Recent KSR Evidence critical appraisals

  • 1

    Does methylprednisolone improve postoperative outcomes after mandibular third molar surgery? A systematic review and meta-analysis

    Nagori, S. A. ; Jose, A. ; Roy, I. D. ; Chattopadhyay, P. K. ; Roychoudhury, A.

    Risk of Bias Assessment: High

    Only studies published in full-text were included. Only PubMed, Scopus, Cochrane CENTRAL and Google Scholar were searched for relevant studies. Searches were restricted to the English language. No information was provided regarding the number of authors involved in the data extraction and risk of bias assessment. Appropriate attempts were not made to explore the possible sources of heterogeneity. Robustness of the findings was not demonstrated.

    Bottom line The current evidence suggests that oral methylprednisolone (MP) might significantly improve both early and late postoperative pain, as well as early oedema and trismus compared to placebo in patients following mandibular third molar surgery. Moreover, intramuscular MP seems to improve early oedema; submucosal MP improves early postoperative pain and intra-masseteric MP improves late trismus compared to placebo. However, no significant difference was observed between intravenous MP and placebo for early or late trismus. The review had significant methodological weaknesses, so the findings should be interpreted with caution. Further research including high-quality randomised clinical trials on the use of MP in third molar surgery is required to support the current findings.

    Int J Oral Maxillofac Surg 2018;Epub ahead of print();

  • 2

    The impact of blood pressure management after spinal cord injury: a systematic review of the literature

    Saadeh, Y. S. ; Smith, B. W. ; Joseph, J. R. ; Jaffer, S. Y. ; Buckingham, M. J. ; Oppenlander, M. E. ; Szerlip, N. J. ; Park, P.

    Risk of Bias Assessment: High

    Studies not published in English were excluded and only a single database was searched, meaning relevant articles may have been missed. No information was provided on the number of authors involved in study selection or data extraction, meaning error and bias may have been present. No risk of bias assessment was performed.

    Bottom line Current evidence suggests that blood pressure management with vasopressors (such as dopamine, norepinephrine or phenylephrine) may stabilise or improve neurological outcomes in patients with spinal cord injury (SCI). However, more complications may be associated with the use of dopamine compared to other vasopressors. A tentative target of a mean arterial pressure of 85-90 mmHg for 5 to 7 days may be considered. However, these findings must be interpreted with caution as important methodological issues mean that relevant articles may have been missed, and error and bias may have been present.

    Neurosurg Focus 2017;43(5);E20

  • 3

    Routine scale and polish for periodontal health in adults

    Lamont, T. ; Worthington, H. V. ; Clarkson, J. E. ; Beirne, P. V.

    Risk of Bias Assessment: Low

    One or two review authors were involved in data extraction; this was considered inadequate to minimise error and bias. However, all other domains were considered to be at low risk.

    Bottom line Limited evidence suggests that regular scale and polish treatments (at 6-month or 12-month intervals) may reduce the level of calculus on teeth compared to no treatment, and that these reductions may be more substantial with a shorter interval between treatments (6-months instead of 12-months). Participants' self-reported perception of oral cleanliness appears to be higher for regular scale and polish treatment compared to no treatment. There was little to no difference reported in gingivitis/gingival bleeding, plaque, probing depths, oral health-related quality of life or costs from an NHS perspective for regular scale and polish treatment compared to no treatment. However, these conclusions should be interpreted with some caution, as the involvement of only one reviewer in some data extractions means reviewer error and bias cannot be ruled out. Further large, high-quality studies are required to provide additional evidence to support these conclusions, particularly with respect to adverse events.

    Cochrane Database Syst Rev 2018, 12, CD004625, 10.1002/14651858.CD004625.pub5

  • 4

    Carbohydrate quality and human health: a series of systematic reviews and meta-analyses

    Reynolds, Andrew ; Mann, Jim ; Cummings, John ; Winter, Nicola ; Mete, Evelyn ; Te Morenga, Lisa

    Risk of Bias Assessment: Low

    All domains were considered at low risk of bias suggesting no limitations with the review process.

    Bottom line This well-conducted review found that a higher intake of total dietary fibre or whole grains was associated with a reduction in the risk of mortality and in the incidence of a wide range of non-communicable diseases and their risk factors.

    Lancet 2019;Epub ahead of print();

  • 5

    Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies

    Toews, Ingrid ; Lohner, Szimonetta ; Küllenberg de Gaudry, Daniela ; Sommer, Harriet ; Meerpohl, Joerg J.

    Risk of Bias Assessment: Unclear

    The authors acknowledged the presence of significant heterogeneity between the studies and also stated that the findings of our review might be biased by the fact that only one reviewer assessed inclusion of studies in the initial title and abstract screening phase. Hence, relevant references could have inadvertently not been included in this review.

    Bottom line The current evidence is limited, and does not allow to draw firm conclusions regarding the association between intake of non-sugar sweeteners and health outcomes. Results should be interpreted cautiously due to significant heterogeneity between the studies. Also, the findings of this review might be biased by the fact that only one reviewer assessed the inclusion of studies in the initial title and abstract screening phase. Hence, relevant references could have inadvertently not been included in this review. Further, well-designed high-quality studies with detailed descriptions of interventions, comparators and outcomes are needed to support these findings.

    BMJ 2019;364();k4718

  • 6

    A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: are guidelines evidence-based?

    Davies, J. ; Read, J.

    Risk of Bias Assessment: High

    Eligibility criteria were not explicitly defined. Only English language studies published in peer-reviewed journals were considered for inclusion in the review. A limited range of databases was searched for study selection process. Search terms were provided but a full search strategy was not reported. No information was provided on the number of reviewers involved in the study selection process and data extraction process. Relevant study results appear to have been extracted. There was no formal assessment of the methodological quality of the included studies. The method of analysis was not explained clearly in the methodology section.

    Bottom line The current evidence suggests that antidepressant withdrawal reactions are widespread and nearly half of them are severe. Hence, the U.K.'s current National Institute for Health and Care Excellence and the American Psychiatric Association's depression guidelines need to be updated immediately. The review had significant methodological weaknesses, so the findings should be interpreted with caution. Further, well-designed studies focused on the dependency-forming nature of antidepressants are needed.

    Addict Behav 2018;Epub ahead of print();

  • 7

    Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis

    Bolland, M.J. ; Grey, A. ; Avenell, A.

    Risk of Bias Assessment: High

    The search strategies were not very sensitive, relevant studies may have been missed.

    Bottom line Evidence indicates that vitamin D supplementation may not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. In addition, there were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. Restriction to one index term for vitamin D in the searches means some relevant studies may have been missed. There was some evidence of publication bias.

    Lancet Diabetes Endocrinol 2018;Epub ahead of print();

  • 8

    Can screening instruments accurately determine poor outcome risk in adults with recent onset low back pain? A systematic review and meta-analysis

    Karran, E. L. ; McAuley, J. H. ; Traeger, A. C. ; Hillier, S. L. ; Grabherr, L. ; Russek, L. N. ; Moseley, G. L.

    Risk of Bias Assessment: High

    The use or search terms for prognostic/predictive studies, and the inclusion of an English language limit, may have resulted in relevant studies being missed by the searches. Weaknesses in the analysis methods and risk of bias assessments limit the usefulness of the reported results.

    Bottom line The results of this review suggest that low back pain screening instruments may perform better in predicting poor disability and absenteeism outcomes than in predicting poor pain outcomes. However, the evidence presented is not sufficiently robust to support firm conclusions. The use or search terms for prognostic/predictive studies, and the inclusion of an English language limit, may have resulted in relevant studies being missed by the searches. Weaknesses in the analysis methods and risk of bias assessments limit the usefulness of the reported results.

    BMC Med 2017;15(1);

  • 9

    Assessment of efficacy and tolerability of medicinal cannabinoids in patients with multiple sclerosis: a systematic review and meta-analysis

    Torres-Moreno, M. ; Papaseit, E. ; Torrens, M. ; Farre, M.

    Risk of Bias Assessment: Low

    The assessment identified no major methodological shortcomings with the systematic review. The abstract focused on statistically significant results, however, full results are presented in the study and the appendices.

    Bottom line Results of this systematic review showed that cannibinoids might be more effective than placebo in addressing spasticity of adults with MS. However, this was limited to self-reported spasticity, i.e. when spasticity was assessed by the more objective Ashworth scale, no statistically significant differences were seen. Similarly, cannabinoids might be beneficial for the treatment of pain and bladder dysfunction in adults with MS. More adverse events were seen in patients treated with cannabinoids compared to placebo, however, no differences in serious adverse events were noted. There are some differences in different forms of medicinal cannabinoids which need to be considered. Overall, the systematic review was well conducted and the results are likely to be reliable. Future research should focus further on the effectiveness of different drug forms and the clinical relevance of these findings.

    JAMA Network Open 2018;1(6);

  • 10

    Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

    Wang, J. H. ; Sun, T.

    Risk of Bias Assessment: High

    A restriction to the Chinese and English language means that some relevant studies may have been missed. The search terms were reported, but full details of the search strategy were not reported. No information was provided regarding the number of authors involved in the study selection process.

    Bottom line The current evidence indicates that bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation can have no marked difference in risk of complex regional pain syndrome in distal radius fracture patients. A restriction to the Chinese and English language means that some relevant studies may have been missed. The search terms were reported, but full details of the search strategy were not reported. No information was provided regarding the number of authors involved in the study selection process.

    Arch Med Sci 2017;13(1);163-73

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