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To give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence‐based” answers to common questions that are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format that has been successfully developed by Kevin Mackway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.

A word of warning. The topic summaries are not systematic reviews, although they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor to search the grey, unpublished literature. What Archimedes offers is practical, best evidence‐based answers to practical, clinical questions.

The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching2 and obtaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question (http://www.cebm.net). A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as the number needed to treat), books by Sackett4 and Moyer5 may help. To pull the information together, a commentary is provided, but to make it all much more accessible, a box provides the clinical bottom lines.

Electronics‐only topics that have been published on the BestBets site (www.bestbets.org) and may be of interest to paediatricians include the following.

Can steroids be used to reduce post tonsillectomy pain?

Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at www.bestbets.org. If your question still hasn't been answered, feel free to submit your summary according to the instructions for authors at www.archdischild.com. Three topics are covered in this issue of the journal:

Is teething the cause of minor ailments?

Should steroid creams be used in cases of labial fusion?

Does erythromycin cause pyloric stenosis?

References

1 Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.

2 Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.

3 Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.

4 Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.

5 Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.

Can: doing, using and replicating evidence‐based child health

The practice of evidence‐based child health is said to be the five‐step way of asking questions, acquiring information, appraising the evidence, applying the results and assessing our performance.

If the truth be known, for the vast majority of the time, most of us perform our clinical practice replicating what we have done previously. Most of the time this is based on the combination of excellent education, skilled interpretation of clinical findings, and good discussions with children and families. We hope that the education we rely on was (and remains) based on the best available scientific evidence. If it is, we are practising a form of “micro‐evidence‐based healthcare (EBHC)” (doing just step 4).

Sometimes, we question our knowledge (or more uncomfortably, someone does this for us), and will head off to top up our understanding of an area. This “using” mode, if we use well‐appraised resources to supply our thirst for information, will also promote the practice of evidence‐based care. This midi‐EBHC asks us to go through steps 1, 2 and 4.

Occasionally, we also actually need to go through the entire process of getting “down and dirty” with the primary research and appraising it to influence our practice. Maxi‐EBHC is considerably more demanding in time, but largely more satisfying intellectually.

If we reframe the practice of EBHC as using the family and child values, the best evidence, and our clinical expertise, then we can do it by micro‐methods, midi‐methods or maxi‐methods, and choose the most appropriate approach for the situation we confront.

Acknowledgement

I thank Dr Sharon Straus, Director of the Center for Evidence‐based Medicine, University of Toronto, Toronto, Ontario, Canada.

In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.

A word of warning. The topic summaries are not systematic reviews, through they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence based answers to practical, clinical questions.

The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching,2 and gaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question.4 A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat, NNT) books by Sackett5 and Moyer6 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.

Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at www.bestbets.org. If your question still hasn't been answered, feel free to submit your summary according to the Instructions for Authors at www.archdischild.com. Three topics are covered in this issue of the journal:

Does neonatal BCG vaccination protect against tuberculous meningitis?

Does dexamethasone reduce the risk of extubation failure in ventilated children?

Should metformin be prescribed to overweight adolescents in whom dietary/behavioural modifications have not helped?

REFERENCES

1. Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.

2. Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.

3. Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.

4. http://cebm.jr2.ox.ac.uk/docs/levels.htm (accessed July 2002).

5. Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.

6. Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.

How to read your journals

Most people have their journals land, monthly, weekly, or quarterly, on their desk, courtesy of their professional associations. Then they sit, gathering dust and guilt, for a period of time. When the layer of either is too great for comfort (or the desk space is needed for some proper work), the wrapper is removed and the journal scanned. But does how people read reflect their information needs or their entertainment requirements?

It is not uncommon to find people straying from the editorial introduction to the value added sections (like obituaries, Lucina‐like summary pages, and end‐of‐article fillers) rather than face the impenetrable science that sits between them. I think that this is probably unhelpful, and would urge readers to do one more thing before placing the journal in the recycling. Scan the table of contents; if it mentions a systematic review or a randomised trial, then read at least the title and the abstract's conclusions. If you agree, pat yourself warmly on the back for being evidence based and up‐to‐date. If you disagree, ask if it will make any impact on your clinical (or personal) life. If it might, run through the methods and quickly appraise them. Does it supply higher quality evidence than that you already possess? If it does, it's worth reading. If it doesn't, don't bother too much.

There are new innovations which might aid the tedious task of consuming research effort. The on‐line Précis section of the Archives provides a highly readable version of the contents page to whet one's appetite. Finally, it's worth mentioning that evidence based summary materials (like Archimedes, or Journal Watch) are always worth reading—and if you didn't think that you wouldn't be here, would you?

To give the best care to patients and families, paediatricians need to integrate the highest‐quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence‐based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format that has been successfully developed by Kevin Macaway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.

A word of warning. The topic summaries are not systematic reviews, although they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence‐based answers to practical, clinical questions.

The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching2 and gaining answers.3) A brief report of the search used follows—this has been carried out in a hierarchical way, to search for the best‐quality evidence to answer the question (http://www.cebm.net/levels_of_evidence.asp). A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal and the measures of effect (such as number needed to treat), books by Sackett et al4 and Moyer et al5 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.

Electronic‐only topics that have been published on the BestBets site (www.bestbets.org) and may be of interest to paediatricians include:

Are meningeal irritation signs reliable in diagnosing meningitis in children?

Is immobilisation effective in Osgood‐Schlatter's disease?

Do all children presenting to the emergency department with a needlestick injury require PEP for HIV to reduce HIV transmission?

Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at www.bestbets.org. If your question still has not been answered, feel free to submit your summary according to the Instructions for Authors at www.archdischild.com. Three topics are covered in this issue of the journal.

Is lumbar puncture necessary for evaluation of early neonatal sepsis?

Does the use of calamine or antihistamine provide symptomatic relief from pruritus in children with varicella zoster infection?

Is supplementary iron useful when preterm infants are treated with erythropoietin?

Is more research needed?

“More research is needed” is a phrase you might have read before. But is more research really needed? Two situations are offered to us in Archimedes this month where clinical questions are, as yet, unanswered. Is iron supplementation really necessary for premature infants treated with erythropoietin, and do antihistamines and calamine lotion help in children with chicken pox? How can we decide if these questions really do “need” research? It may be worth thinking of how likely benefits and harms may be, what the importance of these outcomes are and finally, how much would you consider reasonable to pay for the answer? For example, what chance is there that antihistamines work in chickenpox? What is the chance that side effects will occur? What is the relative severity of side effects versus the delight of being itch free? If we pay for research and spend hours and hours of time pressing through the increasing regulatory frameworks for clinical trials to define the answer to this question, what will be the opportunity cost? What would we fail to do by looking at this? The same questions can be asked of iron supplementation in premature infants, the salvage treatment of relapsing systemic histocytosis or the promotion of car‐seat use in low‐income families. Such value judgements are important; they will have different answers from different perspectives; they will be subject to political influences from pressure groups; being aware of them might stop us from frequently expounding “more research is needed”.

References

1Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.

2Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.

3Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.

4Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.

5Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.

In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence‐based” answers to common questions which are not at the forefront of research but are at the core of practice. In doing this, we are adapting a format which has been successfully developed by Kevin Macaway‐Jones and the group at the Emergency Medicine Journal—“BestBets”.

A word of warning. The topic summaries are not systematic reviews, though they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence‐based answers to practical, clinical questions.

The format of Archimedes may be familiar. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching2 and gaining answers.3) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best‐quality evidence to answer the question. (http://www.cebm.net). A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat), books by Sackett et al4 and Moyer et al5 may help. To pull the information together, a commentary is provided. But to make it all much more accessible, a box provides the clinical bottom lines.

Electronic‐only topics that have been published on the BestBets site (www.bestbets.org) and may be of interest to paediatricians include:

When is a second course of indomethacin effective for PDA in neonates?

Does delayed cord clamping prevent sepsis?

Readers wishing to submit their own questions—with best evidence answers—are encouraged to review those already proposed at www.bestbets.org. If your question still hasn't been answered, feel free to submit your summary according to the Instructions for Authors at www.archdischild.com. Three topics are covered in this issue of the journal:

In children aged <3 years does procalcitonin help exclude serious bacterial infection in fever without focus?

Does avoidance of breast feeding reduce mother‐to‐infant transmission of hepatitis C virus infection?

Should children under treatment for juvenile idiopathic arthritis receive flu vaccination?

CAN gambling with other people's children

When we use tests to “rule out” a condition, we generally accept that we are left with a small risk of being wrong. (I think we have all discharged a child with an “upper respiratory tract infection” on a Friday to be greeted with them on antibiotics for pneumonia the following Monday.) How much faith we place in a test result is a product of two things: our initial assumption about the likelihood of the diagnosis (pretest probability) and our opinion as to how effective the test is (accuracy), but our actions do not just reflect these factors.

For instance, a well, afebrile child with a scattering of petechiae over its wrist 8 hours before, is unlikely to have meningococcal disease. If you perform a couple of tests, you can find that it has a low C‐reactive protein and a normal full blood count. What we do with this varies widely; some people would treat this with 48 h of antibiotics, others would discharge the patient home.

It is interesting to reflect on two things: first, what chance of meningococcal disease would you put on this clinical picture (before the test), and what about with the test results? What about your colleagues? You may be surprised by how widely this varies. Second, even those who have the same estimates of risk of disease may have different preferred actions (depending on their attitude to risk).

In looking at the diagnostic test for the ruling out of a disease, we can make our arguments more useful by having some data on the assumptions we make, and then transparently discussing our attitudes to risk. It is only after doing this that we can really decide if a test is good enough for us, regardless of how accurate it might be.

References

1Moyer VA, Ellior EJ. Preface. In: Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health, Issue 1. London: BMJ Books, 2000.

2Richardson WS, Wilson MC, Nishikawa J, et al. The well‐built clinical question: a key to evidence‐based decisions. ACP J Club 1995;123:A12–13.

3Bergus GR, Randall CS, Sinift SD, et al. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9:541–7.

4Sackett DL, Starus S, Richardson WS, et al. Evidence‐based medicine. How to practice and teach EBM. San Diego: Harcourt‐Brace, 2000.

5Moyer VA, Elliott EJ, Davis RL, et al, eds. Evidence based pediatrics and child health. Issue 1. London: BMJ Books, 2000.

Background

Neuropathic pain can reduce the quality of life and independence of 30% to 50% of patients with diabetes. The comparative effectiveness of analgesics for patients with diabetic neuropathy remains unclear. The aim of the current work, therefore, was to summarize the evidence about the analgesic effectiveness of the most common oral and topical agents used for the treatment of peripheral diabetic neuropathy.

Methods

We will use an umbrella approach (systematic review of systematic reviews) to identify eligible randomized controlled trials (RCTs) for the most common oral or topical analgesics for painful diabetic neuropathy. Two reviewers will independently determine RCT eligibility. Disagreement will be solved by consensus and arbitrated by a third reviewer. We will extract descriptive, methodological and efficacy data in duplicate. Results will be pooled and analyzed using classic random-effects meta-analyses and network meta-analyses to compute the absolute and relative efficacy of therapeutic options. We will use the I2 statistic and Cochran’s Q test to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as overall strength of the evidence.

Discussion

This network meta-analysis aims to synthesize available direct and indirect evidence of effectiveness of analgesics in the treatment of painful diabetic neuropathy. The network approach will offer the opportunity to generate a ranking based on efficacy and along with known side effects, costs, and administration burdens will enable patients and clinicians to make choices that best reflect their preferences for treatment of painful diabetic neuropathy.

Background

Meta-narrative review is one of an emerging menu of new approaches to qualitative and mixed-method systematic review. A meta-narrative review seeks to illuminate a heterogeneous topic area by highlighting the contrasting and complementary ways in which researchers have studied the same or a similar topic. No previous publication standards exist for the reporting of meta-narrative reviews. This publication standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for meta-narrative reviews.

Methods

We (a) collated and summarized existing literature on the principles of good practice in meta-narrative reviews; (b) considered the extent to which these principles had been followed by published reviews, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, meta-narrative reviews, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing meta-narrative reviews and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence review and real-time problem analysis into a definitive set of standards.

Results

We identified nine published meta-narrative reviews, provided real-time support to four ongoing reviews and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature, and common questions and challenges into briefing materials for the Delphi panel, comprising 33 members. Within three rounds this panel had reached consensus on 20 key publication standards, with an overall response rate of 90%.

Conclusion

This project used multiple sources to draw together evidence and expertise in meta-narrative reviews. For each item we have included an explanation for why it is important and guidance on how it might be reported. Meta-narrative review is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further theoretical and methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of meta-narrative reviews.

To encourage dissemination of the RAMESES publication standards, this article is co-published in the Journal of Advanced Nursing and is freely accessible on Wiley Online Library (http://www.wileyonlinelibrary.com/journal/jan).

Please see related articles http://www.biomedcentral.com/1741-7015/11/21 and http://www.biomedcentral.com/1741-7015/11/22

Introduction:

Aim of this systematic review was to assess the orthodontic related issues which currently provide the best evidence as documented by meta-analyses, by critically evaluating and discussing the methodology used in these studies.

Material and Methods:

Several electronic databases were searched and handsearching was also performed in order to identify the corresponding meta-analyses investigating orthodontic related subjects. In total, 197 studies were retrieved initially. After applying specific inclusion and exclusion criteria, 27 articles were identified as meta-analyses treating orthodontic-related subjects.

Results:

Many of these 27 papers presented sufficient quality and followed appropriate meta-analytic approaches to quantitatively synthesize data and presented adequately supported evidence. However, the methodology used in some of them presented weaknesses, limitations or deficiencies. Consequently, the topics in orthodontics which currently provide the best evidence, include some issues related to Class II or Class III treatment, treatment of transverse problems, external apical root resorption, dental anomalies, such as congenital missing teeth and tooth transposition, frequency of severe occlusal problems, nickel hypersensitivity, obstructive sleep apnea syndrome, and computer-assisted learning in orthodontic education.

Conclusions:

Only a few orthodontic related issues have been so far investigated by means of MAs. In addition, for some of these issues investigated in the corresponding MAs no definite conclusions could be drawn, due to significant methodological deficiencies of these studies. According to this investigation, it can be concluded that at the begin of the 21st century there is evidence for only a few orthodontic related issues as documented by meta-analyses, and more well-conducted high quality research studies are needed to produce strong evidence in order to support evidence-based clinical practice in orthodontics.

Research synthesis seeks to gather, examine and evaluate systematically research reports that converge toward answering a carefully crafted research question, which states the problem patient population, the intervention under consideration, and the clinical outcome of interest. The product of the process of systematically reviewing the research literature pertinent to the research question thusly stated is the “systematic review”.

The objective and transparent approach of the systematic review aims to minimize bias. Most systematic reviews yield quantitative analyses of measurable data (e.g., acceptable sampling analysis, meta-analysis). Systematic reviews may also be qualitative, while adhering to accepted standards for gathering, evaluating, and reporting evidence. Systematic reviews provide highly rated recommendations for evidence-based health care; but, systematic reviews are not equally reliable and successful in minimizing bias.

Several instruments are available to evaluate the quality of systematic reviews. The 'assessment of multiple systematic reviews' (AMSTAR) was derived from factor analysis of the most relevant items among them. AMSTAR consists of eleven items with good face and content validity for measuring the methodological quality of systematic reviews, has been widely accepted and utilized, and has gained in reliability, reproducibility. AMSTAR does not produce quantifiable assessments of systematic review quality and clinical relevance.

In this study, we have revised the AMSTAR instrument, detracting nothing from its content and construct validity, and utilizing the very criteria employed in the development of the original tool, with the aim of yielding an instrument that can quantify the quality of systematic reviews. We present validation data of the revised AMSTAR (R-AMSTAR), and discuss its implications and application in evidence-based health care.

Introduction:

Systematic reviews and meta-analyses of well-designed and executed randomized controlled trials have the potential to provide the highest levels of evidence to support diagnostic and therapeutic interventions in urology.

Materials and Methods:

The role of systematic reviews in the urological literature is described. A three-step appraisal of the validity, magnitude and applicability of results will permit an evidence-based approach to incorporating findings of systematic reviews and meta-analyses into practice.

Results:

The validity of systematic reviews depends on a focused clinical question that generates specific inclusion and exclusion criteria for identifying studies through an exhaustive literature search. The primary studies must be of high methodological quality and assessments should be reproducible. Informed consumers of the urological literature should be aware of the consistency of results between trials in a review, as well as the magnitude and precision of the best estimate of the treatment effects. When making decisions about implementing the results, urologists should consider all patient-important outcomes, the overall quality of the evidence and the balance between benefits, potential harms and costs.

Conclusion:

This framework will lead to a more evidence-based application of systematic reviews within the urological literature. Ideally, utilization of an evidence-based approach to systematic reviews will improve the quality of urological patient care.

Introduction

Meta-analyses have been suggested to be the highest form of evidence available to clinicians to guide clinical practice in critical care. The purpose of this study was to systematically evaluate the quality of meta-analyses that address topics pertinent to critical care.

Methods

To identify potentially eligible meta-analyses for inclusion, a systematic search of Medline, EMBASE and the Cochrane Database of Systematic Reviews was undertaken, using broad search terms relevant to intensive care, including: intensive care, critical care, shock, resuscitation, inotropes and mechanical ventilation. Predetermined inclusion criteria were applied to each identified meta-analysis independently by two authors. To assess report quality, the included meta-analyses were assessed using the component and overall scores from the Overview Quality Assessment Questionnaire (OQAQ). The quality of reports published before and after the publication of the QUOROM statement was compared.

Results

A total of 139 reports of meta-analyses were included (kappa = 0.93). The overall quality of reports of meta-analyses was found to be poor, with an estimated mean overall OQAQ score of 3.3 (95% CI; 3.0–3.6). Only 43 (30.9%) were scored as having minimal or minor flaws (>5). We noted problems with the reporting of key characteristics of meta-analyses, such as performing a thorough literature search, avoidance of bias in the inclusion of studies and appropriately referring to the validity of the included studies. After the release of the QUOROM statement, however, an improvement in the overall quality of published meta-analyses was noted.

Conclusion

The overall quality of the reports of meta-analyses available to critical care physicians is poor. Physicians should critically evaluate these studies prior to considering applying the results of these studies in their clinical practice.

Background

A systematic review is used to investigate the best available evidence of clinical safety and effectiveness of healthcare intervention. This requires methodological rigor in order to minimize bias and random error. The purpose of this study is to assess the quality of systematic reviews or meta-analyses for nursing interventions conducted by Korean researchers.

Methods

We searched electronic databases from 1950 to July 2010, including ovidMEDLINE, ovidEMBASE, and Korean databases, including KoreaMed, Korean Medical Database, and Korean studies Information Service System etc. Two reviewers independently screened and selected all references, and assessed the quality of systematic reviews or meta-analyses using the “Assessment of Multiple Systematic Reviews" (AMSTAR) tool.

Results

Twenty two systematic reviews or meta-analyses were included in this study. The median overall score (out of 11) for included reviews was 5 (range 2–11) and the mean overall score for AMSTAR was 4.7 (95% confidence interval 3.8-5.7). Nine out of 22 reviews were rated as low quality (AMSTAR score 0–4), 11 were rated as moderate quality (AMSTAR score 5–8), and two reviews were categorized as high quality (AMSTAR score 9–11).

Conclusions

The methodological quality of published reviews on nursing interventions conducted by Korean reviewers was assessed as low to moderate. In order to use the best available evidence in clinical decision making, reviewers should conduct systematic reviews or meta- analyses using rigorous research methods.

Background

Prevention of diarrhea has presented indomitable challenges. A preventive strategy that has received significant interest is zinc supplementation. Existing literature including quantitative meta-analyses and systematic reviews tend to show that zinc supplementation is beneficial however evidence to the contrary is augmenting. We therefore conducted an updated and comprehensive meta-analytical synthesis of the existing literature on the effect of zinc supplementation in prevention of diarrhea.

Methods

EMBASE®, MEDLINE ® and CINAHL® databases were searched for published reviews and meta-analyses on the use of zinc supplementation for the prevention childhood diarrhea. Additional RCTs published following the meta-analyses were also sought. Effect of zinc supplementation on the following five outcomes was studied: incidence of diarrhea, prevalence of diarrhea, incidence of persistent diarrhea, incidence of dysentery and incidence of mortality. The published RCTs were combined using random-effects meta-analyses, subgroup meta-analyses, meta-regression, cumulative meta-analyses and restricted meta-analyses to quantify and characterize the role of zinc supplementation with the afore stated outcomes.

Results

We found that zinc supplementation has a modest beneficial association (9% reduction) with incidence of diarrhea, a stronger beneficial association (19% reduction) with prevalence of diarrhea and occurrence of multiple diarrheal episodes (28% reduction) but there was significant unexplained heterogeneity across the studies for these associations. Age, continent of study origin, zinc salt and risk of bias contributed significantly to between studies heterogeneity. Zinc supplementation did not show statistically significant benefit in reducing the incidence of persistent diarrhea, dysentery or mortality. In most instances, the 95% prediction intervals for summary relative risk estimates straddled unity.

Conclusions

Demonstrable benefit of preventive zinc supplementation was observed against two of the five diarrhea-related outcomes but the prediction intervals straddled unity. Thus the evidence for a preventive benefit of zinc against diarrhea is inconclusive. Continued efforts are needed to better understand the sources of heterogeneity. The outcomes of zinc supplementation may be improved by identifying subgroups that need zinc supplementation.

Objective:

To introduce the concept of evidence-based medicine (EBM) to athletic trainers. This overview provides information on how EBM can affect the clinical practice of athletic training and enhance the care given to patients.

Data Sources:

We searched the MEDLINE and CINHAL bibliographic databases using the terms evidence-based medicine and best practice and the online Index to Abstracts of Cochrane Reviews by group (injury, musculoskeletal injuries, and musculoskeletal) to identify reviews on topics pertinent to athletic training.

Data Synthesis:

Evidence-based medical practice has 5 components: defining a clinically relevant question, searching for the best evidence, appraising the quality of the evidence, applying the evidence to clinical practice, and evaluating the process. Evidence-based medicine integrates the research evidence, clinician's expertise, and patient's preferences to guide clinical decision making. Critical to this effort is the availability of quality research on the effectiveness of sports medicine techniques. Athletic training outcomes research is lagging behind that of other health care professions.

Recommendations:

Athletic trainers need to embrace the critical-thinking skills to assess the medical literature and incorporate it into their clinical practice. The profession should encourage more clinically related research and enhance the scientific foundation of athletic training. Evidence-based medicine provides an important next step in the growth of the athletic training profession.

Background

Although nonoperative treatment is considered the standard of care for the treatment of grade I and II acromioclavicular joint injuries, the treatment of grade III injuries is controversial. There are as many methods of nonoperative treatment as there are for operative stabilization. That is why we conducted a literature research to find out the best evidence regarding the treatment of acute grade III acromioclavicular dislocation.

Method

The research was limited to RCTs, systematic review and meta-analysis in the most representative databases. Even if research identifies more than 600 articles, only five were included in the study because there were RCTs, and systematic reviews, but no meta-analysis articles were found. Moreover, no meta-analysis was performed because of differences of data published in the three RCTs (different type of surgical treatments and different outcome measures).

Results

From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, but complications are more evident in the surgery group. Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation.

Conclusion

More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.

Strong, evidence-based practice requires that objective, unbiased research is available to inform individual clinical decisions, systematic reviews, meta-analyses, and expert guideline recommendations. Seeding trials, publication planning, messaging, and ghostwriting, as well as selective publication and reporting of trial outcomes have been used by industry to distort the medical literature and undermine clinical trial research, explicitly by obscuring information that is relevant to patients and physicians. Policies that promote transparency into the clinical trial research process, through improved and expanded disclosure of investigator contributions and funding, comprehensive publicly-available trial registration, and independent analysis of clinical trial data, have the potential to address these subversive practices by improving accountability among industry and investigators. Minimizing the impact of marketing on clinical trial research, and strengthening the science, will protect both the integrity of the medical literature as well as the public’s health.

Meta-analyses are an essential tool of clinical research. Meta-analyses of individual randomized controlled trials frequently constitute the highest possible level of scientific evidence for a given research question and allow surgeons to rapidly gain a comprehensive understanding of an important clinical issue. Moreover, meta-analyses often serve as cornerstones for evidence-based surgery, treatment guidelines, and knowledge transfer. Given the importance of meta-analyses to the medical (and surgical) knowledge base, it is of cardinal importance that surgeons have a basic grasp of the principles that guide a high-quality meta-analysis, and be able to weigh objectively the advantages and potential pitfalls of this clinical research tool. Unfortunately, surgeons are often ill-prepared to successfully conduct, critically appraise, and correctly interpret meta-analyses. The objective of this educational review is to provide surgeons with a brief introductory overview of the knowledge and skills required for understanding and critically appraising surgical meta-analyses as well as assessing their implications for their own surgical practice.

Background

The rationale for centre selection in randomised controlled trials (RCTs) is often unclear but may have important implications for the generalisability of trial results. The aims of this study were to evaluate the factors which currently influence centre selection in RCTs and consider how generalisability considerations inform current and optimal practice.

Methods and Findings

Mixed methods approach consisting of a systematic review and meta-summary of centre selection criteria reported in RCT protocols funded by the UK National Institute of Health Research (NIHR) initiated between January 2005-January 2012; and an online survey on the topic of current and optimal centre selection, distributed to professionals in the 48 UK Clinical Trials Units and 10 NIHR Research Design Services. The survey design was informed by the systematic review and by two focus groups conducted with trialists at the Birmingham Centre for Clinical Trials. 129 trial protocols were included in the systematic review, with a total target sample size in excess of 317,000 participants. The meta-summary identified 53 unique centre selection criteria. 78 protocols (60%) provided at least one criterion for centre selection, but only 31 (24%) protocols explicitly acknowledged generalisability. This is consistent with the survey findings (n = 70), where less than a third of participants reported generalisability as a key driver of centre selection in current practice. This contrasts with trialists’ views on optimal practice, where generalisability in terms of clinical practice, population characteristics and economic results were prime considerations for 60% (n = 42), 57% (n = 40) and 46% (n = 32) of respondents, respectively.

Conclusions

Centres are rarely enrolled in RCTs with an explicit view to external validity, although trialists acknowledge that incorporating generalisability in centre selection should ideally be more prominent. There is a need to operationalize ‘generalisability’ and incorporate it at the design stage of RCTs so that results are readily transferable to ‘real world’ practice.

Purpose: This paper will provide a description of the methods, skills, and knowledge of expert searchers working on systematic review teams.

Brief Description: Systematic reviews and meta-analyses are very important to health care practitioners, who need to keep abreast of the medical literature and make informed decisions. Searching is a critical part of conducting these systematic reviews, as errors made in the search process potentially result in a biased or otherwise incomplete evidence base for the review. Searches for systematic reviews need to be constructed to maximize recall and deal effectively with a number of potentially biasing factors. Librarians who conduct the searches for systematic reviews must be experts.

Discussion/Conclusion: Expert searchers need to understand the specifics about data structure and functions of bibliographic and specialized databases, as well as the technical and methodological issues of searching. Search methodology must be based on research about retrieval practices, and it is vital that expert searchers keep informed about, advocate for, and, moreover, conduct research in information retrieval. Expert searchers are an important part of the systematic review team, crucial throughout the review process—from the development of the proposal and research question to publication.

Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.

Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.

The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

Background

The reasoning behind evaluating medical interventions is that a hierarchy of methods exists which successively produce improved and therefore more rigorous evidence based medicine upon which to make clinical decisions. At the foundation of this hierarchy are case studies, retrospective and prospective case series, followed by cohort studies with historical and concomitant non-randomized controls. Open-label randomized controlled studies (RCTs), and finally blinded, placebo-controlled RCTs, which offer most internal validity are considered the most reliable evidence. Rigorous RCTs remove bias. Evidence from RCTs forms the basis of meta-analyses and systematic reviews. This hierarchy, founded on a pharmacological model of therapy, is generalized to other interventions which may be complex and non-pharmacological (healing, acupuncture and surgery).

Discussion

The hierarchical model is valid for limited questions of efficacy, for instance for regulatory purposes and newly devised products and pharmacological preparations. It is inadequate for the evaluation of complex interventions such as physiotherapy, surgery and complementary and alternative medicine (CAM). This has to do with the essential tension between internal validity (rigor and the removal of bias) and external validity (generalizability).

Summary

Instead of an Evidence Hierarchy, we propose a Circular Model. This would imply a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at pragmatic but equally rigorous evidence which would provide significant assistance in clinical and health systems innovation. Such evidence would better inform national health care technology assessment agencies and promote evidence based health reform.

Dentists need to make clinical decisions based on limited scientific evidence. In clinical practice, a clinician must weigh a myriad of evidences every day. The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment. Periodontology has a rich background of research and scholarship. Therefore, efficient use of this wealth of research data needs to be a part of periodontal practice. Evidence-based periodontology aims to facilitate such an approach and it offers a bridge from science to clinical practice. The clinician must integrate the evidence with patient preference, scientific knowledge, and personal experience. Most important, it allows us to care for our patients. Therefore, evidence-based periodontology is a tool to support decision-making and integrating the best evidence available with clinical practice.

Background

There are increasing numbers of randomised trials and systematic reviews examining the efficacy of interventions designed to bring about a change in clinical practice. The findings of this research are being used to guide strategies to increase the uptake of evidence into clinical practice. Knowledge of the outcomes measured by these trials is vital not only for the interpretation and application of the work done to date, but also to inform future research in this expanding area of endeavour and to assist in collation of results in systematic reviews and meta-analyses.

Methods

The objective of this review was to identify methods used to measure change in the clinical practices of health professionals following an intervention aimed at increasing the uptake of evidence into practice. All published trials included in a recent, comprehensive Health Technology Assessment of interventions to implement clinical practice guidelines and change clinical practice (n = 228) formed the sample for this study. Using a standardised data extraction form, one reviewer (SH), extracted the relevant information from the methods and/or results sections of the trials.

Results

Measures of a change of health practitioner behaviour were the most common, with 88.8% of trials using these as outcome measures. Measures that assessed change at a patient level, either actual measures of change or surrogate measures of change, were used in 28.8% and 36.7% of studies (respectively). Health practitioners' knowledge and attitudes were assessed in 22.8% of the studies and changes at an organisational level were assessed in 17.6%.

Conclusion

Most trials of interventions aimed at changing clinical practice measured the effect of the intervention at the level of the practitioner, i.e. did the practitioner change what they do, or has their knowledge of and/or attitude toward that practice changed? Less than one-third of the trials measured, whether or not any change in practice, resulted in a change in the ultimate end-point of patient health status.

Background

Meta-analysis is a statistical method for combining the results of primary studies. It is often used in systematic reviews and is increasingly a method and topic that appears in student dissertations. MetaLight is a freely available software application that runs simple meta-analyses and contains specific functionality to facilitate the teaching and learning of meta-analysis. While there are many courses and resources for meta-analysis available and numerous software applications to run meta-analyses, there are few pieces of software which are aimed specifically at helping those teaching and learning meta-analysis. Valuable teaching time can be spent learning the mechanics of a new software application, rather than on the principles and practices of meta-analysis.

Findings

We discuss ways in which the MetaLight tool can be used to present some of the main issues involved in undertaking and interpreting a meta-analysis.

Conclusions

While there are many software tools available for conducting meta-analysis, in the context of a teaching programme such software can require expenditure both in terms of money and in terms of the time it takes to learn how to use it. MetaLight was developed specifically as a tool to facilitate the teaching and learning of meta-analysis and we have presented here some of the ways it might be used in a training situation.

Purpose. To review the literature and make recommendations for the use of anthracycline-based adjuvant chemotherapy in adult patients with soft tissue sarcoma (STS).

Patients. The recommendations apply to patients >15 years old with completely resected STS.

Methods. A systematic overview of the published literature was combined with a consensus process around the interpretation of the evidence in the context of conventional practice to develop an evidence-based practice guideline.

Results. Four meta-analyses and 17 randomized clinical trials comparing anthracycline-based adjuvant chemotherapy versus observation were reviewed. The Sarcoma Meta-Analysis Collaboration (SMAC) was the best analysis because it assessed individual patient data and had the longest follow-up. The results of the SMAC meta-analysis together with data from more recently published randomized trials, as well as our analysis of the toxicity and compliance data, are incorporated in this systematic review.

Discussion. It is reasonable to consider anthracycline-based adjuvant chemotherapy in patients who have had removal of a sarcoma with features predicting a high likelihood of relapse (deep location, size >5 cm, high histological grade). Although the benefits of adjuvant chemotherapy are most apparent in patients with extremity sarcomas, patients with high-risk tumours at other sites should also be considered for such therapy.

Background In high-income countries, administration of antenatal steroids is standard care for women with anticipated preterm labour. However, although >1 million deaths due to preterm birth occur annually, antenatal steroids are not routine practice in low-income countries where most of these deaths occur.

Objectives To review the evidence for and estimate the effect on cause-specific neonatal mortality of administration of antenatal steroids to women with anticipated preterm labour, with additional analysis for the effect in low- and middle-income countries.

Methods We conducted systematic reviews using standardized abstraction forms. Quality of evidence was assessed using an adapted GRADE approach. Existing meta-analyses were reviewed for relevance to low/middle-income countries, and new meta-analysis was performed.

Results We identified 44 studies, including 18 randomised control trials (RCTs) (14 in high-income countries) in a Cochrane meta-analysis, which suggested that antenatal steroids decrease neonatal mortality among preterm infants (<36 weeks gestation) by 31% [relative risk (RR) = 0.69; 95% confidence interval (CI) 0.58–0.81]. Our new meta-analysis of four RCTs from middle-income countries suggests 53% mortality reduction (RR = 0.47; 95% CI 0.35–0.64) and 37% morbidity reduction (RR = 0.63; 95% CI 0.49–0.81). Observational study mortality data were consistent. The control group in these equivalent studies was routine care (ventilation and, in many cases, surfactant). In low-income countries, many preterm babies currently receive little or no medical care. It is plausible that antenatal steroids may be of even greater effect when tested in these settings.

Conclusions Based on high-grade evidence, antenatal steroid therapy is very effective in preventing neonatal mortality and morbidity, yet remains at low coverage in low/middle-income countries. If fully scaled up, this intervention could save up to 500 000 neonatal lives annually.