Recent KSR Evidence critical appraisals

  • 1

    Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis

    Black, N. ; Stockings, E. ; Campbell, G. ; Tran, L.T. ; Zagic, Z. ; Hall, W.D. ; Farrell, M. ; Degenhardt, L.

    Risk of Bias Assessment: Low

    It was unclear which criteria were used for the methodological quality assessment of the observational studies. However, overall, no major issues were identified.

    Bottom line There is limited evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder (ADHD), Tourette syndrome, post-traumatic stress disorder (PTSD), or psychosis. The certainty of evidence was usually rated to be low or even very low. However, pharmaceutical tetrahydrocannabinol (THC, with or without cannabidiol) seems to show a small improvement in symptoms of anxiety among individuals with other medical conditions. There is insufficient evidence to provide clear guidance on the use of cannabinoids for treating mental disorders, e.g. within a regulatory framework. Bias in primary studies was addressed while interpreting the findings, but the criteria used for the observational studies were unclear. Further high-quality studies directly examining the effect of cannabinoids on treating mental disorders are needed to support the current findings.

    Lancet Psychiatry 2019;Epub ahead of print();

  • 2

    The effect of interactive virtual reality on pain perception: a systematic review of clinical studies

    Wittkopf, P.G. ; Lloyd, D.M. ; Coe, O. ; Yacoobali, S. ; Billington, J.

    Risk of Bias Assessment: High

    Studies were restricted based on publication format (only published full-texts were included). No information was provided on the number of reviewers involved in the data extraction or quality assessment.

    Bottom line The current limited evidence suggests that interactive virtual reality may reduce pain associated with ankylosing spondylitis, mastectomy, neuropathy, phantom limb or complex regional pain syndrome. Evidence from the studies in chronic neck pain, subacromial impingement syndrome and chronic low back pain is inconsistent. However, these conclusions should be interpreted with caution, as several methodological weaknesses mean that relevant studies may have been missed, and reviewer error and bias may be present. Further randomised controlled trials are needed to fully appraise the effectiveness of virtual reality in pain management.

    Disabil Rehabil 2019;Epub ahead of print();1-12

  • 3

    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

  • 4

    Health-related values and preferences regarding meat consumption. A mixed-methods systematic review

    Valli, C. ; Rabassa, M. ; Johnston, B.C. ; Kuijpers, R. ; Prokop-Dorner, A. ; Zajac, J. ; Storman, D. ; Storman, M., ; Bala, M.M. ; Solà, I. ; Zeraatkar, D. ; Han, M.A. ; et al.

    Risk of Bias Assessment: Low

    No relevant concerns were identified.

    Bottom line This systematic review identified low-certainty evidence indicating that omnivores are attached to meat and have low willingness to reduce meat consumption. People following a diet with low or no meat consumption cite health as a main reason for that diet. The findings of this systematic review are likely to be robust. However, due to only including studies conducted in Europe, Australia, Canada, the United States, and New Zealand, the results are not generalisable to other settings, e.g. lower income countries.

    Ann Intern Med 2019;Epub ahead of print();

  • 5

    Red and processed meat consumption and risk for all-cause mortality and cardiometabolic outcomes. A systematic review and meta-analysis of cohort studies

    Zeraatkar, D. ; Han, M.A. ; Guyatt, G.H. ; Vernooij, R.W.M. ; El Dib, R. ; Cheung, K. ; Milio, K. ; Zworth, M. ; Bartoszko, J.J. ; Valli, C. ; Rabassa, M. ; Lee, Y. ; et al.

    Risk of Bias Assessment: Unclear

    It was unclear why the review was restricted to studies of more than 1000 participants. Baseline study characteristics regarding cancer risk were not reported. Different meta-analysis methods were used but the results and GRADE assessment were based on the dose-response analysis as this was considered to be the most reliable. However, no justification was provided and 44% of the studies were excluded from this analysis. Some analyses had high statistical heterogeneity and the pooled results may not be reliable.

    Bottom line Evidence from observational studies shows that a reduction of three servings per week of processed or unprocessed red meat may reduce all-cause mortality and cardiometabolic morbidity and mortality. However, the estimated lifetime effects of exposure are very small, the overall certainty of evidence is low or very low, and a causal relationship has not been established. There was a lack of information about other cancer and cardiovascular risk factors and the results of each study. In addition, no justification was provided for the choice of analysis method and 44% of the studies were not analysed.

    Ann Intern Med 2019;Epub ahead of print();

  • 6

    Effect of lower versus higher red meat intake on cardiometabolic and cancer outcomes: a systematic review of randomized trials

    Zeraatkar, D. ; Johnston, B.C. ; Bartoszko, J. ; Cheung, K. ; Bala, M.M. ; Valli, C. ; Rabassa, M. ; Sit, D. ; Milio, K. ; Sadeghirad, B. ; Agarwal, A. ; Zea, A.M. ; Lee, Y. ; et al.

    Risk of Bias Assessment: Low

    No relevant concerns were identified.

    Bottom line This systematic review identified low- or very-low certainty evidence suggesting that diets restricted in red meat may have little or no effect on major cardiometabolic outcomes and cancer mortality and incidence. The systematic review used rigorous methods, i.e. the results are likely to be correct. However, it was largely based on a single study conducted in postmenopausal women (70% overweight or obese, 30%-40% with hypertension) which limits the generalisability of these findings.

    Ann Intern Med 2019;171(10);721-31

  • 7

    Patterns of red and processed meat consumption and risk for cardiometabolic and cancer outcomes: a systematic review and meta-analysis of cohort studies

    Vernooij, R.W.M. ; Zeraatkar, D. ; Han, M.A. ; El Dib, R. ; Zworth, M. ; Milio, K. ; Sit, D. ; Lee, Y. ; Gomaa, H. ; Valli, C. ; Swierz, M.J. ; Chang, Y. ; Hanna, S.E. ; Brauer, P.M. ; Sievenpiper, J. ; de Souza, R. ; et al.

    Risk of Bias Assessment: Unclear

    It was unclear why the review was restricted to studies of more than 1000 participants. Baseline study characteristics regarding cancer risk were not reported. Some analyses used multivariate methods (factor or principal component analyses) to establish dietary patterns prior to meta-analysis and full details of the methods and results were not reported. Some analyses had high statistical heterogeneity and the pooled results may not be reliable.

    Bottom line Evidence from observational studies shows that dietary patterns lower in red and processed meat may result in very small reductions in all-cause and cardiometabolic diseases and mortality and cancer morbidity and mortality. However, the estimated lifetime effects of exposure are very small, the overall certainty of evidence is low or very low, and a causal relationship has not been established. There was a lack of information about other cancer or cardiovascular risk factors and the results of each study. Furthermore, there is some concern regarding the similarity of the pooled studies.

    Ann Intern Med 2019;171(10);732-741

  • 8

    Reduction of red and processed meat intake and cancer mortality and incidence: a systematic review and meta-analysis of cohort studies

    Han, M.A. ; Zeraatkar, D. ; Guyatt, G.H. ; Vernooij, R.W.M. ; El Dib, R. ; Zhang, Y. ; Algarni, A., Leung, G. ; Storman, D. ; Valli, C. ; Rabassa, M. ; Rehman, N. ; Parvizian, M.K. ; Zworth, M. ; Bartoszko, J.J. ; et al.

    Risk of Bias Assessment: Unclear

    It was unclear why the review was restricted to studies of more than 1000 participants. Baseline study characteristics regarding cancer risk were not reported. Three different meta-analysis methods were used but the results and GRADE assessment were based on the dose-response analysis as this was considered to be the most reliable but no justification was provided. Some analyses had high statistical heterogeneity and the pooled results may not be reliable.

    Bottom line Evidence from observational studies shows that a reduction of three servings per week of red meat or processed meat may reduce the risk of death from cancer. There was also evidence for very small reductions in deaths from prostate cancer and incidence of oesophageal, colorectal and breast cancer with reductions in processed meat intake. However, the estimated lifetime effects of exposure are very small, the overall certainty of evidence is low or very low, and a causal relationship has not been established. There was a lack of information about other cancer risk factors and the results of each study. Some analyses had high statistical heterogeneity and the pooled results may not be reliable, as reflected by certainty of the evidence.

    Ann Intern Med 2019;Epub ahead of print();

  • 9

    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

  • 10

    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

  • 11

    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

  • 12

    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

  • 13

    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

  • 14

    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

  • 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