The recently published Cochrane Review from the Bone, Joint and Muscle Trauma Group assessed the best-quality evidence for different treatments of wrist fractures in children.

 Wrist fractures are the most common bone injury in children. Most are buckle (or torus) fractures, where the bone surface bulges out. These minor fractures heal well. They are often treated with a wrist splint or a below-elbow plaster cast.

More serious fractures are where the bone breaks, generally resulting in displacement of the bone parts. Usually the bone is manipulated back into place ('reduction'), followed by cast immobilisation, often with an above-elbow cast including the elbow. When considered, surgery generally involves placing wires through the skin and into the bone (percutaneous wiring).

The review includes 30 studies with 2930 children. Most of the 14 comparisons made by the studies were tested in one study only. The review focussed on five key comparisons. The three comparisons involving children with buckle fractures compared a removable splint with a below-elbow cast (6 studies); a soft or elasticated bandage with a below-elbow cast (4 studies); and cast removal at home by parents versus at the hospital fracture clinic by clinicians (2 studies). The other two comparisons, which involved children with displaced fractures, compared below-elbow versus above-elbow casts (4 studies) and percutaneous wiring and above-elbow cast immobilisation versus above-elbow cast immobilisation alone (5 studies).

Lead author Helen Handoll concluded, “There is not enough evidence to determine the best ways of treating different types of wrist fractures in children. However, the review findings are consistent with the treatment trend away from cast immobilisation for buckle fractures.”

• Read the full review
• Learn more about the Cochrane Bone, Joint and Muscle Trauma Group

Up to 70 million people worldwide have epilepsy and there are many Cochrane Reviews of ways to treat it. These include reviews that work with the original researchers to gather data on everyone who was in their studies, to perform individual participant data meta-analyses. In June 2018, Sarah Nevitt and colleagues from the University of Liverpool in the UK updated one of these reviews, comparing two commonly used drugs, lamotrigine and carbamazepine.

"Carbamazepine and lamotrigine are both recommended as first-line treatments for people with newly diagnosed focal onset epileptic seizures and as second-line treatments for those with newly diagnosed generalised onset seizures, if first-line treatment with sodium valproate is considered unsuitable. Therefore, in order to help choose between them, we have brought together the evidence from randomised trials, increasing the precision of results relating to efficacy and tolerability of the two drugs. 

Our primary outcome for the analyses was the time between a patient starting the drug and being withdrawn from it, which reflects both how effective the drugs are for seizure control and the tolerability of the drugs in terms of side effects. We also examined secondary efficacy outcomes, including time to first seizure and remission of seizures, as well as the types and frequency of side effects. 

We found fourteen relevant trials for this updated review, involving nearly 3800 people, and were able to obtain individual participant data for more than 2500 people from nine of the trials, representing nearly 70 percent of all the data. 

Our main results from the meta-analyses of these data suggest that people are more likely to withdraw earlier from carbamazepine than from lamotrigine treatment, with the most common reason for withdrawal being side effects, followed by seizure recurrence. The results also suggest that recurrence of seizures after starting treatment with lamotrigine may happen earlier than with carbamazepine and that people will achieve a period of six months without a seizure quicker on carbamazepine than lamotrigine. Adverse events occurred with a similar frequency for both drugs. The most common ones were dizziness, fatigue, gastrointestinal disturbances, headache and skin problems.

In summary, the evidence from the randomised trials shows that both carbamazepine and lamotrigine are effective treatments for people with focal onset seizures. Carbamazepine may be superior in terms of seizure control, while lamotrigine therapy is less likely to be withdrawn than carbamazepine therapy. This means that a choice between these first-line treatments should be made with careful consideration, taking personal circumstances of individuals into account, and using the information in our updated review as a guide to what might happen to patients on either drug."

• Read the Cochrane Review
• Listen to more Cochrane Podcasts
• Get Cochrane Podcasts on iTunes
• Visit the Cochrane Epilepsy website

Buruli ulcer is a neglected tropical disease caused by Mycobacterium ulcerans. It predominantly affects children below age 15 in sub‐Saharan Africa and people of any age in Australia. The infection manifests as a skin nodule, oedematous lesion, plaque, or ulcer. Transmission of Buruli ulcer is not entirely understood, with aquatic insects and mosquitoes being linked to disease transmission in some settings. It is clear, however, that disease is caused by the puncturing injury and introduction of the environmental pathogen into the skin and subcutaneous tissues. Whether the bacteria are thriving within a vector before they are transmitted (biological transmission) or merely transported and injected (mechanical transmission) is yet to be elucidated. Another hypothesis is that M ulcerans on the host skin is introduced following an insect bite or minor trauma.

A new Cochrane Infectious Diseases Review by included and discussed five randomized controlled trials and 13 prospective observational studies on drug treatment of Buruli ulcer - the first of its kind to formally assess the available evidence for drug treatment. This Cochrane Library Editorial discusses the latest findings, what we know, and what questions are still left unanswered.

• Read the Editorial - Treatment for Buruli ulcer: the long and winding road to antimicrobials‐first
• Read the Cochrane Review - Drugs for treating Buruli ulcer (Mycobacterium ulcerans disease)
• Visit the Cochrane Infectious Diseases website

Cochrane Crowd, Cochrane’s citizen science platform, is a global community of volunteers who are helping to classify the research needed to support informed decision-making about health care.

The job of the Cochrane Crowd community is to review descriptions of research studies to identify and classify randomized controlled trials (RCTs), a type of study that is considered the gold standard for clinical trials. Reports of RCTs are then fed into Cochrane’s Central Register of Controlled Trials, helping Cochrane authors and other systematic reviewers around the world quickly find the evidence they need to determine whether a treatment works, or whether a diagnostic test is accurate.

A challenge held in partnership with the Cochrane Associated Centre at Sinaloa’s Pediatric Hospital (Mexico) and the Autonomous University of Sinaloa (Mexico) recently broke all previously held challenge records. 

Giordano Perez-Gaxiola, director of Cochrane Mexico and key challenge organiser said; "I had run a couple of small challenges through Cochrane Classmate with my students in the past year. I thought it was a simple way to motivate them to learn what Cochrane is, what a clinical trial is, and how an easy-to-use platform like Cochrane Crowd could help them learn. A couple of months ago I had a meeting with the dean of the medical faculty of the Autonomous University of Sinaloa (Universidad Autónoma de Sinaloa, UAS), Dr. Gerardo Alapizco, to discuss how the university and our Cochrane Associated Centre at Sinaloa’s Pediatric Hospital (Hospital Pediátrico de Sinaloa, HPS) could collaborate. I proposed setting up a university-wide challenge in order to engage a large number of students. This would introduce them to Cochrane and hopefully pique their interest, potentially leading to further engagement with Cochrane. This proposal was then discussed and approved by the medical faculty’s governing committee. We agreed that all students at UAS would be invited to take part."

Over three days from Dec 5-8, 738 people signed up, 455 participated and 319,643 individual assessments were made equating to 89,692 records being screened. 90 people screened at least 1000 records during the challenge and as a result were invited to become Cochrane members. And finally, almost 10,000 RCTs were identified for Cochrane’s CENTRAL register of controlled trials, where they can be accessed by systematic reviewers around the world.

Perez-Gaxiola added; "In my opinion, a Cochrane Crowd challenge is a simple way to engage students, to help them learn about Cochrane and about clinical trials. It is very easy to set up (takes about 10 minutes) and easy for the students to participate. It can be a useful teaching tool, too. And if you make it a competition, it can be fun."

• Learn about the benefits of joining Copchrane Crowd as a student
  
• Read the full interview with Giordano Perez-Gaxiola
• Learn more about Cochrane Crowd
• Learn more about Cochrane ClassMate
• Visit the Cochrane Mexico website

The review 'Adverse events in people taking macrolide antibiotics'  asked, “Will people taking a macrolide antibiotic experience more adverse events than those treated with placebo?”

Macrolide antibiotics are one of many types of antibiotic. They are commonly used to treat both acute and chronic infections. The four most commonly used macrolides are azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk of experiencing adverse events such as nausea, diarrhoea or rashes.

Lead author of the review Malene Plejdrup Hansen explains, “This review was undertaken to quantify adverse events in patients using macrolide antibiotics, independently of the indication or effects of the treatments. The intent is to support clinicians and patients in evaluating harms as well as benefits in the choice of management when antibiotics are considered.”

The review includes 183 studies with 252,886 participants. Most studies were conducted in hospitals. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin. Most studies (89%) reported some adverse events or at least stated that no adverse events were observed. 

• People treated with a macrolide antibiotic experienced gastrointestinal adverse events, such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo.
• Taste disturbances were more often reported by people taking macrolides than those taking a placebo. However, very few studies reported on these adverse events, and results should be interpreted with caution.
• Hearing loss was more often reported by people taking macrolide antibiotics; however, only four studies reported this outcome.
• Macrolides caused less cough and less respiratory tract infections than placebo.
• We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo.
• We did not find more deaths in people treated with macrolides than in those treated with placebo.
• Very limited information was available to assess if people taking a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those treated with placebo, but differences in resistance thereafter were inconsistent.

The quality of evidence ranged from very low (cardiac disorders, change in liver enzymes, liver disorders), to low (abdominal pain, death, diarrhoea, dizziness, hearing loss, skin and soft tissue infections, taste disturbance, wheeze), to moderate (appetite loss, blood infection, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory tract infections, vomiting) according to GRADE assessment.

•  Read the full Cochrane Review
• Visit the Acute Respiratory Infections website

 Knowledge Translation in Cochrane is delighted to share this request for proposal for the project to agree a set of ‘principles for dissemination’ and to develop practical tools in order to improve the quality of Cochrane’s dissemination products.

This new and exciting opportunity is a commissioned piece of work open to the Cochrane community and will involve working with the Knowledge Translation (KT) ‘Improving and Upscaling KT products’ Working Group and our KT Advisory Group.

The deadline is Friday 18th January 2019, 17:00 GMT. For further information or any questions please contact Karen Head (khead@cochrane.org).

• Review the request for proposal
• Find out more information about KT in Cochrane
  

On Friday, 7th December, Cochrane enthusiasts gathered at the University of Split School of Medicine to celebrate the 10th anniversary of Cochrane Croatia.

Cochrane Croatia was founded as a Branch of the Italian Cochrane Centre on 8th December, 2008, ten years following initial discussions between Prof. Ana Marušić, Sir Iain Chalmers and Prof. Alessandro Liberati. Prof. Peter Tugwell, and his team, were instrumental in building capacity within Cochrane Croatia, along with the Mamić family who warmly welcomed several members of Cochrane Croatia into their family home, in Ottawa. Together, with the support of the Italian Cochrane Centre, later lead by Roberto D’Amico, Cochrane Croatia grew to become an independent Cochrane Centre in 2017. 

Today, Cochrane Croatia has 20 members, 19 partner organisations, 1 Affiliate - with another two in the pipeline. The Anniversary celebration was opened by the Vice-Dean for Research at the University of Split School of Medicine, Prof. Mirna Saraga-Babić, and by Cochrane Croatia’s Co-Director, Dr. Tina Poklepović Peričić. This was followed by an address given by the Chancellor of the University of Split, Prof. Dragan Ljutić and by Prof. Stipan Janković, Dean of the medical school in Split at the time Cochrane Croatia was founded. Prof. Ozren Polašek, Director of Croatian Centre for Global Health, underlined the importance of systematic reviews and Cochrane’s crucial role in their production and dissemination. Prof. Žarko Alfirević, from Cochrane Pregnancy and Childbirth, shared how Cochrane reviews influenced his clinical practice.  

The videos ‘Three patients and their stories contributing to Cochrane’s success’ and ‘Recognising success in Cochrane in 2017’ were screened. This was followed by Prof. Matko Marušić’s reminder of the early days of Cochrane Croatia, after which Cochrane Croatia’s Co-Director, Irena Zakarija-Grković, provided an overview of the first ten years, summarized in a published report ‘Cochrane Croatia: 2008-2018’. Finally, Dr Ljubo Znaor, Research Office Coordinator at the University Hospital Split, spoke of future projects with Cochrane Croatia.

All present celebrated Cochrane Croatia’s achievements with an appropriately decorated birthday cake and plenty of good cheer!

Irena Zakarija-Grković, Co-Director Cochrane Croatia

• Visit the Cochrane Croatia website
• Read Cochrane Evidence in Croatian

Cochrane, a global independent network of researchers, professionals, patients, carers and people interested in health, is proud to announce its newest Associate Centre,  Cochrane Czech Republic, at the Faculty of Medicine, Masaryk University, Brno.

Cochrane Czech Republic will promote evidence-based decision making in healthcare in the Czech Republic by supporting and training authors of Cochrane Reviews, as well as working with clinicians, professional associations, policy-makers, patients, and the media to encourage the dissemination and use of Cochrane evidence.

Cochrane works with collaborators from more than 130 countries to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest.  Cochrane’s work is recognized as representing an international gold standard for high quality, trusted information.

Cochrane Czech Republic will be coordinated and led by its new Associate Director, Professor Dr. Miloslav Klugar: “The launch of Cochrane Czech Republic is very important. Producing and increasing the dissemination of the best available information on healthcare is critical for clinicians and patients everywhere in the world, including the Czech Republic. Cochrane Czech Republic is one of three important pillars of the Czech National Centre for Evidence-Based Healthcare and Knowledge Translation as an umbrella centre."

Cochrane’s Chief Executive Officer, Mark Wilson, warmly welcomed today’s news: “I am delighted we are announcing the launch of Cochrane Czech Republic, which I’m confident will deepen and expand the reach and impact of Cochrane activities on health and healthcare decision-making across the Czech Republic and therefore improve health outcomes for its 10.5 million citizens. This is why the establishment of Cochrane Czech Republic is so important. We hope that it will also promote health research in the Czech Republic
and Central European region and its application into policy and clinical practice across the country and the world.”

Jitka Klugarová, Associate Professor and Deputy Director for evidence syntheses and implementation, added: “This is an innovation for our region and we intend to collaborate in the dissemination of Cochrane Reviews and to continue supporting Cochrane to reach its 2020 strategic objectives.”

Andrea Pokorná, Associate Professor and Deputy Director for education activities also commented: “This is an excellent opportunity for scientific growth and gives us the chance to train students and a future generation of health workers that will develop high-quality research. Our chance to support health professionals in improving their decision-making based on the best available Cochrane evidence will support patient care.” 

Cochrane Czech Republic is an Associate Centre of Cochrane Germany. This means it will be supported by Cochrane Germany who will offer methodological support, mentoring, and supervision.

For more information on the work of the Cochrane Czech Republic, please visit the website: https://czechrepublic.cochrane.org

Facebook: @CochraneCzechRepublic

Twitter: @czcochrane

About Cochrane
Cochrane is a global independent network of researchers, professionals, patients, carers and people interested in health.

Cochrane produces reviews which study all of the best available evidence generated through research and make it easier to inform decisions about health. These are called systematic reviews.

Cochrane is a not-for profit organization with collaborators from more than 130 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Our work is recognized as representing an international gold standard for high quality, trusted information.

If you are a journalist or member of the press and wish to receive news alerts before their online publication or if you wish to arrange an interview with an author, please contact the Cochrane press office: pressoffice@cochrane.org

Specifications: Part time 0.6 FTE, 1-year consultancy/secondment contract with potential to be extended
Salary: Competitive
Location: Flexible location within US
Application Closing Date: 19 January 2019

This role is an exciting opportunity to use your experience to make a difference in the field of health care research. 

The successful candidate will support the development of the Cochrane US Network. Working with a US-based Advisory Group and Cochrane’s Central Executive, the Cochrane US Network Coordinator will facilitate and support the Network’s establishment and development to deliver its strategic and operational objectives.

We are looking for a self-motivated and highly organised individual who is able to work effectively and collaboratively with a diverse range of contacts across the world.  The successful candidate will also have:

• Master’s degree in communications; journalism; management; health sciences or a related discipline relevant to this position.
• Experience in working in a networked setting.
• Demonstrable experience in working with various partner organizations.
• Understanding of the US research environment.
• Experience in developing funding applications and engaging with funding agencies.
• Ability to work independently under general direction, willing and able to work in a self-directed way.
• Excellent interpersonal and communication skills, with a natural flair for networking.
• Time management skills and ability to work flexible hours as needed.
• Experience related to all aspects of the planning and organising of meetings, workshops and conferences.
• Experience of working in an international context.
• Willingness to travel nationally and internationally when required.
• Be US based.

Cochrane is a global, independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making vast amounts of research evidence useful for informing decisions about health. We do this by synthesizing research findings to produce the best available evidence on what can work, what might harm and where more research is needed. Our work is recognised as the international gold standard for high quality, trusted information

If you would like to apply for this position, please send a CV along with a supporting statement to recruitment@cochrane.org with “Cochrane US Network Coordinator” in the subject line.  The supporting statement should indicate why you are applying for the post, and how far you meet the requirements for the post outlined in the job description using specific examples.  List your experience, achievements, knowledge, personal qualities, and skills which you feel are relevant to the post.

For further information, please see the full job description and the Cochrane US website.
Deadline for applications: 19 January 2019 (12 midnight GMT)
Interviews to be held on: (TBC)

Cochrane Russia Symposium 2018, with the theme 'Cochrane Systematic Reviews as a key resource for health challenges in Knowledge Translation', was organized by the Research & Education Centre for Evidence-Based Medicine Cochrane Russia of the Kazan Federal University (KFU), Wiley ,and Nikolay Lobachevsky Scientific Library of KFU. It was held at the Kazan Federal University on December, 7, 2018.

The Symposium summed up Cochrane Russia activities for the three years of its existence, from the official start on December 7, 2015 at the International Conference "Evidence-Based Medicine: achievements and barriers" (QiQUM 2015), the major achievements and successes, plans for the future and the new promising projects.

Over 100 participants from all over Russia (Volgograd, Donetsk, Irkutsk, Kazan, Kaliningrad, Korolev, Moscow, Nizhnekamsk, Novosibirsk, Rostov-on-Don, St. Petersburg, Sochi, Tyumen, Ulyanovsk, Ufa) and other countries (Germany, Kazakhstan, Kyrgyzstan, Nigeria, the Netherlands, Uzbekistan, Ukraine) registered for the Symposium.

At the closure of the symposium, the organizers and participants provided feed-back on the event, identified areas for cooperation, plans and prospects for joint coordinated work.

A warm congratulations to Cochrane Russia for another successful Symposium!

• Read more about the presentations at Cochrane Russia Symposium
• Learn more about Cochrane Russia
• Read Cochrane evidence in Russian

Dear Cochrane Members,

Thank you for voting in the recent election for new members of the Cochrane Governing Board. Over 1200 people voted and over 4000 votes were cast.

We’re delighted to announce that the following four candidates have been elected:

• Xavier BONFILL
• Sally GREEN
• Karsten Juhl JØRGENSEN
• Jordi PARDO PARDO

Thank you to all the candidates who stood in this election, your contributions and willingness to serve Cochrane in this way are greatly appreciated. The full vote count is available on elections.cochrane.org. Learn more about the Governing Board on the Cochrane Community website. Questions about any aspects of the elections process can be raised with Lucie Binder, Senior Advisor to the CEO (Governance & Management) and Electoral Officer for this election.

Specifications: Full Time
Salary: up to £35,000 DOE
Location: London with flexibility to work from home up to 3 days a week
Application Closing Date: 2nd January 2019

This role is an exciting opportunity to use your experience as a Contracts Officer to make a difference in the field of health care research. 

The successful candidate will support the Senior Contracts Specialist in delivering an effective contracts management service to the Central Executive Team.

Key Tasks:

• Manage and maintain a contracts database in conjunction with the Senior Contracts Specialist, including: record set-up and archiving; maintaining clean, searchable records through consistent use of naming conventions; establish thorough working knowledge of the database system and provide support to other internal users.
• Prepare and issue (internally) monthly deadline reports for contracts due to end/be renewed/payments due.
• Review final drafts of agreements, checking for key details (dates), errors and missing information.
• Prepare spreadsheets collating information/metadata from contracts database on request.
• Communicate with project leads (internal) and third parties to secure key contract details and signature.
• Undertake responsibility for the execution of contracts, responding to any queries arising during the signature process and following-up on records awaiting signature to expedite execution.
• Collate and record relevant information on Cochrane entities in the contracts database.
• Assist the Office manager on an ad-hoc basis when required.

We are looking for a self-motivated and highly organised individual who is able to work effectively and collaboratively with a diverse range of contacts across the world.  The successful candidate will also have:

Essential

• Degree in law or significant experience in contracts management
• Previous experience of providing administrative support to a solicitor/contracts team
• Excellent written and verbal communication skills
• Experience of, or an interest in, learning about contracts drafting and negotiation in the research/healthcare sector
• Experience of skim-reading contracts/reports
• Previous demonstrable experience of database management
• Ability to work methodically and accurately
• Ability to work independently and use initiative/self-starter
• A pro-active approach to problem-solving
• Awareness of handling confidential and sensitive information
• Intermediate level IT skills, including Word, Excel and PowerPoint
• Strong organization and prioritization skills - a flexible approach with the ability to respond quickly to issues as they arise
• Excellent interpersonal skills and ability to maintain a diplomatic, measured approach at all times.

Preferred:

• Experience of contract drafting and negotiation
• Experience of explaining complex issues and terms to non-experts clearly, accurately and concisely
• Experience using online, cloud-based records management systems, such as Concord
• Working in an international organisation

Cochrane is a global, independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making vast amounts of research evidence useful for informing decisions about health. We do this by synthesizing research findings to produce the best available evidence on what can work, what might harm and where more research is needed. Our work is recognised as the international gold standard for high quality, trusted information.

If you would like to apply for this position, please send a CV along with a supporting statement to recruitment@cochrane.org with “Contracts Officer” in the subject line.  The supporting statement should indicate why you are applying for the post, and how far you meet the requirements for the post outlined in the job description using specific examples.  List your experience, achievements, knowledge, personal qualities, and skills which you feel are relevant to the post.

For further information, please see the full job description.

Deadline for applications: 2nd January 2019 (12 midnight GMT)
Interviews to be held on: w/c 7th January 2019 (TBC)

A common consequence for people who have a stroke is a reduction in their arm function. Various approaches are available to try to help and, in September 2018, the Cochrane Review for one of these, electromechanical and robot‐assisted arm training, was updated by a team of researchers from Germany. We asked lead author, Jan Mehrholz from Dresden Medical School, to tell us about the latest findings in this podcast.

"More than two‐thirds of people who have had a stroke have difficulties with reduced arm function. This can limit their ability to perform everyday activities and electromechanical and robot‐assisted arm training might help by using specialised machines to support shoulder, elbow and hand movements. Our review looks at the effects on arm function and muscle strength, and whether patients find it acceptable.

We identified 45 trials, involving a total of approximately 1600 participants; ranging from a trial with just eight participants to a US study with nearly 130. The trials assessed 24 different electromechanical devices, which were tested for between two and 12 weeks, and compared to a variety of other interventions.

Although the trials also used a variety of outcome measures, we can say that, on average, electromechanical and robot‐assisted arm training improves daily living for people after stroke, and improves the function and muscle strength of the affected arm. However, the effects were relatively small and might not be big enough to be seen as clinically important. Adverse events, such as injuries and pain, were seldom described, and so it does seem reasonable to include these devices in the rehabilitation of patients after a stroke but with some uncertainty about when and how often they should be used.

In summary, people who receive electromechanical and robot‐assisted arm training after a stroke might improve their activities of daily living, arm function, and arm muscle strength. However, although the quality of the evidence was high, we still need to be cautious because the benefits are small and there were substantial differences between the trials in the intensity, duration, and amount of training; and the types of treatment, participants and outcomes measurements used."

• Read the Cochrane Review
• Read the featured news story on this Cochrane Review
• Listen to more Cochrane Podcasts
• Get Cochrane Podcasts on iTunes
• Visit the Stroke website

Omega-3 fats are the subject of more than two dozen Cochrane Reviews for conditions including cardiovascular health, dementia and gastrointestinal problems. In November 2018, the review on the effects on preterm birth when these are taken by pregnant women was updated. The review was led by Associate Professor Philippa Middleton and Professor Maria Makrides, from the Healthy Mothers Babies and Children theme at the South Australian Health and Medical Research Institute. Professor Makrides tells us about the latest evidence.

"In Australia, about 1 in 12 babies are born prematurely, this means that they are born more than three weeks before the usual 40 weeks of pregnancy. This is a problem because premature birth is responsible for around 85% of all health complications in early life and is the leading cause of death in children under 5.

There are very few strategies to prevent women from going into early labour and delivering a premature baby. However, one of the things that our research team has been studying is whether the omega-3 long-chain fatty acids, such as DHA and EPA that are found in fish and fish oils, can extend the length of pregnancy.

We have now completed our Cochrane systematic review that brings together all the published randomised trials that test the effects of these long chain omega-3 fats during pregnancy on the health of mothers and their babies. We included 70 studies, which contained more than 19,000 women in the trials. The review shows that there is high-quality evidence that supplementation with long-chain omega-3 fats during pregnancy, particularly with DHA, reduced the risk of having a premature baby by 11% and it also reduced the risk of having a very premature baby, born before 34 weeks, by 42%.

Based on these findings, we suggest that pregnant women with one baby take between 500 and 1000mg of long-chain omega-3s every day from the 12th week of pregnancy. It’s best if these supplements contain at least 500mg of DHA per day. As a result of the review, we are revising clinical practice guidelines for health professionals who are working in pregnancy care to try and encourage pregnant women to supplement their diets with omega-3s, to increase their chances of having a healthy full-length pregnancy."

• Read the Cochrane Review
• Read the news item about this Cochrane Review in English,  French, German, Japanese, Malay,  Russian, and Spanish
• Listen to more Cochrane Podcasts
• Get Cochrane Podcasts on iTunes
• Visit the Pregnancy and Childbirth website

The call for ‘Expressions of Interest’ to join the Cochrane US Network is now open. This call invites US-based organizations and institutions of different kinds to indicate their interest to support and/or join and become part of a new Cochrane US Network. The deadline for submitting an Expression of Interest is January 31, 2019.

• View the US Network Expression of Interest Information

This recently published Cochrane Review assessed which long-acting inhalers are the most effective and safest for people with advanced chronic obstructive pulmonary disease (COPD.)

Chronic obstructive lung disease (COPD) is usually caused by smoking or other airway irritants. COPD damages the lungs and causes airways to narrow which makes it difficult to breathe. The disease accounts for more than three million deaths annually and is the third leading cause of death world-wide, it is also a major cause of disability and hospitalisation. Quality of life can be poor as people find it hard to carry out everyday tasks

There are two types of inhalers for COPD: rescue and maintenance. A rescue inhaler is short- and fast-acting, and used as needed for quick relief of symptoms, whereas a maintenance inhaler is long-acting and used on a daily basis to relieve daily symptoms and reduce flare-ups. The long-acting inhalers are usually reserved for more advanced COPD.

Does it matter which long-acting inhaler is used in people with advanced COPD?
Commonly used maintenance inhalers are grouped into four different groups: long-acting beta2-agonists (LABAs); long-acting muscarinic antagonists (LAMAs); LABA/inhaled corticosteroid (ICS) combinations; and LABA/LAMA combinations. Combination inhalers are usually reserved for individuals whose single-maintenance inhaler, such as LAMA or LABA fails.

There are not many head-to-head comparisons to determine which treatment group or individual inhaler is better compared to the others. Preventing severe flare-ups and hospital admissions is especially important to people with COPD, healthcare providers, policy makers and society.

How did the review group answer the question?
We collected and analysed data from 99 studies, including a total of 101,311 participants with advanced COPD, using a special method called network meta-analysis, which enabled us to simultaneously compare the four inhaler groups and 28 individual inhalers.

What did it find?

• The LABA/LAMA combination was the best treatment, followed by LAMA, in preventing flare-ups although there was some uncertainty in the results.
• Combination inhalers (LABA/LAMA and LABA/ICS), are more effective for controlling symptoms than single-agent therapies (LAMA and LABA), in general.
• The LABA/LAMA combination was better than LABA/ICS combination, especially in people with a prior episode of flare-ups.
• The LABA/ICS combination had a higher incidence of severe pneumonia compared to the others.
• oWe did not find a difference in benefits and harms, including side effects, among individual inhalers within the same treatment groups.

Conclusion 
The LABA/LAMA combination is likely the best treatment in preventing COPD flare-ups. LAMA-containing inhalers appear to have an advantage over those without LAMA for preventing flare-ups.

Combination inhalers (LABA/LAMA and LABA/ICS), appear more effective for controlling symptoms than single-agent therapies (LAMA and LABA). Inhaled steroids carry an increased risk of pneumonia.

Yuji Oba, lead author of this Cochrane review said, “ There are a range of different treatments for COPD, and this review provides a comprehensive assessment of how effective they are at preventing flare ups of COPD, managing symptoms and improving quality of life, but it also looks at important harms including the risk of pneumonia. The findings of the network meta-analysis feed in to guidelines published by NICE and are testament to a strong collaboration between Cochrane Airways group and the guideline group who have developed guidance on managing COPD.”

• Read an interview with the editors of this review
• Read the Cochrane Review
• Visit the  Cochrane Airways website

Cochrane Airways have published its biggest ever Cochrane Review. The meta-analysis review assesses which long-acting inhalers are the most effective and safest for people with advanced chronic obstructive pulmonary disease (COPD) and  supports a recently published NICE guideline.

The logistics of getting such a large review done with time tight timescales have been an enormous challenge for the review team. We asked Rebecca Normansell, Joint Co-ordinating Editor and Emma Dennett, Managing Editor, Cochrane Airways, how this review came about and its potential impact.

How did the review come about?
We received a review proposal towards the end of 2015 from a chest physician in the USA, Yuji Oba, who had identified from his own practice an important clinical question about inhalers for COPD. He had already reviewed the literature and published on the subject, but was aware of new data and was interested in producing a Cochrane Review. He had assembled a team including a UK-based expert in network meta-analysis (NMA), Sofia Dias, with whom we had worked before. We agreed it was an important question, but needed to refine the comparisons in the NMA to minimise overlap with an existing Airways NMA and other reviews. After a bit of back and forth between the editorial base and the authors, we registered the title and the protocol was published in March 2017.

This is the biggest the airways group has done - how many people were involved, did it 'draw' on the team in a unique way?
The review was the biggest review we have ever done. Not only did it have 99 studies, but there were six pairwise comparisons, each with multiple outcomes, and network meta-analyses of multiple outcomes in both high and low risk COPD populations – a vast amount of data!

One of the challenges for the editorial team was the sheer volume of material to edit. We felt overwhelmed at times and making sure the review met the standards and all the data matched up throughout the review and the summary versions was time-consuming. Denise Mitchell, UK-based copy-editor, spent two weeks on it - copy editors are some of the unsung heroes in Cochrane!

While the payoff from working to get the review finished for the NICE guideline has been great, it was quite nerve-wracking. We are essentially trusting an author team to do what they said they will do, but without the control you would have of someone you are employing or paying to deliver a service. Yuji and Sofia were brilliant at keeping in touch with us and doing what they said they would in the timeframe.

What does the review mean? How will it inform policy or practice?
There is an overwhelming number of inhaled drugs licenced for use in COPD, and now multiple ‘fixed dose’ combined inhalers. Health care professionals and health services have to make difficult choices every day, balancing efficacy, safety, patient preference and cost. This huge review compared two single drug options – LABA or LAMA – to combined options – LAMA/LABA or LABA/ICS. The review found that one particular combination – LABA/LAMA – is probably the best treatment for reducing harmful flare-ups of COPD. LAMA containing inhalers (combined with LABA and on its own) are likely to have an advantage over those without a LAMA for preventing COPD flare-ups. Combined drugs appeared more effective than single drugs for improving symptom and quality-of-life scores. Importantly, ICS-containing inhalers were found to be associated with an increased risk of pneumonia – a potentially serious lung infection.

These are important findings that they give extra weight to the direction that most current guidelines are going – to favour LAMA-containing inhalers, especially for those having frequent flare-ups, and reserve ICS-containing inhalers for those who keep having flare-ups despite treatment, or have features suggestive of asthma. The next question is what are the risk and benefits of triple therapy, i.e. adding ICS to LAMA/LABA combinations? Cochrane Airways has just started a review update on this topic.  

The other finding that may interest health care professionals and policy makers is that, in general, when the review authors looked at individual drugs within a class and at the class of drugs as a whole in the NMA, they found little difference. This suggests that drugs within a class are probably broadly equivalent, so perhaps other factors such as cost and patient preference can be considered when prescribing.

In terms of it appearing in guidelines, can you say a little about the history of this relationship? How does it build on what has happened before?
Back in 2016, we started the process of applying for a Cochrane Programme Grant, focussed on COPD. We were aware that NICE were working on a COPD guidelines update at the same time. We made contact with NICE to find out if there were sensible ways for us to work together and share resources. We had already had some contact with NICE in previous Programme Grants, and are registered stakeholders for their respiratory-related consultations.

We had a discussion and agreed that we would deliver one of our Programme Grant reviews, about long-term antibiotics for COPD, in time for the guideline and to share our data early – which we have done – the published review can be read here. But during the discussion, we also found out that NICE would be very interested in the findings of this NMA, which was about to be published as a protocol. We approached the author team to find out if they could deliver data and the finished review to the NICE deadline and we were delighted when they agreed to do their best. We kept in close contact with NICE and the author team over the following 18 months. We shared data from the NMA with NICE in January 2018 and were thrilled to be able to publish the finished review just a couple days before the guideline itself – phew!

• Read the Cochrane Review
• Read a summary of this Review
• Visit the Cochrane Airways Group  website
• Read the NICE guideline

The Cochrane Fertility Regulation Group (CFRG) is looking to appoint one or more new Co-ordinating Editor(s) to provide leadership of the Group. The CFRG is part of the Cochrane Children & Families Network. This is an important opportunity to lead and shape the future development of a strategically important area of Cochrane’s healthcare evidence coverage. The CFRG portfolio of reviews includes 81 active reviews and 13 protocols.

Applications are welcomed from individuals based in any country. We invite applications from within existing Cochrane Groups and beyond, and also individuals interested in a job share. Applicants should be aware of the following requirements:

1.        The Co-ordinating Editor(s) must have:

• Experience of authoring Cochrane or alternative high quality systematic reviews
• Clinical expertise and standing in the field of contraception and abortion
• Methodology expertise in the field of evidence synthesis, including risk of bias and GRADE assessments

2.        The following attributes are highly desirable

• Experience of editing Cochrane reviews or alternative high quality systematic reviews
• Advanced methodological skills and knowledge

3.        The new Co-ordinating Editor(s) must work within the terms of the Collaboration Agreement that defines the responsibilities of Cochrane and the Cochrane Review Group. 

4.        The new Co-ordinating Editor(s) must actively engage with the Children & Families Network and adhere to the Network’s strategic plan.

Potential applicants should familiarise themselves with Cochrane’s commercial sponsorship and conflict of interest policy.

Individuals who are interested to explore this opportunity are welcome to speak with David Tovey, Editor-in-Chief (dtovey@cochrane.org).

To apply, please send a cover letter detailing the responses to the numbered bullet points above, and a short Curriculum Vitae to David Tovey.

For further information, please review the full role description.

Deadline for applications: 07 January 2019 (12 midnight GMT)

Details of interviews will be provided in the due course

This Special Collection of Cochrane Systematic Reviews brings together a large body of research on the accuracy of tests used to diagnose skin cancer.

The suite of eleven reviews was led by Dr Jac Dinnes at the University of Birmingham and supported by the Cochrane Skin Group and a team of over 30 researchers and expert advisors, funded by the National Institute for Health Research (NIHR).   

The reviews summarise research evidence assessing the accuracy of different diagnostic tests to support clinical and policy related decision making in the diagnosis of all types of skin cancer. 

Dr Jac Dinnes, of the University of Birmingham’s Institute of Applied Health Research, said: “Early and accurate detection of all skin cancer types is essential to manage the disease and to improve survival rates in melanoma, especially given the rate of skin cancer world-wide is rising. 

The visual nature of skin cancer means that it can be detected and treated in many different ways and by a number of different types of specialists, therefore the aim of these reviews is to provide the world’s best evidence for how this endemic type of cancer should be identified and treated."

“We have found that careful consideration should be given of the technologies that could be used to make sure that skin cancers are not missed, at the same time ensuring that inappropriate referrals for specialist assessment and inappropriate excision of benign skin lesions are kept to a minimum.” 

Key findings of the Special Collection were:

• Visual inspection using the naked eye alone is not good enough and melanomas may be missed.
• Smartphone applications used by people with concerns about new or changing moles or other skin lesions have a high chance of missing melanomas.
•  When used by specialists, dermoscopy - a technique using a handheld device to zoom in on a mole and the underlying skin - is better at diagnosing melanoma than visual inspection alone, and may also help in the diagnosis of BCCs.
•  Dermoscopy might also help GPs to correctly identify people with suspicious lesions who need to be seen by a specialist. 
•  Dermoscopy is already widely used by dermatologists to diagnose melanoma but its use in primary care has not been widely evaluated therefore more specific research is needed.
•  Checklists to help interpret dermoscopy might improve the accuracy of diagnosis for practitioners with less expertise and training. 
•  Teledermatology - remote specialist assessment of skin lesions using dermoscopic images and photographs - is likely to be a good way of helping GPs to decide which skin lesions need to be seen by a skin specialist but future research needs to be better designed. 
• Artificial intelligence techniques, such as computer-assisted diagnosis (CAD), can identify more melanomas than doctors using dermoscopy images. However, CAD systems also produce far more false positive diagnoses than dermoscopy and could lead to considerable increases in unnecessary surgery. 
• Further research is needed on the use of specialist tests such as reflectance confocal microscopy (RCM) – a non-invasive imaging technique, which allows a clinician to do a ‘virtual biopsy’ of the skin and obtain diagnostic clues while minimising unnecessary skin biopsies.  RCM is not currently widely used in the UK but the evidence suggests that RCM may be better than dermoscopy for the diagnosis of melanoma in lesions that are difficult to diagnose.
•  Other tests such as using high frequency ultrasound have some promise, particularly for the diagnosis of BCCs, but the evidence base is small and more work is needed.

Cochrane Skin founder Professor Hywel Williams, of the Centre of Evidence-Based Dermatology at the University of Nottingham, said: “Completing this broad suite of detailed reviews was a real marathon. 

“Apart from a few exceptions, I was surprised by how poor the overall study designs were, especially in terms of accurately documenting where on the clinical pathway patients were tested. 

“Although some useful conclusions have emerged, for example, on the role of dermoscopy, the greatest value of the research is to serve as a yardstick for designing future studies evaluating skin cancer diagnosis techniques on patients who are typically seen in GP and specialist settings.”

The research team said that future studies evaluating diagnostic skin cancer tests should recruit patients with suspicious skin lesions at the point on the clinical pathway where the test under evaluation will be used in practice. Further research is also needed to evaluate whether checklists to assist diagnosis by visual inspection alone can improve accuracy and to identify how much accuracy varies according to the level of expertise of the clinician carrying out the assessment.  Well-designed studies of dermoscopy in primary care are needed, and the best ways of delivering dermoscopy training need to be identified. 

The reviews have been shared with The National Institute for Health and Care Excellence (NICE) to inform a potential update of the NICE Melanoma guideline, which was last updated in 2015.  

• Read the Special Collection
• Learn more about Cochrane Skin

Are you living with Heart Disease and interested in helping Cochrane Heart focus on research relevant to your condition?

Cochrane Heart aims to prepare, maintain, and promote the access of systematic reviews of the effect of interventions for treating and preventing heart disease. Visit the Cochrane Heart website to find out more about their work.

The Cochrane Consumer Network describes the importance of including people who access health services in the work that Cochrane does.  As someone with experience of heart disease, Cochrane Heart would welcome your perspective and input at all stages of the review process.

Perhaps you could help select new topics for reviews, or check that review protocols contain outcomes of relevance to patients and their families?  All Cochrane reviews have Plain Language Summaries for a wider audience, and your input here would be really valuable in helping to get the review’s message across to everyone.

If this sounds like something you’d like to get involved with, please contact cochrane.heart@ucl.ac.uk for further information.