Antibiotics versus placebo for acute bacterial conjunctivitis.

BACKGROUND: Acute bacterial conjunctivitis is an infection of the conjunctiva. Both the palpebral and the bulbar ocular conjunctival surfaces are usually affected and typically become red and inflamed. Antibiotic therapy is widely used for the treatment of acute bacterial conjunctivitis. This Cochrane Review was first published in The Cochrane Library in 1999; updated in 2006 and again in 2012. OBJECTIVES: To assess the benefits and harms of antibiotic therapy in the management of acute bacterial conjunctivitis. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), MEDLINE (January 1950 to July 2012), EMBASE (January 1980 to July 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 18 July 2012. SELECTION CRITERIA: We included double-masked randomised controlled trials (RCTs) in which any form of antibiotic treatment had been compared with placebo/vehicle in the management of acute bacterial conjunctivitis. This included topical, systemic and combination (for example, antibiotics and steroids) antibiotic treatments. DATA COLLECTION AND ANALYSIS: Two authors (UN and SM) independently checked and reviewed the titles and abstracts of identified studies. We assessed the full text of all potentially relevant studies. We graded the included RCTs for methodological quality using Cochrane methodology. We performed data extraction in a standardised manner. We performed random-effects meta-analyses using RevMan. MAIN RESULTS: We identified 11 eligible RCTs which randomised a total of 3673 participants. One further trial, which was published in abstract form in 1990 but has yet to be reported fully, is currently 'awaiting assessment'. Six of the 11 included studies have been included for the first time in this latest (2012) update. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. We judged two of the trials to be of high quality and graded the remainder as poor quality.Meta-analyses of data on clinical and microbiological remission rates revealed that topical antibiotics were of benefit in improving 'early' (days two to five) clinical (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.15 to 1.61) and microbiological (RR 1.55, 95% CI 1.37 to 1.76) remission rates. At the 'late' time point (days six to 10), antibiotics were found to still confer modest benefits in clinical remission (RR 1.21, 95% CI 1.10 to 1.33) and microbiological cure rates (RR 1.37, 95% CI 1.24 to 1.52). By days six to 10, 41% (95% CI 38 to 43) of cases had resolved in those receiving placebo. We found no data on the cost-effectiveness of antibiotics. No serious outcomes were reported in either the active or placebo arms of these trials, suggesting that important sight-threatening complications are an infrequent occurrence. AUTHORS' CONCLUSIONS: Although acute bacterial conjunctivitis is frequently self limiting, the findings from this updated systematic review suggest that the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission in comparison to the use of placebo. Use of antibiotic eye drops should therefore be considered in order to speed the resolution of symptoms and infection.

Healthcare financing systems for increasing the use of tobacco dependence treatment.

BACKGROUND: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. OBJECTIVES: The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012. SELECTION CRITERIA: We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives. MAIN RESULTS: We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450. AUTHORS' CONCLUSIONS: Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

House dust mite avoidance measures for perennial allergic rhinitis.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2001 and previously updated in 2003 and 2007.It is estimated that in developed countries approximately 30% of the general population suffer from one or more allergic disorders, of which allergic rhinitis is particularly common. Perennial rhinitis is most often due to allergy to the house dust mite. In such patients house dust mite avoidance is logical, but there is considerable uncertainty regarding the efficacy and effectiveness of interventions designed to reduce dust mite exposure. OBJECTIVES: To assess the benefit (and harm) of measures designed to reduce house dust mite exposure in the management of house dust mite sensitive allergic rhinitis. SEARCH STRATEGY: Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library Issue 4, 2009), MEDLINE and EMBASE. The date of the last search was 31 December 2009. SELECTION CRITERIA: Randomised controlled trials, with or without blinding, in which house dust mite control measures have been evaluated in comparison with placebo or other dust mite avoidance measures, in patients with clinician-diagnosed allergic rhinitis and confirmed allergy to dust mite. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts, graded methodological quality using the Cochrane approach and extracted data. Meta-analysis was neither possible nor appropriate due to heterogeneity of the patient groups studied. MAIN RESULTS: Nine trials involving 501 participants satisfied the inclusion criteria. Only two studies investigating the effectiveness of mite impermeable bedding covers were of good quality; the remaining seven studies were small and of poor quality. Two trials investigated the efficacy of acaricides, another two trials investigated the role of high-efficiency particulate air (HEPA) filters. One trial, using a factorial design, investigated the efficacy of both acaricide and house dust mite impermeable bedding covers in isolation and combination; the remaining four trials investigated the efficacy of bedroom environmental control programmes involving use of house dust mite impermeable bedding covers. Seven of the nine trials reported that, when compared with control, the interventions studied resulted in significant reductions in house dust mite load. Of the interventions studied to date, acaricides appear to be the most promising type of intervention, although the findings from these studies need to be interpreted with care because of their methodological limitations. House dust mite impermeable bedding as an isolated intervention is unlikely to offer clinical benefit. No serious adverse effects were reported from any of the interventions. AUTHORS' CONCLUSIONS: Trials to date have on the whole been small and of poor methodological quality, making it difficult to offer any definitive recommendations on the role, if any, of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis. The results of these studies suggest that use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms and, if considered appropriate, these should be the interventions of choice. Isolated use of house dust mite impermeable bedding is unlikely to prove effective.

Mono and multifaceted inhalant and/or food allergen reduction interventions for preventing asthma in children at high risk of developing asthma.

BACKGROUND: Allergen exposure is one of the environmental factors seemingly associated with the development of asthma. If asthma is a multi-factorial disease, it is hypothesised that prevention might only prove effective if most or all relevant environmental factors are simultaneously avoided. OBJECTIVES: To assess effect(s) of monofaceted and multifaceted interventions compared with control interventions in preventing asthma and asthma symptoms in high risk children. SEARCH STRATEGY: We searched the Cochrane Airways Trials Register (December 2008). SELECTION CRITERIA: Randomised controlled trials of allergen exposure reduction for the primary prevention of asthma in children. Interventions were multifaceted (reducing exposure to both inhalant and food allergens) or monofaceted (reducing exposure to either inhalant or food allergens) Follow up had to be from birth (or during pregnancy) up to a minimum of two years of age. DATA COLLECTION AND ANALYSIS: We included in the analysis studies assessing the primary outcome (current diagnosis: asthma) and/or one of the secondary outcomes (current respiratory symptoms: wheezing, nocturnal coughing and dyspnoea). We pooled multifaceted and monofaceted intervention trials separately. We made an indirect comparison of their effects using tests for interaction to calculate relative odds ratios. MAIN RESULTS: We included three multifaceted and six monofaceted intervention studies (3271 children). Physician diagnosed asthma in children less than five years, and asthma as defined by respiratory symptoms and lung function criteria in children aged five years and older, both favoured treatment with a multifaceted intervention compared to usual care (< 5 years: odds ratio (OR) 0.72, 95% confidence interval (CI) 0.54 to 0.96, and > 5 years: OR 0.52, 95% CI 0.32 to 0.85). However, there was no significant difference in outcome between monofaceted intervention and control interventions (< 5 years: OR 1.12, 95% CI 0.76 to 1.64, and > 5 years: OR 0.83, 95% CI 0.59 to 1.16). Indirect comparison between these treatments did not demonstrate a significant difference between multiple interventions and mono-interventions in reducing the frequency of asthma diagnosis in children under five years (relative OR 0.64 (95% CI 0.40 to 1.04, P = 0.07) or five years and older (relative OR 0.63, 95% CI 0.35 to 1.13, P = 0.12). There was also no significant difference between either mono- and multifaceted intervention and control in reducing the likelihood of symptoms of nocturnal coughing at follow up. Wheezing, however, showed a significant difference between multifaceted and mono-interventions (relative OR 0.59, 95% CI 0.35 to 0.99, P = 0.04), but the significance was lost when data on treatment only was analysed. AUTHORS' CONCLUSIONS: The available evidence suggests that the reduction of exposure to multiple allergens compared to usual care reduces the likelihood of a current diagnosis of asthma in children (at ages < 5 years and 5 years and older). Mono-intervention studies have not produced effects which are statistically significant compared with control. In children who are at risk of developing childhood asthma, multifaceted interventions, characterised by dietary allergen reduction and environmental remediation, reduce the odds of a physician diagnosis of asthma later in childhood by half. This translates to a number needed to treat (NNT) of 17. The effect of multi-faceted interventions on parent reported wheeze was inconsistent and had no significant impact on nocturnal coughing or dyspnoea. Data from monofaceted intervention exposed children studies were not significantly different from those of control groups for all outcomes. There remains uncertainty as to whether multiple interventions are more effective than mono-component interventions. The comparisons made were indirect, making the conclusions drawn uncertain. To our knowledge there are no ongoing studies in which both intervention strategies are randomly compared. The findings, however, warrant further direct comparison between multiple- and monofaceted interventions aimed at reducing the prevalence of asthma in children.

Healthcare financing systems for increasing the use of tobacco dependence treatment.

BACKGROUND: We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts. OBJECTIVES: The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both. DATA COLLECTION AND ANALYSIS: Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives. MAIN RESULTS: We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers.There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453. AUTHORS' CONCLUSIONS: Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

Influence of two different inhalation devices on therapy compliance in asthmatic patients.

OBJECTIVE: To examine the influence of inhalation device (Autohaler versus metered dose inhaler) and patients' subjective opinion towards the different devices, as well as daily frequency and duration of treatment on medication compliance. DESIGN: Prospective study measuring compliance in the same patients of the Autohaler twice daily with the metered dose inhaler twice daily, as well the Autohaler twice daily with the Autohaler four times daily. SETTING: Primary health care. SUBJECTS: 34 subjects with asthma. MAIN OUTCOME MEASURES: Patients preference and compliance. RESULTS: Patients preferred the Autohaler. The percentage of patients with a negative opinion towards the metered dose inhaler was 38% compared with 12% towards the Autohaler. The median values of the compliance rate of the Autohaler with twice and four times daily frequency were 90.8% (25-75th percentile 61.6-98.0%) and 78.5% (25-75th percentile 49.0%-91.2%), respectively (p < 0.001). The duration of treatment period had a significant negative influence on compliance when four times daily dosage frequency was prescribed (p = 0.05). CONCLUSION: In conclusion, the devices (metered dose inhaler and Autohaler) and the patients' opinion about the devices did not significantly contribute to the compliance rates. Compliance towards the medication treatment, however, is negatively influenced by a high daily frequency.