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PubMed2004

Optimal search strategies for retrieving systematic reviews from Medline: analytical survey.

OBJECTIVE: To develop optimal search strategies in Medline for retrieving systematic reviews. DESIGN: Analytical survey. DATA SOURCES: 161 journals published in 2000 indexed in Medline. MAIN OUTCOME MEASURES: The sensitivity, specificity, and precision of retrieval of systematic reviews of 4862 unique terms in 782,485 combinations of one to five terms were determined by comparison with a hand search of all articles (the criterion standard) in 161 journals published during 2000 (49,028 articles). RESULTS: Only 753 (1.5%) of the 49,028 articles were systematic reviews. The most sensitive strategy included five terms and had a sensitivity of 99.9% (95% confidence interval 99.6% to 100%) and a specificity of 52% (51.6% to 52.5%). The strategy that best minimised the difference between sensitivity and specificity had a sensitivity of 98% (97% to 99%) and specificity of 90.8% (90.5% to 91.1%). Highest precision for multiterm strategies, 57% (54% to 60%), was achieved at a sensitivity of 71% (68% to 74%). The term "cochrane database of systematic reviews.jn." was the most precise single term search strategy (sensitivity of 56% (52% to 60%) and precision of 96% (94% to 98%)). These strategies are available through the "limit" screen of Ovid's search interface for Medline. CONCLUSIONS: Systematic reviews can be retrieved from Medline with close to perfect sensitivity or specificity, or with high precision, by using empirical search strategies.

Information Storage and Retrieval↗

PubMed1997

The systematic review: an essential element of an evidence based approach to nursing.

Consistent with a move towards evidence based practice, systematic review of research relating to effective health care practices is having an increasing influence on health care decision making at all levels. This paper explains the systematic review as a specific type of literature review, one that contrasts with less rigorous approaches to assessing current best available research evidence. The use of this process to achieve effective nursing practice is discussed in the context of systematic review in medicine and health services in general. It is asserted that, in the 'information age', understanding and being able to assess the quality of systematic reviews is an essential area of nursing research.

Humans↗

PubMed1999

Systematic reviews: a logical methodological extension of evidence-based medicine.

Academic Emergency Medicine is interested in publishing systematic reviews (also known as meta-analyses) containing explicit, quantitative compilations of valid, critically appraised evidence targeted at topics relevant to the science and practice of emergency medicine. This article presents a strategy for the performance and reporting of systematic reviews, based on established recommendations. A well-performed systematic review of the literature may provide clinically relevant information otherwise unobtainable, and has potential to alter patient care. Systematic reviews are logical methodological extensions of evidence-based medicine.

Data Collection↗

PubMed2006

Systematic reviews and meta-analysis for the surgeon scientist.

BACKGROUND: Understanding of data-reporting methods is imperative for correct interpretation of the medical literature as well as for proper performance of future clinical research. Recent developments in biostatistics have greatly changed the types of statistical analyses used and the minimum quality standards that must be maintained. METHOD: Different types of review are described, including systematic review with and without meta-analysis. Minimum reporting standards, sources of bias, both quantitative and qualitative, and references are discussed. RESULTS AND CONCLUSION: Meta-analysis has become a clearly defined technique, with reporting standards for both randomized controlled trials and observational studies. It is assuming a wider role in the surgical literature. Although many sources of bias exist, there are clear reporting standards and readers should be aware of these when studying the literature.

General Surgery↗

PubMed2004

[Systematic review: a resource that allows for the incorporation of evidence into nursing practice].

Systematic review is an important resource in evidence-based practice, which consists in a form of synthesizing the research results related to a specific problem. This article aimed to offer subsidies for reflections with a view to the construction and/or application of systematic reviews in the nursing environment. Based on the literature, authors presented the phases comprising a systematic review and the relevant aspects that must be considered for using this resource.

Evidence-Based Medicine↗

PubMed2004

Gastrostomy feeding in cerebral palsy: a systematic review.

AIMS: To determine benefits and risks for gastrostomy or jejunostomy feeding compared with oral feeding for children with cerebral palsy. METHODS: Systematic review. SEARCH STRATEGY: electronic databases--Cochrane Library, Medline, Embase, Cinahl, Lilacs, databases of theses, grey literature. INCLUDED: relevant systematic reviews, randomised controlled trials, observational studies, case reports. EXCLUDED: non-systematic reviews and qualitative research. PARTICIPANTS: children with cerebral palsy. INTERVENTION: use of gastrostomy or jejunostomy tube to provide nutrition. OUTCOME: evaluated outcome measures included death, growth, gastro-oesophageal reflux, other complications, psychosocial aspects, and caregiver wellbeing. RESULTS: No relevant systematic reviews or randomised controlled trials were found. Two cohort studies, 15 case series, and eight case reports met the inclusion criteria. Eight studies specifically described percutaneous endoscopic gastrostomy as the intervention. Weight gain resulted from gastrostomy feeding in most cases. There was an approximately fourfold increased risk of death reported in one cohort study for the gastrostomy fed children. Many complications were reported, including potential for increased gastro-oesophageal reflux and fluid aspiration into the lungs. CONCLUSIONS: Benefits associated with gastrostomy or jejunostomy feeding are difficult to assess from the available evidence. Risks of gastrostomy, particularly in relation to surgical complications, have been described but the size of the risk could not be quantified. The finding of a higher death rate for children fed by gastrostomy may merely reflect the greater disability of these compared with orally fed children. Lack of available evidence and the substantial risk of bias in observational studies suggests that a well conducted randomised controlled trial of sufficient size will be needed to answer these problems.

Cerebral Palsy↗

PubMed2004

Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness.

BACKGROUND AND STUDY AIMS: The current standard approach to the management of malignant gastric outlet obstruction mainly involves bypass surgery, which is associated with significant rates of mortality and morbidity. Recently, metal stents have emerged as a new therapeutic option. The aim of the present study was to review the currently published evidence on the effectiveness and safety of this form of endoscopic treatment. MATERIALS AND METHODS: A systematic review of the published data was carried out by searching medline, embase, and abstracts from the major gastroenterological conferences from January 1992 to September 2003. A total of 136 relevant publications were identified (case series, single case reports, letters and editorials, or reviews). The systematic review included 32 case series from a total of 46 publications identified as reporting primary clinical data. Abstracts and single case reports were not taken into account. Analysis of these 32 case series included data on technical success (successful stent placement and deployment), clinical success (relief of symptoms such as nausea and vomiting, and/or improvement of food intake), and complications. Pooled results were calculated from the 32 studies (10 of which were prospective). RESULTS: Stent insertion was attempted in 606 patients with malignant symptomatic gastroduodenal obstruction; 94 % of the patients were unable to take food orally or were mainly ingesting liquids. Stent placement and deployment were successful in 589 of the patients (97 %). Clinical success was achieved in 526 patients in the group in which technical success was reported (89 %; 87 % of the entire group undergoing stenting). Disease-related factors accounted for the majority of clinical failures. Oral intake became possible in all of the patients in whom a successful procedure was carried out, with 87 % taking soft solids or a full diet, with final resolution of symptoms occurring after a mean of 4 days. There was no procedure-related mortality. Severe complications (bleeding and perforation) were observed in seven patients (1.2 %). Stent migration was reported in 31 patients (5 %). Stent obstruction occurred in 104 cases (18 %), mainly due to tumor infiltration. The mean survival period was 12.1 weeks. CONCLUSIONS: Published evidence from case series suggests that gastroduodenal stenting offers good palliation and is a safe and effective treatment option in patients with a short remaining lifespan. However, patient selection for this intervention continues to be an issue requiring thorough consideration, and studies comparing the method with surgery are needed.

Alloys↗

PubMed2003

Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions.

UNLABELLED: In this systematic review, we compared the effectiveness of media-based patient education about anesthesia. Fifteen randomized controlled trials (n = 1506) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, CINAHL, PSYCINFO, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were anxiety, knowledge, and patient satisfaction. Anxiety levels before anesthesia were less intense in subjects receiving the video and printed information compared with those receiving no intervention (weighted mean difference of 3; 95% confidence interval [95%CI], 1-5 Spielberger's State and Trait Anxiety Inventory). Patients in the video group were more likely to answer all knowledge questions correctly compared with patients with no intervention (relative risk of 6.64; 95%CI, 2.05-21.52). The level of knowledge about pain management was higher in the video group compared with patients with no intervention (weighted mean difference of 17%; 95%CI, 9-25). However, the level of patient satisfaction with the intervention (expectation versus actual anesthetic experience) was similar between the groups (relative risk of 1.06; 95%CI, 0.93-1.22). This systematic review supports the use of video and printed information about general process and risks of anesthesia for patient education before surgery. IMPLICATIONS: The effectiveness of media-based interventions for educating patients about general process and risks of anesthesia were compared in this systematic review. The use of video and/or printed information can decrease patient anxiety and increase patient knowledge. However, patient satisfaction was similar between media-based intervention and nonintervention groups.

Adult↗

PubMed2004

Is the placebo powerless? Update of a systematic review with 52 new randomized trials comparing placebo with no treatment.

BACKGROUND: It is widely believed that placebo interventions induce powerful effects. We could not confirm this in a systematic review of 114 randomized trials that compared placebo-treated with untreated patients. AIM: To study whether a new sample of trials would reproduce our earlier findings, and to update the review. METHODS: Systematic review of trials that were published since our last search (or not previously identified), and of all available trials. RESULTS: Data was available in 42 out of 52 new trials (3212 patients). The results were similar to our previous findings. The updated review summarizes data from 156 trials (11 737 patients). We found no statistically significant pooled effect in 38 trials with binary outcomes, relative risk 0.95 (95% confidence interval 0.89-1.01). The effect on continuous outcomes decreased with increasing sample size, and there was considerable variation in effect also between large trials; the effect estimates should therefore be interpreted cautiously. If this bias is disregarded, the pooled standardized mean difference in 118 trials with continuous outcomes was -0.24 (-0.31 to -0.17). For trials with patient-reported outcomes the effect was -0.30 (-0.38 to -0.21), but only -0.10 (-0.20 to 0.01) for trials with observer-reported outcomes. Of 10 clinical conditions investigated in three trials or more, placebo had a statistically significant pooled effect only on pain or phobia on continuous scales. CONCLUSION: We found no evidence of a generally large effect of placebo interventions. A possible small effect on patient-reported continuous outcomes, especially pain, could not be clearly distinguished from bias.

Humans↗

PubMed2003

A systematic review of exercise trials post stroke.

OBJECTIVE: To perform a systematic review of exercise trials post stroke. DESIGN: A systematic review of controlled clinical trials. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Amed, Sports Discus, Cochrane controlled trials register and PEDro were searched for relevant trials. INCLUSION CRITERIA: Studies--randomized or quasi-randomized controlled clinical trials. Participants--Adults of any age with a clinical diagnosis of stroke. Interventions--Any cardiovascular exercise intervention aimed at improving cardiovascular fitness and/or function. OUTCOMES: Impairment: gait speed, strength, endurance, balance, flexibility, tonus and exercise capacity. Disability: global dependency, functional independence. Extended activities of daily living. Quality of life. Death. DATA COLLECTION AND ANALYSIS: Two independent reviewers categorized selected trials, documented the methodological quality and extracted the relevant data. Comparisons of cardiovascular exercise interventions versus no cardiovascular intervention were made. Statistical comparisons were carried out using a random effects model to calculate standardized mean differences. RESULTS: We identified three eligible trials. Small numbers and heterogeneous outcomes limited the analyses and comparisons. Based on the limited data available, we found that cardiovascular exercise post stroke was no better than no exercise with respect to disability, impairment, extended activities of daily living, quality of life and death. CONCLUSION: Insufficient evidence was identified to establish if cardiovascular exercise has a positive effect on disability, impairment, extended activities of daily living, quality of life and case fatality post stroke.

Activities of Daily Living↗

PubMed1994

Reporting, updating, and correcting systematic reviews of the effects of health care.

The recent growth in the numbers of published systematic reviews reflects growing recognition of their importance for improving knowledge about the effects of health care. In Britain the NHS R&D Programme has established two centres to prepare systematic reviews of existing information, and the Cochrane Collaboration--an international network of individuals and institutions--evolved to produce systematic, periodically updated reviews of randomised controlled trials. The large amount of existing evidence that needs to be considered creates a problem for the reporting of systematic reviews: the need to ensure that methods and results of systematic reviews are adequately described has to be reconciled with the limited space available in printed journals. A possible solution is the use of electronic publications: reviews could be published simultaneously in a short, printed form and in a more detailed electronic form. Electronic publications also have the advantage of the ease with which reviews may be updated as new evidence becomes available or mistakes are identified.

Health Services Research↗

PubMed2003

Treatments for spasticity and pain in multiple sclerosis: a systematic review.

OBJECTIVES: To identify the drug treatments currently available for the management of spasticity and pain in multiple sclerosis (MS), and to evaluate their clinical and cost-effectiveness. DATA SOURCES: Electronic bibliographic databases, National Research Register, MRC Clinical Trials Register and the US National Institutes of Health Clinical Trials Register. REVIEW METHODS: Systematic searches identified 15 interventions for the treatment of spasticity and 15 interventions for treatment of pain. The quality and outcomes of the studies were evaluated. Reviews of the treatment of spasticity and pain when due to other aetiologies were also sought. RESULTS: There is limited evidence of the effectiveness of four oral drugs for spasticity: baclofen, dantrolene, diazepam and tizanidine. Tizanidine appears to be no more effective than comparator drugs such as baclofen and has a slightly different side-effects profile. Despite claims that it causes less muscle weakness, there was very little evidence that tizanidine performed any better in this respect than other drugs, although it is more expensive. The findings of this review are consistent with reviews of the same treatments for spasticity derived from other aetiologies. There is good evidence that both botulinum toxin (BT) and intrathecal baclofen are effective in reducing spasticity, and both are associated with functional benefit. However, they are invasive, and substantially more expensive. None of the studies included in the review of pain were designed specifically to evaluate the alleviation of pain in patients with MS and there was no consistency regarding the use of validated outcome measures. It was suggested that, although expensive, the use of intrathecal baclofen may be associated with significant savings in hospitalisation costs in relation to bed-bound patients who are at risk of developing pressure sores, thus enhancing its cost-effectiveness. No studies of cost-effectiveness were identified in the review of pain. There is evidence, albeit limited, of the clinical effectiveness of baclofen, dantrolene, diazepam, tizanidine, intrathecal baclofen and BT and of the potential cost-effectiveness of intrathecal baclofen in the treatment of spasticity in MS. CONCLUSIONS: Many of the interventions identified are not licensed for the alleviation of pain or spasticity in MS and the lack of evidence relating to their effectiveness may also limit their widespread use. Indeed, forthcoming information relating to the use of cannabinoids in MS may result in there being better evidence of the effectiveness of new treatments than of any of the currently used drugs. It may therefore be of value to carry out double-blind randomised controlled trials of interventions used in current practice, where outcomes could include functional benefit and impact on quality of life. Further research into the development and validation of outcomes measures for pain and spasticity may also be useful, as perhaps would cost-utility studies.

Adolescent↗

PubMed2005

Language of publication restrictions in systematic reviews gave different results depending on whether the intervention was conventional or complementary.

OBJECTIVE: To assess whether language of publication restrictions impact the estimates of an intervention's effectiveness, whether such impact is similar for conventional medicine and complementary medicine interventions, and whether the results are influenced by publication bias and statistical heterogeneity. STUDY DESIGN AND SETTING: We set out to examine the extent to which including reports of randomized controlled trials (RCTs) in languages other than English (LOE) influences the results of systematic reviews, using a broad dataset of 42 language-inclusive systematic reviews, involving 662 RCTs, including both conventional medicine (CM) and complementary and alternative medicine (CAM) interventions. RESULTS: For CM interventions, language-restricted systematic reviews, compared with language-inclusive ones, did not introduce biased results, in terms of estimates of intervention effectiveness (random effects ration of odds rations ROR=1.02; 95% CI=0.83-1.26). For CAM interventions, however, language-restricted systematic reviews resulted in a 63% smaller protective effect estimate than language-inclusive reviews (random effects ROR=1.63; 95% CI=1.03-2.60). CONCLUSION: Language restrictions do not change the results of CM systematic reviews but do substantially alter the results of CAM systematic reviews. These findings are robust even after sensitivity analyses, and do not appear to be influenced by statistical heterogeneity and publication bias.

Complementary Therapies↗

PubMed2005

Reducing workload in systematic review preparation using automated citation classification.

OBJECTIVE: To determine whether automated classification of document citations can be useful in reducing the time spent by experts reviewing journal articles for inclusion in updating systematic reviews of drug class efficacy for treatment of disease. DESIGN: A test collection was built using the annotated reference files from 15 systematic drug class reviews. A voting perceptron-based automated citation classification system was constructed to classify each article as containing high-quality, drug class-specific evidence or not. Cross-validation experiments were performed to evaluate performance. MEASUREMENTS: Precision, recall, and F-measure were evaluated at a range of sample weightings. Work saved over sampling at 95% recall was used as the measure of value to the review process. RESULTS: A reduction in the number of articles needing manual review was found for 11 of the 15 drug review topics studied. For three of the topics, the reduction was 50% or greater. CONCLUSION: Automated document citation classification could be a useful tool in maintaining systematic reviews of the efficacy of drug therapy. Further work is needed to refine the classification system and determine the best manner to integrate the system into the production of systematic reviews.

Artificial Intelligence↗

PubMed2003

Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome.

STUDY DESIGN: Systematic review of the literature. OBJECTIVES: To develop a grading scale to judge the quality of randomized clinical trials (RCTs) and conduct a systematic review of the published RCTs that assess nonoperative treatments for patellofemoral pain syndrome (PFPS). BACKGROUND: Systematic reviews of the quality and usefulness of clinical trials allow for efficient synthesis and dissemination of the literature, which should facilitate clinicians' efforts to incorporate principles of evidence-based practice in the clinical decision-making process. METHODS AND MEASURES: Using a scale based on criteria in the Cochrane Collaboration Handbook, we sought to critically appraise the methodology used in RCTs related to the nonoperative management of PFPS, synthesize and interpret our results, and report our findings in a user-friendly fashion. A scale to assess the methodological quality of trials was designed and pilot tested for its content and reliability. Published RCTs identified during a literature search were then selected and rated by 6 raters. We used predefined cutoff scores to identify specific weaknesses in the clinical research process that need to be improved in future clinical trials. RESULTS: The quality scale we developed was demonstrated to be sufficiently reliable to warrant interpretation of the reviewers' findings. The percentage of trials that met a minimum level of quality for each specific criterion ranged from a low of 25% for the adequacy of the description of the randomization procedure to a high of 95% for the description and standardization of the intervention. CONCLUSIONS: Based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with PFPS were acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback. The use of soft foot orthotics in patients with excessive foot pronation appeared useful in decreasing pain. In addition, at a short-term follow-up, patients who received exercise programs were discharged earlier from physical therapy. Unfortunately, most RCTs reviewed contained qualitative flaws that bring the validity of the results into question, thus diminishing the ability to generalize the results to clinical practice. These flaws were primarily in the areas of randomization procedures, duration of follow-up, control of cointerventions, assurance of blinding, accountability and proper analysis of dropouts, number of subjects, and the relevance of outcomes. Also, given the limited number of high-quality clinical trials, recommendations about supporting or refuting specific treatment approaches may be premature and can only be made with caution.

Evidence-Based Medicine↗

PubMed2006

Systematic review of preservation methods and clinical outcome of infrainguinal vascular allografts.

OBJECTIVE: We systematically reviewed clinical studies on the use of venous and arterial allografts for infrainguinal revascularization. We attempted to find evidence for the best infrainguinal vascular allograft by a systematic review of the available literature. METHODS: An electronic search of the MEDLINE, EMBASE, and Cochrane databases was used to determine key articles from studies on the different types of vascular allografts used in infrainguinal reconstruction from 1966 to 2004. Articles were independently reviewed by using previously defined inclusion and exclusion criteria. Study results were gathered with cumulative primary patency as the primary end point. Secondary end points were major complications, graft disintegration, and major limb loss. Quantitative analysis was performed on the prospective randomized trials, and linear regression analysis was performed on cumulative primary patency. Fontaine's classification system was applied. RESULTS: No systematic review of randomized controlled trials was found. Five randomized controlled trials, 3 prospective cohort or case series, and 15 retrospective case series with 3,837 vascular allografts were found. Methods of allograft preservation were cryopreservation (5 studies), cold storage (3 studies), and glutaraldehyde preservation of human umbilical veins (15 studies). One-year cumulative primary patency rates were 13% to 79% for cryopreservation, 63% to 80% for cold storage, and 40% to 91% for glutaraldehyde. The weighted mean 1-year cumulative primary graft patency rate was 41% for cryopreservation, 71% for cold storage, and 70% for glutaraldehyde allografts. Four randomized trials on femoropopliteal bypasses demonstrated higher patency rates of glutaraldehyde-preserved human umbilical veins than polytetrafluoroethylene grafts. Statistical heterogeneity between studies (I(2) = 91.4%) was too high to perform a formal meta-analysis. The rate of major limb loss was 20% to 58% for cryopreservation, 10% to 69% for cold storage, and 0% to 65% for glutaraldehyde, and the percentage of graft disintegration was 2% to 6% for cryopreservation, 4% to 15% for cold storage, and 0% to 11% for glutaraldehyde. CONCLUSIONS: A firm conclusion could not be made because there were no studies available in which direct comparison was performed between different preservation methods of vascular allografts. In addition, heterogeneity of the individual studies hampered direct comparison of different types of vascular allografts. However, the overall graft performance of glutaraldehyde-preserved human umbilical vein allografts may be superior to that of other vascular allografts.

Arterial Occlusive Diseases↗

PubMed2005

Challenges in systematic reviews of economic analyses.

Economic analyses can provide valuable information for health care decision makers. Systematic reviews of economic analyses can integrate information from multiple studies and provide important insights by systematically examining how differences between models lead to different results. We use our experience in developing and implementing systematic reviews of economic analyses for the U.S. Preventive Services T ask Force, particularly our systematic review of the cost-effectiveness of colorectal cancer screening, to illustrate key methodologic challenges and suggest a framework for other researchers in this area.

Colorectal Neoplasms↗

PubMed2000

[How to produce systematic reviews of excellent quality and to define evidence-based nephrology].

Since recent years, a number of systematic reviews have been published in the renal field. These publications will be used to develop the concept of evidence based nephrology. The design and quality of renal systematic reviews relies on technical skills and efficient trials search. The reasons for discrepancies that are sometimes reported between systematic reviews and controlled clinical trials are now better understood and may be partly explained by inadequate trial recovery and publication biases. The applicability of evidence findings is not always an easy task on patients level. The example of the low protein diet in chronic renal failure highlights such caveats. However, producing high level systematic reviews in the renal field may be of great help to clarify the use of controversial treatments and to design new studies in the renal field.

Evidence-Based Medicine↗