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Busse JW, Casassus R, Carrasco-Labra A, Durham J, Mock D, Zakrzewska JM, Palmer C, Samer CF, Coen M, Guevremont B, Hoppe T, Guyatt GH, Crandon HN, Yao L, Sadeghirad B, Vandvik PO, Siemieniuk RAC, Lytvyn L, Hunskaar BS, Agoritsas T. Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline. BMJ 2023; 383:e076227. [PMID: 38101929 DOI: 10.1136/bmj-2023-076227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
CLINICAL QUESTION What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)? CURRENT PRACTICE TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations. RECOMMENDATIONS For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and β blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids. HOW THIS GUIDELINE WAS CREATED An international guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective. THE EVIDENCE Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD. UNDERSTANDING THE RECOMMENDATION These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.
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Affiliation(s)
- Jason W Busse
- Michael G DeGroote National Pain Centre, McMaster University, Hamilton ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
- Department of Anesthesia, McMaster University, Hamilton ON, Canada
| | - Rodrigo Casassus
- Orofacial Pain Unit, Maxillo-Facial Department, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Alonso Carrasco-Labra
- Center for Integrative Global Oral Health, University of Pennsylvania, School of Dental Medicine, Philadelphia PA, USA
| | | | - David Mock
- Faculty of Dentistry and Mount Sinai Hospital, University of Toronto, Canada
| | - Joanna M Zakrzewska
- Royal National ENT &Eastman Dental Hospitals University College London Hospitals, London, UK
| | | | - Caroline F Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals
- Faculty of Medicine, University of Geneva, Switzerland
| | - Matteo Coen
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bruno Guevremont
- The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
| | - Thomas Hoppe
- The Canadian Veterans Chronic Pain Centre of Excellence, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
| | - Holly N Crandon
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
- Department of Anesthesia, McMaster University, Hamilton ON, Canada
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
| | - Lyuba Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
| | | | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton ON, Canada
- Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
- The MAGIC Evidence Ecosystem Foundation, Oslo, Norway
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Zeng L, Helsingen LM, Bretthauer M, Agoritsas T, Vandvik PO, Mustafa RA, Busse J, Siemieniuk RAC, Lytvyn L, Li SA, Yang M, Yan L, Zhang L, Brignardello-Petersen R, Guyatt GH. A novel framework for incorporating patient values and preferences in making guideline recommendations: guideline panel surveys. J Clin Epidemiol 2023; 161:164-172. [PMID: 37453455 DOI: 10.1016/j.jclinepi.2023.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/13/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Universally acknowledged standards for trustworthy guidelines include the necessity to ground recommendations in patient values and preferences. When information is limited-which is typically the case-guideline panels often find it difficult to explicitly integrate patient values and preferences into their recommendations. Our objective was to develop and evaluate a framework for systematically navigating guideline panels in incorporating patient values and preferences in making recommendations. STUDY DESIGN AND SETTING In the context of developing a guideline for colorectal cancer screening, we generated an initial framework for creating panel surveys to elicit guideline panelists' views of patient values and preferences and to inform panel discussions on recommendations. With further applications in guidelines of diverse topic areas, we dynamically refined the framework through iterative discussions and consensus. RESULTS The finial framework consists of five steps for creating and implementing panel surveys. The surveys can serve three objectives following from the quantitative information regarding patient values and preferences that guideline panels usually require. An accompanying video provides detailed instructions of the survey. CONCLUSION The framework for creating and implementing panel surveys offers explicit guidance for guideline panels considering transparently and systematically incorporating patient values and preferences into guideline recommendations.
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Affiliation(s)
- Linan Zeng
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Lise M Helsingen
- Clinical Effectiveness Research, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division General Internal Medicine & Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Hospital Trust, Oslo, Norway
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jason Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shelly-Anne Li
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mengting Yang
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lijiao Yan
- Centre for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Lingli Zhang
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | | | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Zeng L, Li SA, Yang M, Yan L, Helsingen LM, Bretthauer M, Agoritsas T, Vandvik PO, Mustafa RA, Busse J, Siemieniuk RAC, Lytvyn L, Zhang L, Brignardello-Petersen R, Guyatt GH. Qualitative study of guideline panelists: innovative surveys provided valuable insights regarding patient values and preferences. J Clin Epidemiol 2023; 161:173-180. [PMID: 37517505 DOI: 10.1016/j.jclinepi.2023.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To explore guideline panelists' understanding of panel surveys for eliciting panels' inferences regarding patient values and preferences, and the influence of the surveys on making recommendations. STUDY DESIGN AND SETTING We performed sampling and data collection from all four guideline panels that had conducted the surveys through October 2020. We collected the records of all panel meetings and interviewed some panelists in different roles. We applied inductive thematic analysis for analyzing and interpreting data. RESULTS We enrolled four guideline panels with 99 panelists in total and interviewed 25 of them. Most panelists found the survey was easy to follow and facilitated the incorporation of patient values and preferences in the tradeoffs between benefits and harms or burdens. The variation of patient preferences and uncertainty regarding patient values and preferences reflected in the surveys helped the panels ponder the strength of recommendations. In doing so, the survey results enhanced a rationale for panels' decision on the recommendations. CONCLUSION The panel surveys have proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. Guideline panels would benefit from widespread use of the panel surveys, particularly when primary evidence regarding patient values and preferences is scarce.
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Affiliation(s)
- Linan Zeng
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Shelly-Anne Li
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mengting Yang
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Lijiao Yan
- Centre for Evidence-based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Lise M Helsingen
- Clinical Effectiveness Research, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division General Internal Medicine & Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Hospital Trust, Oslo, Norway
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jason Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lingli Zhang
- Evidence-based Pharmacy Centre/Pharmacy Department, West China Second University Hospital, Sichuan University, Chengdu, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | | | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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O'Connor D, Johnston RV, Brignardello-Petersen R, Poolman RW, Cyril S, Vandvik PO, Buchbinder R. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev 2022; 3:CD014328. [PMID: 35238404 PMCID: PMC8892839 DOI: 10.1002/14651858.cd014328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Arthroscopic knee surgery remains a common treatment for symptomatic knee osteoarthritis, including for degenerative meniscal tears, despite guidelines strongly recommending against its use. This Cochrane Review is an update of a non-Cochrane systematic review published in 2017. OBJECTIVES To assess the benefits and harms of arthroscopic surgery, including debridement, partial menisectomy or both, compared with placebo surgery or non-surgical treatment in people with degenerative knee disease (osteoarthritis, degenerative meniscal tears, or both). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trials registers up to 16 April 2021, unrestricted by language. SELECTION CRITERIA We included randomised controlled trials (RCTs), or trials using quasi-randomised methods of participant allocation, comparing arthroscopic surgery with placebo surgery or non-surgical interventions (e.g. exercise, injections, non-arthroscopic lavage/irrigation, drug therapy, and supplements and complementary therapies) in people with symptomatic degenerative knee disease (osteoarthritis or degenerative meniscal tears or both). Major outcomes were pain, function, participant-reported treatment success, knee-specific quality of life, serious adverse events, total adverse events and knee surgery (replacement or osteotomy). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. The primary comparison was arthroscopic surgery compared to placebo surgery for outcomes that measured benefits of surgery, but we combined data from all control groups to assess harms and knee surgery (replacement or osteotomy). MAIN RESULTS Sixteen trials (2105 participants) met our inclusion criteria. The average age of participants ranged from 46 to 65 years, and 56% of participants were women. Four trials (380 participants) compared arthroscopic surgery to placebo surgery. For the remaining trials, arthroscopic surgery was compared to exercise (eight trials, 1371 participants), a single intra-articular glucocorticoid injection (one trial, 120 participants), non-arthroscopic lavage (one trial, 34 participants), non-steroidal anti-inflammatory drugs (one trial, 80 participants) and weekly hyaluronic acid injections for five weeks (one trial, 120 participants). The majority of trials without a placebo control were susceptible to bias: in particular, selection (56%), performance (75%), detection (75%), attrition (44%) and selective reporting (75%) biases. The placebo-controlled trials were less susceptible to bias and none were at risk of performance or detection bias. Here we limit reporting to the main comparison, arthroscopic surgery versus placebo surgery. High-certainty evidence indicates arthroscopic surgery leads to little or no difference in pain or function at three months after surgery, moderate-certainty evidence indicates there is probably little or no improvement in knee-specific quality of life three months after surgery, and low-certainty evidence indicates arthroscopic surgery may lead to little or no difference in participant-reported success at up to five years, compared with placebo surgery. Mean post-operative pain in the placebo group was 40.1 points on a 0 to 100 scale (where lower score indicates less pain) compared to 35.5 points in the arthroscopic surgery group, a difference of 4.6 points better (95% confidence interval (CI) 0.02 better to 9 better; I2 = 0%; 4 trials, 309 participants). Mean post-operative function in the placebo group was 75.9 points on a 0 to 100 rating scale (where higher score indicates better function) compared to 76 points in the arthroscopic surgery group, a difference of 0.1 points better (95% CI 3.2 worse to 3.4 better; I2 = 0%; 3 trials, 302 participants). Mean post-operative knee-specific health-related quality of life in the placebo group was 69.7 points on a 0 to 100 rating scale (where higher score indicates better quality of life) compared with 75.3 points in the arthroscopic surgery group, a difference of 5.6 points better (95% CI 0.36 better to 10.68 better; I2 = 0%; 2 trials, 188 participants). We downgraded this evidence to moderate certainty as the 95% confidence interval does not rule in or rule out a clinically important change. After surgery, 74 out of 100 people reported treatment success with placebo and 82 out of 100 people reported treatment success with arthroscopic surgery at up to five years (risk ratio (RR) 1.11, 95% CI 0.66 to 1.86; I2 = 53%; 3 trials, 189 participants). We downgraded this evidence to low certainty due to serious indirectness (diversity in definition and timing of outcome measurement) and serious imprecision (small number of events). We are less certain if the risk of serious or total adverse events increased with arthroscopic surgery compared to placebo or non-surgical interventions. Serious adverse events were reported in 6 out of 100 people in the control groups and 8 out of 100 people in the arthroscopy groups from eight trials (RR 1.35, 95% CI 0.64 to 2.83; I2 = 47%; 8 trials, 1206 participants). Fifteen out of 100 people reported adverse events with control interventions, and 17 out of 100 people with surgery at up to five years (RR 1.15, 95% CI 0.78 to 1.70; I2 = 48%; 9 trials, 1326 participants). The certainty of the evidence was low, downgraded twice due to serious imprecision (small number of events) and possible reporting bias (incomplete reporting of outcome across studies). Serious adverse events included death, pulmonary embolism, acute myocardial infarction, deep vein thrombosis and deep infection. Subsequent knee surgery (replacement or high tibial osteotomy) was reported in 2 out of 100 people in the control groups and 4 out of 100 people in the arthroscopy surgery groups at up to five years in four trials (RR 2.63, 95% CI 0.94 to 7.34; I2 = 11%; 4 trials, 864 participants). The certainty of the evidence was low, downgraded twice due to the small number of events. AUTHORS' CONCLUSIONS Arthroscopic surgery provides little or no clinically important benefit in pain or function, probably does not provide clinically important benefits in knee-specific quality of life, and may not improve treatment success compared with a placebo procedure. It may lead to little or no difference, or a slight increase, in serious and total adverse events compared to control, but the evidence is of low certainty. Whether or not arthroscopic surgery results in slightly more subsequent knee surgery (replacement or osteotomy) compared to control remains unresolved.
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Affiliation(s)
- Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | | | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Sheila Cyril
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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Zeng L, Walsh M, Guyatt GH, Siemieniuk RAC, Collister D, Booth M, Brown P, Farrar L, Farrar M, Firth T, Fussner LA, Kilian K, Little MA, Mavrakanas TA, Mustafa RA, Piram M, Stamp LK, Xiao Y, Lytvyn L, Agoritsas T, Vandvik PO, Mahr A. Plasma exchange and glucocorticoid dosing for patients with ANCA-associated vasculitis: a clinical practice guideline. BMJ 2022; 376:e064597. [PMID: 35217581 DOI: 10.1136/bmj-2021-064597] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CLINICAL QUESTIONS What is the role of plasma exchange and what is the optimal dose of glucocorticoids in the first 6 months of therapy of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV)? This guideline was triggered by the publication of a new randomised controlled trial. CURRENT PRACTICE Existing guideline recommendations vary regarding the use of plasma exchange in AAV and lack explicit recommendations regarding the tapering regimen of glucocorticoids during induction therapy. RECOMMENDATIONS The guideline panel makes a weak recommendation against plasma exchange in patients with low or low-moderate risk of developing end stage kidney disease (ESKD), and a weak recommendation in favour of plasma exchange in patients with moderate-high or high risk of developing ESKD. For patients with pulmonary haemorrhage without renal involvement, the panel suggests not using plasma exchange (weak recommendation). The panel made a strong recommendation in favour of a reduced dose rather than standard dose regimen of glucocorticoids, which involves a more rapid taper rate and lower cumulative dose during the first six months of therapy. HOW THIS GUIDELINE WAS CREATED A guideline panel including patients, a care giver, clinicians, content experts, and methodologists produced these recommendations using GRADE and in adherence with standards for trustworthy guidelines. The recommendations are based on two linked systematic reviews. The panel took an individual patient perspective in the development of recommendations. THE EVIDENCE The systematic review of plasma exchange identified nine randomised controlled trials (RCTs) that enrolled 1060 patients with AAV. Plasma exchange probably has little or no effect on mortality or disease relapse (moderate and low certainty). Plasma exchange probably reduces the one year risk of ESKD (approximately 0.1% reduction in those with low risk, 2.1% reduction in those with low-moderate risk, 4.6% reduction in those with moderate-high risk, and 16.0% reduction in those with high risk or requiring dialysis) but increases the risk of serious infections (approximately 2.7% increase in those with low risk, 4.9% increase in those with low-moderate risk, 8.5% increase in those with moderate-high risk, to 13.5% in high risk group) at 1 year (moderate to high certainty). The guideline panel agreed that most patients with low or low-moderate risk of developing ESKD would consider the harms to outweigh the benefits, while most of those with moderate-high or high risk would consider the benefits to outweigh the harms. For patients with pulmonary haemorrhage without kidney involvement, based on indirect evidence, plasma exchange may have little or no effect on death (very low certainty) but may have an important increase in serious infections at 1 year (approximately 6.8% increase, low certainty). The systematic review of different dose regimens of glucocorticoids identified two RCTs at low risk of bias with 704 and 140 patients respectively. A reduced dose regimen of glucocorticoid probably reduces the risk of serious infections by approximately 5.9% to 12.8% and probably does not increase the risk of ESKD at the follow-up of 6 months to longer than 1 year (moderate certainty for both outcomes). UNDERSTANDING THE RECOMMENDATION The recommendations were made with the understanding that patients would place a high value on reduction in ESKD and less value on avoiding serious infections. The panel concluded that most (50-90%) of fully informed patients with AAV and with low or low-moderate risk of developing ESKD with or without pulmonary haemorrhage would decline plasma exchange, whereas most patients with moderate-high or high risk or requiring dialysis with or without pulmonary haemorrhage would choose to receive plasma exchange. The panel also inferred that the majority of fully informed patients with pulmonary haemorrhage without kidney involvement would decline plasma exchange and that all or almost all (≥90%) fully informed patients with AAV would choose a reduced dose regimen of glucocorticoids during the first 6 months of therapy.
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Affiliation(s)
- Linan Zeng
- Pharmacy department/Evidence-based pharmacy centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Michael Walsh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Collister
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | | | | | | | | | | | - Lynn A Fussner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Karin Kilian
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mark A Little
- Trinity Translational Medicine Institute, Trinity College Dublin, Ireland
- Irish Centre for Vascular Biology, Tallaght University Hospital, Dublin, Ireland
| | - Thomas A Mavrakanas
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas, USA
| | - Maryam Piram
- CHU Sainte Justine Research Center, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
- CEREMAIA, Centre d'épidémiologie et de santé des populations (CESP), University Paris-Saclay, Le Kremlin Bicêtre, France
| | - Lisa K Stamp
- University of Otago Christchurch, Christchurch, New Zealand
| | - Yingqi Xiao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- West China School of Nursing/Department of Nursing, West China Hospital, Sichuan University, China
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Department of Medicine, Lovisenberg Hospital Trust, Oslo, Norway
| | - Alfred Mahr
- Rheumatology Clinic, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
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Siemieniuk RA, Bartoszko JJ, Díaz Martinez JP, Kum E, Qasim A, Zeraatkar D, Izcovich A, Mangala S, Ge L, Han MA, Agoritsas T, Arnold D, Ávila C, Chu DK, Couban R, Cusano E, Darzi AJ, Devji T, Foroutan F, Ghadimi M, Khamis A, Lamontagne F, Loeb M, Miroshnychenko A, Motaghi S, Murthy S, Mustafa RA, Rada G, Rochwerg B, Switzer C, Vandvik PO, Vernooij RW, Wang Y, Yao L, Guyatt GH, Brignardello-Petersen R. Antibody and cellular therapies for treatment of covid-19: a living systematic review and network meta-analysis. BMJ 2021; 374:n2231. [PMID: 34556486 PMCID: PMC8459162 DOI: 10.1136/bmj.n2231] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of antiviral antibody therapies and blood products for the treatment of novel coronavirus disease 2019 (covid-19). DESIGN Living systematic review and network meta-analysis, with pairwise meta-analysis for outcomes with insufficient data. DATA SOURCES WHO covid-19 database, a comprehensive multilingual source of global covid-19 literature, and six Chinese databases (up to 21 July 2021). STUDY SELECTION Trials randomising people with suspected, probable, or confirmed covid-19 to antiviral antibody therapies, blood products, or standard care or placebo. Paired reviewers determined eligibility of trials independently and in duplicate. METHODS After duplicate data abstraction, we performed random effects bayesian meta-analysis, including network meta-analysis for outcomes with sufficient data. We assessed risk of bias using a modification of the Cochrane risk of bias 2.0 tool. The certainty of the evidence was assessed using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We meta-analysed interventions with ≥100 patients randomised or ≥20 events per treatment arm. RESULTS As of 21 July 2021, we identified 47 trials evaluating convalescent plasma (21 trials), intravenous immunoglobulin (IVIg) (5 trials), umbilical cord mesenchymal stem cells (5 trials), bamlanivimab (4 trials), casirivimab-imdevimab (4 trials), bamlanivimab-etesevimab (2 trials), control plasma (2 trials), peripheral blood non-haematopoietic enriched stem cells (2 trials), sotrovimab (1 trial), anti-SARS-CoV-2 IVIg (1 trial), therapeutic plasma exchange (1 trial), XAV-19 polyclonal antibody (1 trial), CT-P59 monoclonal antibody (1 trial) and INM005 polyclonal antibody (1 trial) for the treatment of covid-19. Patients with non-severe disease randomised to antiviral monoclonal antibodies had lower risk of hospitalisation than those who received placebo: casirivimab-imdevimab (odds ratio (OR) 0.29 (95% CI 0.17 to 0.47); risk difference (RD) -4.2%; moderate certainty), bamlanivimab (OR 0.24 (0.06 to 0.86); RD -4.1%; low certainty), bamlanivimab-etesevimab (OR 0.31 (0.11 to 0.81); RD -3.8%; low certainty), and sotrovimab (OR 0.17 (0.04 to 0.57); RD -4.8%; low certainty). They did not have an important impact on any other outcome. There was no notable difference between monoclonal antibodies. No other intervention had any meaningful effect on any outcome in patients with non-severe covid-19. No intervention, including antiviral antibodies, had an important impact on any outcome in patients with severe or critical covid-19, except casirivimab-imdevimab, which may reduce mortality in patients who are seronegative. CONCLUSION In patients with non-severe covid-19, casirivimab-imdevimab probably reduces hospitalisation; bamlanivimab-etesevimab, bamlanivimab, and sotrovimab may reduce hospitalisation. Convalescent plasma, IVIg, and other antibody and cellular interventions may not confer any meaningful benefit. SYSTEMATIC REVIEW REGISTRATION This review was not registered. The protocol established a priori is included as a data supplement. FUNDING This study was supported by the Canadian Institutes of Health Research (grant CIHR- IRSC:0579001321). READERS' NOTE This article is a living systematic review that will be updated to reflect emerging evidence. Interim updates and additional study data will be posted on our website (www.covid19lnma.com).
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Affiliation(s)
- Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Joint first authors
| | - Jessica J Bartoszko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Anila Qasim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Ariel Izcovich
- Servicio de Clinica Médica del Hospital Alemán, Buenos Aires, Argentina
| | - Sophia Mangala
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Donald Arnold
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Ellen Cusano
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Tahira Devji
- Medical school, University of Toronto, Toronto, ON, Canada
| | - Farid Foroutan
- Ted Rogers Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Francois Lamontagne
- Department of Medicine and Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Sharhzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | | | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Charlotte Switzer
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Robin Wm Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ying Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Busse JW, Vankrunkelsven P, Zeng L, Heen AF, Merglen A, Campbell F, Granan LP, Aertgeerts B, Buchbinder R, Coen M, Juurlink D, Samer C, Siemieniuk RAC, Kumar N, Cooper L, Brown J, Lytvyn L, Zeraatkar D, Wang L, Guyatt GH, Vandvik PO, Agoritsas T. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. BMJ 2021; 374:n2040. [PMID: 34497062 DOI: 10.1136/bmj.n2040] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CLINICAL QUESTION What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes? CURRENT PRACTICE Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries. RECOMMENDATION The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. HOW THIS GUIDELINE WAS CREATED An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective. THE EVIDENCE This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain. UNDERSTANDING THE RECOMMENDATION The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.
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Affiliation(s)
- Jason W Busse
- Michael G DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada
| | - Patrick Vankrunkelsven
- Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
- Department of Public Health and Primary Care, Katholieke Universiteiti Leuven, Leuven, Belgium
| | - Linan Zeng
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Pharmacy Department/Evidence-based Pharmacy Centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Anja Fog Heen
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Arnaud Merglen
- Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fiona Campbell
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Lars-Petter Granan
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | - Matteo Coen
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Juurlink
- Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals
- Faculty of Medicine, University of Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nimisha Kumar
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lynn Cooper
- Canadian Injured Workers' Alliance, Thunder Bay, ON, Canada
| | - John Brown
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Li Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland
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8
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Bartoszko JJ, Siemieniuk RAC, Kum E, Qasim A, Zeraatkar D, Martinez JPD, Azab M, Ibrahim S, Izcovich A, Soto GB, Roldan Y, Agarwal A, Agoritsas T, Chu DK, Couban R, Devji T, Foroutan F, Ghadimi M, Honarmand K, Khamis A, Lamontagne F, Loeb M, McLeod SL, Motaghi S, Murthy S, Mustafa RA, Rochwerg B, Switzer C, Thabane L, Vandvik PO, Vernooij RWM, Wang Y, Yao L, Guyatt GH, Brignardello-Petersen R. Prophylaxis against covid-19: living systematic review and network meta-analysis. BMJ 2021; 373:n949. [PMID: 33903131 PMCID: PMC8073806 DOI: 10.1136/bmj.n949] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UPDATES This is the second version (first update) of the living systematic review, replacing the previous version (available as a data supplement). When citing this paper please consider adding the version number and date of access for clarity. OBJECTIVE To determine and compare the effects of drug prophylaxis on severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (covid-19). DESIGN Living systematic review and network meta-analysis (NMA). DATA SOURCES World Health Organization covid-19 database, a comprehensive multilingual source of global covid-19 literature to 4 March 2022. STUDY SELECTION Randomised trials in which people at risk of covid-19 were allocated to prophylaxis or no prophylaxis (standard care or placebo). Pairs of reviewers independently screened potentially eligible articles. METHODS After duplicate data abstraction, we conducted random-effects bayesian network meta-analysis. We assessed risk of bias of the included studies using a modification of the Cochrane risk of bias 2.0 tool and assessed the certainty of the evidence using the grading of recommendations assessment, development and evaluation (GRADE) approach. RESULTS The second iteration of this living NMA includes 32 randomised trials which enrolled 25 147 participants and addressed 21 different prophylactic drugs; adding 21 trials (66%), 18 162 participants (75%) and 16 (76%) prophylactic drugs. Of the 16 prophylactic drugs analysed, none provided convincing evidence of a reduction in the risk of laboratory confirmed SARS-CoV-2 infection. For admission to hospital and mortality outcomes, no prophylactic drug proved different than standard care or placebo. Hydroxychloroquine and vitamin C combined with zinc probably increase the risk of adverse effects leading to drug discontinuation—risk difference for hydroxychloroquine (RD) 6 more per 1000 (95% credible interval (CrI) 2 more to 10 more); for vitamin C combined with zinc, RD 69 more per 1000 (47 more to 90 more), moderate certainty evidence. CONCLUSIONS Much of the evidence remains very low certainty and we therefore anticipate future studies evaluating drugs for prophylaxis may change the results for SARS-CoV-2 infection, admission to hospital and mortality outcomes. Both hydroxychloroquine and vitamin C combined with zinc probably increase adverse effects. SYSTEMATIC REVIEW REGISTRATION This review was not registered. The protocol established a priori is included as a supplement. FUNDING This study was supported by the Canadian Institutes of Health Research (grant CIHR-IRSC:0579001321).
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Affiliation(s)
- Jessica J Bartoszko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Reed AC Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Anila Qasim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Juan Pablo Diaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maria Azab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Sara Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Ariel Izcovich
- Servicio de Clinica Médica del Hospital Alemán, Buenos Aires, Argentina
| | - Gonzalo Bravo Soto
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tahira Devji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Francois Lamontagne
- Department of Medicine and Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sharhzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Charlotte Switzer
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Robin WM Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Ying Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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9
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Agarwal A, Fernando SM, Honarmand K, Bakaa L, Brar S, Granton D, Chaudhuri D, Chetan D, Hu M, Basmaji J, Muttalib F, Rochwerg B, Adhikari NKJ, Lamontagne F, Murthy S, Hui DS, Gomersall CD, Mubareka S, Diaz J, Burns KE, Couban R, Vandvik PO. Risk of dispersion or aerosol generation and infection transmission with nasopharyngeal and oropharyngeal swabs for detection of COVID-19: a systematic review. BMJ Open 2021; 11:e040616. [PMID: 33737418 PMCID: PMC7977073 DOI: 10.1136/bmjopen-2020-040616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES SARS-CoV-2-related disease, referred to as COVID-19, has emerged as a global pandemic since December 2019. While there is growing recognition regarding possible airborne transmission, particularly in the setting of aerosol-generating procedures and treatments, whether nasopharyngeal and oropharyngeal swabs for SARS-CoV-2 generate aerosols remains unclear. DESIGN Systematic review. DATA SOURCES We searched Ovid MEDLINE and EMBASE up to 3 November 2020. We also searched the China National Knowledge Infrastructure, Chinese Medical Journal Network, medRxiv and ClinicalTrials.gov up to 29 March 2020. ELIGIBILITY CRITERIA All comparative and non-comparative studies that evaluated dispersion or aerosolisation of viable airborne organisms, or transmission of infection associated with nasopharyngeal or oropharyngeal swab testing. RESULTS Of 7702 citations, only one study was deemed eligible. Using a dedicated sampling room with negative pressure isolation room, personal protective equipment including N95 or higher masks, strict sterilisation protocols, structured training with standardised collection methods and a structured collection and delivery system, a tertiary care hospital proved a 0% healthcare worker infection rate among eight nurses conducting over 11 000 nasopharyngeal swabs. No studies examining transmissibility with other safety protocols, nor any studies quantifying the risk of aerosol generation with nasopharyngeal or oropharyngeal swabs for detection of SARS-CoV-2, were identified. CONCLUSIONS There is limited to no published data regarding aerosol generation and risk of transmission with nasopharyngeal and oropharyngeal swabs for the detection of SARS-CoV-2. Field experiments to quantify this risk are warranted. Vigilance in adhering to current standards for infection control is suggested.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, Ontario, Canada
| | - Layla Bakaa
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Sonia Brar
- School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, New York, USA
| | - David Granton
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Devin Chetan
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Malini Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Western University, London, Ontario, Canada
| | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francois Lamontagne
- Centre de recherche due CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Département de Médecine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Srinivas Murthy
- Faculty of Medicine, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David S Hui
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong
- Stanley Ho Center for Emerging Infectious Diseases, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles D Gomersall
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Samira Mubareka
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Janet Diaz
- Pacific Medical Center, San Francisco, California, USA
- World Health Organization, Geneva, Switzerland
| | - Karen Ea Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rachel Couban
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
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Affiliation(s)
- Frank C Brosius
- From the Department of Medicine, University of Arizona, Tucson (F.C.B.); the Department of Internal Medicine, University of Michigan, Ann Arbor (F.C.B.); and the Institute of Health and Society, University of Oslo, and the Department of Medicine, Lovisenberg Diaconal Hospital, Oslo (P.O.V.)
| | - Per O Vandvik
- From the Department of Medicine, University of Arizona, Tucson (F.C.B.); the Department of Internal Medicine, University of Michigan, Ann Arbor (F.C.B.); and the Institute of Health and Society, University of Oslo, and the Department of Medicine, Lovisenberg Diaconal Hospital, Oslo (P.O.V.)
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Naci H, Kesselheim AS, Røttingen JA, Salanti G, Vandvik PO, Cipriani A. Producing and using timely comparative evidence on drugs: lessons from clinical trials for covid-19. BMJ 2020; 371:m3869. [PMID: 33067179 DOI: 10.1136/bmj.m3869] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John-Arne Røttingen
- Research Council of Norway, Oslo, Norway
- Blavatnik School of Government, University of Oxford, Oxford, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Per O Vandvik
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Agarwal A, Basmaji J, Muttalib F, Granton D, Chaudhuri D, Chetan D, Hu M, Fernando SM, Honarmand K, Bakaa L, Brar S, Rochwerg B, Adhikari NK, Lamontagne F, Murthy S, Hui DSC, Gomersall C, Mubareka S, Diaz JV, Burns KEA, Couban R, Ibrahim Q, Guyatt GH, Vandvik PO. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth 2020; 67:1217-1248. [PMID: 32542464 PMCID: PMC7294988 DOI: 10.1007/s12630-020-01740-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - David Granton
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Devin Chetan
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Malini Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Schulich School of Medicine and Dentistry, Department of Medicine, Western University, London, ON, Canada
| | - Layla Bakaa
- Honours Life Sciences Program, Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Sonia Brar
- School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Bram Rochwerg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Francois Lamontagne
- Université de Sherbrooke, Sherbrooke, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Srinivas Murthy
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David S C Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
- Stanley Ho, Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Samira Mubareka
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Janet V Diaz
- Pacific Medical Center, San Francisco, CA, USA
- World Health Organization, Geneva, Switzerland
| | - Karen E A Burns
- Unity Health Toronto - St. Michael's Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Rachel Couban
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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13
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Siemieniuk RA, Bartoszko JJ, Zeraatkar D, Kum E, Qasim A, Martinez JPD, Izcovich A, Lamontagne F, Han MA, Agarwal A, Agoritsas T, Azab M, Bravo G, Chu DK, Couban R, Devji T, Escamilla Z, Foroutan F, Gao Y, Ge L, Ghadimi M, Heels-Ansdell D, Honarmand K, Hou L, Ibrahim Q, Khamis A, Lam B, Mansilla C, Loeb M, Miroshnychenko A, Marcucci M, McLeod SL, Motaghi S, Murthy S, Mustafa RA, Pardo-Hernandez H, Rada G, Rizwan Y, Saadat P, Switzer C, Thabane L, Tomlinson G, Vandvik PO, Vernooij RW, Viteri-García A, Wang Y, Yao L, Zhao Y, Guyatt GH, Brignardello-Petersen R. Drug treatments for covid-19: living systematic review and network meta-analysis. BMJ 2020; 370:m2980. [PMID: 32732190 PMCID: PMC7390912 DOI: 10.1136/bmj.m2980] [Citation(s) in RCA: 484] [Impact Index Per Article: 121.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare the effects of treatments for coronavirus disease 2019 (covid-19). DESIGN Living systematic review and network meta-analysis. DATA SOURCES WHO covid-19 database, a comprehensive multilingual source of global covid-19 literature, up to 3 December 2021 and six additional Chinese databases up to 20 February 2021. Studies identified as of 1 December 2021 were included in the analysis. STUDY SELECTION Randomised clinical trials in which people with suspected, probable, or confirmed covid-19 were randomised to drug treatment or to standard care or placebo. Pairs of reviewers independently screened potentially eligible articles. METHODS After duplicate data abstraction, a bayesian network meta-analysis was conducted. Risk of bias of the included studies was assessed using a modification of the Cochrane risk of bias 2.0 tool, and the certainty of the evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. For each outcome, interventions were classified in groups from the most to the least beneficial or harmful following GRADE guidance. RESULTS 463 trials enrolling 166 581 patients were included; 267 (57.7%) trials and 89 814 (53.9%) patients are new from the previous iteration; 265 (57.2%) trials evaluating treatments with at least 100 patients or 20 events met the threshold for inclusion in the analyses. Compared with standard care, three drugs reduced mortality in patients with mostly severe disease with at least moderate certainty: systemic corticosteroids (risk difference 23 fewer per 1000 patients, 95% credible interval 40 fewer to 7 fewer, moderate certainty), interleukin-6 receptor antagonists when given with corticosteroids (23 fewer per 1000, 36 fewer to 7 fewer, moderate certainty), and Janus kinase inhibitors (44 fewer per 1000, 64 fewer to 20 fewer, high certainty). Compared with standard care, two drugs probably reduce hospital admission in patients with non-severe disease: nirmatrelvir/ritonavir (36 fewer per 1000, 41 fewer to 26 fewer, moderate certainty) and molnupiravir (19 fewer per 1000, 29 fewer to 5 fewer, moderate certainty). Remdesivir may reduce hospital admission (29 fewer per 1000, 40 fewer to 6 fewer, low certainty). Only molnupiravir had at least moderate quality evidence of a reduction in time to symptom resolution (3.3 days fewer, 4.8 fewer to 1.6 fewer, moderate certainty); several others showed a possible benefit. Several drugs may increase the risk of adverse effects leading to drug discontinuation; hydroxychloroquine probably increases the risk of mechanical ventilation (moderate certainty). CONCLUSION Corticosteroids, interleukin-6 receptor antagonists, and Janus kinase inhibitors probably reduce mortality and confer other important benefits in patients with severe covid-19. Molnupiravir and nirmatrelvir/ritonavir probably reduce admission to hospital in patients with non-severe covid-19. SYSTEMATIC REVIEW REGISTRATION This review was not registered. The protocol is publicly available in the supplementary material. READERS' NOTE This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This is the fifth version of the original article published on 30 July 2020 (BMJ 2020;370:m2980), and previous versions can be found as data supplements. When citing this paper please consider adding the version number and date of access for clarity.
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Affiliation(s)
- Reed Ac Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Jessica J Bartoszko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Joint first authors
| | - Elena Kum
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Anila Qasim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Ariel Izcovich
- Servicio de Clinica Médica del Hospital Alemán, Buenos Aires, Argentina
| | - Francois Lamontagne
- Department of Medicine and Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Maria Azab
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gonzalo Bravo
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Derek K Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Tahira Devji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Zaira Escamilla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Ted Rogers Center for Heart Research, Toronto General Hospital, ON, Canada
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Long Ge
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
- Joint first authors
| | - Maryam Ghadimi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Liangying Hou
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Bonnie Lam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Christian Mansilla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Sharhzad Motaghi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Hector Pardo-Hernandez
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gabriel Rada
- Epistemonikos Foundation, Santiago, Chile
- UC Evidence Center, Cochrane Chile Associated Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Yamna Rizwan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Pakeezah Saadat
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Charlotte Switzer
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | | | - Robin Wm Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Andrés Viteri-García
- Epistemonikos Foundation, Santiago, Chile
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Ying Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Yunli Zhao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
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Johnston BC, Alonso-Coello P, Bala MM, Zeraatkar D, Rabassa M, Valli C, Marshall C, El Dib R, Vernooij RWM, Vandvik PO, Guyatt GH. Correction to: Methods for trustworthy nutritional recommendations NutriRECS (Nutritional Recommendations and accessible Evidence summaries Composed of Systematic reviews): a protocol. BMC Med Res Methodol 2019; 19:240. [PMID: 31847819 PMCID: PMC6918667 DOI: 10.1186/s12874-019-0888-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Following publication of the original article [1], the authors reported a change in the 'Competing interests' section as described below.
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Affiliation(s)
- Bradley C Johnston
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Pablo Alonso-Coello
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Catherine Marshall
- Cochrane Consumer and Honorary Patron of the Guidelines International Network, Wellington, New Zealand
| | - Regina El Dib
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Institute of Science and Technology, Unesp - Univ Estadual Paulista, São José dos Campos, Brazil
| | - Robin W M Vernooij
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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15
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Bekkering GE, Agoritsas T, Lytvyn L, Heen AF, Feller M, Moutzouri E, Abdulazeem H, Aertgeerts B, Beecher D, Brito JP, Farhoumand PD, Singh Ospina N, Rodondi N, van Driel M, Wallace E, Snel M, Okwen PM, Siemieniuk R, Vandvik PO, Kuijpers T, Vermandere M. Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ 2019; 365:l2006. [PMID: 31088853 DOI: 10.1136/bmj.l2006] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CLINICAL QUESTION What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice. CURRENT PRACTICE Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing. RECOMMENDATION The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old). HOW THIS GUIDELINE WAS CREATED A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. THE EVIDENCE The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up. UNDERSTANDING THE RECOMMENDATION The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.
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Affiliation(s)
- G E Bekkering
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | - T Agoritsas
- Division of General Internal Medicine and Division of Clinical Epidemiology, University
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - L Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - A F Heen
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - M Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - E Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - B Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | | | - J P Brito
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - P D Farhoumand
- Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - N Singh Ospina
- Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, Florida, USA
| | - N Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane Qld 4029, Australia
| | - E Wallace
- HRB Centre for Primary Care Research and Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - M Snel
- Department of Endocrinology/General Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - P M Okwen
- Effective Basic Services (eBASE), Bamenda, Cameroon
| | - R Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - P O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - T Kuijpers
- Dutch College of General Practitioners, Utrecht, Netherlands
| | - M Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
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Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev 2019; 1:CD005619. [PMID: 30707445 PMCID: PMC6357907 DOI: 10.1002/14651858.cd005619.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for rotator cuff disease is usually used after non-operative interventions have failed, although our Cochrane Review, first published in 2007, found that there was uncertain clinical benefit following subacromial decompression surgery. OBJECTIVES To synthesise the available evidence of the benefits and harms of subacromial decompression surgery compared with placebo, no intervention or non-surgical interventions in people with rotator cuff disease (excluding full thickness rotator cuff tears). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry from 2006 until 22 October 2018, unrestricted by language. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs) of adults with rotator cuff disease (excluding full-thickness tears), that compared subacromial decompression surgery with placebo, no treatment, or any other non-surgical interventions. As it is least prone to bias, subacromial decompression compared with placebo was the primary comparison. Other comparisons were subacromial decompression versus exercises or non-operative treatment. Major outcomes were mean pain scores, shoulder function, quality of life, participant global assessment of success, adverse events and serious adverse events. The primary endpoint for this review was one year. For serious adverse events, we also included data from prospective cohort studies designed to record harms that evaluated subacromial decompression surgery or shoulder arthroscopy. DATA COLLECTION AND ANALYSIS We used standard methodologic procedures expected by Cochrane. MAIN RESULTS We included eight trials, with a total of 1062 randomised participants with rotator cuff disease, all with subacromial impingement. Two trials (506 participants) compared arthroscopic subacromial decompression with arthroscopy only (placebo surgery), with all groups receiving postoperative exercises. These trials included a third treatment group: no treatment (active monitoring) in one and exercises in the other. Six trials (556 participants) compared arthroscopic subacromial decompression followed by exercises with exercises alone. Two of these trials included a third arm: sham laser in one and open subacromial decompression in the other.Trial size varied from 42 to 313 participants. Participant mean age ranged between 42 and 65 years. Only two trials reported mean symptom duration (18 to 22 months in one trial and 30 to 31 months in the other), two did not report duration and four reported it categorically.Both placebo-controlled trials were at low risk of bias for the comparison of surgery versus placebo surgery. The other trials were at high risk of bias for several criteria, most notably at risk of performance or detection bias due to lack of participant and personnel blinding. We have restricted the reporting of results of benefits in the Abstract to the placebo-controlled trials.Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence, downgraded due to imprecision).At one year, mean pain (on a scale zero to 10, higher scores indicate more pain), was 2.9 points after placebo surgery and 0.26 better (0.84 better to 0.33 worse), after subacromial decompression (284 participants), an absolute difference of 3% (8% better to 3% worse), and relative difference of 4% (12% better to 5% worse). At one year, mean function (on a scale 0 to 100, higher score indicating better outcome), was 69 points after placebo surgery and 2.8 better (1.4 worse to 6.9 better), after surgery (274 participants), an absolute difference of 3% (7% better to 1% worse), and relative difference of 9% (22% better to 4% worse). Global success rate was 97/148 (or 655 per 1000), after placebo and 101/142 (or 708 per 1000) after surgery corresponding to RR 1.08 (95% CI 0.93 to 1.27). Health-related quality of life was 0.73 units (European Quality of Life EQ-5D, -0.59 to 1, higher score indicating better quality of life), after placebo and 0.03 units worse (0.011 units worse to 0.06 units better), after subacromial decompression (285 participants), an absolute difference of 1.3% (5% worse to 2.5% better), and relative difference of 4% (15% worse to 7% better).Adverse events including frozen shoulder or transient minor complications of surgery were reported in approximately 3% of participants across treatment groups in two randomised controlled trials, but due to low event rates we are uncertain if the risks differ between groups: 5/165 (37 per 1000) reported adverse events with subacromial decompression and 9/241 (34 per 1000) with placebo or non-operative treatment, RR 0.91 (95% CI 0.31 to 2.65) (moderate-certainty evidence, downgraded due to imprecision). The trials did not report serious adverse events.Based upon moderate-certainty evidence from two observational trials from the same prospective surgery registry, which also included other shoulder arthroscopic procedures (downgraded for indirectness), the incidence proportion of serious adverse events within 30 days following surgery was 0.5% (0.4% to 0.7%; data collected 2006 to 2011), or 0.6% (0.5 % to 0.7%; data collected 2011 to 2013). Serious adverse events such as deep infection, pulmonary embolism, nerve injury, and death have been observed in participants following shoulder surgery. AUTHORS' CONCLUSIONS The data in this review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.Adverse event rates were low, 3% or less across treatment groups in the trials, which is consistent with adverse event rates reported in the two observational studies. Although precise estimates are unknown, the risk of serious adverse events is likely less than 1%.
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Affiliation(s)
- Teemu V Karjalainen
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
- University of HelsinkiFinnish Center of Evidence based Orthopaedics (FICEBO)HelsinkiFinland
| | - Nitin B Jain
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Cristina M Page
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Tuomas A Lähdeoja
- University of HelsinkiFinnish Center of Evidence based Orthopaedics (FICEBO)HelsinkiFinland
- Helsinki University Hospital, Töölö HospitalDepartment of Orthopaedics and TraumatologyHelsinkiFinland
| | - Renea V Johnston
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
| | - Paul Salamh
- University of IndianapolisCollege of Health SciencesIndianapolisUSA
| | - Lauri Kavaja
- University of HelsinkiMedical FacultyHelsinkiFinland
- South Carelia Central HospitalDepartment of SurgeryLappeenrantaFinland
| | - Clare L Ardern
- Linköping UniversityDivision of PhysiotherapyLinköpingSweden
- La Trobe UniversitySchool of Allied HealthMelbourneAustralia
| | - Arnav Agarwal
- University of TorontoDepartment of MedicineTorontoCanada
| | - Per O Vandvik
- Lovisenberg Diaconal HospitalDepartment of MedicineOsloNorway
- University of OsloFaculty of Medicine, Institute of Health and SocietyOsloNorway
| | - Rachelle Buchbinder
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
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Johnston BC, Alonso-Coello P, Bala MM, Zeraatkar D, Rabassa M, Valli C, Marshall C, El Dib R, Vernooij RWM, Vandvik PO, Guyatt GH. Methods for trustworthy nutritional recommendations NutriRECS (Nutritional Recommendations and accessible Evidence summaries Composed of Systematic reviews): a protocol. BMC Med Res Methodol 2018; 18:162. [PMID: 30518328 PMCID: PMC6280455 DOI: 10.1186/s12874-018-0621-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Background Recent systematic reviews and editorials suggest that many organizations that produce nutritional guideline recommendations do not adhere to internationally recognized standards set forth by the Institute of Medicine (IoM), Guidelines International Network (GIN), Appraisal of Guidelines Research and Evaluation (AGREE), and Grading Recommendations, Assessment, Development and Evaluation (GRADE). Methods The potential solution is an independent group with content expertise and skilled in the methodology of systematic reviews and practice guidelines to produce trustworthy guideline recommendations, recommendations that are supported by publication in a top tier journal. The BMJ Rapid Recommendations project has recently demonstrated the feasibility and utility of this approach. Here, we are proposing trustworthy nutritional guideline recommendations based on internationally accepted guideline development standards, recommendations that will be informed by rigorous and novel systematic reviews of the benefits and harms associated with nutritional exposures, as well as studies on the values and preferences related to dietary behaviors among members of the international community. Discussion Adhering to international guideline standards, conducting high quality systematic reviews, and actively assessing the values and preferences of key stakeholders is expected to improve the quality of nutritional guidelines and their relevance to end-users, particularly patients and community members. We will send our work for peer review, and if found acceptable, we will publish our nutritional recommendations in top-tier general medicine journals.
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Affiliation(s)
- Bradley C Johnston
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Pablo Alonso-Coello
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Montserrat Rabassa
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Claudia Valli
- Iberoamerican Cochrane Centre Barcelona, Biomedical Research Institute San Pau (IIB Sant Pau), Barcelona, Spain
| | - Catherine Marshall
- Cochrane Consumer and Honorary Patron of the Guidelines International Network, Wellington, New Zealand
| | - Regina El Dib
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Institute of Science and Technology, Unesp - Univ Estadual Paulista, São José dos Campos, Brazil
| | - Robin W M Vernooij
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Canada.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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18
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Siemieniuk RAC, Chu DK, Kim LHY, Güell-Rous MR, Alhazzani W, Soccal PM, Karanicolas PJ, Farhoumand PD, Siemieniuk JLK, Satia I, Irusen EM, Refaat MM, Mikita JS, Smith M, Cohen DN, Vandvik PO, Agoritsas T, Lytvyn L, Guyatt GH. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ 2018; 363:k4169. [PMID: 30355567 DOI: 10.1136/bmj.k4169] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
| | - Lisa Ha-Yeon Kim
- Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
| | - Maria-Rosa Güell-Rous
- Departament de Pneumologia, Hospital de la Santa Creu I Sant Pau. Barcelona, Catalonia 08041, Spain
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
| | - Paola M Soccal
- Division of Pulmonary Medicine, Geneva University Hospitals, 1211 Geneva, Switzerland
- Faculty of Medicine, Geneva University, 1206 Geneva, Switzerland
| | - Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Pauline D Farhoumand
- Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | | | - Imran Satia
- Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
| | - Elvis M Irusen
- Divisions of Pulmonology and Medical Intensive Care, Stellenbosch University, Cape Town 7505, South Africa
| | - Marwan M Refaat
- Departments of Internal Medicine and Biochemistry & Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut 1107 2020, Lebanon
| | | | | | | | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
- Division General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland
- Division Clinical Epidemiology, University Hospitals of Geneva, 1205 Geneva, 1205, Switzerland
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton L8S 4K1, Canada
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19
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Lamontagne F, Rochwerg B, Lytvyn L, Guyatt GH, Møller MH, Annane D, Kho ME, Adhikari NKJ, Machado F, Vandvik PO, Dodek P, Leboeuf R, Briel M, Hashmi M, Camsooksai J, Shankar-Hari M, Baraki MK, Fugate K, Chua S, Marti C, Cohen D, Botton E, Agoritsas T, Siemieniuk RAC. Corticosteroid therapy for sepsis: a clinical practice guideline. BMJ 2018; 362:k3284. [PMID: 30097460 PMCID: PMC6083439 DOI: 10.1136/bmj.k3284] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
- Centre de recherche du CHU de Sherbrooke, Centre intégré universitaire de santé et de services sociaux - Estrie, Sherbrooke, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Djillali Annane
- Service de Médecine Intensive et Réanimation, Hôpital Raymond Poincaré, Garches, France
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Flavia Machado
- Federal University of Sao Paulo, Sao Paulo, Brazil
- Latin America Sepsis Institute, Sao Paulo, Brazil
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Peter Dodek
- Center for Health Evaluation and Outcome Sciences and Division of Critical Care Medicine, St Paul's Hospital and University of British Columbia, Vancouver, Canada
| | - Rebecca Leboeuf
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Matthias Briel
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | | | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- NIHR Clinician Scientist, School of Immunology & Microbial Sciences, Kings College London, United Kingdom
| | | | | | | | - Christophe Marti
- Division of General Internal Medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Dian Cohen
- Centre de santé de la vallée Massawippi, Ayer's Cliff, Canada
| | - Edouard Botton
- Comité stratégique patient-partenaire, Centre de recherche du CHU de Sherbrooke, Centre intégré universitaire de santé et de services sociaux - Estrie, Sherbrooke, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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20
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Mir H, Siemieniuk RAC, Ge LC, Foroutan F, Fralick M, Syed T, Lopes LC, Kuijpers T, Mas JL, Vandvik PO, Agoritsas T, Guyatt GH. Patent foramen ovale closure, antiplatelet therapy or anticoagulation in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence. BMJ Open 2018; 8:e023761. [PMID: 30049703 PMCID: PMC6067350 DOI: 10.1136/bmjopen-2018-023761] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To examine the relative impact of three management options in patients aged <60 years with cryptogenic stroke and a patent foramen ovale (PFO): PFO closure plus antiplatelet therapy, antiplatelet therapy alone and anticoagulation alone. DESIGN Systematic review and network meta-analysis (NMA) supported by complementary external evidence. DATA SOURCES Medline, EMBASE and Cochrane CENTRAL. STUDY SELECTION Randomised controlled trials (RCTs) addressing PFO closure and/or medical therapies in patients with PFO and cryptogenic stroke. REVIEW METHODS We conducted an NMA complemented with external evidence and rated certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Ten RCTs in eight studies proved eligible (n=4416). Seven RCTs (n=3913) addressed PFO closure versus medical therapy. Of these, three (n=1257) addressed PFO closure versus antiplatelet therapy, three (n=2303) addressed PFO closure versus mixed antiplatelet and anticoagulation therapies and one (n=353) addressed PFO closure versus anticoagulation. The remaining three RCTs (n=503) addressed anticoagulant versus antiplatelet therapy. PFO closure versus antiplatelet therapy probably results in substantial reduction in ischaemic stroke recurrence (risk difference per 1000 patients over 5 years (RD): -87, 95% credible interval (CrI) -100 to -33; moderate certainty). Compared with anticoagulation, PFO closure may confer little or no difference in ischaemic stroke recurrence (low certainty) but probably has a lower risk of major bleeding (RD -20, 95% CrI -27 to -2, moderate certainty). Relative to either medical therapy, PFO closure probably increases the risk of persistent atrial fibrillation (RD 18, 95% CI +5 to +56, moderate certainty) and device-related adverse events (RD +36, 95% CI +23 to +50, high certainty). Anticoagulation, compared with antiplatelet therapy, may reduce the risk of ischaemic stroke recurrence (RD -71, 95% CrI -100 to +17, low certainty), but probably increases the risk of major bleeding (RD +12, 95% CrI -5 to +65, moderate certainty). CONCLUSIONS In patients aged <60 years, PFO closure probably confers an important reduction in ischaemic stroke recurrence compared with antiplatelet therapy alone but may make no difference compared with anticoagulation. PFO closure incurs a risk of persistent atrial fibrillation and device-related adverse events. Compared with alternatives, anticoagulation probably increases major bleeding. PROSPERO REGISTRATION NUMBER CRD42017081567.
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Affiliation(s)
- Hassan Mir
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reed Alexander C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Long Cruz Ge
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Fralick
- Eliot Phillipson Clinician Scientist Training Program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Talha Syed
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Graduate Course, University of Sorocaba, UNISO, Sao Paulo, Brazil
| | - Ton Kuijpers
- Department of Guideline Development and Research, Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Jean-Louis Mas
- Department of Neurology, Sainte-Anne Hospital, Paris, France
| | - Per O Vandvik
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust—Division Gjøvik, Oslo, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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21
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Kuijpers T, Spencer FA, Siemieniuk RAC, Vandvik PO, Otto CM, Lytvyn L, Mir H, Jin AY, Manja V, Karthikeyan G, Hoendermis E, Martin J, Carballo S, O'Donnell M, Vartdal T, Baxter C, Patrick-Lake B, Scott J, Agoritsas T, Guyatt G. Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline. BMJ 2018; 362:k2515. [PMID: 30045912 PMCID: PMC6058599 DOI: 10.1136/bmj.k2515] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ton Kuijpers
- Department of guideline development and research, Dutch College of General Practitioners, Utrecht, The Netherlands
| | | | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Per O Vandvik
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
| | | | | | | | - Albert Y Jin
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Veena Manja
- University of California Davis, Sacramento, CA, USA
| | | | - Elke Hoendermis
- University Medical Center of Groningen, Groningen, The Netherlands
| | - Janet Martin
- Departments of Anesthesia & Perioperative Medicine, and Epidemiology & Biostatistics, Western University, London, Canada
| | - Sebastian Carballo
- Division General Internal Medicine, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | | | | | | | | | | | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Gordon Guyatt
- McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
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22
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Vermandere M, Aertgeerts B, Agoritsas T, Liu C, Burgers J, Merglen A, Okwen PM, Lytvyn L, Chua S, Vandvik PO, Guyatt GH, Beltran-Arroyave C, Lavergne V, Speeckaert R, Steen FE, Arteaga V, Sender R, McLeod S, Sun X, Wang W, Siemieniuk RAC. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018; 360:k243. [PMID: 29437651 PMCID: PMC5799894 DOI: 10.1136/bmj.k243] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Mieke Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center; Division of Allergy and Infectious Diseases, University of Washington
| | - Jako Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands
| | - Arnaud Merglen
- Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Patrick Mbah Okwen
- Bali District Hospital, Bali, and Centre for Development of Best Practices in Health, Yaounde, Cameroon
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Oslo University Hospital, Blindern 0317 Oslo, Norway
| | | | - Per O Vandvik
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Norwegian Institute of Public Health, Oslo, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
| | | | - Valéry Lavergne
- Department of medical microbiology and infectious diseases, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
| | | | | | | | - Rachelle Sender
- Department of Family Medicine, McMaster University Medical School, Hamilton, Ontario, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System; Department of Family & Community Medicine, University of Toronto, Ontario, Canada
| | - Xin Sun
- Chinese Evidence-based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and CREAT Group, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open 2017; 7:e018593. [PMID: 29150475 PMCID: PMC5701989 DOI: 10.1136/bmjopen-2017-018593] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION UpToDate is widely used by clinicians worldwide and includes more than 9400 recommendations that apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. GRADE guidance warns against strong recommendations when certainty of the evidence is low or very low (discordant recommendations) but has identified five paradigmatic situations in which discordant recommendations may be justified. OBJECTIVES Our objective was to document the strength of recommendations in UpToDate and assess the frequency and appropriateness of discordant recommendations. DESIGN Analytical survey of all recommendations in UpToDate. METHODS We identified all GRADE recommendations in UpToDate and examined their strength (strong or weak) and certainty of the evidence (high, moderate or low certainty). We identified all discordant recommendations as of January 2015, and pairs of reviewers independently classified them either into one of the five appropriate paradigms or into one of three categories inconsistent with GRADE guidance, based on the evidence presented in UpToDate. RESULTS UpToDate included 9451 GRADE recommendations, of which 6501 (68.8%) were formulated as weak recommendations and 2950 (31.2%) as strong. Among the strong, 844 (28.6%) were based on high certainty in effect estimates, 1740 (59.0%) on moderate certainty and 366 (12.4%) on low certainty. Of the 349 discordant recommendations 204 (58.5%) were judged appropriately (consistent with one of the five paradigms); we classified 47 (13.5%) as good practice statements; 38 (10.9%) misclassified the evidence as low certainty when it was at least moderate and 60 (17.2%) warranted a weak rather than a strong recommendation. CONCLUSION The proportion of discordant recommendations in UpToDate is small (3.7% of all recommendations) and the proportion that is truly problematic (strong recommendations that would best have been weak) is very small (0.6%). Clinicians should nevertheless be cautious and look for clear explanations-in UpToDate and elsewhere-when guidelines offer strong recommendations based on low certainty evidence.
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Affiliation(s)
- Thomas Agoritsas
- Division of General Internal Medicine, Department of Internal medicine, Rehabilitation and Geriatrics, University Hospitals of Geneva, Geneva, Switzerland
- Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Arnaud Merglen
- Division of General Pediatrics, Faculty of Medicine, University Hospitals of Geneva, University of Geneva, Geneva, Geneva, Switzerland
| | - Anja Fog Heen
- Department of Internal Medicine, Innlandet Hospital Trust-division Gjøvik, Gjøvik, Norway
| | - Annette Kristiansen
- Department of Internal Medicine, Innlandet Hospital Trust-division Gjøvik, Gjøvik, Norway
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine and Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, USA
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Faculty of Dentistry, University of Chile, Santiago, Chile
| | - Paul E Alexander
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David M Rind
- Institute for Clinical and Economic Review, Boston, Massachusetts, USA
| | - Per O Vandvik
- Department of Internal Medicine, Innlandet Hospital Trust-division Gjøvik, Gjøvik, Norway
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A, van Driel M, Vermandere M, Bullens D, Okwen PM, Niño R, van den Bruel A, Lytvyn L, Berg-Nelson C, Chua S, Leahy J, Raven J, Weinberg M, Sadeghirad B, Vandvik PO, Brignardello-Petersen R. Corticosteroids for sore throat: a clinical practice guideline. BMJ 2017; 358:j4090. [PMID: 28931507 PMCID: PMC6284245 DOI: 10.1136/bmj.j4090] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jako Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- School CAPHRI, Department Family Medicine, Maastricht, The Netherlands
| | - Geertruida E Bekkering
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
| | - Arnaud Merglen
- Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mieke van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Mieke Vermandere
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
| | - Dominique Bullens
- Pediatric Immunology, Department of microbiology and immunology, KU Leuven, Belgium
- Pediatric allergy, Clinical division of pediatrics UZ Leuven, Leuven, Belgium
| | - Patrick Mbah Okwen
- Bali District Hospital, Bali and Centre for Development of Best practices in Health Yaounde, Cameroon
| | - Ricardo Niño
- Otorhinolaryngology-Head and Neck Surgery, Clinica del Country, Bogota, Colombia
| | - Ann van den Bruel
- NIHR Oxford Diagnostic Evidence Cooperative, Oxford, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lyubov Lytvyn
- Oslo University Hospital, Forskningsveien 2b, Blindern 0317 Oslo, Norway
| | - Carla Berg-Nelson
- The Society for Participatory Medicine, Newburyport, MA 01950-1183, USA
- Arizona Senior Academy, Tucson, AZ 85747, USA
| | - Shunjie Chua
- MOH Holdings, 1 Maritime Square, Singapore, Singapore 099253
| | | | | | | | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Per O Vandvik
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
| | - Romina Brignardello-Petersen
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
- Faculty of Dentistry, Universidad de Chile, Santiago, Chile
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Foroutan F, Guyatt GH, Otto CM, Siemieniuk RA, Schandelmaier S, Agoritsas T, Vandvik PO, Bhagra S, Bagur R. Structural valve deterioration after transcatheter aortic valve implantation. Heart 2017; 103:1899-1905. [DOI: 10.1136/heartjnl-2017-311329] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/17/2017] [Accepted: 05/03/2017] [Indexed: 11/03/2022] Open
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26
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Doust J, Vandvik PO, Qaseem A, Mustafa RA, Horvath AR, Frances A, Al-Ansary L, Bossuyt P, Ward RL, Kopp I, Gollogly L, Schunemann H, Glasziou P. Guidance for Modifying the Definition of Diseases: A Checklist. JAMA Intern Med 2017; 177:1020-1025. [PMID: 28505266 DOI: 10.1001/jamainternmed.2017.1302] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE No guidelines exist currently for guideline panels and others considering changes to disease definitions. Panels frequently widen disease definitions, increasing the proportion of the population labeled as unwell and potentially causing harm to patients. We set out to develop a checklist of issues, with guidance, for panels to consider prior to modifying a disease definition. OBSERVATIONS We assembled a multidisciplinary, multicontinent working group of 13 members, including members from the Guidelines International Network, Grading of Recommendations Assessment, Development and Evaluation working group, and the World Health Organisation. We used a 5-step process to develop the checklist: (1) a literature review of issues, (2) a draft outline document, (3) a Delphi process of feedback on the list of issues, (4) a 1-day face-to-face meeting, and (5) further refinement of the checklist. The literature review identified 12 potential issues. From these, the group developed an 8-item checklist that consisted of definition changes, number of people affected, trigger, prognostic ability, disease definition precision and accuracy, potential benefits, potential harms, and the balance between potential harms and benefits. The checklist is accompanied by an explanation of each item and the types of evidence to assess each one. We used a panel's recent consideration of a proposed change in the definition of gestational diabetes mellitus (GDM) to illustrate use of the checklist. CONCLUSIONS AND RELEVANCE We propose that the checklist be piloted and validated by groups developing new guidelines. We anticipate that the use of the checklist will be a first step to guidance and better documentation of definition changes prior to introducing modified disease definitions.
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Affiliation(s)
- Jenny Doust
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Australia
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Amir Qaseem
- Department of Clinical Policy, American College of Physicians, Philadelphia, Pennsylvania
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada5Department of Medicine, McMaster University, Hamilton, Canada
| | - Andrea R Horvath
- NSW Health Pathology SEALS Department of Clinical Chemistry and Endocrinology, Prince of Wales Hospital, Sydney, Australia
| | | | - Lubna Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Patrick Bossuyt
- Department of Clinical Epidemiology and Biostatistics, University of Amsterdam, Amsterdam, the Netherlands
| | - Robyn L Ward
- Brian Wilson Chancellery, University of Queensland, St Lucia, Australia
| | - Ina Kopp
- Association of the Scientific Medical Societies´ Institute of Medical Knowledge-Management (AWMF-IMWi), Philipps-University, Marburg, Germany
| | - Laragh Gollogly
- Department of Strategy, Policy, and Information, World Health Organisation, Geneva, Switzerland
| | - Holger Schunemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Paul Glasziou
- Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Australia
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Devji T, Guyatt GH, Lytvyn L, Brignardello-Petersen R, Foroutan F, Sadeghirad B, Buchbinder R, Poolman RW, Harris IA, Carrasco-Labra A, Siemieniuk RAC, Vandvik PO. Application of minimal important differences in degenerative knee disease outcomes: a systematic review and case study to inform BMJ Rapid Recommendations. BMJ Open 2017; 7:e015587. [PMID: 28495818 PMCID: PMC5777462 DOI: 10.1136/bmjopen-2016-015587] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To identify the most credible anchor-based minimal important differences (MIDs) for patient important outcomes in patients with degenerative knee disease, and to inform BMJ Rapid Recommendations for arthroscopic surgery versus conservative management DESIGN: Systematic review. OUTCOME MEASURES Estimates of anchor-based MIDs, and their credibility, for knee symptoms and health-related quality of life (HRQoL). DATA SOURCES MEDLINE, EMBASE and PsycINFO. ELIGIBILITY CRITERIA We included original studies documenting the development of anchor-based MIDs for patient-reported outcomes (PROs) reported in randomised controlled trials included in the linked systematic review and meta-analysis and judged by the parallel BMJ Rapid Recommendations panel as critically important for informing their recommendation: measures of pain, function and HRQoL. RESULTS 13 studies reported 95 empirically estimated anchor-based MIDs for 8 PRO instruments and/or their subdomains that measure knee pain, function or HRQoL. All studies used a transition rating (global rating of change) as the anchor to ascertain the MID. Among PROs with more than 1 estimated MID, we found wide variation in MID values. Many studies suffered from serious methodological limitations. We identified the following most credible MIDs: Western Ontario and McMaster University Osteoarthritis Index (WOMAC; pain: 12, function: 13), Knee injury and Osteoarthritis Outcome Score (KOOS; pain: 12, activities of daily living: 8) and EuroQol five dimensions Questionnaire (EQ-5D; 0.15). CONCLUSIONS We were able to distinguish between more and less credible MID estimates and provide best estimates for key instruments that informed evidence presentation in the associated systematic review and judgements made by the Rapid Recommendation panel. TRIAL REGISTRATION NUMBER CRD42016047912.
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Affiliation(s)
- Tahira Devji
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Romina Brignardello-Petersen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Evidence-Based Dentistry, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute; Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Ian A Harris
- South Western Sydney Clinical School, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Level 2, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Alonso Carrasco-Labra
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Evidence-Based Dentistry, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Reed A C Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Gjøvik, Gjøvik, Norway
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Brignardello-Petersen R, Guyatt GH, Buchbinder R, Poolman RW, Schandelmaier S, Chang Y, Sadeghirad B, Evaniew N, Vandvik PO. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open 2017; 7:e016114. [PMID: 28495819 PMCID: PMC5541494 DOI: 10.1136/bmjopen-2017-016114] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine the effects and complications of arthroscopic surgery compared with conservative management strategies in patients with degenerative knee disease. DESIGN Systematic review. MAIN OUTCOME MEASURES Pain, function, adverse events. DATA SOURCES MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar and Open Grey up to August 2016. ELIGIBILITY CRITERIA For effects, randomised clinical trials (RCTs) comparing arthroscopic surgery with a conservative management strategy (including sham surgery) in patients with degenerative knee disease. For complications, RCTs and observational studies. REVIEW METHODS Two reviewers independently extracted data and assessed risk of bias for patient-important outcomes. A parallel guideline committee (BMJ Rapid Recommendations) provided input on the design and interpretation of the systematic review, including selection of patient-important outcomes. We used the GRADE approach to rate the certainty (quality) of the evidence. RESULTS We included 13 RCTs and 12 observational studies. With respect to pain, the review identified high-certainty evidence that knee arthroscopy results in a very small reduction in pain up to 3 months (mean difference =5.4 on a 100-point scale, 95% CI 2.0 to 8.8) and very small or no pain reduction up to 2 years (mean difference =3.1, 95% CI -0.2 to 6.4) when compared with conservative management. With respect to function, the review identified moderate-certainty evidence that knee arthroscopy results in a very small improvement in the short term (mean difference =4.9 on a 100-point scale, 95% CI 1.5 to 8.4) and very small or no improved function up to 2 years (mean difference =3.2, 95% CI -0.5 to 6.8). Alternative presentations of magnitude of effect, and associated sensitivity analyses, were consistent with the findings of the primary analysis. Low-quality evidence suggested a very low probability of serious complications after knee arthroscopy. CONCLUSIONS Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function. TRIAL REGISTRATION NUMBER PROSPERO CRD42016046242.
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Affiliation(s)
- Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
| | - Rudolf W Poolman
- Department of Orthopedic Surgery and Traumatology, Joint Research, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Stefan Schandelmaier
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Orthopedic Surgery and Traumatology, Joint Research, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
- Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Medical University Campus, Haft-Bagh Highway, Kerman, Iran
| | - Nathan Evaniew
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Gjøvik, Norway
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
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29
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Schandelmaier S, Tomonaga Y, Bassler D, Meerpohl JJ, von Elm E, You JJ, Bluemle A, Lamontagne F, Saccilotto R, Amstutz A, Bengough T, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Busse JW, Ferreira-González I, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Guyatt G, Bucher HC, Kasenda B, Briel M. Premature Discontinuation of Pediatric Randomized Controlled Trials: A Retrospective Cohort Study. J Pediatr 2017; 184:209-214.e1. [PMID: 28410086 DOI: 10.1016/j.jpeds.2017.01.071] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/30/2016] [Accepted: 01/30/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the proportion of pediatric randomized controlled trials (RCTs) that are prematurely discontinued, examine the reasons for discontinuation, and compare the risk for recruitment failure in pediatric and adult RCTs. STUDY DESIGN A retrospective cohort study of RCTs approved by 1 of 6 Research Ethics Committees (RECs) in Switzerland, Germany, and Canada between 2000 and 2003. We recorded trial characteristics, trial discontinuation, and reasons for discontinuation from protocols, corresponding publications, REC files, and a survey of trialists. RESULTS We included 894 RCTs, of which 86 enrolled children and 808 enrolled adults. Forty percent of the pediatric RCTs and 29% of the adult RCTs were discontinued. Slow recruitment accounted for 56% of pediatric RCT discontinuations and 43% of adult RCT discontinuations. Multivariable logistic regression analyses suggested that pediatric RCT was not an independent risk factor for recruitment failure after adjustment for other potential risk factors (aOR, 1.22; 95% CI, 0.57-2.63). Independent risk factors were acute care setting (aOR, 4.00; 95% CI, 1.72-9.31), nonindustry sponsorship (aOR, 4.45; 95% CI, 2.59-7.65), and smaller planned sample size (aOR, 1.05; 95% CI 1.01-1.09, in decrements of 100 participants). CONCLUSION Forty percent of pediatric RCTs were discontinued prematurely, owing predominately to slow recruitment. Enrollment of children was not an independent risk factor for recruitment failure.
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Affiliation(s)
- Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland.
| | - Yuki Tomonaga
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Joerg J Meerpohl
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany; Center of Research in Epidemiology and Statistics Sorbonne Paris Cité-U1153, INSERM/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, Paris Cedex 04, France
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - John J You
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anette Bluemle
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany
| | - Francois Lamontagne
- Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Alain Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Theresa Bengough
- Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria
| | - Mihaela Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kelechi K Olu
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kari A O Tikkinen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alonso Carrasco-Labra
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Markus Faulhaber
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sohail M Mulla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Xin Sun
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Ignacio Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - Alain Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Heike Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Lorenzo Moja
- IRCCS Orthopedic Institute Galeazzi, Milano, Italy
| | - Rachel Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Shanil Ebrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Stanford Prevention Research Center, Stanford University, Stanford, CA
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Oppland, Norway
| | - Bradley C Johnston
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Martin A Walter
- Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Bernard Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Clinical Research, University of Basel, Basel, Switzerland
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Bagur R, Solo K, Alghofaili S, Nombela-Franco L, Kwok CS, Hayman S, Siemieniuk RA, Foroutan F, Spencer FA, Vandvik PO, Schäufele TG, Mamas MA. Cerebral Embolic Protection Devices During Transcatheter Aortic Valve Implantation. Stroke 2017; 48:1306-1315. [DOI: 10.1161/strokeaha.116.015915] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/01/2017] [Accepted: 02/15/2017] [Indexed: 12/29/2022]
Abstract
Background and Purpose—
Silent ischemic embolic lesions are common after transcatheter aortic valve implantation (TAVI). The use of embolic protection devices (EPD) may reduce the occurrence of these embolic lesions. Thus, a quantitative overview and credibility assessment of the literature was necessary to draw a robust message about EPD. Therefore, the aim of this meta-analysis was to study whether the use of EPD reduces silent ischemic and clinically evident cerebrovascular events associated with TAVI.
Methods—
We conducted a comprehensive search to identify studies that evaluated patients undergoing TAVI with or without EPD. Random-effects meta-analyses were performed to estimate the effect of EPD compared with no-EPD during TAVI using aggregate data.
Results—
Sixteen studies involving 1170 patients (865/305 with/without EPD) fulfilled the inclusion criteria. The EPD delivery success rate was reported in all studies and was achieved in 94.5% of patients. Meta-analyses evaluating EPD versus without EPD strategies could not confirm or exclude any differences in terms of clinically evident stroke (relative risk, 0.70; 95% confidence interval [CI], 0.38–1.29;
P
=0.26) or 30-day mortality (relative risk, 0.58; 95% CI, 0.20–1.64;
P
=0.30). There were no significant differences in new-single, multiple, or total number of lesions. The use of EPD was associated with a significantly smaller ischemic volume per lesion (standardized mean difference, −0.52; 95% CI, −0.85 to −0.20;
P
=0.002) and smaller total volume of lesions (standardized mean difference, −0.23; 95% CI, −0.42 to −0.03;
P
=0.02). Subgroup analysis by type of valve showed an overall trend toward significant reduction in new lesions per patient using EPD (standardized mean difference, −0.41; 95% CI, −0.82 to 0.00;
P
=0.05), driven by self-expanding devices.
Conclusions—
The use of EPD during TAVI may be associated with smaller volume of silent ischemic lesions and smaller total volume of silent ischemic lesions. However, EPD may not reduce the number of new-single, multiple, or total number of lesions. There was only very low quality of evidence showing no significant differences between patients undergoing TAVI with or without EPD with respect to clinically evident stroke and mortality.
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Affiliation(s)
- Rodrigo Bagur
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Karla Solo
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Saleh Alghofaili
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Luis Nombela-Franco
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Chun Shing Kwok
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Samual Hayman
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Reed A. Siemieniuk
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Farid Foroutan
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Frederick A. Spencer
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Per O. Vandvik
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Tim G. Schäufele
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
| | - Mamas A. Mamas
- From the Division of Cardiology, Department of Medicine, London Health Sciences Center (R.B., S.A., S.H.) and Department of Epidemiology and Biostatistics (R.B., K.S.), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Keele Cardiovascular Research Group, Institute of Applied Clinical Science (R.B., C.S.K., M.A.M.), Keele University and Royal Stoke Hospital, Stoke-on-Trent, United Kingdom; Division of Cardiology, Hospital Clínico San Carlos, Madrid, Spain (L.N
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Schandelmaier S, Siemieniuk RAC, Agoritsas T, Vandvik PO, Guyatt GH, Busse JW. Authors' reply to Farrar. BMJ 2017; 356:j1483. [PMID: 28341658 DOI: 10.1136/bmj.j1483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Stefan Schandelmaier
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Reed A C Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
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Schandelmaier S, Kaushal A, Lytvyn L, Heels-Ansdell D, Siemieniuk RAC, Agoritsas T, Guyatt GH, Vandvik PO, Couban R, Mollon B, Busse JW. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ 2017; 356:j656. [PMID: 28348110 PMCID: PMC5484179 DOI: 10.1136/bmj.j656] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 11/16/2022]
Abstract
Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965.
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Affiliation(s)
- Stefan Schandelmaier
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031 Basel, Switzerland
| | - Alka Kaushal
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Lyubov Lytvyn
- Oslo University Hospital, Forskningsveien 2b, Postboks 1089, Blindern 0317 Oslo, Norway
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Reed A C Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Division General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Brent Mollon
- Orillia Soldiers' Memorial Hospital, 41 Frederick Street, Orillia, ON L3V 5W6, Canada
| | - Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada
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Lytvyn L, Guyatt GH, Manja V, Siemieniuk RA, Zhang Y, Agoritsas T, Vandvik PO. Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review. BMJ Open 2016; 6:e014327. [PMID: 27687903 PMCID: PMC5051506 DOI: 10.1136/bmjopen-2016-014327] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To investigate patients' values and preferences regarding aortic valve replacement therapy for aortic stenosis. SETTING Studies published after transcatheter aortic valve insertion (TAVI) became available (2002). PARTICIPANTS Adults with aortic stenosis who are considering or have had valve replacement, either TAVI or via surgery (surgical aortic valve replacement, SAVR). OUTCOME MEASURES We sought quantitative measurements, or qualitative descriptions, of values and preferences. When reported, we examined correlations between preferences and objective (eg, ejection fraction) or subjective (eg, health-related quality of life) measures of health. RESULTS We reviewed 1348 unique citations, of which 2 studies proved eligible. One study of patients with severe aortic stenosis used a standard gamble study to ascertain that the median hypothetical mortality risk patients were willing to tolerate to achieve full health was 25% (IQR 25-50%). However, there was considerable variability; for mortality risk levels defined by current guidelines, 130 participants (30%) were willing to accept low-to-intermediate risk (≤8%), 224 (51%) high risk (>8-50%) and 85 (19%) a risk that guidelines would consider prohibitive (>50%). Study authors did not, however, assess participants' understanding of the exercise, resulting in a potential risk of bias. A second qualitative study of 15 patients identified the following factors that influence patients to undergo assessment for TAVI: symptom burden; expectations; information support; logistical barriers; facilitators; obligations and responsibilities. The study was limited by serious risk of bias due to authors' conflict of interest (5/9 authors industry-funded). CONCLUSIONS Current evidence on patient values and preferences of adults with aortic stenosis is very limited, and no studies have enrolled patients deciding between TAVI and SAVR. On the basis of the data available, there is evidence of variability in individual values and preferences, highlighting the importance of well-informed and shared decision-making with patients facing this decision. TRIAL REGISTRATION NUMBER PROSPERO CRD42016041907.
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Affiliation(s)
- Lyubov Lytvyn
- Systematic Overviews through Advancing Research Technology, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Veena Manja
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, State University of New York at Buffalo, Buffalo, New York, USA
- VA Western New York Healthcare System at Buffalo, Buffalo, New York, USA
| | - Reed A Siemieniuk
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuan Zhang
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Per O Vandvik
- Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-Division, Gjøvik, Norway
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34
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Affiliation(s)
- Reed A Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8
| | - Linn Brandt
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
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35
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Vandvik PO, Otto CM, Siemieniuk RA, Bagur R, Guyatt GH, Lytvyn L, Whitlock R, Vartdal T, Brieger D, Aertgeerts B, Price S, Foroutan F, Shapiro M, Mertz R, Spencer FA. Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline. BMJ 2016; 354:i5085. [PMID: 27680583 DOI: 10.1136/bmj.i5085] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA 98195
| | - Reed A Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Bagur
- Division of Cardiology, London Health Sciences Centre and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada N6A 3K7
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8
| | - Lyubov Lytvyn
- Systematic Overviews through advancing Research Technology, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario Canada M5G 0A4
| | - Richard Whitlock
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Population Health Research Institute, Hamilton, Ontario, Canada L8L 2X2
| | - Trond Vartdal
- Department of Cardiology, Oslo University Hospital - Rikshospitalet, 0424 Oslo, Norway
| | - David Brieger
- Concord Repatriation General Hospital, Concord, New South Wales 2139, Australia
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | | | - Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada M5G 2C4
| | | | | | - Frederick A Spencer
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8
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36
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Foroutan F, Guyatt GH, O'Brien K, Bain E, Stein M, Bhagra S, Sit D, Kamran R, Chang Y, Devji T, Mir H, Manja V, Schofield T, Siemieniuk RA, Agoritsas T, Bagur R, Otto CM, Vandvik PO. Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ 2016; 354:i5065. [PMID: 27683072 PMCID: PMC5040922 DOI: 10.1136/bmj.i5065] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis. DESIGN Systematic review and meta-analysis of observational studies. DATA SOURCES Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016. STUDY SELECTION Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years. METHODS Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay. RESULTS In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15). CONCLUSION Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.
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Affiliation(s)
- Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Kathleen O'Brien
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eva Bain
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Madeleine Stein
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sai Bhagra
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Daegan Sit
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Rakhshan Kamran
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Yaping Chang
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Tahira Devji
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Hassan Mir
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Veena Manja
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Department of Internal Medicine, State University of New York at Buffalo, Buffalo, USA VA WNY Health Care System at Buffalo, Department of Veterans Affairs, USA
| | - Toni Schofield
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Reed A Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Rodrigo Bagur
- Division of Cardiology, London Health Sciences Centre and Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada N6A 5W9
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Per O Vandvik
- Department of Internal Medicine, Innlandet Hospital Trust-division Gjøvik, Norway Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway
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Agarwal A, Johnston BC, Vernooij RWM, Carrasco-Labra A, Brignardello-Petersen R, Neumann I, Akl EA, Sun X, Briel M, Busse JW, Ebrahim S, Granados CE, Iorio A, Irfan A, Martínez García L, Mustafa RA, Ramirez-Morera A, Selva A, Solà I, Sanabrai AJ, Tikkinen KAO, Vandvik PO, Zhang Y, Zazueta OE, Zhou Q, Schunemann HJ, Guyatt GH, Alonso-Coello P. Authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts. J Clin Epidemiol 2016; 81:3-12. [PMID: 27555080 DOI: 10.1016/j.jclinepi.2016.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 07/08/2016] [Accepted: 08/09/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Explicit reporting of absolute measures is important to ensure treatment effects are correctly interpreted. We examined the extent to which authors report absolute effects for patient-important outcomes in abstracts of systematic review (SR). STUDY DESIGN AND SETTING We searched OVID MEDLINE and Cochrane Database of Systematic Reviews to identify eligible SRs published in the year 2010. Citations were stratified into Cochrane and non-Cochrane reviews, with repeated random sampling in a 1:1 ratio. Paired reviewers screened articles and recorded abstract characteristics, including reporting of effect measures for the most patient-important outcomes of benefit and harm. RESULTS We included 96 Cochrane and 94 non-Cochrane reviews. About 117 (77.5%) relative measures were reported in abstracts for outcomes of benefit, whereas only 34 (22.5%) absolute measures were reported. Similarly, for outcomes of harm, 41 (87.2%) relative measures were provided in abstracts, compared with only 6 (12.8%) absolute measures. Eighteen (9.5%) abstracts reported both absolute and relative measures for outcomes of benefit, whereas only two (1.1%) abstracts reported both measures for outcomes of harm. Results were similar between Cochrane and non-Cochrane reviews. CONCLUSION SR abstracts seldom report measures of absolute effect. Journal editors should insist that authors report both relative and absolute effects for patient-important outcomes.
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Affiliation(s)
- Arnav Agarwal
- School of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Bradley C Johnston
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, Ontario M5T 3M6, Canada; Systematic Overviews through advancing Research Technology (SORT), Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, University of Toronto, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada; Department of Anesthesia & Pain Medicine, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario M5G 1X8, Canada.
| | - Robin W M Vernooij
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Alonso Carrasco-Labra
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Sergio Livingstone 943, Santiago, Chile
| | - Romina Brignardello-Petersen
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Sergio Livingstone 943, Santiago, Chile
| | - Ignacio Neumann
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Medicine, Pontificia Universidad Católica de Chile, Avenida Libertador Bernardo O Higgins 340, Santiago, Región Metropolitana, Chile
| | - Elie A Akl
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box: 11-0236, Riad-El-Solh, Beirut 1107 2020, Lebanon
| | - Xin Sun
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu 610041, China
| | - Matthias Briel
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Spitalstrasse 12, Basel 4031, Switzerland
| | - Jason W Busse
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Anesthesia, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Shanil Ebrahim
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Department of Anesthesia, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Carlos E Granados
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Área de investigaciones, Facultad de Medicina, Universidad de La Sabana, Campus del Puente del Común Km, 7 Autopista Norte, Chía, Colombia
| | - Alfonso Iorio
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Affan Irfan
- Internal Medicine Residency Program, University of Illinois, Urbana-Champaign, 506 S. Mathews Ave., Urbana, IL 61801, USA
| | - Laura Martínez García
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Reem A Mustafa
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Departments of Medicine and Biomedical & Health Informatics, University of Missouri-Kansas City, School of Medicine, M4-303, 2411 Holmes St, Kansas City, MO, USA
| | - Anggie Ramirez-Morera
- CCSS Permanent Medical Advisor, Health Care Development Division, IHCAI Foundation & Central America Cochrane, 1st Ave., 35th and 37th St, Number 3530, Barrio Escalante, San José, Costa Rica
| | - Anna Selva
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Ivan Solà
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Andrea J Sanabrai
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, Helsinki 00029, Finland
| | - Per O Vandvik
- Norwegian Knowledge Centre for the Health Services, P.O. Box 4404 Nydalen, Oslo 0403 Norway
| | - Yuqing Zhang
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Oscar E Zazueta
- Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain
| | - Qi Zhou
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Holger J Schunemann
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - Pablo Alonso-Coello
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Clinical Epidemiology and Public Health Department, Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pavelló 18, planta 0, 08025 Barcelona, Spain; CIBER of Epidemiology and Public Health (CIBERESP-IIB Sant Pau), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, Madrid 28029, Spain
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Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ 2016; 353:i2089. [PMID: 27365494 DOI: 10.1136/bmj.i2089] [Citation(s) in RCA: 424] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Andrew D Oxman
- Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
| | - Jenny Moberg
- Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
| | - Romina Brignardello-Petersen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Evidence Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Elie A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Internal Medicine, Clinical Epidemiology Unit, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Reem A Mustafa
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Per O Vandvik
- Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
| | - Joerg Meerpohl
- Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, McMaster University, Hamilton, Canada
| | - Holger J Schünemann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, McMaster University, Hamilton, Canada
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Kasenda B, von Elm E, You JJ, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Bassler D, Busse JW, Ferreira-González I, Lamontagne F, Nordmann A, Gloy V, Raatz H, Moja L, Ebrahim S, Schandelmaier S, Sun X, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Bucher HC, Guyatt GH, Briel M. Agreements between Industry and Academia on Publication Rights: A Retrospective Study of Protocols and Publications of Randomized Clinical Trials. PLoS Med 2016; 13:e1002046. [PMID: 27352244 PMCID: PMC4924795 DOI: 10.1371/journal.pmed.1002046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 05/06/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Little is known about publication agreements between industry and academic investigators in trial protocols and the consistency of these agreements with corresponding statements in publications. We aimed to investigate (i) the existence and types of publication agreements in trial protocols, (ii) the completeness and consistency of the reporting of these agreements in subsequent publications, and (iii) the frequency of co-authorship by industry employees. METHODS AND FINDINGS We used a retrospective cohort of randomized clinical trials (RCTs) based on archived protocols approved by six research ethics committees between 13 January 2000 and 25 November 2003. Only RCTs with industry involvement were eligible. We investigated the documentation of publication agreements in RCT protocols and statements in corresponding journal publications. Of 647 eligible RCT protocols, 456 (70.5%) mentioned an agreement regarding publication of results. Of these 456, 393 (86.2%) documented an industry partner's right to disapprove or at least review proposed manuscripts; 39 (8.6%) agreements were without constraints of publication. The remaining 24 (5.3%) protocols referred to separate agreement documents not accessible to us. Of those 432 protocols with an accessible publication agreement, 268 (62.0%) trials were published. Most agreements documented in the protocol were not reported in the subsequent publication (197/268 [73.5%]). Of 71 agreements reported in publications, 52 (73.2%) were concordant with those documented in the protocol. In 14 of 37 (37.8%) publications in which statements suggested unrestricted publication rights, at least one co-author was an industry employee. In 25 protocol-publication pairs, author statements in publications suggested no constraints, but 18 corresponding protocols documented restricting agreements. CONCLUSIONS Publication agreements constraining academic authors' independence are common. Journal articles seldom report on publication agreements, and, if they do, statements can be discrepant with the trial protocol.
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Affiliation(s)
- Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - John J. You
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anette Blümle
- Cochrane Germany, University of Freiburg, Freiburg, Germany
| | - Yuki Tomonaga
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Alain Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Theresa Bengough
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
- Austrian Federal Institute for Health Care, Department of Health and Society, Vienna, Austria
| | | | - Mihaela Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Kelechi K. Olu
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Kari A. O. Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ignacio Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alonso Carrasco-Labra
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Markus Faulhaber
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sohail M. Mulla
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| | - Elie A. Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Medicine, State University of New York at Buffalo, Buffalo, New York, United States of America
| | - Dirk Bassler
- Department of Neonatology, University Hospital of Zurich, Zurich, Switzerland
| | - Jason W. Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Ignacio Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d’Hebron Hospital and Centro de Investigación Biomédica en Red de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - Francois Lamontagne
- Centre de Recherche Clinique Étienne-Le Bel and Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
- Institute of Nuclear Medicine, University Hospital of Bern, Bern, Switzerland
| | - Heike Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Lorenzo Moja
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - Shanil Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Stanford Prevention Research Center, Stanford University, Stanford, California, United States of America
| | - Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
- Academy of Swiss Insurance Medicine, University Hospital of Basel, Basel, Switzerland
| | - Xin Sun
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Per O. Vandvik
- Department of Medicine, Innlandet Hospital Trust–Division Gjøvik, Oppland, Norway
| | - Bradley C. Johnston
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin A. Walter
- Institute of Nuclear Medicine, University Hospital of Bern, Bern, Switzerland
| | - Bernard Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Lars G. Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Heiner C. Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Gordon H. Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Schandelmaier S, von Elm E, You JJ, Blümle A, Tomonaga Y, Lamontagne F, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Bassler D, Busse JW, Ferreira-González I, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Cook DJ, Meade MO, Bucher HC, Kasenda B, Briel M. Premature Discontinuation of Randomized Trials in Critical and Emergency Care: A Retrospective Cohort Study. Crit Care Med 2016; 44:130-7. [PMID: 26468895 DOI: 10.1097/ccm.0000000000001369] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Randomized clinical trials that enroll patients in critical or emergency care (acute care) setting are challenging because of narrow time windows for recruitment and the inability of many patients to provide informed consent. To assess the extent that recruitment challenges lead to randomized clinical trial discontinuation, we compared the discontinuation of acute care and nonacute care randomized clinical trials. DESIGN Retrospective cohort of 894 randomized clinical trials approved by six institutional review boards in Switzerland, Germany, and Canada between 2000 and 2003. SETTING Randomized clinical trials involving patients in an acute or nonacute care setting. SUBJECTS AND INTERVENTIONS We recorded trial characteristics, self-reported trial discontinuation, and self-reported reasons for discontinuation from protocols, corresponding publications, institutional review board files, and a survey of investigators. MEASUREMENTS AND MAIN RESULTS Of 894 randomized clinical trials, 64 (7%) were acute care randomized clinical trials (29 critical care and 35 emergency care). Compared with the 830 nonacute care randomized clinical trials, acute care randomized clinical trials were more frequently discontinued (28 of 64, 44% vs 221 of 830, 27%; p = 0.004). Slow recruitment was the most frequent reason for discontinuation, both in acute care (13 of 64, 20%) and in nonacute care randomized clinical trials (7 of 64, 11%). Logistic regression analyses suggested the acute care setting as an independent risk factor for randomized clinical trial discontinuation specifically as a result of slow recruitment (odds ratio, 4.00; 95% CI, 1.72-9.31) after adjusting for other established risk factors, including nonindustry sponsorship and small sample size. CONCLUSIONS Acute care randomized clinical trials are more vulnerable to premature discontinuation than nonacute care randomized clinical trials and have an approximately four-fold higher risk of discontinuation due to slow recruitment. These results highlight the need for strategies to reliably prevent and resolve slow patient recruitment in randomized clinical trials conducted in the critical and emergency care setting.
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Affiliation(s)
- Stefan Schandelmaier
- 1Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland.2Department of Medicine, Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland.3Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland.4Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.5Department of Medicine, McMaster University, Hamilton, Ontario, Canada.6German Cochrane Centre, Medical Center-University of Freiburg, Freiburg, Germany.7Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.8Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Canada.9Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria.10Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.11Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile.12Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile.13Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, Ontario, Canada.14Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.15Department of Medicine, State University of New York at Buffalo, Buffalo, NY.16Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China.17Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.18Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.19Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada.20Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidem
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Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S, Vandvik PO, Agoritsas T, Heels-Ansdell D, Guyatt GH, Tikkinen KAO. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg 2016; 103:656-667. [PMID: 26990957 PMCID: PMC5069642 DOI: 10.1002/bjs.10147] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 12/22/2015] [Accepted: 02/08/2016] [Indexed: 12/12/2022]
Abstract
Background For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis. Methods A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year. Conclusion The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary. Limitations of each evolving
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Affiliation(s)
- V Sallinen
- Departments of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Departments of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - J J You
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Medicine, McMaster University, Hamilton, Canada
| | - A Agarwal
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Shoucair
- University of Balamand, Tripoli, Lebanon
| | - P O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - T Agoritsas
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Division of General Internal Medicine, Department of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - D Heels-Ansdell
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - G H Guyatt
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Medicine, McMaster University, Hamilton, Canada
| | - K A O Tikkinen
- Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Stegert M, Kasenda B, von Elm E, You JJ, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Briel M, Stegert M, Kasenda B, Elm EV, You JJ, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Tikkinen KA, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla S, Mertz D, Akl EA, Bassler D, Busse JW, Ferreira-González I, Lamontagne F, Nordmann A, Gloy V, Olu KK, Raatz H, Moja L, Rosenthal R, Ebrahim S, Schandelmaier S, Sun X, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Bucher HC, Guyatt GH, Briel M. An analysis of protocols and publications suggested that most discontinuations of clinical trials were not based on preplanned interim analyses or stopping rules. J Clin Epidemiol 2016; 69:152-60. [DOI: 10.1016/j.jclinepi.2015.05.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 05/15/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022]
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Schandelmaier S, Conen K, von Elm E, You JJ, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Bassler D, Busse JW, Ferreira-González I, Lamontagne F, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Bucher HC, Guyatt GH, Briel M, Kasenda B. Planning and reporting of quality-of-life outcomes in cancer trials. Ann Oncol 2015; 27:209. [PMID: 26612098 DOI: 10.1093/annonc/mdv559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- S Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland
| | - K Conen
- Department of Oncology, University Hospital of Basel, Switzerland
| | - E von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - J J You
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, McMaster University, Hamilton, Canada
| | - A Blümle
- German Cochrane Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - Y Tomonaga
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - R Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - A Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - T Bengough
- Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria
| | - J J Meerpohl
- German Cochrane Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - M Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - K K Olu
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - K A O Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - I Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - A Carrasco-Labra
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - M Faulhaber
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - S M Mulla
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - D Mertz
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Medicine, McMaster University, Hamilton, Canada Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, Canada
| | - E A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Internal Medicine, American University of Beirut, Beirut, Lebanon Department of Medicine, State University of New York at Buffalo, Buffalo, USA
| | - X Sun
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - D Bassler
- Department of Neonatolgy, University Hospital Zurich, Zurich, Switzerland
| | - J W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Anesthesia, McMaster University, Hamilton, Canada Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - I Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - F Lamontagne
- Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Canada
| | - A Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - V Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - H Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - L Moja
- IRCCS Orthopedic Institute Galeazzi, Milan, Italy
| | - R Rosenthal
- Department of Surgery, University Hospital Basel, Switzerland
| | - S Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Anesthesia and Pain Medicine, Hospital for Sick Children Research Institute, Hospital for Sick Children, Toronto, Canada Department of Anesthesia, McMaster University, Hamilton, Canada Stanford Prevention Research Center, Stanford University, Stanford, USA
| | - P O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Oppland, Norway
| | - B C Johnston
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Anesthesia and Pain Medicine, Hospital for Sick Children Research Institute, Hospital for Sick Children, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - M A Walter
- Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - B Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - M Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - L G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - H C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland
| | - G H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - M Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada Department of Clinical Research, University of Basel, Switzerland
| | - B Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Switzerland Department of Oncology, University Hospital of Basel, Switzerland Department of Medical Oncology, Royal Marsden Hospital, London, UK
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Johnston BC, Alonso-Coello P, Friedrich JO, Mustafa RA, Tikkinen KAO, Neumann I, Vandvik PO, Akl EA, da Costa BR, Adhikari NK, Dalmau GM, Kosunen E, Mustonen J, Crawford MW, Thabane L, Guyatt GH. Do clinicians understand the size of treatment effects? A randomized survey across 8 countries. CMAJ 2015; 188:25-32. [PMID: 26504102 DOI: 10.1503/cmaj.150430] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Meta-analyses of continuous outcomes typically provide enough information for decision-makers to evaluate the extent to which chance can explain apparent differences between interventions. The interpretation of the magnitude of these differences - from trivial to large - can, however, be challenging. We investigated clinicians' understanding and perceptions of usefulness of 6 statistical formats for presenting continuous outcomes from meta-analyses (standardized mean difference, minimal important difference units, mean difference in natural units, ratio of means, relative risk and risk difference). METHODS We invited 610 staff and trainees in internal medicine and family medicine programs in 8 countries to participate. Paper-based, self-administered questionnaires presented summary estimates of hypothetical interventions versus placebo for chronic pain. The estimates showed either a small or a large effect for each of the 6 statistical formats for presenting continuous outcomes. Questions addressed participants' understanding of the magnitude of treatment effects and their perception of the usefulness of the presentation format. We randomly assigned participants 1 of 4 versions of the questionnaire, each with a different effect size (large or small) and presentation order for the 6 formats (1 to 6, or 6 to 1). RESULTS Overall, 531 (87.0%) of the clinicians responded. Respondents best understood risk difference, followed by relative risk and ratio of means. Similarly, they perceived the dichotomous presentation of continuous outcomes (relative risk and risk difference) to be most useful. Presenting results as a standardized mean difference, the longest standing and most widely used approach, was poorly understood and perceived as least useful. INTERPRETATION None of the presentation formats were well understood or perceived as extremely useful. Clinicians best understood the dichotomous presentations of continuous outcomes and perceived them to be the most useful. Further initiatives to help clinicians better grasp the magnitude of the treatment effect are needed.
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Affiliation(s)
- Bradley C Johnston
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont.
| | - Pablo Alonso-Coello
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Jan O Friedrich
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Reem A Mustafa
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Kari A O Tikkinen
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Ignacio Neumann
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Per O Vandvik
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Elie A Akl
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Bruno R da Costa
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Neill K Adhikari
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Gemma Mas Dalmau
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Elise Kosunen
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Jukka Mustonen
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Mark W Crawford
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Lehana Thabane
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
| | - Gordon H Guyatt
- Department of Anesthesia and Pain Medicine (Johnston, Crawford), The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Johnston), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Child Health Evaluative Sciences (Johnston), The Hospital for Sick Children Research Institute, Toronto, Ont.; Iberoamerican Cochrane Center (Alonso-Coello, Dalmau), Biomedical Research Institute Sant Pau, CIBER Epidemiologiay Salud Publica, Barcelona, Spain; Departments of Critical Care and Medicine (Friedrich), St. Michael's Hospital, Toronto, Ont.; Department of Medicine and Interdepartmental Division of Critical Care (Friedrich), University of Toronto, Toronto, Ont.; Departments of Medicine and Biomedical and Health Informatics (Mustafa), University of Missouri-Kansas City, Kansas City, Mo.; Department of Clinical Epidemiology and Biostatistics (Mustafa, Tikkinen, Neumann, Akl, Thabane, Guyatt), McMaster University, Hamilton, Ont.; Departments of Urology and Public Health (Tikkinen), Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland; Department of Internal Medicine (Neumann), Pontificia Universidad Catolica de Chile, Santiago, Chile; Institute of Health and Society (Vandvik), Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Medicine (Vandvik), Innlandet Hospital Trust, Division Gjövik, Norway; Clinical Epidemiology Unit (Akl), American University of Beirut, Beirut, Lebanon; Institute of Primary Health Care (da Costa), University of Bern, Bern, Switzerland; Department of Critical Care Medicine and Sunnybrook Research Institute (Adhikari), Sunnybrook Health Sciences Centre, Toronto, Ont.; Interdepartmental Division of Critical Care (Adhikari), University of Toronto, Toronto, Ont.; School of Medicine and Centre for General Practice (Kosunen), University of Tampere and Pirkanmaa Hospital District, Tampere, Finland; School of Medicine and Department of Internal Medicine (Mustonen), University of Tampere and Tampere University Hospital, Tampere, Finland; Physiology and Experimental Medicine (Crawford), The Hospital for Sick Children Research Institute, Toronto, Ont.; Biostatistics Unit of the Centre for Evaluation of Medicines (Thabane), McMaster University, Hamilton, Ont.; Population Health Research Unit, Hamilton Health Sciences (Thabane), McMaster University, Hamilton, Ont.; Department of Medicine (Guyatt), McMaster University, Hamilton, Ont
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Siemieniuk RAC, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:519-28. [PMID: 26258555 DOI: 10.7326/m15-0715] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is common and often severe. PURPOSE To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with CAP. DATA SOURCES MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015. STUDY SELECTION Randomized trials of systemic corticosteroids in hospitalized adults with CAP. DATA EXTRACTION Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation system by consensus among the authors. DATA SYNTHESIS The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to 0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, -1.22 days [CI, -2.08 to -0.35 days]; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, -1.00 day [CI, -1.79 to -0.21 days]; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage. LIMITATIONS There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events. CONCLUSION For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day. PRIMARY FUNDING SOURCE None.
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Akl EA, Carrasco-Labra A, Brignardello-Petersen R, Neumann I, Johnston BC, Sun X, Briel M, Busse JW, Ebrahim S, Granados CE, Iorio A, Irfan A, Martínez García L, Mustafa RA, Ramírez-Morera A, Selva A, Solà I, Sanabria AJ, Tikkinen KAO, Vandvik PO, Vernooij RWM, Zazueta OE, Zhou Q, Guyatt GH, Alonso-Coello P. Reporting, handling and assessing the risk of bias associated with missing participant data in systematic reviews: a methodological survey. BMJ Open 2015; 5:e009368. [PMID: 26423858 PMCID: PMC4593136 DOI: 10.1136/bmjopen-2015-009368] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To describe how systematic reviewers are reporting missing data for dichotomous outcomes, handling them in the analysis and assessing the risk of associated bias. METHODS We searched MEDLINE and the Cochrane Database of Systematic Reviews for systematic reviews of randomised trials published in 2010, and reporting a meta-analysis of a dichotomous outcome. We randomly selected 98 Cochrane and 104 non-Cochrane systematic reviews. Teams of 2 reviewers selected eligible studies and abstracted data independently and in duplicate using standardised, piloted forms with accompanying instructions. We conducted regression analyses to explore factors associated with using complete case analysis and with judging the risk of bias associated with missing participant data. RESULTS Of Cochrane and non-Cochrane reviews, 47% and 7% (p<0.0001), respectively, reported on the number of participants with missing data, and 41% and 9% reported a plan for handling missing categorical data. The 2 most reported approaches for handling missing data were complete case analysis (8.5%, out of the 202 reviews) and assuming no participants with missing data had the event (4%). The use of complete case analysis was associated only with Cochrane reviews (relative to non-Cochrane: OR=7.25; 95% CI 1.58 to 33.3, p=0.01). 65% of reviews assessed risk of bias associated with missing data; this was associated with Cochrane reviews (relative to non-Cochrane: OR=6.63; 95% CI 2.50 to 17.57, p=0.0001), and the use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (OR=5.02; 95% CI 1.02 to 24.75, p=0.047). CONCLUSIONS Though Cochrane reviews are somewhat less problematic, most Cochrane and non-Cochrane systematic reviews fail to adequately report and handle missing data, potentially resulting in misleading judgements regarding risk of bias.
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Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Alonso Carrasco-Labra
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Evidence Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Romina Brignardello-Petersen
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Evidence Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ignacio Neumann
- Department of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bradley C Johnston
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia & Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xin Sun
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Clinical Research and Evaluation Unit, Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Matthias Briel
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Jason W Busse
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Shanil Ebrahim
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Stanford Prevention Research Center, Stanford University, Palo Alto, California, USA
| | - Carlos E Granados
- Área de investigaciones, Facultad de Medicina, Universidad de La Sabana, Chía, Colombia
| | - Alfonso Iorio
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Affan Irfan
- Department of Cardiology, University of Louisville, Louisville, Kentucky, USA
| | - Laura Martínez García
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Reem A Mustafa
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Departments of Medicine, Nephrology and Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Anggie Ramírez-Morera
- Health Care Development Division, IHCAI Foundation & Central America Cochrane, San José, Costa Rica
| | - Anna Selva
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Andrea Juliana Sanabria
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Kari A O Tikkinen
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Departments of Urology and Public Health, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Per O Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Robin W M Vernooij
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Oscar E Zazueta
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
| | - Qi Zhou
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau-CIBER of Epidemiology and Public Health (CIBERESP- IIB Sant Pau), Barcelona, Spain
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Spencer FA, Prasad M, Vandvik PO, Chetan D, Zhou Q, Guyatt G. Longer- Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:118-26. [PMID: 26005909 DOI: 10.7326/m15-0083] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The appropriate duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) placement remains controversial. PURPOSE To summarize data on clinical outcomes with longer- versus shorter-duration DAPT after DES placement in adults with coronary artery disease. DATA SOURCES Ovid MEDLINE and EMBASE, 1996 to 27 March 2015, and manual screening of references. STUDY SELECTION Randomized, controlled trials comparing longer- versus shorter-duration DAPT after DES placement. DATA EXTRACTION Two reviewers screened potentially eligible articles; extracted data on populations, interventions, and outcomes; assessed risk of bias; and used the Grading of Recommendations Assessment, Development and Evaluation guidelines to rate overall confidence in effect estimates. DATA SYNTHESIS Among 1010 articles identified, 9 trials including 29,531 patients were eligible; data were complete for 28,808 patients. Moderate-quality evidence showed that longer-duration DAPT decreased risk for myocardial infarction (risk ratio [RR], 0.73 [95% CI, 0.58 to 0.92]) and increased mortality (RR, 1.19 [CI, 1.04 to 1.36]). High-quality evidence showed that DAPT increased risk for major bleeding (RR, 1.63 [CI, 1.34 to 1.99]). LIMITATION Confidence in estimates were decreased owing to imprecision for most outcomes (particularly myocardial infarction), risk of bias from limited blinding in 7 of 9 studies, indirectness due to variability in use of first- and second-generation stents, and off-protocol use of DAPT in some studies. CONCLUSION Extended DAPT is associated with approximately 8 fewer myocardial infarctions per 1000 treated patients per year but 6 more major bleeding events than shorter-duration DAPT. Because absolute effects are very small and closely balanced, decisions regarding the duration of DAPT therapy must take into account patients' values and preference. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Frederick A. Spencer
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
| | - Manya Prasad
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
| | - Per O. Vandvik
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
| | - Devin Chetan
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
| | - Qi Zhou
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
| | - Gordon Guyatt
- From McMaster University, Hamilton, Ontario, Canada; Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India; and Innlandet Hospital Trust, Gjøvik, Norway
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Li L, Shen JT, Bala MM, Busse JW, Ebrahim S, Vandvik PO, Rios LP, Malaga G, Wong E, Sohani Z, Guyatt GH, Sun X. Incretin Therapy and Risk of Pancreatitis in Type 2 Diabetes Mellitus: Systematic Review of Randomized and Non-Randomized Studies. Value Health 2014; 17:A740-1. [PMID: 27202666 DOI: 10.1016/j.jval.2014.08.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L Li
- West China Hospital, Sichuan University, Chengdu, China
| | - J T Shen
- Huzhou Teachers College, Huzhou, China
| | - M M Bala
- Jagiellonian University School of Medicine, Krakow, Poland
| | - J W Busse
- McMaster University, Hamilton, ON, Canada
| | - S Ebrahim
- McMaster University, Hamilton, ON, Canada
| | - P O Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - L P Rios
- Hospital Clinico FUSAT, Rancagua, Chile
| | - G Malaga
- Universidad Peruana Cayetano Heredia, Lima, Peru
| | - E Wong
- University of British Columbia, Vancouver, BC, Canada
| | - Z Sohani
- McMaster University, Hamilton, ON, Canada
| | - G H Guyatt
- McMaster University, Hamilton, ON, Canada
| | - X Sun
- West China Hospital, Sichuan University, Chengdu, China
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Kasenda B, Schandelmaier S, Sun X, von Elm E, You J, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Bassler D, Busse JW, Ferreira-González I, Lamontagne F, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Bucher HC, Guyatt GH, Briel M. Subgroup analyses in randomised controlled trials: cohort study on trial protocols and journal publications. BMJ 2014; 349:g4539. [PMID: 25030633 PMCID: PMC4100616 DOI: 10.1136/bmj.g4539] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the planning of subgroup analyses in protocols of randomised controlled trials and the agreement with corresponding full journal publications. DESIGN Cohort of protocols of randomised controlled trial and subsequent full journal publications. SETTING Six research ethics committees in Switzerland, Germany, and Canada. DATA SOURCES 894 protocols of randomised controlled trial involving patients approved by participating research ethics committees between 2000 and 2003 and 515 subsequent full journal publications. RESULTS Of 894 protocols of randomised controlled trials, 252 (28.2%) included one or more planned subgroup analyses. Of those, 17 (6.7%) provided a clear hypothesis for at least one subgroup analysis, 10 (4.0%) anticipated the direction of a subgroup effect, and 87 (34.5%) planned a statistical test for interaction. Industry sponsored trials more often planned subgroup analyses compared with investigator sponsored trials (195/551 (35.4%) v 57/343 (16.6%), P<0.001). Of 515 identified journal publications, 246 (47.8%) reported at least one subgroup analysis. In 81 (32.9%) of the 246 publications reporting subgroup analyses, authors stated that subgroup analyses were prespecified, but this was not supported by 28 (34.6%) corresponding protocols. In 86 publications, authors claimed a subgroup effect, but only 36 (41.9%) corresponding protocols reported a planned subgroup analysis. CONCLUSIONS Subgroup analyses are insufficiently described in the protocols of randomised controlled trials submitted to research ethics committees, and investigators rarely specify the anticipated direction of subgroup effects. More than one third of statements in publications of randomised controlled trials about subgroup prespecification had no documentation in the corresponding protocols. Definitive judgments regarding credibility of claimed subgroup effects are not possible without access to protocols and analysis plans of randomised controlled trials.
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50
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Kasenda B, von Elm E, You J, Blümle A, Tomonaga Y, Saccilotto R, Amstutz A, Bengough T, Meerpohl JJ, Stegert M, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Bassler D, Busse JW, Ferreira-González I, Lamontagne F, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Schandelmaier S, Xin S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Bucher HC, Guyatt GH, Briel M. Prevalence, characteristics, and publication of discontinued randomized trials. JAMA 2014; 311:1045-51. [PMID: 24618966 DOI: 10.1001/jama.2014.1361] [Citation(s) in RCA: 236] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE The discontinuation of randomized clinical trials (RCTs) raises ethical concerns and often wastes scarce research resources. The epidemiology of discontinued RCTs, however, remains unclear. OBJECTIVES To determine the prevalence, characteristics, and publication history of discontinued RCTs and to investigate factors associated with RCT discontinuation due to poor recruitment and with nonpublication. DESIGN AND SETTING Retrospective cohort of RCTs based on archived protocols approved by 6 research ethics committees in Switzerland, Germany, and Canada between 2000 and 2003. We recorded trial characteristics and planned recruitment from included protocols. Last follow-up of RCTs was April 27, 2013. MAIN OUTCOMES AND MEASURES Completion status, reported reasons for discontinuation, and publication status of RCTs as determined by correspondence with the research ethics committees, literature searches, and investigator surveys. RESULTS After a median follow-up of 11.6 years (range, 8.8-12.6 years), 253 of 1017 included RCTs were discontinued (24.9% [95% CI, 22.3%-27.6%]). Only 96 of 253 discontinuations (37.9% [95% CI, 32.0%-44.3%]) were reported to ethics committees. The most frequent reason for discontinuation was poor recruitment (101/1017; 9.9% [95% CI, 8.2%-12.0%]). In multivariable analysis, industry sponsorship vs investigator sponsorship (8.4% vs 26.5%; odds ratio [OR], 0.25 [95% CI, 0.15-0.43]; P < .001) and a larger planned sample size in increments of 100 (-0.7%; OR, 0.96 [95% CI, 0.92-1.00]; P = .04) were associated with lower rates of discontinuation due to poor recruitment. Discontinued trials were more likely to remain unpublished than completed trials (55.1% vs 33.6%; OR, 3.19 [95% CI, 2.29-4.43]; P < .001). CONCLUSIONS AND RELEVANCE In this sample of trials based on RCT protocols from 6 research ethics committees, discontinuation was common, with poor recruitment being the most frequently reported reason. Greater efforts are needed to ensure the reporting of trial discontinuation to research ethics committees and the publication of results of discontinued trials.
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Affiliation(s)
- Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - John You
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada14Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anette Blümle
- German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, Freiburg University Medical Center, Freiburg, Germany
| | - Yuki Tomonaga
- Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Alain Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Theresa Bengough
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | - Joerg J Meerpohl
- German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, Freiburg University Medical Center, Freiburg, Germany
| | - Mihaela Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Kari A O Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada15Department of Urology, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Ignacio Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada16Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago
| | - Alonso Carrasco-Labra
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada25Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago
| | - Markus Faulhaber
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada17Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sohail M Mulla
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada26Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, Ontario, Canada
| | - Elie A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada18Department of Internal Medicine, American University of Beirut, Beirut, Lebanon19Department of Medicine, State University of New York at Buffalo, Buffal
| | - Dirk Bassler
- Center for Pediatric Clinical Studies, Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada20Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada27Michael G. DeGroote Institute for Pain Research and Care, McMaster University
| | - Ignacio Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - Francois Lamontagne
- Centre de Recherche Clinique Étienne-Le Bel and Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Alain Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland13Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Heike Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Lorenzo Moja
- IRCCS Orthopedic Institute Galeazzi, Milano, Italy
| | - Rachel Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Shanil Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada20Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada21Stanford Prevention Research Center, Stanford University, Stanford, California
| | - Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland22Academy of Swiss Insurance Medicine, University Hospital of Basel, Basel, Switzerland
| | - Sun Xin
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada23Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Oppland, Norway
| | - Bradley C Johnston
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada12Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada24Institute of Health Policy, Management and Evaluation
| | - Martin A Walter
- Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Bernard Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
| | | | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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