scholarly journals Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence

BMJ ◽  
2021 ◽  
pp. n1511
Author(s):  
Ashley W Blom ◽  
Richard L Donovan ◽  
Andrew D Beswick ◽  
Michael R Whitehouse ◽  
Setor K Kunutsor
Keyword(s):  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Meniscal Repair ◽  
Clinical Effectiveness ◽  
Controlled Trials ◽  
Operative Care ◽  
Total Knee ◽  
Randomised Controlled ◽  
Meta Analyses ◽  
Study Designs

AbstractObjectiveTo determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines.DesignUmbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials.Data sourcesTen of the most common elective orthopaedic procedures—arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement—were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020.Eligibility criteria for selecting studiesMeta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care.Data extraction and synthesisSummary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence.Main outcome measuresQuality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines.ResultsRandomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care.ConclusionsAlthough they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.Systematic review registrationPROSPERO CRD42018115917.

scholarly journals Comparative efficacy and safety of interventions for treating head lice: a protocol for systematic review and network meta-analysis

2021 ◽  
Vol 5 (1) ◽  
pp. e001129
Author(s):  
Bill Stevenson ◽  
Wubshet Tesfaye ◽  
Julia Christenson ◽  
Cynthia Mathew ◽  
Solomon Abrha ◽  
...  
Keyword(s):  
Systematic Review ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Grey Literature ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Head Lice ◽  
Efficacy And Safety ◽  
Randomised Controlled ◽  
Meta Analyses

BackgroundHead lice infestation is a major public health problem around the globe. Its treatment is challenging due to product failures resulting from rapidly emerging resistance to existing treatments, incorrect treatment applications and misdiagnosis. Various head lice treatments with different mechanism of action have been developed and explored over the years, with limited report on systematic assessments of their efficacy and safety. This work aims to present a robust evidence summarising the interventions used in head lice.MethodThis is a systematic review and network meta-analysis which will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement for network meta-analyses. Selected databases, including PubMed, Embase, MEDLINE, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials will be systematically searched for randomised controlled trials exploring head lice treatments. Searches will be limited to trials published in English from database inception till 2021. Grey literature will be identified through Open Grey, AHRQ, Grey Literature Report, Grey Matters, ClinicalTrials.gov, WHO International Clinical Trials Registry and International Standard Randomised Controlled Trials Number registry. Additional studies will be sought from reference lists of included studies. Study screening, selection, data extraction and assessment of methodological quality will be undertaken by two independent reviewers, with disagreements resolved via a third reviewer. The primary outcome measure is the relative risk of cure at 7 and 14 days postinitial treatment. Secondary outcome measures may include adverse drug events, ovicidal activity, treatment compliance and acceptability, and reinfestation. Information from direct and indirect evidence will be used to generate the effect sizes (relative risk) to compare the efficacy and safety of individual head lice treatments against a common comparator (placebo and/or permethrin). Risk of bias assessment will be undertaken by two independent reviewers using the Cochrane Risk of Bias tool and the certainty of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations guideline for network meta-analysis. All quantitative analyses will be conducted using STATA V.16.DiscussionThe evidence generated from this systematic review and meta-analysis is intended for use in evidence-driven treatment of head lice infestations and will be instrumental in informing health professionals, public health practitioners and policy-makers.PROSPERO registration numberCRD42017073375.

scholarly journals Surgical interventions for women with stress urinary incontinence: systematic review and network meta-analysis of randomised controlled trials

BMJ ◽  
2019 ◽  
pp. l1842 ◽  
Author(s):  
Mari Imamura ◽  
Jemma Hudson ◽  
Sheila A Wallace ◽  
Graeme MacLennan ◽  
Michal Shimonovich ◽  
...  
Keyword(s):  
Urinary Incontinence ◽  
Stress Urinary Incontinence ◽  
Adverse Events ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Surgical Interventions ◽  
Randomised Controlled ◽  
Meta Analyses

Abstract Objectives To compare the effectiveness and safety of surgical interventions for women with stress urinary incontinence. Design Systematic review and network meta-analysis. Eligibility criteria for selecting studies Randomised controlled trials evaluating surgical interventions for the treatment of stress urinary incontinence in women. Methods Identification of relevant randomised controlled trials from Cochrane reviews and the Cochrane Incontinence Specialised Register (searched May 2017), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Medline In-Process, Medline Epub Ahead of Print, CINAHL, ClinicalTrials.gov, and WHO ICTRP. The reference lists of relevant articles were also searched. Primary outcomes were “cure” and “improvement” at 12 months, analysed by means of network meta-analyses, with results presented as the surface under the cumulative ranking curve (SUCRA). Adverse events were analysed using pairwise meta-analyses. Risk of bias was assessed using the Cochrane risk of bias tool. The quality of evidence for network meta-analysis was assessed using the GRADE approach. Results 175 randomised controlled trials assessing a total of 21 598 women were included. Most studies had high or unclear risk across all risk of bias domains. Network meta-analyses were based on data from 105 trials that reported cure and 120 trials that reported improvement of incontinence symptoms. Results showed that the interventions with highest cure rates were traditional sling, retropubic midurethral sling (MUS), open colposuspension, and transobturator MUS, with rankings of 89.4%, 89.1%, 76.7%, and 64.1%, respectively. Compared with retropubic MUS, the odds ratio of cure for traditional sling was 1.06 (95% credible interval 0.62 to 1.85), for open colposuspension was 0.85 (0.54 to 1.33), and for transobtrurator MUS was 0.74 (0.59 to 0.92). Women were also more likely to experience an improvement in their incontinence symptoms after receiving retropubic MUS or transobturator MUS compared with other surgical procedures. In particular, compared with retropubic MUS, the odds ratio of improvement for transobturator MUS was 0.76 (95% credible interval 0.59 to 0.98), for traditional sling was 0.69 (0.39 to 1.26), and for open colposuspension was 0.65 (0.41 to 1.02). Quality of evidence was moderate for retropubic MUS versus transobturator MUS and low or very low for retropubic MUS versus the other two interventions. Data on adverse events were available mainly for mesh procedures, indicating a higher rate of repeat surgery and groin pain but a lower rate of suprapubic pain, vascular complications, bladder or urethral perforation, and voiding difficulties after transobturator MUS compared with retropubic MUS. Data on adverse events for non-MUS procedures were sparse and showed wide confidence intervals. Long term data were limited. Conclusions Retropubic MUS, transobturator MUS, traditional sling, and open colposuspension are more effective than other procedures for stress urinary incontinence in the short to medium term. Data on long term effectiveness and adverse events are, however, limited, especially around the comparative adverse events profiles of MUS and non-MUS procedures. A better understanding of complications after surgery for stress urinary incontinence is imperative. Systematic review registration PROSPERO CRD42016049339.

scholarly journals Comparison of intravenous, topical or combined routes of tranexamic acid administration in patients undergoing total knee and hip arthroplasty: a meta-analysis of randomised controlled trials

BMJ Open ◽  
2019 ◽  
Vol 9 (1) ◽  
pp. e024350 ◽  
Author(s):  
Qi Sun ◽  
Jinyu Li ◽  
Jiang Chen ◽  
Chenying Zheng ◽  
Chuyin Liu ◽  
...  
Keyword(s):  
Blood Loss ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Total Blood Loss ◽  
Controlled Trials ◽  
Transfusion Rate ◽  
Total Blood ◽  
Total Knee ◽  
Randomised Controlled ◽  
Blood Loss Volume

ObjectiveThis study aimed to compare the effects of intravenous, topical and combined routes of tranexamic acid (TXA) administration on blood loss and transfusion requirements in patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).DesignThis was a meta-analysis of randomised controlled trials (RCT) wherein the weighted mean difference (WMD) and relative risk (RR) were used for data synthesis applied in the random effects model. Stratified analyses based on the surgery type, region, intravenous and topical TXA dose and transfusion protocol were also conducted. The main outcomes included intraoperative and total blood loss volume, transfusion rate, low postoperative haemoglobin (Hb) level and postoperative Hb decline. However, the secondary outcomes included length of hospital stay (LOS) and/or occurrence of venous thromboembolism (VTE).SettingWe searched the PubMed, Embase and Cochrane CENTRAL databases for RCTs that compared different routes of TXA administration.ParticipantsPatients undergoing TKA or THA.InterventionsIntravenous, topical or combined intravenous and topical TXA.ResultsTwenty-six RCTs were selected, and the intravenous route did not differ substantially from the topical route with respect to the total blood loss volume (WMD=30.92, p=0.31), drain blood loss (WMD=−34.53, p=0.50), postoperative Hb levels (WMD=−0.01, p=0.96), Hb decline (WMD=−0.39, p=0.08), LOS (WMD=0.15, p=0.38), transfusion rate (RR=1.08, p=0.75) and VTE occurrence (RR=1.89, p=0.15). Compared with the combined-delivery group, the single-route group had significantly increased total blood loss volume (WMD=198.07, p<0.05), greater Hb decline (WMD=0.56, p<0.05) and higher transfusion rates (RR=2.51, p<0.05). However, no significant difference was noted in the drain blood loss, postoperative Hb levels and VTE events between the two groups. The intravenous and topical routes had comparable efficacy and safety profiles.ConclusionsThe combination of intravenous and topical TXA was relatively more effective in controlling bleeding without increased risk of VTE.

scholarly journals What is the best catheter lock solution in preventing catheter-related blood infections? A protocol for a Bayesian network meta-analysis of randomised controlled trials

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e030019 ◽  
Author(s):  
Fangping Dang ◽  
Huiju Li ◽  
Jinhui Tian ◽  
Ruijuan Wang ◽  
Jingjie Ren
Keyword(s):  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Major Complication ◽  
Venous Catheter ◽  
Cochrane Library ◽  
Controlled Trials ◽  
Exit Site Infection ◽  
Safety Considerations ◽  
Randomised Controlled ◽  
Meta Analyses

IntroductionCatheter-related bloodstream infection (CRBSI) is a major complication after central venous catheter insertion, which is associated with significant morbidity, mortality and additional medical costs. Many lock solutions for CRBSI have been evaluated. However, using traditional pairwise meta-analyses to summarise the evidence does not allow the inclusion of data from treatments that have not been compared head to head, which could impact the precision of pooled estimates in a meta-analysis. Therefore, we evaluated the efficacy and safety of the different lock solutions for CRBSI through a network meta-analysis.Methods and analysisThe primary outcome of this network meta-analysis is the CRBSI. The secondary outcomes are exit-site infection and catheter-related thrombosis. We will search the PubMed, Embase, Web of Science and the Cochrane Library databases for recent relevant meta-analysis and their reference lists to include randomised controlled trials (RCTs) that compared lock solutions for CRBSI prevention. Two individuals will independently extract data from each included RCT according to a predesigned Excel spreadsheet and will assess the methodological quality using the Cochrane risk of bias tool. We will analyse the data using WinBUGS (V.1.4.3) and Stata (V.15.0). We will also estimate the pooled direct and indirect effects for all lock solutions using the network meta-analysis.Ethics and disseminationAs the present meta-analysis is performed based on previous published studies, no ethical approval and patient safety considerations are required. This study commenced on 18 January 2019, and its expected completion date is 1 December 2019. We will disseminate the results of our network meta-analysis through an international peer-reviewed journal.PROSPERO registration numberCRD42019121089.

scholarly journals Pharmacological treatment for unipolar psychotic depression

2006 ◽  
Vol 188 (5) ◽  
pp. 410-415 ◽  
Author(s):  
Jaap Wijkstra ◽  
Jeroen Lijmer ◽  
Ferdi J. Balk ◽  
John R. Geddes ◽  
Willem A. Nolen
Keyword(s):  
Systematic Review ◽  
Pharmacological Treatment ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Clinical Effectiveness ◽  
Controlled Trials ◽  
Psychotic Depression ◽  
Pharmacological Treatments ◽  
Risks And Benefits ◽  
Randomised Controlled

BackgroundThe optimal pharmacological treatment of unipolar psychotic depression is uncertain.AimsTo compare the clinical effectiveness of pharmacological treatments for patients with unipolar psychotic depression.MethodSystematic review and meta-analysis of randomised controlled trials.ResultsTen trials were included in the review. We found no evidence that the combination of an antidepressant with an antipsychotic is more effective than an antidepressant alone. This combination was statistically more effective than an antipsychotic alone.ConclusionsAntidepressant mono-therapy and adding an antipsychotic if the patient does not respond, or starting with the combination of an antidepressant and an antipsychotic, both appear to be appropriate options for patients with unipolar psychotic depression. However, clinically the balance between risks and benefits may suggest the first option should be preferred for many patients. Starting with an antipsychotic alone appears to be inadequate.

scholarly journals Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials

2014 ◽  
Vol 204 (2) ◽  
pp. 98-107 ◽  
Author(s):  
Rebecca L. Gould ◽  
Mark C. Coulson ◽  
Natasha Patel ◽  
Elizabeth Highton-Williamson ◽  
Robert J. Howard
Keyword(s):  
Older People ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Post Intervention ◽  
Treatment As Usual ◽  
Benzodiazepine Use ◽  
Benzodiazepine Withdrawal ◽  
Randomised Controlled ◽  
Meta Analyses

BackgroundThe use of benzodiazepines has been advised against in older people, but prevalence rates remain high.AimsTo review the evidence for interventions aimed at reducing benzodiazepine use in older people.MethodWe conducted a systematic review, assessment of risk of bias and meta-analyses of randomised controlled trials of benzodiazepine withdrawal and prescribing interventions.ResultsTen withdrawal and eight prescribing studies met the inclusion criteria. At post-intervention, significantly higher odds of not using benzodiazepines were found with supervised withdrawal with psychotherapy (odds ratio (OR) = 5.06, 95% CI 2.68–9.57,P<0.00001) and withdrawal with prescribing interventions (OR = 1.43, 95% CI 1.02–2.02,P=0.04) in comparison with the control interventions treatment as usual (TAU), education placebo, withdrawal with or without drug placebo, or psychotherapy alone. Significantly higher odds of not using benzodiazepines were also found for multifaceted prescribing interventions (OR = 1.37, 95% CI 1.10–1.72,P= 0.006) in comparison with control interventions (TAU and prescribing placebo).ConclusionsSupervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

The effectiveness of telemedicine on body mass index: A systematic review and meta-analysis

2018 ◽  
Vol 25 (7) ◽  
pp. 389-401 ◽  
Author(s):  
Jen-Wu Huang ◽  
Yi-Ying Lin ◽  
Nai-Yuan Wu
Keyword(s):  
Systematic Review ◽  
Body Mass Index ◽  
Body Mass ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Clinical Effectiveness ◽  
Cochrane Library ◽  
Controlled Trials ◽  
Obese People ◽  
Randomised Controlled

Object The purpose of this study was to evaluate the clinical effectiveness of telemedicine on changes in body mass index for overweight and obese people as well as for diabetes and hypertension patients. Methods A systematic review of articles published before 31 August 2014, was conducted using searches of Medline, Cochrane Library, EMBASE, and CINAHL Plus. The inclusion criteria were randomised controlled trials that compared telemedicine interventions with usual care or standard treatment in adults and reported a change in body mass index. A meta-analysis was conducted for eligible studies, and the primary outcome was a change in body mass index. Subgroup analysis was performed for the type of telemedicine, main purpose of intervention, and length of intervention. Results Twenty-five randomised controlled trials comprising 6253 people were included in the qualitative and quantitative analyses. The length of intervention ranged from nine weeks to two years. The meta-analysis revealed significant differences in body mass index changes (pooled difference in means = –0.49, 95% confidence interval –0.63 to –0.34, p < 0.001) between the telemedicine and control groups. The subgroup analyses found that either Internet-based or telephone-based intervention was associated with greater changes in body mass index than in controls. Telemedicine intervention was effective in improving body mass index whether it was used for diabetes control, hypertension control, weight loss, or increasing physical activity and was also effective for people with and without diabetes or hypertension. However, only interventions with a duration ≥ 6 months significantly decreased body mass index compared to controls. Conclusion Both patients with chronic disease and overweight/obese people could benefit from telemedicine interventions. We suggest that an effective telemedicine approach should be longer than six months and emphasise the importance of post-interventional follow-ups.

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