Recent KSR Evidence critical appraisals

  • 1

    Family therapy approaches for anorexia nervosa

    Fisher, C. A. ; Skocic, S. ; Rutherford, K. A. ; Hetrick, S. E.

    Risk of Bias Assessment: Low

    All domains were considered at low concern suggesting no significant limitations with the review process.

    Bottom line The low-quality evidence suggests that family therapy approaches seem to be effective compared to treatment as usual in the short term. The evidence is insufficient to determine whether one type of family therapy approach is more effective than another. The review had no significant methodological weaknesses. Further, large, well-conducted trials are needed to address the present review question.

    Cochrane Database Syst Rev 2019, 5, CD004780, 10.1002/14651858.CD004780.pub4

  • 2

    Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis

    Ochen, Y. ; Beks, R. B. ; van Heijl, M. ; Hietbrink, F. ; Leenen, L. P. H. ; van der Velde, D. ; Heng, M. ; van der Meijden, O. ; Groenwold, R. H. H. ; Houwert, R. M.

    Risk of Bias Assessment: High

    Restrictions based on language and publication format mean that relevant studies may have been missed. Moderate or high heterogeneity was reported for some outcomes; however, the source of this heterogeneity was not explored. Quality of included studies was assessed using an inappropriate tool for the RCT studies.

    Bottom line Current evidence suggests that operative treatment may reduce the risk of re-rupture compared with non-operative treatment in patients with Achilles tendon ruptures. However, re-rupture rates are generally low and differences between treatment groups are relatively small, with a risk difference of 1.6%. Evidence also suggests that operative treatment may increase the risk of overall complications compared to non-operative treatment. These conclusions should be interpreted with caution, since several methodological weaknesses mean relevant studies may have been missed, and the quality of the studies was not appropriately assessed for randomised controlled trials. Further well-designed, high-quality studies are needed to support these findings and to develop shared decision making tools to promote evidence-based decision making.

    BMJ 2019;364();k5120

  • 3

    The clinical effect of arthroscopic rotator cuff repair techniques: a network meta-analysis and systematic review

    Xu, B. ; Chen, L. ; Zou, J. ; Gu, Y. ; Hao, L. ; Peng, K.

    Risk of Bias Assessment: High

    Further attempts to identify additional studies were not made. Weaknesses in the search strategy mean that relevant studies may have been missed. Insufficient information was provided on which studies were included in network meta-analyses, making it impossible to assess whether the pooling was appropriate. Heterogeneity was assessed and found to be significant for some outcomes; this was not assessed further.

    Bottom line Current evidence suggests that suture bridge repairs may achieve lower retear rates than single- or double-row repairs in patients undergoing surgical repair of rotator cuff tears; however, each technique may be similar in terms of functional recovery (based on constant score, external rotation and forward flexion). These conclusions should be interpreted with caution due to several methodological weaknesses meaning relevant studies may have been missed; heterogeneity in some analyses was also high, and the source of this was not explored further. Further studies are needed to provide additional evidence to increase the sample size and thus increase the robustness of the conclusions.

    Sci Rep 2019;9(1);4143

  • 4

    Systematic screening and assessment of psychosocial well‐being and care needs of people with cancer

    Schouten, B. ; Avau, B. ; Bekkering, G.E. ; Vankrunkelsven, P. ; Mebis, J. ; Hellings, J. ; Van Hecke, A.

    Risk of Bias Assessment: High

    Restrictions based on language, and the lack of assessment of seven potentially eligible studies meant relevant studies may have been missed.

    Bottom line Limited evidence suggests that screening for psychosocial well-being and care needs may not improve health-related quality of life, psychological distress or supportive care needs in people with cancer. However, this conclusion should be interpreted with caution, since methodological weaknesses mean that relevant studies may have been missed, and the certainty of the evidence is very low. Future studies are needed that capture both subjective patient-reported outcome measures (PROMs) and objective outcomes, such as biomedical indicators of distress, to provide further evidence to address this review question.

    Cochrane Database Syst Rev 2019, 3, CD012387, 10.1002/14651858.CD012387.pub2

  • 5

    Shared decision-making for people with asthma

    Kew, Kayleigh M. ; Malik, Poonam ; Aniruddhan, Krishnan ; Normansell, Rebecca

    Risk of Bias Assessment: High

    The synthesis did not appear to include all relevant studies, since one study was awaiting assessment and had not been formally included or excluded, meaning a relevant study may have been missed. It should also be noted that searches were based on a Cochrane Review Group’s specialised trials register and major bibliographic databases were not searched directly.

    Bottom line Current, limited evidence suggests that shared decision-making may improve patient/parent satisfaction, medication adherence and asthma control; but may have a minimal impact on asthma-related quality of life and asthma exacerbations compared to usual care in adults or children with asthma. However, these conclusions should be interpreted with caution, since several methodological weaknesses mean that relevant studies may have been missed. The patient populations described were also generally quite different in each study, which limited comparability. Further large studies that include adolescents and that focus on the benefits and the side effects of shared decision making are needed to support the current findings.

    Cochrane Database Syst Rev 2017, 10, CD012330, 10.1002/14651858.CD012330.pub2

  • 6

    Progressive resistance training increases strength after stroke but this may not carry over to activity: a systematic review

    Dorsch, Simone ; Ada, Louise ; Alloggia, Daniella

    Risk of Bias Assessment: High

    No information was provided on the number of authors involved in the risk of bias assessment, meaning reviewer error and bias cannot be ruled out. Heterogeneity was assessed and found to be moderate for some outcomes; the source of this heterogeneity was not explored further. Publication bias was not assessed; however, this was considered appropriate due to the small number of included studies. Robustness of the findings was not assessed.

    Bottom line Current evidence suggests that progressive resistance training can generally increase immediate muscle strength but may not impact immediate activity levels compared to no intervention or placebo in patients who have had a stroke. Of note, these findings should be interpreted with caution, since methodological weaknesses mean that reviewer error and bias cannot be ruled out, and heterogeneity and the robustness of the data were not adequately explored. Future studies are needed to provide additional evidence for patients early after stroke and for those who need to engage in upper limb strengthening following stroke.

    J Physiother 2018;64(2);84-90

  • 7

    Effectiveness of vibratory stimulation on needle-related procedural pain in children: a systematic review

    Ueki, S. ; Yamagami, Y. ; Makimoto, K.

    Risk of Bias Assessment: High

    Studies were restricted based on quality and language (only English and Japanese studies were included), meaning relevant studies may have been missed. Heterogeneity remained high for some outcomes even after subgroup analysis. Publication bias was present for some outcomes.

    Bottom line Current evidence suggests that vibratory stimulation may reduce pain and anxiety in children undergoing needle-related procedures. For venipuncture procedures, vibratory stimulation may not impact the duration of the procedure or its success rate. Of note, these conclusions should be interpreted with caution, since methodological restrictions based on study quality and language mean that relevant studies may have been missed, and publication bias and heterogeneity were high for some outcomes.Future trials with an adequate placebo-controlled comparator arm and assessor blinding are needed to provide higher quality evidence to address this review question.

    JBI Database System Rev Implement Rep 2019;17(7);1428-63

  • 8

    Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors

    Arbyn, M. ; Xu, L. ; Simoens, C. ; Martin‐Hirsch, P. P. L.

    Risk of Bias Assessment: Low

    All domains were considered at low concern. A range of comments were made about the review which can be found or are cited in the comments section of the review in the Cochrane Library.

    Bottom line HPV vaccines protect against cervical precancer in adolescent girls and women vaccinated between 15 and 26 years of age. The protection is lower when a part of the population is already infected with HPV. Longer-term follow-up is needed to assess the impact on cervical cancer. There are limited data from trials on the effect of vaccines on deaths, stillbirth and babies born with malformations. However, no increased risk of serious adverse effects, miscarriage or pregnancy termination was found. These findings are likely to be reliable.

    Cochrane Database Syst Rev 2018, 5, CD009069, 10.1002/14651858.CD009069.pub3

  • 9

    Oropharyngeal colostrum in preventing mortality and morbidity in preterm infants

    Nasuf, A. W. A. ; Ojha, S. ; Dorling, J.

    Risk of Bias Assessment: Low

    All domains were considered at low concern suggesting no limitations regarding the review process. The authors highlighted how the review was limited by the low number of the included studies which impeded analysing the risk of publication bias via a funnel plot, however abstracts and proceedings of relevant conferences were included. Further, to minimise the potential bias resulting from incomplete reporting of the results, the primary study authors were contacted.

    Bottom line Current evidence suggests that placing a very small volume of colostrum directly onto the buccal mucosa of preterm infants has no impact on rates of necrotising enterocolitis, late-onset invasive infection or death compared to controls. A robust methodology supports these findings. The authors recommend that further, large well-designed trials are required to evaluate more precisely and reliably the effects of oropharyngeal colostrum on important outcomes for preterm infants.

    Cochrane Database Syst Rev 2018, 9, CD011921, 10.1002/14651858.CD011921.pub2

  • 10

    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

  • 11

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

    Reynolds A, Mann J, Cummings J, Winter N, Mete E, Te Morenga L

    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;393(10170);434-445

  • 12

    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

  • 13

    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 2019;97();111-21

  • 14

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

    Bolland MJ, 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;6(11);847-858

  • 15

    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);

  • 16

    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

  • 17

    Percutaneous endoscopic lumbar discectomy for recurrent lumbar disc herniation

    Li, X. ; Hu, Z. ; Cui, J. ; Han, Y. ; Pan, J. ; Yang, M. ; Tan, J. ; Sun, G. ; Li, L.

    Risk of Bias Assessment: Unclear

    Search terms were provided but a full search strategy was not reported, therefore it was not possible to judge if all relevant studies had been retrieved.

    Bottom line The evidence indicated that operative time, blood loss and complication rates were significantly reduced with percutaneous endoscopic lumbar discectomy in patients with recurrent lumbar disc herniation in comparison with open lumbar microdiscectomy. Whereas, the difference between the treatment groups were similar in terms of pain reduction, global perceived effect (MacNab score), re-operation and recurrence rate. Hence, percutaneous endoscopic lumbar discectomy could be used as an alternative to the conventional procedure in the treatment of recurrent lumbar disc herniation. Search terms were provided, but a full search strategy was not reported, therefore it was not possible to judge if all relevant studies had been retrieved. Further high-quality randomised controlled trials were required to address the present review question.

    Int J Surg 2016;27();8-16