The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128:305-310. [PMID: 21701348 DOI: 10.1097/prs.0b013e318219c171]

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

OBJECTIVE

To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.

METHODS

We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.

RESULTS

Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.

CONCLUSIONS

These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Surgery for Liver Metastases From Gastric Cancer: A Meta-Analysis of Observational Studies

The role of surgical therapy in patients with liver metastases from gastric cancer is still controversial. In this study, we investigated the results obtained with local treatment of hepatic metastases in patients with gastric cancer, by performing a systematic literature review and meta-analysis.We performed a systematic review and meta-analysis of observational studies published between 1990 and 2014. These works included multiple studies that evaluated the different survival rate among patients who underwent local treatment, such as hepatectomy or radiofrequency ablation, for hepatic metastases derived from primary gastric cancer. The collected studies were evaluated for heterogeneity, publication bias, and quality, and a pooled hazard ratio (HR) was calculated with a confidence interval estimated at 95% (95% CI).After conducting a thorough research among all published works, 2337 studies were found and after the review process 11 observational studies were included in the analysis. The total amount of patients considered in the survival analysis was 1010. An accurate analysis of all included studies reported a significantly higher survival rate in the group of patients who underwent the most aggressive local treatment for hepatic metastases (HR 0.54, 95% CI 0.46-0.95) as opposed to patients who underwent only palliation or systemic treatment. Furthermore, palliative local treatment of hepatic metastases had a higher survival rate if compared to surgical (without liver surgery) and systemic palliation (HR 0.50, 95% CI 0.26-0.96). Considering the only 3 studies where data from multivariate analyses was available, we found a higher survival rate in the local treatment groups, but the difference was not significant (HR 0.50, 95% CI 0.22-1.15).Curative and also palliative surgery of liver metastases from gastric cancer may improve patients' survival. However, further trials are needed in order to better understand the role of surgery in this group of patients.

Surgery for Liver Metastases From Gastric Cancer: A Meta-Analysis of Observational Studies

The role of surgical therapy in patients with liver metastases from gastric cancer is still controversial. In this study, we investigated the results obtained with local treatment of hepatic metastases in patients with gastric cancer, by performing a systematic literature review and meta-analysis.We performed a systematic review and meta-analysis of observational studies published between 1990 and 2014. These works included multiple studies that evaluated the different survival rate among patients who underwent local treatment, such as hepatectomy or radiofrequency ablation, for hepatic metastases derived from primary gastric cancer. The collected studies were evaluated for heterogeneity, publication bias, and quality, and a pooled hazard ratio (HR) was calculated with a confidence interval estimated at 95% (95% CI).After conducting a thorough research among all published works, 2337 studies were found and after the review process 11 observational studies were included in the analysis. The total amount of patients considered in the survival analysis was 1010. An accurate analysis of all included studies reported a significantly higher survival rate in the group of patients who underwent the most aggressive local treatment for hepatic metastases (HR 0.54, 95% CI 0.46-0.95) as opposed to patients who underwent only palliation or systemic treatment. Furthermore, palliative local treatment of hepatic metastases had a higher survival rate if compared to surgical (without liver surgery) and systemic palliation (HR 0.50, 95% CI 0.26-0.96). Considering the only 3 studies where data from multivariate analyses was available, we found a higher survival rate in the local treatment groups, but the difference was not significant (HR 0.50, 95% CI 0.22-1.15).Curative and also palliative surgery of liver metastases from gastric cancer may improve patients' survival. However, further trials are needed in order to better understand the role of surgery in this group of patients.

[Evidence based surgery. A necessary tool]

BACKGROUND

Evidence-based surgery is a tool that has been adopted worldwide by surgeons. As all decisions must be current and have a scientific basis, the approach for performing it must be standardised. Five important steps are required to perform surgery based on evidence. Convert the need for information into a question that can be answered, finding the best information to answer that question, critical evaluation of the evidence, and its validity, impact and applicability, integrating the evidence with your own experience, and with the evaluation of the patients. This should take into account their biology, values and specific circumstances, as well as to evaluate the effectiveness and efficiency of the execution of steps 1-4 and propose how to improve them.

CONCLUSION

This article presents the main tools to perform surgery properly based on evidence.

Minimally invasive renal autotransplantation

Minimally invasive renal allotransplantation techniques have been recently described; reported benefits include reduced morbidity/complications. These benefits have been successfully adapted for minimally invasive renal autotransplantation, however, in a non-oncological setting. We, here, describe a novel alternative robot-assisted renal autotransplantation technique, utilizing GelPOINT, which by permitting ex vivo graft examination and surgery might allow further broadening of indications for minimally-invasive renal autotransplantation, to include complex oncological renal/ureteral lesions. Future studies are needed to evaluate the utility of these techniques.

Confirmed and Potential Sources of Legionella Reviewed

Legionella bacteria are ubiquitous in natural matrices and man-made systems. However, it is not always clear if these reservoirs can act as source of infection resulting in cases of Legionnaires' disease. This review provides an overview of reservoirs of Legionella reported in the literature, other than drinking water distribution systems. Levels of evidence were developed to discriminate between potential and confirmed sources of Legionella. A total of 17 systems and matrices could be classified as confirmed sources of Legionella. Many other man-made systems or natural matrices were not classified as a confirmed source, since either no patients were linked to these reservoirs or the supporting evidence was weak. However, these systems or matrices could play an important role in the transmission of infectious Legionella bacteria; they might not yet be considered in source investigations, resulting in an underestimation of their importance. To optimize source investigations it is important to have knowledge about all the (potential) sources of Legionella. Further research is needed to unravel what the contribution is of each confirmed source, and possibly also potential sources, to the LD disease burden.

Research trends in evidence-based medicine: a joinpoint regression analysis of more than 50 years of publication data

Background

Evidence-based medicine (EBM) has developed as the dominant paradigm of assessment of evidence that is used in clinical practice. Since its development, EBM has been applied to integrate the best available research into diagnosis and treatment with the purpose of improving patient care. In the EBM era, a hierarchy of evidence has been proposed, including various types of research methods, such as meta-analysis (MA), systematic review (SRV), randomized controlled trial (RCT), case report (CR), practice guideline (PGL), and so on. Although there are numerous studies examining the impact and importance of specific cases of EBM in clinical practice, there is a lack of research quantitatively measuring publication trends in the growth and development of EBM. Therefore, a bibliometric analysis was constructed to determine the scientific productivity of EBM research over decades.

Methods

NCBI PubMed database was used to search, retrieve and classify publications according to research method and year of publication. Joinpoint regression analysis was undertaken to analyze trends in research productivity and the prevalence of individual research methods.

Findings

Analysis indicates that MA and SRV, which are classified as the highest ranking of evidence in the EBM, accounted for a relatively small but auspicious number of publications. For most research methods, the annual percent change (APC) indicates a consistent increase in publication frequency. MA, SRV and RCT show the highest rate of publication growth in the past twenty years. Only controlled clinical trials (CCT) shows a non-significant reduction in publications over the past ten years.

Conclusions

Higher quality research methods, such as MA, SRV and RCT, are showing continuous publication growth, which suggests an acknowledgement of the value of these methods. This study provides the first quantitative assessment of research method publication trends in EBM.

Breastfeeding, bottle feeding practices and malocclusion in the primary dentition: a systematic review of cohort studies

The World Health Organization recommends exclusive breast feeding for at least six months. However, there is no scientific evidence of the benefits of breast feeding for oral health in children under primary dentition. This study aimed to search for scientific evidence regarding the following question: is bottle feeding associated with malocclusion in the primary dentition compared to children that are breastfed? An electronic search was performed in seven databases. The systematic review included 10 cohort studies. It was not possible to conduct meta-analysis; therefore a qualitative analysis was assessed. The majority of studies evaluated feeding habits by means of questionnaires and conducted a single examination. Three studies observed that bottle feeding was significantly associated with overjet and posterior crossbite. Studies reported several cut-off times for breastfeeding (varying from 1 month up to 3 years of age) and several types of malocclusion. Controlling for non-nutritive sucking habits was reported for only half of the studies and this may have led to biased results. The scientific evidence could not confirm a specific type of malocclusion associated with the feeding habits or an adequate time of breastfeeding to benefit the children against malocclusion. Further cohort studies are needed to confirm this evidence.

Uptake of systematic reviews and meta-analyses based on individual participant data in clinical practice guidelines: descriptive study

OBJECTIVE

To establish the extent to which systematic reviews and meta-analyses of individual participant data (IPD) are being used to inform the recommendations included in published clinical guidelines.

DESIGN

Descriptive study.

SETTING

Database maintained by the Cochrane IPD Meta-analysis Methods Group, supplemented by records of published IPD meta-analyses held in a separate database.

POPULATION

A test sample of systematic reviews of randomised controlled trials that included a meta-analysis of IPD, and a separate sample of clinical guidelines, matched to the IPD meta-analyses according to medical condition, interventions, populations, and dates of publication.

DATA EXTRACTION

Descriptive information on each guideline was extracted along with evidence showing use or critical appraisal, or both, of the IPD meta-analysis within the guideline; recommendations based directly on its findings and the use of other systematic reviews in the guideline.

RESULTS

Based on 33 IPD meta-analyses and 177 eligible, matched clinical guidelines there was evidence that IPD meta-analyses were being under-utilised. Only 66 guidelines (37%) cited a matched IPD meta-analysis. Around a third of these (n=22, 34%) had critically appraised the IPD meta-analysis. Recommendations based directly on the matched IPD meta-analyses were identified for only 18 of the 66 guidelines (27%). For the guidelines that did not cite a matched IPD meta-analysis (n=111, 63%), search dates had preceded the publication of the IPD meta-analysis in 23 cases (21%); however, for the remainder, there was no obvious reasons why the IPD meta-analysis had not been cited.

CONCLUSIONS

Our results indicate that systematic reviews and meta-analyses based on IPD are being under-utilised. Guideline developers should routinely seek good quality and up to date IPD meta-analyses to inform guidelines. Increased use of IPD meta-analyses could lead to improved guidelines ensuring that routine patient care is based on the most reliable evidence available.

Workplace exercise for control of occupational neck/shoulder disorders: a review of prospective studies

A review was conducted of prospective studies (1997-2014) examining the efficacy of exercise as a workplace intervention to control neck/shoulder pain, symptoms, and disability. The review identified 38 relevant studies - 20 were classified with positive effects, 13 with null effects, and 5 as inconclusive. Of the positive studies, 12 were consistent with Level I evidence, 3 with Level II evidence, and 5 with Level IV evidence. Specific resistance training (SRT) exercise appeared to be associated with more positive studies (eight Level I studies) than other exercise modalities such as general resistance training, general physical exercise, stretching, and movement awareness exercises. Studies of longer trial duration tended toward more null findings and lower program compliance. Evidence for a primary preventive effect of workplace exercise is minimal. The findings of this review suggest that workplace exercise can be effective as tertiary prevention and therapeutic relief of neck/shoulder symptoms, at least over the shorter term.

Curative versus palliative surgical resection of liver metastases in patients with neuroendocrine tumors: a meta-analysis of observational studies

BACKGROUND

The role of surgical therapy in patients with liver metastases from neuroendocrine tumors (NETs) is unclear. In this study, the results obtained with curative or palliative resection, by reviewing recent literature and performing a meta-analysis, were examined.

MATERIALS AND METHODS

A systematic review and meta-analysis of observational studies published between January 1990 and October 2013 were performed. Studies that evaluated the different survival between patients treated by curative or palliative surgical resection of hepatic metastases from NETs were considered. The collected studies were evaluated for heterogeneity, publication bias, and quality. To calculate the pooled hazard ratio (HR) estimate and the 95% confidence interval (95% CI), a fixed-effects model was applied.

RESULTS

After the literature search, 2,546 studies were found and, among 38 potentially eligible studies, 3 were considered. We did not find a significant longer survival in patients treated with curative surgical resection of hepatic metastases when compared to palliative hepatic resection HR 0.40 (95% CI: 0.14-1.11). In one study, palliative resection of hepatic metastases significantly increased survival when compared to embolization.

CONCLUSIONS

Curative and also palliative surgery of NETs liver metastases may improve survival outcome. However, further randomized clinical trials are needed to elucidate this argument.

Quantifying observational evidence for risk of fatal and nonfatal cardiovascular disease following androgen deprivation therapy for prostate cancer: a meta-analysis

CONTEXT

Whether androgen deprivation therapy (ADT) for men with prostate cancer (PCa) increases the risk of cardiovascular disease (CVD) remains controversial. Pooled analyses using data from randomised controlled trials suggest no increased risk of fatal CVD following ADT, but no pooled analyses exist for observational studies.

OBJECTIVE

To perform a meta-analysis using observational data on ADT and risk of CVD events in men with PCa.

EVIDENCE ACQUISITION

PubMed and Embase were searched using predefined inclusion criteria to perform meta-analyses on associations between types of ADT and nonfatal and fatal CVD outcomes using information from observational studies. Random effects meta-analyses were conducted to estimate relative risks (RRs) and 95% confidence intervals (CIs).

EVIDENCE SYNTHESIS

A total of eight observational studies were identified studying at least one type of ADT and a nonfatal or fatal CVD outcome. The RR for risk of any type of nonfatal CVD was 1.38 (95% CI, 1.29-1.48) for men with PCa on gonadotropin-releasing hormone (GnRH) agonists, compared with men not treated with ADT. When analysing nonfatal ischemic heart disease only, the RR was 1.39 (95% CI, 1.26-1.54). The associations between GnRH agonists and nonfatal or fatal myocardial infarction or stroke were even stronger: RR: 1.57 (95% CI, 1.26-1.94) and RR: 1.51 (95% CI, 1.24-1.84), respectively. The results for other types of ADT in relation to the risk of any nonfatal CVD were RR: 1.44 (95% CI, 1.28-1.62) for orchiectomy and RR: 1.21 (95% CI, 1.07-1.367) for antiandrogens.

CONCLUSIONS

Observational data show a consistent positive association between ADT and the risk of CVD. This finding supports the need for future randomised trials of PCa patients that include older patients and men with multiple comorbidities to better reflect the general population.

PATIENT SUMMARY

We investigated all the available data from observational studies on hormonal treatment for prostate cancer and its possible cardiovascular adverse effects. We found consistent evidence that this treatment may increase the risk of cardiovascular disease.

Dissemination and implementation of evidence based, mental health interventions in post conflict, low resource settings

The burden of mental health problems in (post)conflict low- and middle-income countries (LMIC) is substantial. Despite growing evidence for the effectiveness of selected mental health programs in conflict-affected LMIC and growing policy support, actual uptake and implementation have been slow. A key direction for future research, and a new frontier within science and practice, is Dissemination and Implementation (DI) which directly addresses the movement of evidence-based, effective health care approaches from experimental settings into routine use. This paper outlines some key implementation challenges, and strategies to address these, while implementing evidence-based treatments in conflict-affected LMIC based on the authors' collective experiences. Dissemination and implementation evaluation and research in conflict settings is an essential new research direction. Future DI work in LMIC should include: 1) defining concepts and developing measurement tools, 2) the measurement of DI outcomes for all programming, and 3) the systematic evaluation of specific implementation strategies.

A systematic review of systematic reviews on interventions for caregivers of people with chronic conditions

AIM

To evaluate the effectiveness of interventions to support caregivers of people with selected chronic conditions.

BACKGROUND

Informal caregivers provide millions of care hours each week contributing to significant healthcare savings. Despite much research evaluating a range of interventions for caregivers, their impact remains unclear.

DESIGN

A systematic review of systematic reviews of interventions to support caregivers of people with selected chronic conditions.

DATA SOURCES

The electronic databases of PubMed, CINAHL, British Nursing Index, PsycINFO, Social Science Index (January 1990-May 2014) and The Cochrane Library (Issue 6, June 2014), were searched using Medical Subject Heading and index term combinations of the keywords caregiver, systematic review, intervention and named chronic conditions.

REVIEW METHODS

Papers were included if they reported a systematic review of interventions for caregivers of people with chronic conditions. The methodological quality of the included reviews was independently assessed by two reviewers using R-AMSTAR. Data were independently extracted by two reviewers using a pre-designed data extraction form. Narrative synthesis of review findings was used to present the results.

RESULTS

Eight systematic reviews were included. There was evidence that education and support programme interventions improved caregiver quality of life. Information-giving interventions improved caregiver knowledge for stroke caregivers.

CONCLUSION

Education, support and information-giving interventions warrant further investigation across caregiver groups. A large-scale funded programme for caregiver research is required to ensure that studies are of high quality to inform service development across settings.

Nerve Injuries in Aesthetic Breast Surgery: Systematic Review and Treatment Options

BACKGROUND

The risk of nerve injuries in aesthetic breast surgery has not been well explored.

OBJECTIVES

The authors conducted a systematic review to provide evidence-based information on the incidence and treatment of nerve injuries resulting from aesthetic breast surgery.

METHODS

A broad literature search of Medline, Embase, and the Cochrane Database of Systematic Reviews was undertaken to identify studies in which nerve injury occurred after breast augmentation or mastopexy. Specific inclusion and exclusion criteria were established before the search was performed.

RESULTS

The initial 4806 citations were narrowed by topic, title, and abstract to 53 articles. After full-text review, 36 studies were included. The risk of any nerve injury after breast augmentation ranged from 13.57% to 15.44%. Specific nerve injury rates were calculated for the intercostal cutaneous nerves, branches to the nipple-areola complex, intercostobrachial nerve, long thoracic nerve, and brachial plexus. Also calculated were the total estimated risks of chronic pain, hyperesthesia, hypoesthesia, and numbness. The meta-analysis showed no associations between the rates of breast nerve injury or sensation change and implant size, incision type, or implant position in patients who underwent breast augmentation. The data were insufficient to determine rates of nerve injury in mastopexy.

CONCLUSIONS

The possibility of nerve injury, sensation change, or chronic pain with breast augmentation is real, and estimating the incidences of these conditions is useful to both patients and surgeons. Optimizing patient outcomes requires timely treatment by a multidisciplinary team and may include peripheral nerve surgery.

LEVEL OF EVIDENCE

3.

Health services research: evolution and applications

Health services research (HSR) is broadly focused on characterizing and improving the access, quality, delivery, and cost of health care. HSR is a multidisciplinary field, engaging experts in clinical medicine and surgery, policy, economics, implementation science, statistics, psychology, and education to improve the care of patients across all specialties. This article summarizes the evolution and distinctive attributes of HSR and present several real-world applications.

Plastic surgery residents' attitudes and understanding of biostatistics: a pilot study

OBJECTIVE

To assess plastic surgery residents' knowledge, attitudes, and comfort with biostatistics.

DESIGN

Cross-sectional study.

SETTING

Department of Plastic and Reconstructive Surgery at Johns Hopkins Hospital.

PARTICIPANTS

A total of 22 plastic surgery residents (91% response rate) completed the study.

RESULTS

The study sample consisted of 18 residents in the integrated training path and 4 in the independent training track and was equally divided between junior and senior residents. Most respondents (>54%) had taken at least 1 course in biostatistics or epidemiology. More than 90% of residents reported reading at least 1 plastic surgical journal on a regular basis (mean 2.1 ± 1.5 journals/month). Most residents expressed a desire to learn more about biostatistics (68.2%), reported using statistical information in forming clinical opinions (86.3%), and placed a high value on knowledge of biostatistics in appraising the surgical literature (90.9%). However, only 45% of respondents reported being able to understand all the statistical terms encountered in journal articles. Only 50% of respondents felt comfortable with assessing whether the appropriate statistical tests were used to answer a research question. In case studies, the mean percentage of correct responses was 53.0 ± 24.5% (range: 0-83.3). Higher performance scores were associated with a prior course in biostatistics (p = 0.04) and the number of journals read monthly (p = 0.003). Respondents had difficulty with study design (45.5% correct), analysis of variance (45.5% correct), time to event analysis (9.1% correct), and interpreting a 95% confidence interval (45.5% correct). The number of correct responses strongly correlated with respondent confidence in biostatistics (r = 0.70, p < 0.001).

CONCLUSION

Plastic surgery residents place a high degree of importance on biostatistics but have only a fair understanding of core statistical concepts.

Analyzing acute procedural pain in clinical trials

Because acute procedural pain tends to increase with procedure time, assessments of pain management strategies must take that time relationship into account. Statistical time-course analyses are, however, complex and require large patient numbers to detect differences. The current study evaluated the abilities of various single and simple composite measures such as averaged pain or individual patient pain slopes to detect treatment effects. Secondary analyses were performed with the data from 3 prospective randomized clinical trials that assessed the effect of a self-hypnotic relaxation intervention on procedural pain, measured every 10-15 minutes during vascular/renal interventions, breast biopsies, and tumor embolizations. Single point-in-time and maximal pain comparisons were poor in detecting treatment effects. Linear data sets of individual patient slopes yielded the same qualitative results as the more complex repeated measures analyses, allowing the use of standard statistical approaches (eg, Kruskal-Wallis), and promising analyses of smaller subgroups, which otherwise would be underpowered. With nonlinear data, a simple averaged score was highly sensitive in detecting differences. Use of these 2 workable and relatively simple approaches may be a first step towards facilitating the development of data sets that could enable meta-analyses of data from acute pain trials.

Deep venous thrombosis: prevention and management

This article summarizes current information on the risk and the assessment of risks for deep venous thrombosis (DVT) resulting from plastic surgery procedures. Risk assessment is the foundation for recommended methods of prevention of DVT and, in turn, possible pulmonary emboli. If prevention fails, treatment of DVT is required to avoid the major complication of pulmonary emboli. The significant risk of DVT and pulmonary emboli after an abdominoplasty is confirmed in this article.

Taking evidence-based plastic surgery to the next level: report of the second summit on evidence-based plastic surgery

Applying the principles of evidence-based medicine has the potential to drastically improve quality of care and patient outcomes. For this reason, evidence-based medicine has been held as one of the 15 most important developments in medicine within the past 100 years. In August of 2010, a broad coalition of leaders from numerous organizations representing societies, boards, journals, foundations, and academic institutions met in Colorado Springs, Colorado, for the first Evidence-Based Plastic Surgery Summit. The summit signaled a sea change in the approach of organized plastic surgery to the promotion of evidence-based medicine within the specialty. It was determined that a strategic, coordinated, and sustained effort to drive an evidence-based medicine culture would accelerate adoption and advance quality of care and patient safety. Over the past 2 years, many of the goals of the initial summit have been met. In order to take our evidence-based medicine efforts to the next level, a second summit was recently held to redefine goals, focus efforts, address barriers, and launch new initiatives with broad consensus. This article documents the outcomes of the second Evidence-Based Plastic Surgery Summit.

Abdominoplasty-related nerve injuries: systematic review and treatment options

BACKGROUND

Abdominoplasty is a common cosmetic procedure; nerve injury is an underexplored risk of the procedure.

OBJECTIVE

The authors review existing literature to examine the incidence and treatment of nerve injuries after abdominoplasty procedures and provide a treatment algorithm based on their results.

METHODS

A search of the literature on MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was undertaken. After full-text review, 23 articles met our criteria. Any mentions of nerve injury, including references to a lack of nerve injury, were documented. All data were pooled for analysis. From our combined data, we calculated the risks of postabdominoplasty nerve injury by dividing the total number of nerve injuries by the total number of patients.

RESULTS

Pooled data showed that 1.94% of patients sustained specific nerve injury, and 1.02% of patients sustained permanent injury after abdominoplasty. In addition, 7.67% experienced decreased sensation, 1.07% reported chronic pain, and 0.44% reported temporary weakness or paralysis. Nerves directly injured were the lateral femoral cutaneous (1.36% of patients) and iliohypogastric (0.10%) nerves. Nerves injured from surgical positioning were the brachial plexus (0.10%), musculocutaneous (0.10%), radial (0.05%), sciatic (0.19%), and common peroneal (0.05%) nerves.

CONCLUSIONS

Although our results showed a low incidence of postabdominoplasty nerve injury, the lasting impact on affected patients' quality of life can be significant. Appropriate and timely treatment by a multidisciplinary team is critical to optimize patient outcomes. Better reporting of nerve injuries in future studies of abdominoplasty will provide more accurate information about the incidence and consequences of these injuries.

LEVEL OF EVIDENCE

4.

Long-term assessment of facial features and functions needing more attention in treatment of Treacher Collins syndrome

AIM

This study aimed to determine which facial features and functions need more attention during surgical treatment of Treacher Collins syndrome (TCS) in the long term.

METHOD

A cross-sectional cohort study was conducted to compare 23 TCS patients with 206 controls (all≥18 years) regarding satisfaction with their face. The adjusted Body Cathexis Scale was used to determine satisfaction with the appearance of the different facial features and functions. Desire for further treatment of these items was questioned. For each patient an overview was made of all facial operations performed, the affected facial features and the objective severity of the facial deformities.

RESULTS

Patients were least satisfied with the appearance of the ears, facial profile and eyelids and with the functions hearing and nasal patency (P<0.001). Residual deformity of the reconstructed facial areas remained a problem in mainly the orbital area. The desire for further treatment and dissatisfaction was high in the operated patients, predominantly for eyelid reconstructions. Another significant wish was for improvement of hearing.

CONCLUSION

In patients with TCS, functional deficits of the face are shown to be as important as the facial appearance. Particularly nasal patency and hearing are frequently impaired and require routine screening and treatment from intake onwards. Furthermore, correction of ear deformities and midface hypoplasia should be offered and performed more frequently. Residual deformity and dissatisfaction remains a problem, especially in reconstructed eyelids.

LEVEL OF EVIDENCE

II.

Measuring treatment effectiveness: a guide to incorporating the principles of evidence-based medicine

Every year, hundreds of new surgical devices and techniques are introduced, and plastic surgeons must determine the associated risks, benefits, and costs of these options when incorporating these advances into their armamentarium. This article will discuss the elements of treatment effectiveness by applying the principles of evidence-based medicine to therapeutics. Current efforts to measure plastic surgery outcomes are evolving and rely on case series and retrospective cohort studies. This review will highlight the basic evidence-based medicine concepts and how they can potentially be applied to understand best practices in plastic surgery.

Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices

BACKGROUND

Use of biologically engineered acellular dermal matrices in the upper and lower extremities is increasingly recognized as a means of achieving definitive healing in the setting of both acute and chronic injuries but data and evidence supporting their use are limited. The authors performed this systematic review to identify all available evidence for the use of matrices in nonburn extremity reconstruction.

METHODS

A systematic review of the Cochrane and MEDLINE databases was performed to identify all reports of the application of matrices in wounds of the upper and lower extremities. Reports that included fewer than five patients and that involved cellular seeding, nonhuman studies, and burn injuries were excluded. Studies were evaluated for quality of statistical measures and outcomes, and a level of evidence was assigned in accordance with the American Society of Plastic Surgeons' Rating Levels of Evidence.

RESULTS

Of an initial 2422 reports, 13 primary reports were identified (10 case series and three randomized controlled trials) representing a total of 432 patients and 441 discrete wounds. After evidence review, 10 of these studies represented level IV evidence, two studies represented level II evidence, and one study achieved level I evidence.

CONCLUSIONS

Extremity wound management continues to rely on adequate vascular supply, débridement with eradication of infection, off-loading, and/or immobilization. Current data, although limited, appear to support the use of acellular dermal matrices in chronic and acute injuries where there is exposed bone, tendon, and/or muscle. They may provide a simple technique to achieve timely and durable tissue coverage in extremity wounds.

Surgical treatment and survival in patients with liver metastases from neuroendocrine tumors: a meta-analysis of observational studies

Introduction. The role of hepatic resection in patients with liver metastases from gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is still poorly defined. Therefore, we examined the results obtained with surgical resection and other locoregional or systemic therapies by reviewing the recent literature on this topic. We performed the meta-analysis for comparing surgical resection of hepatic metastases with other treatments. Materials and Methods. In this systematic review and meta-analysis of observational studies, the literature search was undertaken between 1990 and 2012 looking for studies evaluating the different survivals between patients treated with surgical resection of hepatic metastases and with other surgical or nonsurgical therapies. The studies were evaluated for quality, publication bias, and heterogeneity. Pooled hazard ratio (HR) estimates and 95% confidence intervals (CI.95) were calculated using fixed-effects model. Results. We selected six studies in the review, five of which were suitable for meta-analysis. We found a significant longer survival in patients treated with hepatic resection than embolisation HR 0.34 (CI.95 0.21-0.55) or all other nonsurgical treatments HR 0.45 (CI.95 0.34-0.60). Only one study compared surgical resection with liver transplantation and meta-analysis was not feasible. Conclusions. Our meta-analysis provides evidence supporting the hypothesis that hepatic resection increases overall survival in patients with liver metastases from GEP-NETs. Further randomized clinical trials are needed to confirm these findings and it would be desirable to identify new markers to properly select patients for surgical treatment.

Developing the art of scientific presentation

PURPOSE

Few guidelines exist regarding the most effective approach to scientific oral presentations. Our purpose is to (1) develop a standardized instrument to evaluate scientific presentations based on a comprehensive review of the available literature regarding the components and organization of scientific presentations and (2) describe the optimal characteristics of scientific presentations.

METHODS

At the Sixty-sixth (2011) Annual Meeting of the American Society for Surgery of the Hand, 69 presentations were evaluated by at least 2 independent observers. A rating instrument was developed a priori to examine presentation content (background, methods, results, and conclusions), presentation style (speech, structure, delivery, slide aesthetics), and overall quality. We examined correlations between reviewers' ratings of each component as well as overall perceived quality of the presentation using regression analysis. Intraclass correlation coefficients were calculated to measure the degree of variation because of reviewer disagreement and identify the aspects of presentations that contribute to overall quality.

RESULTS

Reviewer agreement was high for presentation content, and less than 1% of variation was caused by reviewer disagreement for background, methods, and conclusions. With respect to presentation style, reviewers agreed most frequently regarding speech and slide appearance, and only 9% and 13%, respectively, of the variation was caused by reviewer disagreement. Disagreement was higher for delivery and presentation structure, and 21% of the variation was attributable to reviewer disagreement. Speaker delivery and slide appearance were the most important predictors of presentation quality, followed by the quality of the presentation of conclusions and background information. Presentation of methods and results were not associated with overall presentation quality.

CONCLUSIONS

Distinct aspects of presentation content and style correlate with quality, which can be reliably and objectively measured. By focusing on selected concepts with visually simple slides, speakers can enhance their delivery and may potentially improve the audience's comprehension of the study findings.