribus répertoriées et des autres classes inférieures présentaient une probabilité réduite d'utilisation exclusive d'absorbants jetables (RC, 0,8-0,9). L'utilisation d'absorbants jetables était associée négativement aux niveaux d'éducation et de richesse du ménage inférieurs, ainsi qu'à la résidence en milieu rural. Par rapport aux femmes ayant fait état d'une exposition journalière aux médias, celles qui y étaient exposées moins fréquemment étaient moins susceptibles d'utiliser des produits absorbants jetables (0,7-0,9). Parmi celles qui s'étaient entretenues récemment avec un agent de santé, la probabilité d'utilisation était moindre si la question de l'hygiène menstruelle n'avait pas été abordée (0,9). Conclusions: La promotion de la sensibilisation à une bonne hygiène menstruelle ­ par l'éducation, les campagnes médiatiques et la discussion avec les agents de santé reproductive ­ et des interventions de dissémination et de subvention de l'achat de serviettes hygiéniques jetables doivent être poursuivies pour éliminer les disparités sanitaires.

Association between modern contraceptive use and child mortality in India: A calendar data analysis of the National Family Health Survey (2015-16).

BACKGROUND: Influence of contraceptive use on increased gap between successive births and attributed reduced risk of child deaths is well documented in developing countries. However, there is scarcity of evidence on direct contribution of contraceptive use on child survival especially in Indian context. METHODS: Using information given in the reproductive calendar history of the National Family Health Survey of India conducted in 2015-16, this study examines the effect of modern contraceptive use on childhood mortality - infant mortality rate (IMR) and under-five mortality rate (U5MR). Bivariate analysis and cox proportional hazard model is applied in the study. RESULTS: Finding reveals that use of reversible contraceptives prior to birth resulted in low childhood mortality rates. IMR is 35 per 1000 live births among births with preceding use of modern reversible contraceptives as compared to 44 per 1000 live births among births with no use. Similarly, U5MR is 41 per 1000 live births as compared to 61 per 1000 live births among births with preceding use of contraceptive and no use respectively. The use of reversible modern contraceptives prior to birth is protective against child mortality even among births with preceding birth interval of less than 24 months. CONCLUSIONS: This study provides evidence of dual benefit of contraceptive use. Such information is important for promoting evidence-based advocacy to expand use of family planning services. This will help the country to achieve Sustainable Development Goal 3.2 which calls for end of preventable deaths during childhood.

Consent and coercion: examining unwanted sex among married young women in India.

CONTEXT: Although there is a growing body of research examining the issue of nonconsensual sex among adolescents, few studies have looked at coerced sex within marriage in settings where early marriage is common, or at sex that may not be perceived as forced, but that is unwanted. METHODS: A cross-sectional study, using both survey research and in-depth interviews, was conducted among 1,664 married young women in Gujarat and West Bengal, India. Descriptive data and multinomial logistic regression were used to identify the prevalence and risk factors for occasional and frequent unwanted sex. Qualitative data were analyzed to examine the context in which unwanted sex takes place. RESULTS: Twelve percent of married young women experienced unwanted sex frequently; 32% experienced it occasionally. The risk of experiencing unwanted sex was lower among women who knew their husband fairly well at the time of marriage, regularly received support from their husband in conflicts with other family members or lived in economically better-off households. Frequent unwanted sex was associated with not yet having had a child or having become pregnant, with lower education and with agreeing with norms that justify wife beating. CONCLUSION: For married young women, sex is not always consensual or wanted. Further research is required to determine the effects of unwanted sex on sexual and reproductive health outcomes and to help programs develop the best strategies for dealing with coerced sex within marriage.

WITHDRAWN: Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.

BACKGROUND: In infants with a family history of atopy, food allergen avoidance has been advocated as means of preventing the development of atopic disease, when breast-feeding is not possible or supplemental feeding is needed. Most infant formulas are based on cow's milk protein. Alternative choices include soya based and hydrolysed cows milk formulas. OBJECTIVES: To estimate the effect of dietary avoidance of cow's milk protein on the development of asthma or wheeze in children. SEARCH STRATEGY: We searched the Cochrane database for eligible trials until February 2002. We obtained the full text papers of all abstracts identified as RCTs and two reviewers independently reviewed them. SELECTION CRITERIA: We included randomised controlled trials involving children with a family history of atopy in at least one first degree relative, if feeding with cow's milk based standard formula was compared to dietary avoidance of cow's milk protein, using soya or other hypoallergenic formula during the initial four months of life or longer. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data independently. A priori defined subgroups were the types of hypoallergenic artificial feed and dietary restrictions on mother and/or child's diet. MAIN RESULTS: Six trials used hydrolysed formula for at least four months, in addition to dietary restrictions and in some cases dust-mite reduction measures. The risk of infants experiencing asthma or wheeze during the first year of life was reduced compared to standard cow's milk based formula (Relative Risk 0.40, 95% Confidence Intervals 0.19 to 0.85). Feeding soya-based formula as opposed to standard cow's milk formula did not reduce the risk of having asthma or wheeze at any age. AUTHORS' CONCLUSIONS: Breast-milk should remain the feed of choice for all babies. In infants with at least one first degree relative with atopy, hydrolysed formula for a minimum of four months combined with dietary restrictions and environment measures may reduce the risk of developing asthma or wheeze in the first year of life. There is insufficient evidence to suggest that soya-based milk formula has any benefit.

Antibiotics for exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Most patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However the value of their use remains uncertain. Some controlled trials of antibiotics have shown benefit (Berry 1960; Pines 1972) while others have not (Elmes 1965b; Nicotra 1982). OBJECTIVES: To conduct a systematic review of the literature estimating the value of antibiotics in the management of acute COPD exacerbations. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005); MEDLINE (1966 to December 2005); EMBASE (1974 to December 2005); Web of Science (December 2005), and other electronically available databases. SELECTION CRITERIA: Randomised controlled trials (RCTs) in patients with acute COPD exacerbations comparing antibiotic (for a minimum of five days) and placebo. DATA COLLECTION AND ANALYSIS: Data were analysed using Review Manager software. Continuous data were analysed using weighted mean differences (WMD) and 95% confidence intervals (CI). Relative risks (RR) (and 95% CI) were calculated for all dichotomous data. Where appropriate, number needed to treat to benefit (NNT) and 95% CI were calculated. MAIN RESULTS: Eleven trials with 917 patients were included. Ten trials used increased cough, sputum volume and purulence diagnostic criteria for COPD exacerbation. Eight-hundred and fifty-seven patients provided data for outcomes including mortality, treatment failure, increased sputum volume, sputum purulence, PaCO(2), PaO(2), peak flow and adverse events. Antibiotic therapy regardless of antibiotic choice significantly reduced mortality (RR 0.23; 95% CI 0.10 to 0.52 with NNT of 8; 95% CI 6 to 17), treatment failure (RR 0.47; 95% CI 0.36 to 0.62 with NNT of 3; 95% CI 3 to 5) and sputum purulence (RR 0.56; 95% CI 0.41 to 0.77 with NNT of 8; 95% CI 6 to 17). There was a small increase in risk of diarrhoea with antibiotics (RR 2.86; 95% CI 1.06 to 7.76). Antibiotics did not improve arterial blood gases and peak flow. AUTHORS' CONCLUSIONS: This review shows that in COPD exacerbations with increased cough and sputum purulence antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%, decrease the risk of treatment failure by 53% and the risk of sputum purulence by 44%; with a small increase in the risk of diarrhoea. These results should be interpreted with caution due to the differences in patient selection, antibiotic choice, small number of included trials and lack of control for interventions that influence outcome, such as use of systemic corticosteroids and ventilatory support. Nevertheless, this review supports antibiotics for patients with COPD exacerbations with increased cough and sputum purulence who are moderately or severely ill.

Efficacy of theophylline in people with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis.

OBJECTIVES: To determine the efficacy of oral theophylline compared with placebo in people with stable chronic obstructive pulmonary disease (COPD). METHODS: Systematic review of randomized-controlled trials comparing oral theophylline with placebo for a minimum of 7 days in people with stable COPD. RESULTS: Twenty randomized-controlled trials were included in this review. The following outcomes showed significant improvement with theophylline compared with placebo: FEV1 and FVC both improved with theophylline (weighted mean difference [WMD] 0.10 L; 95% confidence interval [95% CI] 0.04-0.16 and WMD 0.21 L; 95% CI 0.10-0.32, respectively). VO2 max also improved with theophylline (WMD 195.27mL/ min; 95% CI 112.71-277.83), as did PaO2 and PaCO2 (WMD 3.18 mmHg; 95% CI 1.23-5.13 and WMD -2.36mmHg; 95% CI -3.52 to -1.21, respectively). Patients preferred theophylline over placebo (relative risk 2.27; 95% CI 1.26-4.11). Theophylline increased the risk of nausea compared with placebo (RR 7.67; 95% CI 1.47-39.94). CONCLUSION: This review has shown that theophylline still has a role in the management of stable COPD, and is preferred by patients over placebo. However, the benefits of theophylline in stable COPD have to be weighed against the risk of adverse effects.

Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) has been shown to be effective in chronic obstructive pulmonary disease patients with acute respiratory failure. However, its role in patients with severe acute asthma is uncertain. The pathophysiologic condition of acute respiratory failure in asthma is in many ways similar to that of acute respiratory failure in COPD. Therefore, there is reason to believe that NPPV could also be successful in patients with severe acute asthma. OBJECTIVES: To determine the efficacy of NPPV in adults with severe acute asthma in comparison to usual medical care with respect to mortality, tracheal intubation, changes in blood gases and hospital length of stay. SEARCH STRATEGY: An initial search for studies was carried out using CENTRAL. Additional searches were also carried out on MEDLINE, EMBASE, CINAHL, Science Citation, web based clinical trials databases and key journals with web sites were also searched as well as respiratory conference proceedings. Following this, the bibliographies of each randomised controlled trial obtained (and any review articles) was searched for additional studies. Date of most recent search for trials was conducted on May 2004. SELECTION CRITERIA: Only RCTs in adults patients with severe acute asthma were considered for inclusion. Studies including patients with features of COPD were excluded unless data was provided separately for patients with asthma in studies recruiting both COPD and asthma patients. DATA COLLECTION AND ANALYSIS: All data was analysed using RevMan. For continuous variables, a weighted mean difference and 95% confidence interval (95%CI) was calculated for each study outcome. For dichotomous variables relative risk with 95% confidence interval was calculated. MAIN RESULTS: From an initial search of 696 abstracts, 11 trials were obtained in full-text for closer examination. Ten trials were excluded and one included. The one included trial, on 30 patients, showed benefit with NPPV when compared to usual medical care alone with significant improvements in hospitalisation rate, number of patients discharged from emergency department, percent predicted FEV(1), FVC, PEFR and respiratory rate. AUTHORS' CONCLUSIONS: The application of NPPV in patients suffering from status asthmaticus, despite some interesting and very promising preliminary results, still remains controversial. Large, prospective, randomised controlled trials are therefore needed to determine the role of NPPV in status asthmaticus.

Long-acting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma.

BACKGROUND: Patients who continue to experience asthma symptoms despite taking regular inhaled corticosteroids (ICS) represent a management challenge. Leukotriene receptor antagonists (LTRA) and long-acting beta2-agonists (LABA) agents may both be considered as add-on therapy to inhaled corticosteroids (ICS). OBJECTIVES: We compare the efficacy and safety profile of adding either daily LABA or LTRA in asthmatic patients with asthma who remained symptomatic on ICS. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL databases were searched for randomised controlled trials up to and including January 2004. Reference lists of all included studies and reviews were screened to identify potentially relevant citations. Inquiries regarding other published or unpublished studies supported by the authors of the included studies or pharmaceutical companies who manufacture these agents were made. Conference proceedings of major respiratory meetings were also searched. SELECTION CRITERIA: Only randomised controlled trials conducted in adults or children with recurrent asthma where a LABA (for example, salmeterol or formoterol) or LTRA (for example, montelukast, pranlukast, zafirlukast) was added to ICS for a minimum of 28 days were considered for inclusion. Inhaled short-acting beta2-agonists and short courses of oral steroids were permitted as rescue medications. Other daily asthma treatments were permitted, providing the dose remained constant during the intervention period. Two reviewers independently reviewed the literature searches. DATA COLLECTION AND ANALYSIS: Data extraction and trial quality assessment were conducted independently by two reviewers. Whenever possible, primary study authors were requested to confirm methodology and data extraction and to provide additional information and clarification when needed. Where necessary, expansion of graphic reproductions and estimation from other data presented in the paper was performed. MAIN RESULTS: Twelve randomised controlled trials met the inclusion criteria; only eight trials including 5,895 patients, provided data in sufficient details to allow aggregation. All eight trials pertained to adults with moderate airway obstruction (% predicted FEV1 66-76%) at baseline. Montelukast (n=6) or Zafirlukast (n=2) was compared to Salmeterol (n=7) or Formoterol (n=1) as add-on therapy to 400-565 mcg of beclomethasone or equivalent. Risk of exacerbations requiring systemic corticosteroids was significantly lower with LABA+ICS when compared to LTRA+ICS (RR= 0.83, 95% Confidence Interval (95%CI): 0.71, 0.97): the number needed to treat with LABA compared to LTRA, to prevent one exacerbation over 48 weeks, was 38 (95% CI: 23 to 247). The following outcomes also improved significantly with the addition of LABA compared to LTRA to inhaled steroids (Weighted Mean Difference; 95%CI): morning PEFR (16 L/min; 13 to 18), evening PEFR (12 L/min; 9 to 15), FEV(1) (80 mL; 60 to 100), rescue-free days (9%; 4 to 14), symptom-free days (6%; 2 to 11), rescue beta2-agonists (-0.4 puffs/day; -0.2 to -0.5), quality of life (0.1; 0.05 to 0.2), symptom score (Standard Mean Difference -0.2; -0.1 to -0.3), night awakenings (-0.1/week; -0.06 to -0.2) and patient satisfaction (RR 1.12; 1.07 to 1.16). Risk of withdrawals due to any reason was significantly lower with LABA+ICS compared to LTRA+ICS (Relative Risk 0.84, 95% CI 0.74 to 0.96). Withdrawals due to adverse events or due to poor asthma control, hospitalisation, osteopenia, serious adverse events, overall adverse events, headache or cardiovascular events were not significantly different between the two study groups. AUTHORS' CONCLUSIONS: In asthmatic adults inadequately controlled on low doses of inhaled steroids, the addition of LABA is superior to LTRA for preventing exacerbations requiring systemic steroids, and for improving lung function, symptoms, and use of rescue beta2-agonists.

Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma.

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) has been shown to be effective in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure. However, its role in patients with severe acute asthma is uncertain. The pathophysiologic condition of acute respiratory failure in asthma is in many ways similar to that of acute respiratory failure in COPD. Therefore, there is reason to believe that NPPV could also be successful in patients with severe acute asthma. OBJECTIVES: To determine the efficacy of NPPV in adults with severe acute asthma, in comparison to usual medical care, with respect to mortality, tracheal intubation, changes in blood gases, and hospital length of stay. SEARCH STRATEGY: An initial search for studies was carried out using the Cochrane Controlled Trials Register (CENTRAL). Additional searches were carried out on MEDLINE, EMBASE, CINAHL, Science Citation and web based clinical trials databases. Key journals with web sites were also searched as well as respiratory conference proceedings. Following this, the bibliographies of each randomised controlled trial obtained (and any review articles) were searched for additional studies. The date of the most recent search for trials was May 2004. SELECTION CRITERIA: All data were analysed using RevMan. For continuous variables a weighted mean difference and 95% confidence interval (95% CI) was calculated for each study outcome. For dichotomous variables relative risk with 95% confidence interval was calculated. DATA COLLECTION AND ANALYSIS: All data was analysed using RevMan. For continuous variables, a weighted mean difference and 95% confidence interval (95%CI) was calculated for each study outcome. For dichotomous variables relative risk with 95% confidence interval was calculated. MAIN RESULTS: From an initial search of 696 abstracts, 11 trials were obtained in full text for closer examination. Ten trials were excluded and one included. The one included trial, on 30 patients, showed benefit with NPPV when compared to usual medical care alone, with significant improvements in hospitalisation rate, number of patients discharged from emergency department, percent predicted forced expiratory volume in one minute (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR) and respiratory rate. AUTHORS' CONCLUSIONS: The application of NPPV in patients suffering from status asthmaticus, despite some interesting and very promising preliminary results, still remains controversial. Large, prospective randomised controlled trials are therefore needed to determine the role of NPPV in status asthmaticus.

Physical training for asthma.

BACKGROUND: Physical training programmes have been designed for asthmatic subjects with the aim of improving physical fitness, neuromuscular coordination and self-confidence. Habitual physical activity increases physical fitness and lowers ventilation during mild and moderate exercise thereby reducing the likelihood of provoking exercise induced asthma. Exercise training may also reduce the perception of breathlessness through a number of mechanisms including strengthening respiratory muscles. Subjectively, many asthmatics report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. OBJECTIVES: The purpose of this review was to assess evidence for the efficacy and effectiveness of physical training in asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register, SportDiscus and the Science Citation Index up to May 2005. SELECTION CRITERIA: Randomised trials in asthmatic subjects undertaking physical training. Subjects had to be eight years and older. Physical training had to be undertaken for at least 20 to 30 minutes, two to three times a week, over a minimum of four weeks. DATA COLLECTION AND ANALYSIS: Eligibility for inclusion and quality of trials were assessed independently by two reviewers. MAIN RESULTS: Thirteen studies (455 participants) were included in this review. Physical training had no effect on resting lung function or the number of days of wheeze. The results of this review have shown that lung function and wheeze is not worsened by physical training in patients with asthma. Physical training improved cardiopulmonary fitness as measured by an increase in maximum oxygen uptake of 5.4 ml/kg/min (95% confidence interval 4.2 to 6.6) and maximum expiratory ventilation 6.0 L/min (95% confidence interval 1.5 to 10.4). There were no data concerning quality of life measurements. AUTHORS' CONCLUSIONS: In people with asthma, physical training can improve cardiopulmonary fitness without changing lung function. It is not known whether improved fitness is translated into improved quality of life. It is comforting to know that physical training does not have an adverse effect on lung function and wheeze in patients with asthma. Therefore, there is no reason why patients with asthma should not participate in regular physical activity.

Inhaled tiotropium for stable chronic obstructive pulmonary disease.

BACKGROUND: Tiotropium is a new anticholinergic therapy for chronic obstructive pulmonary disease (COPD) that differs from ipratropium by its functional relative selectivity for muscarinic receptor subtypes and which allows once-per-day dosing. OBJECTIVES: To determine the efficacy of tiotropium on clinical endpoints such exacerbations and hospitalisations, symptom scales and pulmonary function compared to placebo and other bronchodilators used for stable COPD. SEARCH STRATEGY: Randomised controlled trials (RCTs) were identified from the Cochrane Airways Review Group Specialised Register, a compilation of systematic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL, and hand searching of 20 respiratory journals. Bibliographies from included studies and reviews were searched. The date of the last search was October 2004. SELECTION CRITERIA: Randomised clinical trials comparing tiotropium with placebo, ipratropium bromide, or long-acting ss2-agonists for greater than, or equal to, one month's duration. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data. Missing data were obtained from authors or the manufacturer of tiotropium. The data were analysed using the Cochrane Review Manager RevMan 4.2. Studies were pooled to yield weighted mean differences (WMD) or odds ratios (OR) and reported using 95% confidence intervals (CI). MAIN RESULTS: From 69 identified references, nine RCTs (6,584 patients) met inclusion criteria. Tiotropium reduced the odds of a COPD exacerbation (OR 0.74; 95% CI 0.66 to 0.83) and related hospitalisations (OR 0.64; 95% CI 0.51 to 0.82) compared to placebo or ipratropium. When applied to an annual baseline risk of 45% for exacerbations and 10% for hospitalisation, the number of patients needed to treat with tiotropium for one year were 14 (95% CI 11 to 22) to prevent one exacerbation and 30 (95% CI 22 to 61) to prevent one hospitalisation compared to placebo and ipratropium. Reductions in these endpoints compared to long-acting ss2-agonists were not statistically significant. Similar patterns were evident for quality-of-life and symptom scales. Increases in FEV1 and FVC from baseline were significantly larger with tiotropium than with placebo, ipratropium and long-acting ss2-agonists over 6 to 12 months. The decline in trough FEV1 from steady state was 30 ml (95% CI 7 to 53 ml) less with tiotropium than with placebo or ipratropium over one year; no data on decline in FEV1 from steady state were available for long-acting ss2-agonists. Dry mouth was increased by tiotropium. AUTHORS' CONCLUSIONS: Tiotropium reduced COPD exacerbations and related hospitalisations compared to placebo and ipratropium. It also improved health-related quality-of-life and symptom scores among patients with moderate and severe disease, and may have slowed decline in FEV1. Additional long-term studies are required to evaluate its effect on mortality and change in FEV1 to clarify its role in comparison to, or in combination with, long-acting ss2-agonists and to assess its effectiveness in mild and very severe COPD.

Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) are common diseases of the airways and lungs that have a major impact on the health of the population. The mainstay of treatment is by inhalation of medication to the site of the disease process. This can be achieved by a number of different device types, which have wide variations in costs to the health service. A number of different inhalation devices are available. The pressurised metered-dose inhaler (pMDI) is the most commonly used and cheapest device, which may also be used in conjunction with a spacer device. Newer chlorofluorocarbons (CFC)-free inhaler devices using hydrofluoroalkanes (HFAs) have also been developed. The drug is dissolved or suspended in the propellant under pressure. When activated, a valve system releases a metered volume of drug and propellant. Other devices include breath-actuated pMDIs (BA-pMDI), such as Autohaler and Easi-Breathe. They incorporate a mechanism activated during inhalation that triggers the metered-dose inhaler. Dry powder inhalers (DPI), such as Turbohaler, Diskhaler, Accuhaler and Rotahaler, are activated by inspiration by the patient. The powdered drug is dispersed into particles by the inspiration. With nebulisers oxygen, compressed air, or ultrasonic power is used to break up solutions or suspensions of medication into droplets for inhalation. The aerosol is administered by mask or by a mouthpiece. There has been no previous systematic review of the evidence of clinical effectiveness and cost-effectiveness of these different inhaler devices. OBJECTIVES: To review systematically the clinical effectiveness and cost-effectiveness of inhaler devices in asthma and COPD. METHODS: The different aspects of inhaler devices were separated into the most clinically relevant comparisons. Methods involved systematic searching of electronic databases and bibliographies for randomised controlled trials (RCTs) and systematic reviews. Pharmaceutical companies and experts in the field were contacted for further information. Trials that met the inclusion criteria were appraised and data extraction was under-taken by one reviewer and checked by a second reviewer, with any discrepancies being resolved through agreement. RESULTS--IN VITRO CHARACTERISTICS VERSUS IN VIVO TESTING AND CLINICAL RESPONSE: There is evidence that when comparative testing is performed on inhaler devices using the same methods, there is some correlation between particle size measurements and clinical response. However, the measurements are dependent upon the methods used, and a single measure of a device in isolation is of limited value. Also, there is little data on comparing devices of different types. There is currently insufficient data to verify the ability of in vitro assessments to predict inhaler performance in vivo. RESULTS--EFFECTIVENESS OF METERED-DOSE INHALERS FOR THE DELIVERY OF CORTICOSTEROIDS IN ASTHMA: The review of three trials in children and 21 trials in adults demonstrated no evidence to suggest clinical benefits of any other inhaler device over a pMDI in corticosteroid delivery. RESULTS--EFFECTIVENESS OF METERED-DOSE INHALERS FOR THE DELIVERY OF BETA-AGONISTS IN STABLE ASTHMA: In children, 11 studies were reviewed, of which seven compared the Turbohaler with the pMDI. One study found a significant treatment difference in peak expiratory flow rate, although there were differences in the patients' baseline characteristics. In adults, a review of 70 studies found no demonstrable difference in the clinical bronchodilator effect of short-acting b2-agonists delivered by the standard pMDI compared with that produced by any other DPI, HFA-pMDI or the Autohaler device. The finding that HFA-pMDIs may reduce treatment failure and oral steroid requirement in beta-agonist delivery needs further confirmatory research in adequately randomised clinical trials. RESULTS--EFFECTIVENESS OF NEBULISERS VERSUS METERED-DOSE INHALERS FOR THE DELIVERY OF BRONCHODILATORS IN STABLE ASTHMA: In children, three included trials compared different devices with a nebuliser and demonstrated no evidence of clinical superiority of nebulisers over inhaler devices in bronchodilator delivery. A total of 23 studies in adults found no equivalence for the main pulmonary outcomes and no evidence of difference in other outcomes. RESULTS--EFFECTIVENESS OF METERED-DOSE INHALERS FOR THE DELIVERY OF BETA-AGONISTS IN COPD: Only two studies were included in this review. No evidence of clinical difference was found in beta-agonist delivery. RESULTS--EFFECTIVENESS OF NEBULISERS VERSUS METERED-DOSE INHALERS FOR THE DELIVERY OF BRONCHODILATORS IN COPD: Evidence from 14 trials demonstrated equivalence for the main outcomes of pulmonary function. For other outcomes there was no evidence of treatment difference in bronchodilator delivery. RESULTS--PATIENTS' ABILITY TO USE METERED-DOSE INHALERS: Differences among studies and the heterogeneity of the results make it difficult to draw conclusions about inhaler technique differences between device types. The review of technique after teaching the correct technique suggests that there is no difference in patients' ability to use DPI or pMDIs. RESULTS--ECONOMIC ANALYSIS: The total number of NHS prescriptions for inhaler therapy for asthma in 1998 was over 31 million, with a net ingredient cost in excess of 392 million GB pounds. This economic assessment uses decision analysis to estimate the relative cost-effectiveness of inhaler devices for the delivery of bronchodilator and corticosteroid inhaled therapy. Overall, there were no differences in patient outcomes among the devices. On the assumption that the devices were clinically equivalent, pMDIs were the most cost-effective devices for asthma treatment. CONCLUSIONS: This systematic review examined the evidence from clinical trials evaluating the clinical effectiveness of different inhaler devices in the delivery of inhaled corticosteroids and beta2-bronchodilators for patients with asthma and COPD. The evidence from the published clinical literature demonstrates no difference in clinical effectiveness between nebulisers and alternative inhaler devices compared to standard pMDI with or without a spacer device. The cost-effectiveness evidence therefore favours pMDIs (or the cheapest inhaler device) as first-line treatment in all patients with stable asthma unless other specific reasons are identified. Patients can use pMDIs as effectively as other inhaler devices as long as the correct inhalation technique is taught. CONCLUSIONS--RECOMMENDATIONS FOR RESEARCH: Further clinical trials are required to demonstrate any differences in the clinical effectiveness and cost-effectiveness of inhaler devices and nebulisers compared with pMDIs. These should be of sufficient statistical power and methodological rigour to demonstrate any clinical benefit. Trials should be undertaken in community settings to ensure the generalisability of results. Outcome measures should be more patient-centred and report adverse effects more completely. Reporting of data from trials should be improved.

Inhaler devices for the treatment of asthma and chronic obstructive airways disease (COPD).

The research evidence on the effectiveness of inhaler devices for the treatment of asthma and chronic obstructive pulmonary disease published in a recent issue of Effective Health Care is reviewed.

Breathing retraining for asthma.

Breathing retraining is used increasingly throughout the world by many patients with asthma in addition to their usual medical care. We undertook a systematic review of the literature in order to determine the effectiveness of breathing retraining in the management of asthma. Six randomised-controlled trials were identified that involved breathing retraining in asthma. Due to the variation in reported trial outcomes, limited reporting of study data and small number of included trials it was not possible to draw any firm conclusions as to its effectiveness. However, outcomes that were reported from individual trials do show that breathing retraining may have a role in the treatment and management of asthma. Further large-scale trials using breathing retraining techniques in asthma are required to address this important issue.

Can women's childbearing and contraceptive intentions predict contraceptive demand? Findings from a longitudinal study in Central India.

CONTEXT: To predict the need for contraceptive services, family planning program managers often rely on levels of unmet need derived from measures of childbearing intentions. However, women's intention to use a method has not received as much attention as a measure of contraceptive demand. METHODS: A survey was conducted in 1999 in rural Madhya Pradesh, India, among a subsample of women who had participated in the 1992-1993 National Family Health Survey (NFHS). The women's childbearing and contraceptive behaviors were compared with the intentions they had stated in the NFHS, and logistic regression was performed to analyze the association between socioeconomic and demographic variables and inconsistent behavior. RESULTS: Among women who were fecund and married in 1992-1993, 29% of those who intended to have children and 61% of those who intended not to have children failed to adhere to their intentions by 1999. Furthermore, 51% of women who were not practicing contraception at the time of the NFHS but planned to do so acted against their intention by 1999, as did 29% of those who planned not to use a method. NFHS respondents who intended both not to have children and to use a method were more likely than others to have used a method by 1999 (63% vs. 25-41%). Age and history of child death were key factors associated with inconsistency between women's intentions and behavior. CONCLUSIONS: In India, use of both contraceptive and childbearing intentions predicts contraceptive demand better than use of either indicator alone, and may thus help program planners estimate future demand for contraceptive services.

Dietary salt reduction or exclusion for allergic asthma.

BACKGROUND: There is a wide geographical variation in asthma prevalence and one explanation may be in dietary salt consumption. OBJECTIVES: To assess the effect of dietary sodium reduction in patients with asthma. SEARCH STRATEGY: A search was conducted using the Cochrane Airways Group asthma register. Bibliographies of included randomised controlled trials (RCTs) were searched for additional studies. Authors of identified RCTs were contacted for other studies. SELECTION CRITERIA: All studies were to be RCTs that involved dietary salt reduction or increased salt intake in patients with asthma. Studies of other allergic conditions such as hay fever, allergic rhinitis and eczema were considered patients with asthma were separately identified. DATA COLLECTION AND ANALYSIS: Study quality was assessed and data extracted by two reviewers. All data analysis was conducted using the Cochrane Collaboration software (RevMan 4.1.1). MAIN RESULTS: Fifty-six abstracts were identified and 15 studies were reviewed in full text. Five fulfilled the inclusion criteria. Nine were excluded. One was published in duplicate. Complete agreement was reached between the reviewers on inclusion or exclusion of all studies. All studies were small and of short duration. Data from only three could be pooled. Low sodium diet was associated with a significantly lower urine sodium excretion than normal or high salt diets. There were no significant differences in any asthma outcome between low salt and normal or high salt diets, but FEV1 was slightly higher with low salt compared to normal, WMD 0.09 L (95% confidence interval (CI) -0.26, 0.44 L, n=88), as was daily PEFR, WMD 11 l/min (95% CI -81, 103 l/min, n=78). With low compared to high salt, FEV1 was slightly higher WMD 0.22 L (95% CI -0.14, 0.59 L, n=88), as was daily PEFR, WMD 14 l/min (95% CI -41, 68 l/min, n=78). Bronchodilator use was slightly lower, WMD 0.7 puffs/day (95% CI -1.8, 0.5 puffs/day, n=62). REVIEWER'S CONCLUSIONS: Based on currently available evidence it is not possible to conclude whether dietary salt reduction has any place in the treatment or management of asthma.

Tartrazine exclusion for allergic asthma.

BACKGROUND: Tartrazine is the best known and one of the most commonly used food additives. Food colorants are also used in many medications as well as foods. There has been conflicting evidence as to whether tartrazine causes exacerbations of asthma with some studies finding a positive association especially in individuals with cross-sensitivity to aspirin. OBJECTIVES: To assess the overall effect of tartrazine (exclusion or challenge) in the management of asthma. SEARCH STRATEGY: A search was carried out using the Cochrane Airways Group specialised register. Bibliographies of each RCT was searched for additional papers. Authors of identified RCTs were contacted for further information for their trials and details of other studies. SELECTION CRITERIA: RCTs of oral administration of tartrazine (as a challenge) versus placebo or dietary avoidance of tartrazine versus normal diet were considered. Studies which focused upon allergic asthma, were also included. Studies of tartrazine exclusion for other allergic conditions such as hay fever, allergic rhinitis and eczema were only considered if the results for subjects with asthma were separately identified. Trials could be in either adults or children with asthma or allergic asthma (e.g. sensitivity to aspirin or food items known to contain tartrazine). DATA COLLECTION AND ANALYSIS: Study quality was assessed and data abstracted by two reviewers independently. Outcomes were analysed using RevMan 4.1.1. MAIN RESULTS: Ninety abstracts were found, of which 18 were potentially relevant. Six met the inclusion criteria, but only three presented results in a format that permitted analysis and none could be combined in a meta-analysis. In none of the studies did tartrazine challenge or avoidance in diet significantly alter asthma outcomes. REVIEWER'S CONCLUSIONS: Due to the paucity of available evidence, it is not possible to provide firm conclusions as to the effects of tartrazine on asthma control. However, the six RCTs that could be included in this review all arrived at the same conclusion. Routine tartrazine exclusion may not benefit most patients, except those very few individuals with proven sensitivity.