Objective: Assessment of the certainty of evidence (CoE) from network meta-analysis is critical to convey the strength of inferences for clinical decision-making.Both the GRADE Working Group (GWG) and the CINeMA framework have been designed to assess the CoE of treatment effects informed by network meta-analysis; however, the concordance of results is uncertain. Study design and setting:We assessed the CoE for treatment effects of individual opioids on pain relief and physical functioning from a network meta-analysis for chronic noncancer pain using the GWG approach and the CINeMA framework.Both approaches evaluate the CoE as high, moderate, low or very low.We quantified the number of discrepant CoE ratings between approaches, and the magnitude of the difference (i.e., 1level, 2-levels, or 3-levels). Results: Across 105 comparisons among individual opioids for pain relief, the GWG andCINeMA approaches provided different CoE ratings in 34% of cases (36 of 105).Across 66 comparisons for physical functioning, there was discordance in 17% of cases (11 of 66).All discrepancies were separated by 1-level.The CINeMA framework typically provided lower CoE ratings compared to the GWG approach, predominantly because of differences in the assessment of transitivity and heterogeneity. Conclusion:Our findings suggest there are differences between the CoE ratings provided by the GWG and CINeMA approaches when applied to network meta-analyses.Further
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.Estimates of anchor-based MIDs, and their credibility, for knee symptoms and health-related quality of life (HRQoL).MEDLINE, EMBASE and PsycINFO.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.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).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.CRD42016047912.
Abstract Clinical question What is the comparative effectiveness and safety of commonly used interventional procedures (such as spinal injections and ablation procedures) for chronic axial and radicular spine pain that is not associated with cancer or inflammatory arthropathy? Current practice Chronic spine pain is a common, potentially disabling complaint, for which clinicians often administer interventional procedures. However, clinical practice guidelines provide inconsistent recommendations for their use. Recommendations For people living with chronic axial spine pain (≥3 months), the guideline panel issued strong recommendations against: joint radiofrequency ablation with or without joint targeted injection of local anaesthetic plus steroid; epidural injection of local anaesthetic, steroids, or their combination; joint-targeted injection of local anaesthetic, steroids, or their combination; and intramuscular injection of local anaesthetic with or without steroids. For people living with chronic radicular spine pain (≥3 months), the guideline panel issued strong recommendations against: dorsal root ganglion radiofrequency with or without epidural injection of local anaesthetic or local anaesthetic plus steroids; and epidural injection of local anaesthetic, steroids, or their combination. How this guideline was created An international guideline development panel including four people living with chronic spine pain, 10 clinicians with experience managing chronic spine pain, and eight methodologists, produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation provided methodological support. The guideline panel applied an individual patient perspective when formulating recommendations. The evidence These recommendations are informed by a linked systematic review and network meta-analysis of randomised trials and a systematic review of observational studies, summarising the current body of evidence for benefits and harms of common interventional procedures for axial and radicular, chronic, non-cancer spine pain. Specifically, injection of local anaesthetic, steroids, or their combination into the cervical or lumbar facet joint or sacroiliac joint; epidural injections of local anaesthetic, steroids, or their combination; radiofrequency of dorsal root ganglion; radiofrequency denervation of cervical or lumbar facet joints or the sacroiliac joint; and paravertebral intramuscular injections of local anaesthetic, steroids, or their combination. Understanding the recommendations These recommendations apply to people living with chronic spine pain (≥3 months duration) that is not associated with cancer or inflammatory arthropathy and do not apply to the management of acute spine pain. Further research is warranted and may alter recommendations in the future: in particular, whether there are differences in treatment effects based on subtypes of chronic spine pain, establishing the effectiveness of interventional procedures currently supported by low or very low certainty evidence, and effects on poorly reported patient-important outcomes (such as opioid use, return to work, and sleep quality).
Objective: To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. Data Sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. Study Selection: Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms “sepsis,” “septicemia,” or “septic shock” in the title or abstract. Data Extraction: Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. Data Synthesis: One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock ( p < 0.0001). Conclusions: Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
Background
Volunteers are increasingly promoted to improve health-related outcomes for community-dwelling elderly without synthesized evidence for effectiveness. This systematic review and meta-analysis evaluates the effects of unpaid volunteer interventions on health-related outcomes for such seniors.
Methods
MEDLINE, EMBASE and Cochrane (CENTRAL) were searched up to November 2018. We included English language, randomized trials. Two reviewers independently identified studies, extracted data, and assessed evidence certainty (using GRADE). Meta-analysis used random-effects models. Univariate meta-regressions investigated the relationship between volunteer intervention effects and trial participant age, percentage females, and risk of bias.
Results
28 included studies focussed on seniors with a variety of chronic conditions (e.g., dementia, diabetes) and health states (e.g., frail, palliative). Volunteers provided a range of roles (e.g., counsellors, educators and coaches). Low certainty evidence found that volunteers may improve both physical function (MD = 3.2 points on the 100-point SF-36 physical component score [PCS]; 95% CI: 1.09, 5.27) and physical activity levels (SMD = 0.5, 95% CI: 0.14 to 0.83). Adverse events were not increased.
Conclusion
Volunteers may increase physical activity levels and subjective ratings of physical function for seniors without apparent harm. These findings support the WHO call to action on evidence-based policies to align health systems in support of older adults.
Importance of the Topic Preventable medication errors may be caused by routine failure (ignorance or inadvertence), insufficient practical skills, or shortcomings in complex systems and medication-delivery procedures [7, 16]. The fallout from these errors may vary: Some errors may lead to no harm, others to temporary or permanent harm, and some are fatal [1, 11]. In addition, medication errors contribute to increased length of hospital stay, treatment burden, and costs [3, 14]. In the United States, medication errors are the third most common cause of death [8, 12], and in Europe, in-hospital medication errors occur in 0.3% to 9.1% of prescriptions [6]. Medication errors are more likely to happen in surgical departments than in medical departments [2, 4], with the omission of preadmission medication being the most common error in scheduled surgeries [8, 13]. Many orthopaedic patients are older and present for care taking a large number prescription medications; polypharmacy in older patients is known to be an especially severe problem, accounting for a large number of serious complications [13, 15]. This highlights the importance of preventing medication errors during the perioperative period [8, 13, 15]. Various interventions have been investigated to reduce or prevent medication errors in hospital settings [10]. These include interventions that target specific sources of error, such as information technology–based interventions (like electronic barcoding and medication reconciliation) and those that seek to reduce the effect of distractions or interruptions on prescribers. Educational interventions and those involving prescriber-pharmacist partnerships have also been tried. Given the large number and variety of such interventions, a synthesis like the recent Cochrane review by Ciapponi et al. [5] is especially welcome. In it, the authors investigated the effects of interventions in reducing medication errors in hospitalized adults compared with usual care or alternative interventions. Upon Closer Inspection The authors included 51 randomized trials and 14 time-series studies consisting of 110,875 adult patients in hospital settings, mostly from high-income countries. They found moderate-quality evidence that improved computerized physician order entry (CPOE)/clinical decision support systems (CDSS) were associated with a lower likelihood of medication errors and adverse drug events. Medication reconciliation (MR) was associated with lower likelihood of adverse drug events (moderate quality). The benefits in the reduction of medication errors and adverse drug events from the remaining interventions (barcoding, feedback on prescribing errors, and using dispensing system) were based on low-quality evidence. However, none of these interventions reduced the length of hospital stay, in-hospital mortality, or improved patients' quality of life (low-to-moderate quality of evidence). Despite the comprehensive review, several limitations on its analysis deserve mention. Almost all comparisons are informed by a limited number of studies, and thus the review authors decided to combine data from different hospital settings, studies with different durations of follow-up, and time-series analyses with randomized trials. There was also important variability in the methods of each intervention and the unit of analysis (patient and prescriptions). These have led to high statistical heterogeneity and imprecise effect estimates in most comparisons and may have resulted in the overestimation of benefits from the interventions. In addition, given the limited available evidence, it is hard to argue whether the lack of statistical significance for some outcomes (such as length of stay, quality of life, or mortality) was due to the inefficacy of interventions or the low statistical power. Even with the shortcomings mentioned, the current review is the best available evidence, and surgeons and healthcare providers should consider the highest quality evidence available when making clinical decisions. Take-home Messages We believe that the most robust and important findings of this Cochrane review were: (1) that MR performed by a pharmacist (the process of comparing medication orders to the medications taken by the patient) and (2) improved CPOE and CDSS may result in a reduction of medication errors and adverse drug events. Although the Cochrane review found that in aggregate these may result in little to no difference in patients' length of stay, quality of life, or all-cause mortality, this is not necessarily surprising. Death and severe complications are rare endpoints; finding statistical differences in them would be surprising in the context of trials of new interventions, and not all important medication errors would be expected to prolong length of stay. It seems safe to expect that even modest reductions in the frequency of serious medication errors would decrease harm, and we believe this is a sufficient goal for interventions of these kinds. Given these findings, orthopaedic surgeons and healthcare decision makers should consider using pharmacist-led medication reconciliation (in which pharmacists work together with surgeons, patients, families, and care providers to consistently communicate accurate and comprehensive medication information across transitions of care), improved CPOE or alternative and more comprehensive CDSS, or a combination of these methods in operating rooms and surgical wards to improve short-term outcomes such as medication errors and medication-related adverse events.
What is the role of a single dose of oral corticosteroids for those with acute sore throat? Using the GRADE framework according to the BMJ Rapid Recommendation process, an expert panel make a weak recommendation in favour of corticosteroid use. The panel produced these recommendations based on a linked systematic review triggered by a large randomised trial published in April 2017. This trial reported that corticosteroids increased the proportion of patients with complete resolution of pain at 48 hours. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides the recommendation together with an overview of the absolute benefits and harms of corticosteroids in the standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article. Clinicians and their patients can find consultation decision aids to facilitate shared decision making in MAGICapp (www.magicapp.org/goto/guideline/JjXYAL/section/j79pvn).
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