Structure modification in knee osteoarthritis: methodology and outcome parameters.
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Managing osteoarthritis (OA) with structure-modifying agents (SMAs) is an important emerging topic receiving increased attention from both lay individuals and health care professionals as a promising alternative in the management of OA. OBJECTIVE: To review the methodology and outcome parameters purported to be used in the assessment of the structure-modifying potential of various interventions. DESIGN: A Medline search was performed to select the relevant published articles. This review does not go into detail about various aspects of the design and conduct of structure-modifying studies; however, a vast number of relevant references are provided and may be accessed by interested readers. RESULTS: Enhancing the feasibility of SMAs trials aimed at documenting efficacy can be accomplished by carefully selecting: (1) the outcome parameters, (2) the imaging methodology, and (3) the patient population. Most of the relevant issues that need to be considered by investigators before embarking on a study of this nature have been addressed in this article. CONCLUSION: Most of the evidence to date focuses on the superiority of the radiographic-based techniques in measuring joint space narrowing among a homogeneous population of OA patients. More research is warranted before other techniques such as ultrasound, chondroscopy, and magnetic resonance imaging, can be proven to be reliable. (+info)
Clinical practice guidelines in dentistry: Part I. Navigating new waters.
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Clinical Practice Guidelines (CPGs) are tools, developed by and for practitioners, to assist in clinical decision making. They are designed to enhance, not replace, clinical judgement and expertise. Well-developed guidelines use the evidence-based approach. The research evidence related to a topic is assembled in a systematic, comprehensive and unbiased manner. Recommendations are made based on the evidence and practitioner feedback is sought prior to formulating the final practice guideline. There are many misperceptions about CPGs and some dentists are wary about their development and use. In this paper, we explore some of the reasons for these misperceptions, review the benefits of sound guidelines, and discuss some of the challenges for guideline development in dentistry in Canada (+info)
Overview of evidence-based medicine: challenges for evidence-based laboratory medicine.
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Evidence-based medicine (EBM) has been driven by the need to cope with information overload, by cost-control, and by a public impatient for the best in diagnostics and treatment. Clinical guidelines, care maps, and outcome measures are quality improvement tools for the appropriateness, efficiency, and effectiveness of health services. Although they are imperfect, their value increases with the quality of the evidence they incorporate. Laboratory professionals must direct more effort to demonstrating the impact of laboratory tests on a greater variety of clinical outcomes. Laboratory and clinical practitioners must be familiar with many of the accessible electronic and paper tools for searching for evidence. Detailed statistical and epidemiologic knowledge is not essential, but critical appraisal skills and a competent understanding of the strengths and weaknesses of systematic review and metaanalysis are necessary. Overemphasis on complexity and failure to recognize time limitations are major barriers to translating EBM into everyday practice. Emphasizing and practicing the role of the laboratory professional as a skilled clinical consultant strongly grounded in evidence as well, in addition to better integration of laboratory and clinical information and improved laboratory reports will overcome most barriers. There is a poverty of good, primary studies of test evaluations. Institution of more consistent standards for the design and reporting of studies on diagnostic accuracy should improve the situation. If nothing else, systematic reviews have demonstrated the need for more good-quality primary research in laboratory medicine. (+info)
Taking advantage of the explosion of systematic reviews: an efficient MEDLINE search strategy.
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CONTEXT: Systematic reviews of the literature are an important resource for clinicians. Unfortunately, the few published strategies for identifying these articles involve MEDLINE interfaces not widely available outside of academic medicine. In addition, the performance of these strategies is unknown. OBJECTIVE: To develop and evaluate a search strategy for identifying systematic reviews by using a publicly available MEDLINE interface (PubMed). DESIGN: Diagnostic test assessment. DEFINITION OF SENSITIVITY: The proportion of recognized systematic reviews (indexed in the Cochrane Library's Database of Abstracts of Reviews of Effectiveness [DARE] or in ACP Journal Club) that are identified by the search strategy. DEFINITION OF POSITIVE PREDICTIVE VALUE: The proportion of articles identified in one of three sample searches (screening for colorectal cancer, thrombolytic therapy for venous thromboembolism, and treatment of dementia) that meet a minimum definition of systematic review. RESULTS: Our PubMed search strategy identified 93 of 100 DARE-indexed systematic reviews, a sensitivity of 93% (95% CI, 86% to 97%). For the sample of systematic reviews drawn from ACP Journal Club (n = 103), the PubMed strategy achieved a sensitivity of 97% (CI, 91% to 99%). When the three sample search strings were used, approximately 50% of retrieved articles met our minimum definition of systematic review. In contrast, the similar precision of a PubMed search restricted to review-type articles (as indexed by MEDLINE) was less than 10%. CONCLUSIONS: This search strategy identified most systematic reviews without over-whelming users with numerous false-positive results. A "single-click" filter based on this strategy is now available as part of the Clinical Queries feature of PubMed. (+info)
Evidence-based dentistry: Part V. Critical appraisal of the dental literature: papers about therapy.
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Evidence-based dentistry involves defining a question focused on a patient-related problem and searching for reliable evidence to provide an answer. Once potential evidence has been found, it is necessary to determine whether the information is credible and whether it is useful in your practice by using the techniques of critical appraisal. In this paper, the fifth in a 6-part series on evidence-based dentistry, a framework is described which provides a series of questions to help the reader assess both the validity and applicability of an article related to questions of therapy or prevention. (+info)
Quality of Cochrane reviews: assessment of sample from 1998.
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OBJECTIVE: To assess the quality of Cochrane reviews. DESIGN: Ten methodologists affiliated with the Cochrane Collaboration independently examined, in a semistructured way, the quality of reviews first published in 1998. Each review was assessed by two people; if one of them noted any major problems, they agreed on a common assessment. Predominant types of problem were categorised. SETTING: Cyberspace collaboration coordinated from the Nordic Cochrane Centre. STUDIES: All 53 reviews first published in issue 4 of the Cochrane Library in 1998. MAIN OUTCOME MEASURE: Proportion of reviews with various types of major problem. RESULTS: No problems or only minor ones were found in most reviews. Major problems were identified in 15 reviews (29%). The evidence did not fully support the conclusion in nine reviews (17%), the conduct or reporting was unsatisfactory in 12 reviews (23%), and stylistic problems were identified in 12 reviews (23%). The problematic conclusions all gave too favourable a picture of the experimental intervention. CONCLUSIONS: Cochrane reviews have previously been shown to be of higher quality and less biased on average than other systematic reviews, but improvement is always possible. The Cochrane Collaboration has taken steps to improve editorial processes and the quality of its reviews. Meanwhile, the Cochrane Library remains a key source of evidence about the effects of healthcare interventions. Its users should interpret reviews cautiously, particularly those with conclusions favouring experimental interventions and those with many typographical errors. (+info)
Use of systematic reviews in clinical practice guidelines: case study of smoking cessation.
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OBJECTIVE: To examine the extent to which recommendations in the national guidelines for the cessation of smoking are based on evidence from systematic reviews of controlled trials. DESIGN: Retrospective analysis of recommendations for the national guidelines for the cessation of smoking. MATERIALS: National guidelines in clinical practice on smoking cessation published in English. MAIN OUTCOME MEASURES: The type of evidence (systematic review of controlled trials, individual trials, other studies, expert opinion) used to support each recommendation. We also assessed whether a Cochrane systematic review was available and could have been used in formulating the recommendation. RESULTS: Four national smoking cessation guidelines (from Canada, New Zealand, the United Kingdom, and the United States) covering 105 recommendations were identified. An explicit evidence base for 100%, 89%, 68%, and 98% of recommendations, respectively, was detected, of which 60%, 56%, 59%, and 47% were based on systematic reviews of controlled studies. Cochrane systematic reviews could have been used to develop between 39% and 73% of recommendations but were actually used in 0% to 36% of recommendations. The UK guidelines had the highest proportion of recommendations based on Cochrane systematic reviews. CONCLUSIONS: Use of systematic reviews in guidelines is a measure of the "payback" on investment in research synthesis. Systematic reviews commonly underpinned recommendations in guidelines on smoking cessation. The extent to which they were used varied by country and there was evidence of duplication of effort in some areas. Greater international collaboration in developing and maintaining an evidence base of systematic reviews can improve the efficiency of use of research resources. (+info)
A newly recognized syndrome--radiation-related bronchiolitis obliterans and organizing pneumonia. A case report and literature review.
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Bronchiolitis obliterans and organizing pneumonia (BOOP) is a syndrome that has been associated with a variety of underlying disorders, including infection, collagen vascular diseases and toxic fume inhalation. Rarely, however, BOOP has been associated with radiation- or chemotherapy-induced pulmonary toxicity. Over the past 3 years, several case series have reported BOOP in the unique setting of radiation in breast cancer patients. This study describes our experience with this newly recognized syndrome and a review of the English-language literature on this syndrome. (+info)