The Cochrane Library: a useful resource for evidencebased stroke medicine

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The Cochrane Library a useful resource for
evidence-based stroke medicine

• Peter Sandercock, Hazel Fraser, Brenda Thomas,
  Alison McInnes Sharon Dixon
• on behalf of the
• Cochrane Stroke Group

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Cochrane Collaboration

• International not-for-profit organisation
• Aim to help people make well- informed decisions
  about healthcare, by
• preparing systematic reviews of the effects of
  health care interventions.
• keeping the reviews up to date
• making the reviews accessible

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Cochrane systematic review, a structured process
Systematic review
Systematic review

• Clear question
• Search for all relevant trials
• Select trials which meet eligibility criteria
• Extract data from eligible studies
• Synthesis of data (meta-analysis)
• Update review every 2 years

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Review Groups

• Acute respiratory infections
• Airways
• Anaesthesia
• Back
• Breast cancer
• Colorectal cancer
• Consumers and communication
• Cystic fibrosis and genetic disorders
• Dementia cognitive improvement
• Depression, anxiety neurosis

• Developmental, psychosocial and learning problems
• Drugs and alcohol
• Ear, nose and throat disorders
• Effective practice and organisation of care
• Epilepsy
• Eyes and vision
• Fertility regulation
• Gynaecological cancer
• Heart
• Hepato-biliary

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Review Groups

• Multiple sclerosis
• Muskuloskeletal
• Musculoskeletal injuries
• Neonatal
• Neuromuscular disease
• Oral health
• Pain, palliative and supportive care
• Peripheral vascular diseases
• Pregnancy and childbirth
• Prostatic diseases and urologic cancers
• Renal

• Haematological malignancies
• HIV/AIDS
• Hypertension
• Incontinence
• Infectious diseases
• Inflammatory bowel disease
• Injuries
• Lung cancer
• Menstrual disorders and subfertility
• Metabolic and endocrine disorders
• Movement disorders

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Review Groups

• Schizophrenia
• Sexually transmitted diseases
• Skin
• Stroke
• Tobacco addiction
• Upper gastrointestinal and pancreatic diseases
• Wounds

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Access to Cochrane Library

• Abstracts of the completed reviews are available
  free at the Group's website http//www.dcn.ed.ac.
  uk/csrg/.
• Free access to whole Cochrane Library in some
  countries, see http//www.update-software.com/Coc
  hrane/provisions.htm
• Access by subscription at http//www.update-softwa
  re.com/
• La Cochrane Library Plus en español at
  http//www.update-software.com/clibplus/

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Free access to CLIB for all is now available in
several countries
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Cochrane Library Issue 2, 2003 contains

• Cochrane Database of Systematic Reviews 1,600
  Reviews
• Database of Abstracts of Reviews of
  Effectiveness 3,900 Abstracts
• Cochrane Central Register of Controlled Trials
  (CENTRAL) 354,000 reports of RCTs and CCTs

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Cochrane Stroke Review Group

• 220 reviewers from
• 21 countries
• preparing systematic reviews on interventions for
  stroke
• prevention
• treatment
• rehabilitation

• The Stroke Group is supported by a grant from the
  Chief Scientists Office, Scottish Executive

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To find stroke trials, Stroke Group

• Searched
• 20 Electronic bibliographic databases,
• 50 specialist journals by hand
• Many conference proceedings.
• Translated non-English reports of trials
• 46 people translating from 17 languages
• Created a Specialised Register of stroke trials
• Today it has gt 6,750 references to gt 3,000 trials
• Updates register regularly
• Publishes register on Cochrane Library

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Cochrane systematic reviewspublished on
therapies for
Number of reviews
Acute stroke 29 Stroke prevention 10
Cerebral vascular surgery/ interventional
neuroradiology 9 Stroke rehabilitation
8 Organisation of stroke services 6
Intracranial haemorrhage 6
Abstracts available free at http//www.dcn.ed.ac.
uk/csrg
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Acute stroke therapies

• Anticoagulants for acute ischaemic stroke
• Anticoagulants versus antiplatelet agents for
  acute ischaemic stroke
• Anticoagulation for cerebral sinus thrombosis
• Antiplatelet therapy for acute ischaemic stroke
• Antithrombotic drugs for carotid artery
  dissection
• Calcium antagonists for acute ischaemic stroke
• Cooling therapy for acute stroke1
• Corticosteroids for acute ischaemic stroke
• Fibrinogen depleting agents for acute ischaemic
  stroke
• Gangliosides for acute ischaemic stroke
• Glycerol for acute stroke1
• Haemodilution for acute ischaemic stroke
• Interventions for deliberately altering blood
  pressure in acute stroke1
• Interventions for dysphagia in acute stroke
• Low-molecular-weight heparins or heparinoids
  versus standard unfractionated heparin for acute
  ischaemic stroke
• Lubeluzole for acute ischaemic stroke
• Mannitol for acute stroke1
• Nitric oxide donors (nitrates), L-arginine, or
  nitric oxide synthase inhibitors for acute
  stroke1
• Physical methods for preventing deep vein
  thrombosis in stroke1

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Therapies for stroke prevention

• Anticoagulants for preventing recurrence
  following presumed non-cardioembolic ischaemic
  stroke or transient ischaemic attack
• Anticoagulants for preventing stroke in patients
  with nonrheumatic atrial fibrillation and a
  history of stroke or transient ischaemic attacks
• Anticoagulants versus antiplatelet therapy for
  preventing stroke in patients with nonrheumatic
  atrial fibrillation and a history of stroke or
  transient ischaemic attacks
• Antiplatelet therapy for preventing stroke in
  patients with nonrheumatic atrial fibrillation
  and a history of stroke or transient ischaemic
  attacks
• Antiplatelet therapy for preventing stroke in
  patients with non-valvular atrial fibrillation
  and no previous history of stroke or transient
  ischaemic attacks
• Dipyridamole for preventing stroke and other
  vascular events in patients with vascular disease
• Interventions in the management of serum lipids
  for preventing stroke recurrence
• Oral anticoagulants for preventing stroke in
  patients with non-valvular atrial fibrillation
  and no previous history of stroke or transient
  ischemic attacks
• Oral anticoagulants versus antiplatelet therapy
  for preventing further vascular events after
  transient ischaemic attack or minor stroke of
  presumed arterial origin
• Thienopyridine derivatives (ticlopidine,
  clopidogrel) versus aspirin for preventing stroke
  and other serious vascular events in high
  vascular risk patients

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Cerebral vascular surgery/ interventional
neuroradiology

• Carotid endarterectomy for asymptomatic carotid
  stenosis
• Carotid endarterectomy for symptomatic carotid
  stenosis
• Eversion versus conventional carotid
  endarterectomy for preventing stroke
• Local versus general anaesthesia for carotid
  endarterectomy
• Patch angioplasty versus primary closure for
  carotid endarterectomy
• Patches of different types for carotid patch
  angioplasty
• Percutaneous transluminal angioplasty and
  stenting for carotid artery stenosis
• Percutaneous transluminal angioplasty and
  stenting for vertebral artery stenosis
• Routine or selective carotid artery shunting for
  carotid endarterectomy

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Rehabilitation

• Cognitive rehabilitation for attention deficits
• Cognitive rehabilitation for memory deficits
• Cognitive rehabilitation for spatial neglect
• Electrical stimulation for preventing and
  treating post-stroke shoulder pain
• Physiotherapy treatment approaches for the
  recovery of postural control and lower limb
  function following stroke
• Pharmacological treatment for aphasia
• Speech and language therapy for aphasia
• Speech and language therapy for dysarthria due to
  non-progressive brain damage

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Organisation of services

• Information provision for stroke patients and
  their caregivers
• In-hospital care pathways for stroke
• Organised inpatient (stroke unit) care for stroke
• Services for helping acute stroke patients avoid
  hospital admission
• Services for reducing duration of hospital care
  for acute stroke patients
• Therapy based rehabilitation services for stroke
  patients at home

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Therapies for intracranial haemorrhage

• Antifibrinolytic therapy
• Calcium antagonists
• Circulatory volume expansion
• Fibrinolytic therapy for intraventricular
  hemorrhage
• Surgery for primary supratentorial intracerebral
  haemorrhage
• Timing of surgery for aneurysmal subarachnoid
  haemorrhage

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Impact of Cochrane Stroke reviews

• Cochrane reviews cited in national stroke
  guidelines and policy documents in UK, Europe,
  USA, Australia, New Zealand Singapore
• UK National Stroke Guideline states 'In each
  hospital, the neurologist or physician with
  special responsibility for stroke should review
  the Cochrane Library regularly.
• Cochrane Corner now a feature in Stroke