Conducting a systematic literature review: a brief guide.
Explore the source record for details and available documents.
Data Collection↗
SEARCH · Search PubMed
Results for “Systematic Reviews as Topic”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Topical corticosteroids for atopic eczema: clinical and cost effectiveness of once-daily vs. more frequent use.
BACKGROUND: Topical corticosteroids remain the mainstay of treatment for atopic eczema, yet there is uncertainty over the frequency of their use in terms of clinical and cost effectiveness. OBJECTIVES: To assess the clinical and cost effectiveness of once-daily vs. more frequent use of same-potency topical corticosteroids in atopic eczema. METHODS: A systematic review of the clinical and cost-effectiveness literature was undertaken, together with a cost-minimization analysis. RESULTS: The review identified a sparse literature, comprising one previous systematic review and 10 randomized controlled trials (RCTs). No published cost-effectiveness studies were identified. RCTs were focused on potent topical corticosteroids (eight RCTs), with no trials (RCTs/controlled clinical trials) identified on mild potency products. There was broad heterogeneity in trial methods, and therefore we considered outcomes according to: (i) at least a good response or 50% improvement, and (ii) eczema rated as cleared or controlled. Studies found little difference between once-daily and more frequent use of topical corticosteroids. The literature on moderately potent and potent corticosteroids offered no basis for favouring once-daily or more frequent use, although some significant differences favouring twice-daily treatment were identified. One RCT on very potent products favoured three times daily use on the basis of clinical response, but reported no difference in the numbers with at least a good response. Given the similar outcomes seen in clinical effectiveness a cost-minimization approach was adopted to consider cost effectiveness, in order to identify the least-cost option. However, cost-minimization analysis proved complex due to wide variations in product price, with the relative cost of product comparisons by frequency proving the most important factor in determining the least-cost alternative. CONCLUSIONS: This review has not identified any clear differences in outcomes between once-daily and more frequent application of topical corticosteroids. We would encourage prescribing clinicians to consider the once-daily use of topical corticosteroids when making treatment decisions for patients with atopic eczema. However, we find that the literature on clinical effectiveness is limited and a broader understanding of compliance and phobia associated with topical steroids is needed to inform on this issue.
Administration, Cutaneous↗
Aspirin for vascular dementia.
BACKGROUND: For patients with a diagnosis of vascular dementia there is evidence that aspirin is widely prescribed - in one study, completed by geriatricians and psychiatrists in the UK, 80% of patients with cognitive impairment (with vascular risk factors) were prescribed aspirin. However, a number of queries remain unanswered: Is there convincing evidence that aspirin benefits patients with vascular dementia? Does aspirin affect cognition or improve prognosis? In addition, does the risk of cerebral or gastric haemorrhage outweigh any benefit? The aim of this review is to assess the evidence of effectiveness of aspirin in those with a diagnosis of vascular dementia. OBJECTIVES: To assess the evidence of effectiveness of the use of aspirin for vascular dementia. SEARCH STRATEGY: Computerised databases were searched independently by two reviewers. In addition, relevant websites were searched and some journals were handsearched. Specialists in the field were approached for unpublished material and also any publications found were searched for additional references. SELECTION CRITERIA: All randomised controlled trials investigating the effect of aspirin for vascular dementia are included. Inclusion/exclusion of studies comprised systematic assessment of the quality of study design and the risk of bias. DATA COLLECTION AND ANALYSIS: Data were extracted independently by both reviewers, using a previously tested data extraction form and, where required, authors were contacted for data not provided in the papers. The aim was to evaluate data recorded via tools assessing cognitive and behavioural changes along with mortality, morbidity and institutionalisation data. MAIN RESULTS: One randomised controlled trial ( approximately approximately Meyer 1989 approximately approximately ) was included, and yielded data for analysis on a total of 70 patients. The only relevant outcome assessed in this trial was cognition. Change in cognitive outcome was towards being in favour of treatment. REVIEWER'S CONCLUSIONS: There is very limited evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia. Further research is needed to assess the effect of aspirin on cognition, and also on additional outcomes such as behaviour, and quality of life. At present it is not possible to provide evidence for other queries regarding the use of aspirin for dementia (these are described in the Background section of this review).
Aspirin↗
Three- or four- versus two-drug antiretroviral maintenance regimens for HIV infection.
BACKGROUND: Combination antiretroviral therapy administered to HIV-infected individuals has been shown to improve immunologic function and delay the progression of HIV infection. However, because patient adherence to complicated combination-therapy antiretroviral regimens is difficult and because of concerns regarding cumulative toxicity of antiretroviral drugs, regimens that utilize fewer antiretroviral agents are desirable. OBJECTIVES: To compare the use three- or four- versus two-drug antiretroviral maintenance regimens following successful induction therapy for HIV infection. SEARCH STRATEGY: The following electronic databases were searched for relevant randomized trials or reviews: 1. MEDLINE for the years 1982-1999 using the search terms human immunodeficiency virus, antiretroviral therapy, maintenance therapy, zidovudine, lamivudine, indinavir, stavudine, saquinivir, nelfinavir, didanosine, zalcitabine, ritonovir, AIDS, anti-HIV agents, HIV infection and HIV seropositivity 2. AIDSLINE for the years 1982-1999 using the search terms antiretroviral therapy, maintenance therapy, zidovudine, lamidvudine, indinavir, stavudine, saquinivir, nelfinavir, didanosine, zalcitabine, ritonovir, anti-HIV agents 3. The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness and the Cochrane Clinical Trials Register in the Cochrane Library, Issue 2, 1999. 4. The specialist register of trials maintained by the Cochrane Collaborative Review Group on HIV Infection and AIDS 5. AIDSTRIALS, a specialist registry of current and completed trials maintained by the U.S. National Library of Medicine The abstracts of relevant conferences, including the International Conferences on AIDS, the Conference on Retroviruses and Opportunistic Infections, the Infectious Disease Society of America annual meeting and the Interscience Conference on Antimicrobial Agents and Chemotherapy, as indexed by AIDSLINE, were also reviewed. All reference lists of all review articles and primary articles identified were searched. SELECTION CRITERIA: Randomized controlled trials in which HIV-infected adults who had successfully completed three- or four-drug antiretroviral induction therapy were randomized to maintenance therapy with three or four drugs or maintenance therapy with two drugs. Successful induction therapy was defined by a plasma viral load of less than 500 copies/ml. DATA COLLECTION AND ANALYSIS: Two reviewers assessed eligibility and trial quality. Attempts were made to contact the authors of the included abstract. Data on the number of patients experiencing loss of viral suppression were abstracted by two reviewers. The data were pooled, where appropriate, to yield odds ratios, using random effects models. MAIN RESULTS: Four trials were identified including three published studies and one abstract. Compared to three- or four-drug maintenance therapy, maintenance therapies including fewer drugs were associated with a higher risk of virologic failure (loss of HIV suppression to non-detectable levels). Combining the results of all four studies yielded an odds ratio of 5.55 (95% confidence interval, 3.14 - 9.80). Similar results were obtained when the one abstract was excluded (odds ratio, 5.48; 95% confidence interval, 2.82 - 10.65). Performing subgroup analyses of studies using the same induction and maintenance regimens gave similar results. Maintenance regimens of zidovudine and lamivudine compared to maintenance regimens with zidovuine, lamivudine and indinavir, were associated with significantly higher rates of virologic failure (odds ratio, 4.57; 95% confidence interval, 1.80 - 11.58). Similarly, maintenance regimens that discontinued one or more protease inhibitor after including them in induction therapy were also associated with a significantly higher risk of virologic failure (odds ratio, 6.15; 95% confidence interval, 3.40 -11.10). (ABSTRACT TRUNCATED)
Anti-HIV Agents↗
Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit.
BACKGROUND: The need for sedation for neonates undergoing uncomfortable procedures in the neonatal intensive care unit (NICU) has often been overlooked. Proper sedation may reduce stress and avoid complications during procedures such as mechanical ventilation. Midazolam is a short acting benzodiazepine that has been increasingly used in the NICU. However, the effectiveness of intravenous midazolam as a sedative in neonates has not been systematically evaluated. OBJECTIVES: To determine whether intravenous midazolam infusion is an effective sedative, as evaluated by behavioural and/or physiologic measurements, for critically ill neonates undergoing intensive care, and to assess clinically significant short and long term adverse effects associated with its use. SEARCH STRATEGY: Literature search according to the Cochrane Neonatal Collaborative Review Group search strategy. Randomized and quasi-randomized controlled trials of intravenous midazolam use in neonates were identified by searching MEDLINE, EMBASE, the Cochrane Controlled Trials Register, reference lists of published studies, personal files, and abstracts published in Pediatric Research from 1990-1999. SELECTION CRITERIA: Randomized controlled trials of intravenous midazolam infusion in infants </= 28 days of age for sedation during mechanical ventilation or radiologic investigations were selected for review. Studies on midazolam use as an anesthetic or an anticonvulsant were excluded. Studies involving neonates and older infants and children were excluded if data for neonates could not be extracted. DATA COLLECTION AND ANALYSIS: Data regarding the primary outcome of level of sedation (as evaluated by behavioural scales or physiologic parameters) were abstracted. Secondary outcomes including intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), death within 28 days of age, adverse effects associated with midazolam (hemodynamic and neurologic), days of ventilation, days of supplemental oxygen use, pneumothorax, length of NICU stay, and long term neurodevelopmental outcome were assessed. When appropriate, meta-analyses were performed using relative risk (RR), risk difference (RD), along with their 95% confidence intervals (95% CI) for categorical variables and weighted mean difference (WMD) for continuous variables. MAIN RESULTS: Two trials were eligible for inclusion in the review. Data on level of sedation from the two trials could not be combined because of differences in tools used to measure sedation levels. One study (Jacqz-Aigrain 1994) showed statistically a significant higher level of sedation in the midazolam group compared to the placebo group. The other study (Anand 1999) comparing midazolam to morphine and placebo found no statistically significant difference in sedation level among the three groups, but statistically significantly higher level of sedation was found in the midazolam group compared with the placebo group during the treatment infusion. However, since the sedation scales used in both studies have not been validated in preterm infants, the effectiveness of midazolam as a sedative in this population could not be ascertained based on the findings of these two studies. In the study by Jacqz-Aigrain (1994), blood pressures were statistically significantly lower in the midazolam group than in the placebo group on days 1 and 2, although there was no statistically significant difference in the incidence of hypotension requiring albumin or vasoactive drugs between groups. The study by Anand (1999) showed a statistically significant higher incidence of adverse neurologic events (death, grade III-IV IVH, PVL) in the midazolam group compared with the other groups. In addition, the midazolam group had a statistically significantly longer duration of NICU stay compared to the placebo group (WMD 5.4 days, 95%CI 0.4, 10.5). (ABSTRACT TRUNCATED)
Humans↗
Toward setting a research agenda for systematic reviews of evidence of the effects of medical education.
PURPOSE: To provide an update on, and a preliminary research agenda for, best evidence medical education (BEME). SUMMARY: Efforts related to evidence-based medical education are summarized briefly, including BEME, the newly formed Campbell Collaboration, and the Cochrane Collaboration's Effective Practice and Organization of Care review group. A list of topics and priorities for which evidence of effectiveness in medical education should be systematically reviewed is provided based on the results of a session at the July 2000 annual meeting of the Society of Directors of Research in Medical Education. The highest ranked topics clustered around four major conceptual areas: (a) curricular design, (b) learning and instructional methods, (c) testing and assessment, and (d) outcomes. CONCLUSIONS: BEME is gaining momentum with growing numbers of people becoming involved as well as an increased number of pertinent workshops, publications, and Web sites. The work of creating pertinent systematic reviews of the medical education literature is at hand.
Education, Medical↗
Oestrogen and progestogen hormone replacement therapy for peri-menopausal and post-menopausal women: weight and body fat distribution.
BACKGROUND: Hormone replacement therapy (HRT) is commonly prescribed to treat menopausal symptoms and to prevent post-menopausal bone loss. However, many women are concerned about hormonal replacement therapy because they believe that such treatment will result in weight gain. The effect of HRT on weight and body fat distribution has not yet been examined in systematic reviews. It is an important topic since many women decline oestrogen therapy due to their concerns about resultant weight gain, and thus forego its potential therapeutic benefits. OBJECTIVES: To evaluate the effect of unopposed oestrogen or combined oestrogen and progestogen hormone replacement therapy (HRT) upon the weight and body fat distribution of perimenopausal and postmenopausal women. SEARCH STRATEGY: The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of randomised controlled trials (RCTs). Computerised searches of MEDLINE, EMBASE, Current Contents, Biological Abstracts and CINAHL were performed. Attempts were made to identify trials from citation lists of review articles and relevant papers already obtained. In most cases, first authors of each eligible trial were contacted for additional information. All those trials that had been located as at August 1998 were examined for eligibility. SELECTION CRITERIA: All randomised, placebo or no treatment controlled trials that detailed the effect of HRT on weight or body fat distribution, including studies where HRT was combined with other therapy such as diet, supplements or exercise. Studies were eligible for consideration even though the main focus of the trial may have been on another aspect of HRT. Previous HRT use should have ceased at least one month (in the case of patches, cream or gel) or three months (for oral preparations or subcutaneous pellets) before commencement of the study. DATA COLLECTION AND ANALYSIS: Twenty two RCTs were identified that fulfilled the inclusion criteria for this review. The results of one trial were not available in a form that allowed it to be included in the meta-analysis; however, it has been included in the text of the review for discussion. Twenty four RCTs are awaiting assessment pending additional information from first authors. Two reviewers extracted the data independently, and the weighted mean differences for continuous outcomes were estimated from the data. Results for unopposed oestrogen and combined oestrogen were analysed separately, and the effect of each treatment regimen on body weight, BMI, waist-hip ratio, fat mass and skinfold measurement was examined where available. The effect of differing dosage levels on these parameters was also examined. MAIN RESULTS: Outcomes were evaluated separately for unopposed oestrogen and oestrogen/progestogen regimens. Statistical analysis was performed using the weighted mean difference for continuous outcomes as recommended by the Cochrane Menstrual Disorders and Subfertility Group. No statistically significant difference was found in mean weight gain between those using unopposed oestrogen and non-HRT users (0.66 kg, 95% CI -0.62, 1.93). No significant difference was found in mean weight gain between those using oestrogen/progestogen therapy and non-HRT users (-0.47 kg, 95% CI -1.63, 0.69). Insufficient data exist to enable meta-analysis of the effect of unopposed oestrogen on BMI. The reviewers found no statistically significant difference in mean BMI increase between those using oestrogen/progestogen and non-HRT users (-0.50, 95% CI -1.06, 0.06). Insufficient data exist to enable meta-analysis of the effect of HRT on waist-hip ratio, fat mass or skinfold thickness. REVIEWER'S CONCLUSIONS: There is evidence of no effect of unopposed oestrogen or combined oestrogen on body weight, indicating that these regimens do not cause extra weight gain in addition to that normally gained at menopause. (ABSTRACT TRUNCATED)
Body Mass Index↗
Antibiotics for acute otitis media in children.
BACKGROUND: Acute otitis media is one of the most common diseases in early infancy and childhood. Antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia. OBJECTIVES: The objective of this review was to assess the effects of antibiotics for children with acute otitis media. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE, Index Medicus, Current Contents and reference lists of articles from 1958 to January 1999. SELECTION CRITERIA: Randomised trials comparing antimicrobial drugs with placebo in children with acute otitis media. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Nine trials were eligible but only six trials, with a total of 1,962 children, included patient-relevant outcomes. The methodological quality of the included trials was generally high. All trials were from developed countries. The trials showed no reduction in pain at 24 hours, but a 34% relative reduction (95% confidence interval 16% to 48%) in pain at two to seven days. Since approximately 85% of patients will have settled spontaneously in this time, this means an absolute reduction of about 5% or that about 20 children must be treated with antibiotics to prevent one child having some pain after two days. There was no effect of antibiotics on deafness, as measured by subsequent tympanometry, other complications, or recurrence. However, audiometry was done in only two studies and incompletely reported, and there were few serious complications seen in these trials: only one case of mastoiditis occurred (in a penicillin treated group). One semi-randomised trial in Sweden in 1954 reported a rate of 17% in the untreated group versus none in the penicillin treated groups. REVIEWER'S CONCLUSIONS: Antibiotics provide a small benefit for acute otitis media in children. As most cases will resolve spontaneously, this benefit must be weighed against the possible adverse reactions. Antibiotic treatment may play an important role in reducing the risk of mastoiditis in populations where it is more common.
Acute Disease↗
Enteral antibiotics for preventing necrotising enterocolitis in low birthweight or preterm infants.
BACKGROUND: Necrotising enterocolitis continues to be a problem, particularly in preterm neonates. There have been reports published suggesting that the use of enteral antibiotics may be effective as prophylaxis. This systematic review was undertaken to clarify the issue. OBJECTIVES: To evaluate the benefits and harms of enteral antibiotic prophylaxis for necrotising enterocolitis in low birth weight and preterm infants. SEARCH STRATEGY: Searches were made of the Oxford Database of Perinatal trials, MEDLINE (search terms: necrotizing enterocolitis, antibiotics; LIMITS: newborn infant), previous reviews with cross references, abstracts, conference and symposia proceedings, expert informants and journal handsearching in the fields of Neonatal Pediatrics and Microbiology. SELECTION CRITERIA: All randomized or quasi-randomized controlled trials where enteral antibiotics were used as prophylaxis against NEC in LBW (<2500g) and/or preterm (<37 weeks gestation) infants. DATA COLLECTION AND ANALYSIS: The standard method of the Cochrane Collaboration and its Neonatal Review Group was used. The methodological quality of each trial was reviewed by the second author who was blinded to the trial authors and institutions. Each author extracted data separately before comparison and resolution of differences. Relative risk (RR), risk difference (RD), and number needed to treat were used in the analysis. MAIN RESULTS: The administration of prophylactic enteral antibiotics resulted in a statistically significant reduction in NEC [RR 0.47 (0.23, 0.98); RD -0.072 (-0.136, -0.008); NNT 13.9 (7.4, 125)]. There was a reduction in NEC-related deaths which was of borderline statistical significance [RR 0.16 (0.02, 1.26); RD -0.097 (-0.183, -0.010); NNT 10.3 (5.46, 100)]. There were no significant differences in all deaths (one trial only) or in NEC-like enteropathies (one trial only). There was a statistically significant increase in the incidence of colonisation with resistant bacteria [RR 1.73 (1.00, 2. 97); RD 0.123 (0.008, 0.238); NNT 8.1 (4.2, 125)]. REVIEWER'S CONCLUSIONS: There is insufficient evidence to support the use of enteral antibiotic prophylaxis for NEC in clinical practice. To address this question further, a large trial would be required with a sample size sufficient to examine all the important benefits and harms. Adverse outcomes associated with infection, particularly with resistant bacteria, should be evaluated.
Anti-Bacterial Agents↗
[Conducting a systematic review of the literature: a brief guide].
Explore the source record for details and available documents.
Data Collection↗
Elective delivery in diabetic pregnant women.
BACKGROUND: In pregnancies complicated by diabetes the major concerns during the third trimester are fetal distress and the potential for birth trauma associated with fetal macrosomia. OBJECTIVES: The objective of this review was to assess the effect of a policy of elective delivery, as compared to expectant management, in term diabetic pregnant women, on maternal and perinatal mortality and morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (last searched July 1999). SELECTION CRITERIA: All available randomized controlled trials of elective delivery, either by induction of labour or by elective caesarean section, compared to expectant management in diabetic pregnant women at term. DATA COLLECTION AND ANALYSIS: The reports of the only available trial were analysed independently by the three co-reviewers to retrieve data on maternal and perinatal outcomes. Results are expressed as relative risks (RR) and 95% confidence intervals (CI). MAIN RESULTS: The participants in the one trial included in this review were 200 insulin-requiring diabetic women. Most had gestational diabetes, except 13 women with type 2 preexisting diabetes (class B). The trial compared a policy of active induction of labour at 38 completed weeks of pregnancy, to expectant management until 42 weeks. The risk of caesarean section was not statistically different between groups (RR 0.81, 95% CI 0.52 - 1.26). The risk of macrosomia was reduced in the active induction group (RR 0.56, 95%CI 0.32 - 0. 98) and 3 cases of mild shoulder dystocia were reported in the expectant management group. No other perinatal morbidity was reported. REVIEWER'S CONCLUSIONS: There is very little evidence to support either elective delivery or expectant management at term in pregnant women with insulin-requiring diabetes. Limited data from a single randomized controlled trial suggest that induction of labour in women with gestational diabetes treated with insulin reduces the risk of macrosomia. Although the small sample size does not permit one to draw conclusions, the risk of maternal or neonatal morbidity was not modified. Women's views on elective delivery and on prolonged surveillance and treatment with insulin should be assessed in future trials.
Cesarean Section↗
Albendazole for lymphatic filariasis.
BACKGROUND: Mass treatment with albendazole, co-administered with another antifilarial drug, is being promoted as part of a global programme to eliminate lymphatic filariasis. OBJECTIVES: To assess the effects of albendazole on patients or populations with filarial infection, and on morbidity in patients with filarial infection; and to assess the frequency of adverse events for albendazole both given singly or in combination with another antifilarial drug (diethylcarbamazine or ivermectin). SEARCH STRATEGY: We searched the Cochrane Infectious Disease Group's trial register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (September 2003), EMBASE (September 2003), LILACS (September 2003); and checked the reference lists and contacted experts, international organizations, and a pharmaceutical company. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials of albendazole singly or in combination with anti-filarial drugs in people or populations with lymphatic filariasis. DATA COLLECTION AND ANALYSIS: Two reviewers assessed eligibility and trial methodological quality. We calculated relative risks (RR) with 95% confidence intervals (CI) for binary outcomes, and where appropriate, combined them in a meta-analysis using the fixed effect model or random effects model. MAIN RESULTS: Four small studies met the inclusion criteria (a total of 2473 children and adults, of whom 536 had detectable microfilariae). No effect of albendazole on microfilaraemia was demonstrated in two studies (placebo controlled, RR 0.97, 95%CI 0.87 to 1.09, n = 195). When compared to ivermectin, albendazole performed worse (RR 0.84, 95% CI 0.72 to 0.98, 2 studies of patients initially microfilariae positive, n = 198). When compared to diethylcarbamazine, no statistically significant difference was detected, but numbers were small (n = 56). Two studies compared albendazole plus ivermectin to ivermectin alone on the presence of microfilaraemia. Results were mixed: one study showed the combination to be more effective (RR 0.27, 95% CI 0.11 to 0.70, n = 52), but the other did not demonstrate a statistically significant difference (RR 1.04, 95% CI 0.87 to 1.25, n = 145). A further study compared albendazole plus diethylcarbamazine to diethylcarbamazine alone and did not demonstrate a difference on microfilaraemia prevalence (RR 1.57, 95% CI 0.44 to 5.60, n=35). No study examined the effects of the drugs on adult worms. REVIEWER'S CONCLUSIONS: There is insufficient reliable research to confirm or refute whether albendazole alone, or co-administered with diethylcarbamazine or ivermectin, has an effect on lymphatic filariasis.
Albendazole↗
The state of rehabilitation research: art or science?
Rehabilitation research has been criticized as not standing up enough to the rigors of scientific method to be called "science." The field has been portrayed as slow to promote its scientific achievements and to include them under the rubric of evidence-based rehabilitation. Following in the footsteps of psychology, rehabilitation as a broad-based discipline has faced many similar obstacles in achieving scientific status. Controversy exists about what exactly constitutes rehabilitation science versus its art and its respective multidisciplinary domains. The conception of these domains is directly related to current methods available to assess the state of the discipline and its research accomplishments. I used quantitative methods, such as randomized clinical and/or controlled trials (RCTs) and systematic reviews, to assess the status of rehabilitation research. Findings suggest that, as a field, rehabilitation makes significant contributions to science, measurable by the number and quality of RCTs and systematic reviews conducted so far on topics of critical importance for clinical care. In "artful" complement, qualitative approaches can be used as research tools to aid investigators in seeking knowledge beyond that obtained by quantitative methods, assessing many complexities associated with the various contexts of rehabilitation research. Other requirements to develop a common vision of rehabilitation science are also discussed.
Art↗
Polyunsaturated fatty acids. Is there a role in postmenopausal osteoporosis prevention?
OBJECTIVE: To review the effect of a diet supplemented with polyunsaturated fatty acids (PUFA) on prevention or treatment of osteoporosis. METHODS: MEDLINE (1966-April 2001), Allied Complementary Medicine (1985-2001), Cochrane Library and Database of Systematic Reviews (1st Quarter 2001) was searched. Five reviews and no systematic reviews were found on this topic in the Cochrane Library. Eleven relevant in-vivo studies were identified on the effect of these compounds on bone. Eight were animal studies and three were randomised control trials (RCT) in human. RESULTS: There are two classes of PUFA designated as n-3 and n-6 with alpha-linolenic acid (ALA). These two different types of PUFA differently influence prostaglandin formation and hence modulate bone metabolism differently. These are several in vitro and animal data suggesting that diet with a low n-6/n-3 ratio may have beneficial effects on bone mineral density. Only three, short-term, small studies have been performed in human so far. Two studies, one performed with bone markers and one with bone density showed a positive effect of PUFA on bone. While a third study showed no effect. CONCLUSIONS: Preliminary, data have suggested that a diet with a low n-6/n-3 ratio may have beneficial effects on bone mineral density. Further studies are, however, required to fully assess the dose and type of PUFA to be used for optimum bone effects. This may be useful particularly for the prevention of disease in the elderly, since a diet rich in n-3 PUFA has been shown to have additional benefit on the cardiovascular, central nervous system and joints.
Animals↗
A model for change to evidence-based practice.
PURPOSE: To describe a model that guides nurses and other healthcare professionals through a systematic process for the change to evidence-based practice. The tremendous increases in clinical research and accessibility to research findings have prepared the way for the paradigm shift from traditional and intuition-driven practice to evidence-based practice. Although several models have emerged to guide practitioners in research utilization, practitioners continue to have difficulty synthesizing empirical and contextual evidence and integrating evidence-based changes into practice. ORGANIZING FRAMEWORK: The model is based on theoretical and research literature related to evidence-based practice, research utilization, standardized language, and change theory. In this model, practitioners are guided through the entire process of developing and integrating an evidence-based practice change. The model supports evidence-based practice changes derived from a combination of quantitative and qualitative data, clinical expertise, and contextual evidence. METHODS: The model was developed using sources identified on searches of Medline, CINAHL, and systematic reviews available on the Internet. Review topics were focused on evidence-based medicine and nursing, research utilization, and change process. Other sources included clinical expertise and quality-improvement information. CONCLUSIONS: Practitioners need skills and resources to appraise, synthesize, and diffuse the best evidence into practice. Patient outcomes must reflect discipline-specific and interdisciplinary accountabilities. Collaboration between researchers and practitioners within and among disciplines will enhance the diffusion of evidence-based practice innovations.
Benchmarking↗
Anabolic-androgenic steroids for alcoholic liver disease: a Cochrane review.
OBJECTIVES: The objectives were to assess the beneficial and harmful effects of anabolic-androgenic steroids for alcoholic liver disease. METHODS: The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, and full text searches were combined. Only randomized clinical trials studying patients with alcoholic liver disease were included. Interventions encompassed anabolic-androgenic steroids at any dose or duration versus placebos or no intervention. The statistical package (RevMan and MetaView) provided by The Cochrane Collaboration was used. RESULTS: Five randomized clinical trials (including mainly men with alcoholic hepatitis and/or cirrhosis) were identified. Only one trial was assessed as adequate regarding all methodological quality components. Anabolic-androgenic steroids versus placebos or no intervention demonstrated no significant effects on mortality (relative risk [RR] = 0.96, 95% CI = 0.72-1.28), liver-related mortality (RR = 0.83, 95% CI = 0.60-1.15), complications to the liver disease (RR = 1.25, 95% CI = 0.74-2.10), liver histology, and a number of other outcome measures. Anabolic-androgenic steroids were not associated with a significantly increased risk of nonserious adverse events, but with the seldom occurrence of serious adverse events (RR = 4.54,95% CI = 0.57-36.30). CONCLUSIONS: This systematic review could not demonstrate any significant beneficial effects of anabolic-androgenic steroids on any clinically important outcomes of patients with alcoholic liver disease.
Anabolic Agents↗
Clinical review: a systematic review of corticosteroid use in infections.
Traditional teaching suggests that corticosteroids should be avoided during acute infectious episodes for fear of compromising the immune response. However, the outcome benefit shown through steroid administration in early septic shock implies this paranoia may be misplaced. We therefore performed a systematic review of the literature to identify the current strength of evidence for the use of corticosteroids in specified infections, and to make appropriate graded recommendations.
Adrenal Cortex Hormones↗
[The systematic review is the foundation of evidence based medicine. One of the most important contributions to clinical medicine of the past decade].
The traditional narrative review has been shown repeatedly to be biased, mostly towards exaggerated treatment size effects. In contrast, the systematic review follows a strict protocol regarding focused questions, explicit criteria for literature searches, inclusion and exclusion criteria, critical appraisal and a synthesis which is quantitative when appropriate. There is empirical evidence that bias is reduced and that the conclusions reached have greater validity for the construction of treatment guidelines. In this paper three sources of systematic reviews are identified: the Cochrane Library, reviews published in peer-reviewed journals, and assessments of health technology (HTA-reports). Editors are encouraged to publish systematic reviews after proper critical appraisal, and readers are advised to search for such reviews when in need of guidance on important clinical questions.
Bias↗