Completeness of reporting of trials published in languages other than English: implications for conduct and reporting of systematic reviews

Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review

This study aimed at providing an answer to two clinical questions related to patients with masticatory muscle pain: 1) Does the use of a full-coverage hard acrylic occlusal appliance (stabilization splint) lead to a significant decrease of symptoms? and 2) Is the treatment success achieved with a stabilization splint more pronounced than the success attained with other forms of treatment (including placebo treatment) or no treatment? A systematic search was carried out in different electronic databases, supplemented by handsearch in four selected dental journals and by examination of the bibliographies of the retrieved articles. Thirteen publications, representing nine controlled clinical studies, could be identified. Reporting quality of most studies as assessed with the Jadad score ranged from 1 to 5. Based on the currently best available evidence it appears that most patients with masticatory muscle pain are helped by the incorporation of a stabilization splint. Nevertheless, evidence is equivocal if improvement of pain symptoms after incorporation of the intraoral appliance is caused by a specific effect of the appliance. A stabilization splint does not appear to yield a better clinical outcome than a soft splint, a non-occluding palatal splint, physical therapy, or body acupuncture. The scarcity of current external evidence emphasizes the need for more and better clinical research.

Systematic review of prognostic cohort studies on shoulder disorders

Shoulder complaints are common and have an unfavourable outcome in many patients. Only 50% of all new episodes of shoulder disorders end in complete recovery within 6 months. There is no consensus about prognostic indicators that can identify patients at high and low risk of chronicity. By a systematic search of the literature we identified 16 studies focusing on the prognosis of shoulder disorders. The methodological quality of these 16 studies was assessed. Six of these were considered to be of relatively 'high quality'. There was a wide variety among the studies in length of follow-up, study population, evaluated prognostic factors, type of outcome measure and method of analysis. Due to this large heterogeneity, we refrained from statistical pooling. Instead, we used a best-evidence synthesis. There is strong evidence that high pain intensity predicts a poorer outcome in primary care populations and that middle age (45-54) is associated with poor outcome in occupational populations. There is moderate evidence that a long duration of complaints, and high disability score at baseline predict a poorer outcome in primary care. These results need to be interpreted with caution because of the small number of studies on which these conclusions are based, and the large heterogeneity among studies regarding follow-up, outcome measures, and analysis.

Adjusting for publication bias: modelling the selection process

RATIONALE, AIMS AND BACKGROUND: Systematic review with meta-analysis, a statistical technique for combining results of several studies, is progressively being used to guide decisions in medicine. Publication bias is acknowledged as a threat to the validity of systematic reviews and its existence may lead to inappropriate decisions about patient management or health policy. It is said to occur when the results of research available in the literature are not representative of the totality of all research. The selection mechanism that causes publication bias is complex, yet despite an extensive literature of empirical research identifying risk factors for publication, little work has been done to improve models of selection. Methods

METHODS

that adjust combined meta-analytic estimates for publication bias are compared and applied to a systematic review of oral rehydration solution in the treatment of dehydration. Within a weighted distributions framework models of the selection process are considered and developed further.

CONCLUSIONS

Weighted distributions offer a flexible approach that allows the potential to modify the selection function to incorporate other factors. Methods that adjust combined estimates should not be used to provide an alternative answer but to consider the robustness of the combined estimate to publication bias.

Spinal manipulative therapy for low back pain

BACKGROUND

Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.

OBJECTIVES

To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.

SELECTION CRITERIA

Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).

MAIN RESULTS

Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.

REVIEWER'S CONCLUSIONS

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Glucocorticoids for croup

BACKGROUND

Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research.

OBJECTIVES

To determine the effect of glucocorticoids for children with croup.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials.

SELECTION CRITERIA

Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment.

DATA COLLECTION AND ANALYSIS

Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed.

MAIN RESULTS

Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone.

REVIEWER'S CONCLUSIONS

Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.

Non-invasive physical treatments for chronic/recurrent headache

BACKGROUND

Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache.

OBJECTIVES

To quantify and compare the magnitude of short- and long-term effects of non-invasive physical treatments for chronic/recurrent headaches.

SEARCH STRATEGY

We searched the following databases from their inception to November 2002: MEDLINE, EMBASE, BIOSIS, CINAHL, Science Citation Index, Dissertation Abstracts, CENTRAL, and the Specialised Register of the Cochrane Pain, Palliative Care and Supportive Care review group. Selected complementary medicine reference systems were searched as well. We also performed citation tracking and hand searching of potentially relevant journals.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing non-invasive physical treatments for chronic/recurrent headaches to any type of control.

DATA COLLECTION AND ANALYSIS

Two independent reviewers abstracted trial information and scored trials for methodological quality. Outcomes data were standardized into percentage point and effect size scores wherever possible. The strength of the evidence of effectiveness was assessed using pre-specified rules.

MAIN RESULTS

Twenty-two studies with a total of 2628 patients (age 12 to 78 years) met the inclusion criteria. Five types of headache were studied: migraine, tension-type, cervicogenic, a mix of migraine and tension-type, and post-traumatic headache. Ten studies had methodological quality scores of 50 or more (out of a possible 100 points), but many limitations were identified. We were unable to pool data because of study heterogeneity. For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). Other possible treatment options with weaker evidence of effectiveness are pulsating electromagnetic fields and a combination of transcutaneous electrical nerve stimulation [TENS] and electrical neurotransmitter modulation. For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. Other possible treatment options with weaker evidence of effectiveness are therapeutic touch; cranial electrotherapy; a combination of TENS and electrical neurotransmitter modulation; and a regimen of auto-massage, TENS, and stretching. For episodic tension-type headache, there is evidence that adding spinal manipulation to massage is not effective. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization. There is weaker evidence that spinal mobilization is more effective in the short term than cold packs in the treatment of post-traumatic headache.

REVIEWERS' CONCLUSIONS

A few non-invasive physical treatments may be effective as prophylactic treatments for chronic/recurrent headaches. Based on trial results, these treatments appear to be associated with little risk of serious adverse effects. The clinical effectiveness and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods. The heterogeneity of the studies included in this review means that the results of a few additional high-quality trials in the future could easily change the conclusions of our review.

Quality of published clinical trials on asthma

The quality of 287 clinical trials on asthma treatment published between 1984 and 1997 is described in this article, using a scale adding to a maximum of 14 points. The mean quality score was 8.60 (standard deviation 1.55). Quality improved throughout time from 8.17 +/- 1.40 before 1989 until 9.55 +/- 1.66 after 1992. Several methodological issues were associated with higher quality, namely parallel design, longer length of the follow-up, complete description of the exclusion criteria, description of the initial and ending recruitment dates, higher sample size, explicit sample size calculation, blinding, full description of randomization, intention-to-treat analysis, full description of the intervention, and evaluation of bias. The higher statistical significance, however, was not associated with higher clinical trial quality.

The cost of allogeneic red blood cells - a systematic review

Several reports suggest that the cost of RBCs may have risen over time, but there exists very little published evidence of that. The objective was to determine whether published studies documenting cost data on RBCs suggest an increase over time and to assess the quality of cost studies. We used the terms 'cost', 'allogeneic/allogenic' and 'blood' to identify cost studies between 1966 and 2002 from Medline, ISIesource and Ingenta electronic databases. Furthermore, we manually searched a number of transfusion and health economics journals for completeness. We included studies that used an established methodology and conducted an economic evaluation using primary/secondary cost data to calculate the cost of RBCs and RBC transfusion. Studies without allogeneic RBCs as comparator were excluded. Two individuals independently reviewed the studies and included studies upon reaching a consensus. Fourteen studies qualified the selection criteria and were included in the review. Ten studies were identified from Medline, two from Ingenta, one from ISIesource and one was a conference paper. Of the 14 studies reviewed, 10 had focused on RBC transfusion and four had focused on both RBCs and RBC transfusion. Ten studies were from the US, and two each from Canada and the UK, respectively. Two studies had explicit objective of cost calculation, and others had calculated costs towards fulfilling other objectives. Most of the reviewed studies were dated and of poor quality. Despite these limitations, it appears that the cost of RBCs has increased over time in the UK, Canada and the US. More studies are needed to fully assess the trend of costs over time. Future cost studies should try to follow the economic evaluation guidelines for greater research implications.

Evidence-based medicine for orthopedic practice

Evidence-based medicine (EBM) is regarded as a new paradigm in medical practice, equal in enormity to the human genome project. However, there is still much confusion and misunderstanding about the concept and content of EBM. It is often limited to searching the literature and reading papers, serving cost cutters, and suppressing clinical freedom. Some believe that the use of clinical guidelines or the managed care system intimidates doctors' discretion during clinical practice and that EBM is a fashionable tendency of a group of medical academics armed with epidemiological and statistical jargon. Medical practice is a lifelong, continuous process of self-learning, and it requires clinicians to keep up to date on various developments. EBM is our practice for integrating individual clinical expertise with the best available evidence when making decisions about our care for each patient. EBM is one answer for making it possible to cover most of our activities as orthopedic surgeons, from the daily practice of patient care to writing and reading scientific papers.

Electronic searching of the literature for systematic reviews of screening and diagnostic tests for preterm birth

BACKGROUND

Published systematic reviews on prediction of preterm birth have tended to focus on a limited number of tests and their search strategies have often been relatively simple. Evaluation of all available tests in a systemic review will require a broad search strategy.

AIM

To describe a case study of electronic searching for a systematic review of accuracy studies evaluating all tests for predicting preterm birth.

METHODS

The search strategy, developed to capture literatures concerning all the tests en-masse consisted of formulation of an appropriate combination of search terms, pilot searches to refine the search term combination, selection of relevant databases, and citation retrieval from the refined searches for selection of potentially relevant papers. Electronic searches were carried out on general bibliographic databases (Biosis, Embase, Medline, Pascal and Scisearch), specialised databases (Database of Abstracts of Reviews of Effectiveness, Medion, National Research Register, Cochrane Controlled Trial Register and Cochrane Database of Systematic Reviews).

RESULTS

A total of 30076 citations were identified. Of these 8855 (29%) citations were duplications either within a database or across databases. Of the remaining 21221 citations, 3333 were considered potentially relevant to the review after assessment by two reviewers. These citations covered 19 different tests for predicting preterm birth.

CONCLUSIONS

This case study suggests that with use of a concerted effort to organise and manage the electronic searching it is feasible to undertake broad searches for systematic reviews with multiple questions.

Publication bias: raising awareness of a potential problem in dental research

With the development of evidence-based dentistry it is important to consider how accurate and representative our published pool of evidence is. In this article we will describe publication bias and discuss the causes and potential effects it may have upon the pool of scientific evidence available in dentistry.

The promise of and problems with evidence-based medicine for paediatric asthma management

The concept of 'evidence-based medicine' has now been in widespread use in clinical practice for over a decade. There are different types of clinical study, which may provide evidence on which to base clinical decisions, but some are much less robust than others. In making decisions about treatment, one of the highest levels of evidence in primary research is the randomized controlled trial. This study design has been used in clinical research for over 50 years. Systematic reviews of randomized controlled trial are scientific studies that review, critically appraise and, where appropriate, aggregate results from a number of different randomized controlled trials. They are increasingly being used throughout health care to provide guidance about treatment. Under the auspices of The Cochrane Collaboration, systematic reviews of randomized controlled trials are being conducted across the whole of health care. One of the most active areas for this work is within the field of asthma and clinicians are now able to access a large number of different systematic reviews on The Cochrane Library. If used appropriately, they can aid the clinician in making decisions about individual patients and provide a sound evidence base from which clinical guidelines can be developed.

Effectiveness of physiotherapy for lateral epicondylitis: a systematic review

AIM

To evaluate the available evidence of the effectiveness of physiotherapy for lateral epicondylitis of the elbow.

METHOD

Randomised controlled trials (RCTs) identified by a highly sensitive search strategy in six databases in combination with reference checking. Two independent reviewers selected RCTs that included a physiotherapy intervention, patients with lateral epicondylitis, and at least one clinically relevant outcome measure. No language restrictions were made. Methodological quality was independently assessed by two blinded reviewers. A best evidence synthesis, including a quantitative and qualitative analysis, was conducted, weighting the studies with respect to their internal validity, statistical significance, clinical relevance, and statistical power.

RESULTS

23 RCTs were included in the review, evaluating the effects of lasertherapy, ultrasound treatment, electrotherapy, and exercises and mobilisation techniques. Fourteen studies satisfied at least 50% of the internal validity criteria. Except for ultrasound, pooling of data from RCTs was not possible because of insufficient data, or clinical or statistical heterogeneity. The pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. There is insufficient evidence either to demonstrate benefit or lack of effect of lasertherapy, electrotherapy, exercises and mobilisation techniques for lateral epicondylitis.

CONCLUSIONS

Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power, and the low number of studies per intervention. Only for ultrasound, weak evidence for efficacy was found. More better designed, conducted and reported RCTs are needed.

Evidence-based neurosurgery

OBJECTIVE

The evidence-based medicine movement is gaining influence in many medical specialties. Although many think that clinical medicine always has been based on evidence, the discipline of evidence-based medicine places particular emphasis on a defined set of principles of critical analysis of individual research reports, methodologically rigorous synthesis of multiple reports, and the collection and dissemination of evidence repositories that allow rapid application of evidence in practice. This article provides a selective introduction to the discipline of evidence-based medicine as it applies to neurological surgery.

METHODS

The vast literature on evidence-based medicine has been reviewed selectively to identify resources that are readable, accessible, and relevant to neurosurgery.

RESULTS

The history, concepts, and techniques of evidence-based medicine are presented in brief, and educational and methodological resources, as well as evidence repositories, are introduced.

CONCLUSION

The techniques of evidence-based medicine are relevant to neurological surgery. There is a relatively large repository of critically analyzed and summarized evidence that is useful to the neurosurgical practitioner. Familiarity with these techniques and repositories can help the neurosurgeon bring the best available evidence to bear on the care of individual patients.

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

STUDY DESIGN

Systematic review of the literature.

OBJECTIVES

To develop a grading scale to judge the quality of randomized clinical trials (RCTs) and conduct a systematic review of the published RCTs that assess nonoperative treatments for patellofemoral pain syndrome (PFPS).

BACKGROUND

Systematic reviews of the quality and usefulness of clinical trials allow for efficient synthesis and dissemination of the literature, which should facilitate clinicians' efforts to incorporate principles of evidence-based practice in the clinical decision-making process.

METHODS AND MEASURES

Using a scale based on criteria in the Cochrane Collaboration Handbook, we sought to critically appraise the methodology used in RCTs related to the nonoperative management of PFPS, synthesize and interpret our results, and report our findings in a user-friendly fashion. A scale to assess the methodological quality of trials was designed and pilot tested for its content and reliability. Published RCTs identified during a literature search were then selected and rated by 6 raters. We used predefined cutoff scores to identify specific weaknesses in the clinical research process that need to be improved in future clinical trials.

RESULTS

The quality scale we developed was demonstrated to be sufficiently reliable to warrant interpretation of the reviewers' findings. The percentage of trials that met a minimum level of quality for each specific criterion ranged from a low of 25% for the adequacy of the description of the randomization procedure to a high of 95% for the description and standardization of the intervention.

CONCLUSIONS

Based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with PFPS were acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback. The use of soft foot orthotics in patients with excessive foot pronation appeared useful in decreasing pain. In addition, at a short-term follow-up, patients who received exercise programs were discharged earlier from physical therapy. Unfortunately, most RCTs reviewed contained qualitative flaws that bring the validity of the results into question, thus diminishing the ability to generalize the results to clinical practice. These flaws were primarily in the areas of randomization procedures, duration of follow-up, control of cointerventions, assurance of blinding, accountability and proper analysis of dropouts, number of subjects, and the relevance of outcomes. Also, given the limited number of high-quality clinical trials, recommendations about supporting or refuting specific treatment approaches may be premature and can only be made with caution.

Nearly half of dental randomized controlled trials published in German are not included in Medline

Randomized controlled trials (RCTs) are considered the most reliable type of clinical intervention studies. However, not all reports of RCTs are accessible in Medline. This can impede the validity of the results of systematic reviews. Ten German-language dental journals were manually searched to locate reports of controlled clinical trials published between 1970 and 2000. The publication type was determined and compared with Medline. Of the 15 777 articles, 210 reports of RCTs and 410 articles of non-randomized controlled clinical trials (CCTs) were identified. Only 56% of the RCTs and 75% of the CCTs are available in Medline. Of the 118 reports of RCTs registered in Medline. 15 are indexed with the correct Publication Type term. Our data suggest that (a) hand-searching plays a valuable role in identifying reports of clinical dental trials, and (b) a literature search in Medline is likely to yield incomplete results.

Addressing the heterogeneity of the ischemic stroke phenotype in human genetics research

BACKGROUND AND PURPOSE

Many investigators have approached ischemic stroke as a complex phenotype by dividing the ischemic stroke population into distinct subtypes. The purpose of this study was to review systematically the methods used to subtype ischemic stroke in recent genetic studies.

METHODS

The MEDLINE database was searched for articles pertaining to research on the genetics of human ischemic stroke published from January 2000 through January 2002. Abstracts and full-length reports were then sequentially screened to select articles pertaining to original case-control or cohort studies.

RESULTS

The initial search yielded 153 publications. Of 41 relevant articles, ischemic stroke was subtyped in 25 (61%). The most common standard subtyping system was the Cerebrovascular Classification of Diseases III system (9 articles). Of the subtyping systems used, 3 had previously published interrater reliability. The subtyping system was reported to have been prespecified in 1 study. Four articles reported using central adjudication. Two articles reported that the person doing the subtyping was blinded to genotype, and 2 reported that the person doing the genotyping was blinded to the patient's subtype status.

CONCLUSIONS

When investigators subtyped ischemic stroke, they typically used either nonstandard classification systems or systems of undetermined reliability. Important methodological issues, including blinding and prespecification of the classification system, were rarely reported. Advances in methodology and scientific reporting standards would foster identification of subtype-specific genetic risk factors.

[Quality of clinical trials published in Spain on asthma in comparison to trials in English language journals]

OBJECTIVES

To evaluate the quality of clinical trials on asthma published in Spanish journals in comparison with those published in European or North American English-language journals.

METHOD

Clinical trials were identified by searching MEDLINE and the Spanish Medical Index (Indice Médico Español), and by manual searches for trials mentioned in the bibliographies of the previously identified trials. Quality was assessed by the method proposed by Detsky and colleagues in their 1992 article in Journal of Clinical Epidemiology.

RESULTS

The articles published in Spanish journals had lower mean quality scores than those in European or North American English-language journals. Trials published in Spain were less likely to give certain details of methodology, including ethics committee approval, details of randomization or patient enrollment and blinding. Among trials published in Spain, those with non-Spanish authors had lower mean quality scores.

CONCLUSION

Clinical trials published in Spain on asthma treatments are of poorer quality than those published in English-language journals. Editors should consider using clinical trial quality checklists during the peer review process to raise the standards for published articles.

Acupuncture: evidence for its use in chronic low back pain

Back pain is a major economic burden in the UK, with increasing numbers of patients seeking complementary therapies, such as acupuncture, as a means to supplement traditional medical treatments. Studies to date have produced conflicting results relating to the efficacy of acupuncture and thus this systematic review will provide a concise summary of the clinical scenario in Western countries. A search of various electronic databases identified 11 articles consisting of three case studies, five randomized controlled trials, and two cross-over trials. Systematic examination of these articles did not provide definitive evidence to support or refute the use of acupuncture in the treatment of low back pain. In an era of increasing demands for evidence-based practice and professional accountability, the absence of irrefutable scientific evidence places nurses and medics in a vulnerable position.

The Cochrane Collaboration - how is it progressing?

During the last seven years, the Cochrane Collaboration has rapidly developed into an important international organization, producing high quality systematic reviews of randomized trials. Challenges, which it will likely meet, include maintaining the quality of the reviews, ensuring that reviews are done of the most common therapies for important diseases, securing stable funding, and making the format of the reviews more accessible for the average clinician.

Surgical strategies for coexisting glaucoma and cataract: an evidence-based update

OBJECTIVE

To assess short- and long-term control of intraocular pressure (IOP) with different surgical treatment strategies for coexisting cataract and glaucoma.

DESIGN

Systematic literature review and analysis.

METHOD

We performed a search of the published literature to identify all eligible articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting different approaches was graded by consensus as good, fair, weak, or insufficient.

MAIN OUTCOME MEASURES

Short-term (24 hours or fewer) and long-term (more than 24 hours) IOP control.

RESULTS

The evidence was good that long-term IOP is lowered more by combined glaucoma and cataract operations than by cataract operations alone. On average, the IOP was 3 to 4 mmHg lower in the combined groups with fewer medications required. The evidence was weak that extracapsular cataract extraction (ECCE) alone results in short-term increase in IOP and was insufficient to determine the short-term impact of phacoemulsification cataract extraction (PECE) on IOP in glaucoma patients. The evidence was weak that short-term IOP control was better with ECCE or PECE combined with an incisional glaucoma procedure compared with ECCE or PECE alone. The evidence was also weak (but consistent) that long-term IOP is lowered by 2 to 4 mmHg after ECCE or PECE. Finally, there was weak evidence that combined PECE and trabeculectomy produces slightly worse long-term IOP control than trabeculectomy alone, and there was fair evidence that the same is true for ECCE combined with trabeculectomy.

CONCLUSIONS

There is strong evidence for better long-term control of IOP with combined glaucoma and cataract operations compared with cataract surgery alone. For other issues regarding surgical treatment strategies for cataract and glaucoma, the available evidence is limited or conflicting.

Inflation of type I error rate in two statistical tests for the detection of publication bias in meta-analyses with binary outcomes

The use of meta-analysis to combine results of several trials is still increasing in the medical field. The validity of a meta-analysis may be affected by various sources of bias (for example, publication bias, language bias). Therefore, an analysis of bias should be an integral part of any systematic review. Statistical tests and graphical methods have been developed for this purpose. In this paper, two statistical tests for the detection of bias in meta-analysis were investigated in a simulation study. Binary outcome data, which are very common in medical applications, were considered and relative effect measures (odds ratios, relative risk) were used for pooling. Sample sizes were generated according to findings in a survey of eight German medical journals. Simulation results indicate an inflation of type I error rates for both tests when the data are sparse. Results get worse with increasing treatment effect and number of trials combined. Valid statistical tests for the detection of bias in meta-analysis with sparse data need to be developed.

Complex regional pain syndrome type I: use of the International Association for the Study of Pain diagnostic criteria defined in 1994

OBJECTIVES

The objective was to assess the reported use in recent publications of the diagnostic criteria for complex regional pain syndrome type I (CRPS I) proposed by the International Association for the Study of Pain (IASP) in 1994.

METHODS

A literature search of MEDLINE (January 1996 to July 2000) was performed with use of the medical subject heading "reflex sympathetic dystrophy" and the free texts words "complex," "regional," "pain," and "syndrome." Publications in English, German, and Dutch were analyzed. From the search, 65 original publications were selected. Another 27 publications (referenced publications) that were referenced in the 65 original publications for the description of diagnostic criteria for CRPS I also were included. A standard form was used to assess a total of 92 publications. A sensitivity analysis was performed by means of analyzing three scenarios in which the diagnostic criteria were used as proposed and two combinations of less stringent criteria.

RESULTS

Use of the diagnostic criterion pain was reported in 35 (38%) of the analyzed publications. None of the original publications satisfied the proposed IASP diagnostic criteria. Four (15%) of the referenced publications satisfied the proposed IASP diagnostic criteria. Ten (15%) of the original publications referred correctly to the referenced publications. With the less strict criteria used in scenarios 2 and 3, 2 (3%) and 3 (5%), respectively, of the original publications fulfilled these criteria.

CONCLUSIONS

If the diagnostic criteria for CRPS I are not used uniformly, the populations in clinical studies may not be uniform either. Whether different authors are describing the same syndrome and whether their findings can be compared is open to question. On the basis of the results of this study, it is concluded that the IASP criteria for CRPS I are poorly used in clinical studies.

Measures of low back function: a review of reproducibility studies

OBJECTIVE

The objective of the present study was to make a systematic literature review with preset quality criteria concerning reproducibility of the tests of the low back regarding strength, endurance and range of motion.

DESIGN

Literature in Medline and local databases was reviewed for articles concerning the reproducibility of strength, endurance, and range of motion measurements.

BACKGROUND

Measures of low back function are widely used, and are important for both clinical and research purposes in relation to low back problems. A review of the reproducibility of these tests has not previously been made.

METHODS

After extensive discussion among all the authors, general evaluation parameters were defined for the quality assessment. Every study was graded from 0 to 2 for each parameter. Parameters evaluated were: number of subjects, subject description, method description, test/retest interval, description of results, and statistics.

RESULTS

The literature search revealed a total of 79 studies. Most studies suffered from methodological weaknesses and only eleven studies received ten or more quality points (maximum 14). The results from the highest graded studies are highlighted.

CONCLUSIONS

It may be concluded that there is a considerable lack of information about the reproducibility of functional measures for the low back, and therefore a recommendation for consensus is difficult. However, most tests performed in the sagittal plane are reliable for use on groups.

RELEVANCE

Measures of low back function are thought to be of great importance for clinicians, and low back researchers in general. A review of reproducibility will be helpful both as a survey of tests, and to provide information on the usefulness in relation to the level of reproducibility.

Corticosteroid injections for lateral epicondylitis: a systematic review

Patients with lateral epicondylitis (tennis elbow) are frequently treated with corticosteroid injections, in order to relieve pain and diminish disability. The objective of this review was to evaluate the effectiveness of corticosteroid injections for lateral epicondylitis. Randomised controlled trials (RCTs) were identified by a highly sensitive search strategy in six databases in combination with reference tracking. Two independent reviewers selected and assessed the methodological quality of RCTs that included patients with lateral epicondylitis treated with corticosteroid injection(s), and reported at least one clinically relevant outcome measure. Standardised mean differences were computed for continuous data and relative risks (RR) for dichotomous data. A best-evidence synthesis was conducted, weighting the studies with respect to their internal validity, statistical significance, clinical relevance, and statistical power. Thirteen studies consisting of 15 comparisons were included in the review, evaluating the effects of corticosteroid injections compared to placebo injection (n=2), injection with local anaesthetic (n=5), another conservative treatment (n=5), or another corticosteroid injection (n=3). Almost all studies had poor internal validity scores. For short-term outcomes (<or=6 weeks), statistically significant and clinically relevant differences were found on pain, global improvement and grip strength for corticosteroid injection compared to placebo, local anaesthetic and conservative treatments. For intermediate (6 weeks-6 months) and long-term outcomes (>or=6 months), no statistically significant or clinically relevant results in favour of corticosteroid injections were found. Although the available evidence shows superior short-term effects of corticosteroid injections for lateral epicondylitis, it is not possible to draw firm conclusions on the effectiveness of injections, due to the lack of high quality studies. No beneficial effects were found for intermediate or long-term follow-up. More, better designed, conducted and reported RCTs with intermediate and long-term follow-up are needed.

Assessing the quality of reports of randomized trials in pediatric complementary and alternative medicine

OBJECTIVE

To evaluate the quality of reports of complementary and alternative medicine (CAM) randomized controlled trials (RCTs) in the pediatric population. We also examined whether there was a change in the quality of reporting over time.

METHODS

We used a systematic sample of 251 reports of RCTs that used a CAM intervention. The quality of each report was assessed using the number of CONSORT checklist items included, the frequency of unclear allocation concealment, and a 5-point quality assessment instrument.

RESULTS

Nearly half (40%) of the CONSORT checklist items were included in the reports, with an increase in the number of items included. The majority (81.3%) of RCTs reported unclear allocation concealment with no significant change over time. The quality of reports achieved approximately 40% of their maximum possible total score as assessed with the Jadad scale with no change over time. Information regarding adverse events was reported in less than one quarter of the RCTs (22%) and information regarding costs was mentioned in only a minority of reports (4%).

CONCLUSIONS

RCTs are an important tool for evidence based health care decisions. If these studies are to be relevant in the evaluation of CAM interventions it is important that they are conducted and reported with the highest possible standards. There is a need to redouble efforts to ensure that children and their families are participating in RCTs that are conducted and reported with minimal bias. Such studies will increase their usefulness to a board spectrum of interested stakeholders.

Searching the Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) database improves systematic reviews

BACKGROUND

An unbiased systematic review (SR) should analyse as many articles as possible in order to provide the best evidence available. However, many SR use only databases with high English-language content as sources for articles. Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) indexes 670 journals from the Latin American and Caribbean health literature but is seldom used in these SR. Our objective is to evaluate if LILACS should be used as a routine source of articles for SR.

METHODS

First we identified SR published in 1997 in five medical journals with a high impact factor. Then we searched LILACS for articles that could match the inclusion criteria of these SR. We also checked if the authors had already identified these articles located in LILACS.

RESULTS

In all, 64 SR were identified. Two had already searched LILACS and were excluded. In 39 of 62 (63%) SR a LILACS search identified articles that matched the inclusion criteria. In 5 (8%) our search was inconclusive and in 18 (29%) no articles were found in LILACS. Therefore, in 71% (44/72) of cases, a LILACS search could have been useful to the authors. This proportion remains the same if we consider only the 37 SR that performed a meta-analysis. In only one case had the article identified in LILACS already been located elsewhere by the authors' strategy.

CONCLUSION

LILACS is an under-explored and unique source of articles whose use can improve the quality of systematic reviews. This database should be used as a routine source to identify studies for systematic reviews.

Direction and impact of language bias in meta-analyses of controlled trials: empirical study

BACKGROUND

Excluding clinical trials reported in languages other than English from meta-analyses may introduce bias and reduce the precision of combined estimates of treatment effects. We examined the influence of trials published in languages other than English on combined estimates and conclusions of published meta-analyses.

METHODS

We searched journals and the Cochrane Database of Systematic Reviews for meta-analyses of at least five trials with binary outcomes that were based on comprehensive literature searches without language restrictions. We compared estimates of treatment effects from trials published in languages other than English to those from trials published in English, and assessed the impact of restricting meta-analyses to trials published in English.

RESULTS

We identified 303 meta-analyses: 159 (52.4%) employed comprehensive literature searches of which 50 included 485 English and 115 non-English language trials. Non-English language trials included fewer participants (median 88 versus 116, P = 0.006) and were more likely to produce significant results at P < 0.05 (41.7% versus 31.3%, P = 0.033). The methodological quality of non-English language trials tended to be lower than that of trials published in English. Estimates of treatment effects were on average 16% (95% CI : 3-26%) more beneficial in non-English-language trials than in English-language trials. In 29 (58.0%) meta-analyses the change in effect estimates after exclusion of non-English language trials was less than 5%. In the remaining meta-analyses, 5 (10.0%) showed more benefit and 16 (32.0%) less benefit after exclusion of non-English language trials.

CONCLUSIONS

This retrospective analysis suggests that excluding trials published in languages other than English has generally little effect on summary treatment effect estimates. The importance of non-English language trials is, however, difficult to predict for individual systematic reviews. Comprehensive literature searches followed by a careful assessment of trial quality are required to assess the contribution of all relevant trials, independent of language of publication.

Quality of reporting randomised clinical trials in dental and medical research

OBJECTIVE

To assess 1) the quality of reporting randomised clinical trials in dental (RCT-Ds) and medical research (RCT-Ms), 2) the quality of RCT reports in relation to the journal impact factor, 3) the source of funding, and 4) the quality of RCT-Ds in different areas of dental research. DESIGN RANDOM: samples of 100 RCT-Ds and 100 RCT-Ms published in 1999 were evaluated for quality of reporting under blinded conditions with the Jadad quality assessment scale. In addition, correlation between the quality scores and journal impact factor or source of funding, as well as area of dental research were analysed.

RESULTS

The quality of RCT-Ds and RCT-Ms published in 1999 was generally inadequate. The quality was largely equivalent in RCT-Ds and RCT-Ms. There was no correlation between the quality scores and the journal impact factor or the source of funding. Some differences were found in the quality scores between different areas of dental research.

CONCLUSIONS

The results from these RCT-Ds and RCT-Ms show that most of them were imperfect in the reporting of methodology and trial conduct. There is a clear need to improve the quality of trial reporting in dental and medical research.

Systematic review of prognostic models in patients with acute stroke

Prognostic models in stroke may be useful in clinical practice and research. We systematically reviewed the methodology and results of studies that have identified independent predictors of survival, independence in activities of daily living, and getting home in patients with acute stroke. Eligible studies (published in full in English) included at least 100 patients in whom at least 3 predictor variables were assessed within 30 days of stroke onset and who were followed up for at least 30 days. We recorded 25 indicators of the validity and practicality of each model and identified variables that were consistent independent predictors of each outcome. Eighty-three separate prognostic models were found but most had potentially serious deficiencies in internal and statistical validity, many had limited generalisability, and none had been adequately validated. Only 4 studies met 8 simple quality criteria. Over 150 different predictor variables have been analysed but most were assessed in only 1 or 2 models. None of the existing prognostic models have been sufficiently well developed and validated to be useful in either clinical practice or research. Better quality models must be produced to enable, for example, adequate case-mix correction when comparing outcome among different groups of stroke patients.

Elements of a systematic review

This paper examines the subject of systematic reviews from a nursing viewpoint. The history of the evidence-based healthcare movement and the major differences between systematic reviews and traditional literature reviews are discussed. The steps of the process used by those conducting reviews are examined in detail. These include structuring a research question, searching and appraising the literature, data extraction, analysis and synthesis, and reporting the results. It is this process that ensures reviews can be considered as a legitimate form of nursing research.

Intramuscular testosterone esters and plasma lipids in hypogonadal men: a meta-analysis

PURPOSE

It is unclear whether intramuscular administration of testosterone esters to hypogonadal men is associated with changes in plasma lipids. We therefore analyzed 19 studies published between 1987 and 1999 that focused on male subjects with nonexperimental hypogonadism, treated subjects with an intramuscular testosterone ester and reported pretreatment and post-treatment concentrations of total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) cholesterol, or total triglyceride.

METHODS

We calculated study-specific, post-treatment minus pretreatment differences in each plasma lipid concentration (mean [95% confidence interval]). After testing of between-study homogeneity, we combined the study-specific differences. We then determined whether heterogeneity of differences could be explained in models of the differences on study and patient characteristics (mean +/- SE) before and after excluding extreme values using a multiple outlier procedure.

RESULTS

The studies represented 272 hypogonadal men (age 44 +/- 4 years; 20% with hypergonadotropic hypogonadism; total testosterone 0.5 +/- 0.2 ng/mL) who received, on average, 179 +/- 13 mg intramuscular testosterone ester every 16 +/- 1 days for 6 +/- 1 months. Fixed-effects estimates of post-treatment minus pretreatment differences were -14 [-17 to -11] mg/dL (total cholesterol), -5 [-8 to -1] mg/dL (LDL cholesterol), -4 [-5 to -2] mg/dL (HDL cholesterol), and -1 [-6 to + 4] mg/dL (triglyceride). Decreases in HDL cholesterol were larger at lower dosages of testosterone ester (r = -0.54, P = 0.055), but were not explained by attrition, regression to the mean, dosing frequency or duration, concomitant elevation of plasma total testosterone, aromatization of testosterone to estradiol, or other study and patient characteristics.

CONCLUSION

Intramuscular administration of testosterone esters to hypogonadal men is associated with a small, dosage-dependent decrease in HDL cholesterol and concomitant declines in total cholesterol and LDL cholesterol. The aggregate effect of these changes on cardiovascular risk remains unknown but deserves further study.

Influencing clinical practice: evidence-based wound care

Influencing clinical practice increasingly requires quality evidence to support recommendations and guidelines. Review of the evidence for wound care interventions provides practitioners with several challenges. Randomized controlled trials are scarce and have many limitations with respect to wound care, while other sources of evidence are often flawed because of the complexities of the wound-healing process or are limited by their methodology. This article attempts to explain some of the benefits and problems associated with different types of evidence, all of which need to be considered in order to influence wound management.

Trends in acute ischemic stroke trials through the 20th century

BACKGROUND AND PURPOSE

The advent of controlled clinical trials revolutionized clinical medicine over the course of the 20th century. The objective of this study was to quantitatively characterize developments in clinical trial methodology over time in the field of acute ischemic stroke.

METHODS

All controlled trials targeting acute ischemic stroke with a final report in English were identified through MEDLINE and international trial registries. Data regarding trial design, implementation, and results were extracted. A formal 100-point scale was used to rate trial quality.

RESULTS

A total of 178 controlled acute stroke trials were identified, encompassing 73 949 patients. Eighty-eight trials involved neuroprotective agents, 59 rheological/antithrombotic agents, 26 agents with both neuroprotective and rheological/antithrombotic effects, and 5 a nonpharmacological intervention. Only 3 trials met conventional criteria for a positive outcome. Between the 1950s and 1990s, the number of trials per decade increased from 3 to 99, and mean trial sample size increased from 38 (median, 26) to 661 (median, 113). During 1980-1999, median time window allowed for enrollment decreased per half decade from 48 to 12 hours. Reported pharmaceutical sponsorship increased substantially over time, from 38% before 1970 to 68% in the 1990s. Trial quality improved substantially from a median score of 12 in the 1950s to 72 in the 1990s.

CONCLUSIONS

Accelerating trends in acute stroke controlled trials include growth in number, sample size, and quality, and reduction in entry time window. These changes reflect an increased understanding of the pathophysiology of acute stroke, the imperative for treatment initiation within a critical time window, and more sophisticated trial design.

The methodological quality of randomized controlled trials of homeopathy, herbal medicines and acupuncture

BACKGROUND

To investigate the methodological quality of randomized controlled trials in three areas of complementary medicine.

METHODS

The methodological quality of 207 randomized trials collected for five previously published systematic reviews on homeopathy, herbal medicine (Hypericum for depression, Echinacea for common cold), and acupuncture (for asthma and chronic headache) was assessed using a validated scale (the Jadad scale) and single quality items.

RESULTS

While the methodological quality of the trials was highly variable, the majority had important shortcomings in reporting and/or methodology. Major problems in most trials were the description of allocation concealment and the reporting of drop-outs and withdrawals. There were relevant differences in single quality components between the different complementary therapies: For example, acupuncture trials reported adequate allocation concealment less often (6% versus 32% of homeopathy and 26% of herb trials), and trials on herbal extracts had better summary scores (mean score 3.12 versus 2.33 for homeopathy and 2.19 for acupuncture trials). Larger trials published more recently in journals listed in Medline and in English language scored significantly higher than trials not meeting these criteria.

CONCLUSION

Trials of complementary therapies often have relevant methodological weaknesses. The type of weaknesses varies considerably across interventions.