GRADE guidelines 6. Rating the quality of evidence—imprecision

Guyatt, Gordon; Oxman, Andrew D; Kunz, Regina; Brožek, Jan; Alonso‐Coello, Pablo; Rind, David M.; Devereaux, P. J.; Montori, Víctor M.; Freyschuss, Bo; Vist, Gunn Elisabeth; Jaeschke, Roman; Williams, John W; Murad, M. Hassan; Sinclair, David; Falck‐Ytter, Yngve; Meerpohl, Joerg J; Whittington, Craig; Thorlund, Kristian; Andrews, Jack R.; Schünemann, Holger J.

doi:10.1016/j.jclinepi.2011.01.012

Cited by 2,093 publications

(1,230 citation statements)

References 26 publications

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“…The same research group designed and conducted all three studies on seroma, and the studies were methodologically homogeneous. The quality of evidence was downgraded to moderate because of missing methodological information resulting in moderate risk of bias, and because of the few studies, with small sample sizes41, 44.…”

Section: Resultsmentioning

confidence: 99%

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Hyldig

Birke-Sørensen

Kruse

et al. 2016

British Journal of Surgery

199

172

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BackgroundPostoperative wound complications are common following surgical procedures. Negative‐pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions.MethodsThis was a systematic review and meta‐analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions.ResultsTen studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence.ConclusionCompared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.

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Section: Resultsmentioning

confidence: 99%

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Hyldig

Birke-Sørensen

Kruse

et al. 2016

British Journal of Surgery

199

172

View full text Add to dashboard Cite

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“…We defined treatment effect estimates as precise when pooled estimates had narrow 95 % CIs or the pooled sample had >300 events (using 25 % relative effect difference for calculation of optimal information size). 70 We did not quantify publication biases or selective outcome reporting biases because of the questionable statistical validity of the available tests. 71 We defined a high level of evidence on the basis of consistent findings from low risk-of-bias RCTs.…”

Section: Methodsmentioning

confidence: 99%

Preventive Pharmacologic Treatments for Episodic Migraine in Adults

et al. 2013

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ELIGIBILITY CRITERIA: English-language randomized controlled trials (RCTs) of preventive drugs compared to placebo or active treatments examining rates of ≥50 % reduction in monthly migraine frequency or improvement in quality of life. STUDY APPRAISAL AND SYNTHESIS METHODS:We assessed risk of bias and strength of evidence and conducted random effects meta-analyses of absolute risk differences and Bayesian network meta-analysis. RESULTS: Of 5,244 retrieved references, 215 publications of RCTs provided mostly low-strength evidence because of the risk of bias and imprecision. RCTs examined 59 drugs from 14 drug classes. All approved drugs, including topiramate (9 RCTs), divalproex (3 RCTs), timolol (3 RCTs), and propranolol (4 RCTs); offlabel beta blockers metoprolol (4 RCTs), atenolol (1 RCT), nadolol (1 RCT), and acebutolol (1 RCT); angiotensin-converting enzyme inhibitors captopril (1 RCT) and lisinopril (1 RCT); and angiotensin II receptor blocker candesartan (1 RCT), outperformed placebo in reducing monthly migraine frequency by ≥50 % in 200-400 patients per 1,000 treated. Adverse effects leading to treatment discontinuation (68 RCTs) were greater with topiramate, off-label antiepileptics, and antidepressants than with placebo. Limited direct evidence as well as frequentist and exploratory network Bayesian meta-analysis showed no statistically significant differences in benefits between approved drugs. Off-label angiotensin-inhibiting drugs and beta-blockers were most effective and tolerable for episodic migraine prevention. LIMITATIONS:We did not quantify reporting bias or contact principal investigators regarding unpublished trials. CONCLUSIONS: Approved drugs prevented episodic migraine frequency by ≥50 % with no statistically significant difference between them. Exploratory network meta-analysis suggested that off-label angiotensin-inhibiting drugs and beta-blockers had favorable benefit-to-harm ratios. Evidence is lacking for longterm effects of drug treatments (i.e., trials of more than 3 months duration), especially for quality of life.KEY WORDS: migraine; evidence based medicine; adverse drug effects.

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“…The quality of the overall evidence (confidence in the estimates) was moderate to high for efficacy vs. placebo, low to moderate for side effects (limited by imprecision) and likely low for the ranking suggesting superiority of escitalopram (limited by indirectness of comparative data). 42,43 In conclusion, given the promising positive effects of SSRIs on hot flashes and the likely favorable side effect profile, their use seems to be an acceptable option for treating menopausal women with hot flashes and is a good alternative to HRT. Future trials should investigate different SSRIs over a long time period (e.g., 6-12 months) and should not use placebo for comparison in order to provide high-quality comparative effectiveness evidence.…”

Section: Implications For Practice and Researchmentioning

confidence: 99%

SSRIs for Hot Flashes: A Systematic Review and Meta-Analysis of Randomized Trials

et al. 2013

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BACKGROUND: Hot flashes are the most commonly reported vasomotor symptom during the peri-and early post-menopausal period. OBJECTIVES: To systematically review, appraise and summarize the evidence of the impact of different SSRIs on peri-menopausal hot flashes in healthy women in randomized, controlled trials. METHODS: A comprehensive literature search was conducted of MEDLINE™, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus through March 2013. Two independent reviewers selected studies and extracted data. Random effects meta-analysis was used to pool outcomes across studies, and Bayesian mixed treatment methods were used to rank SSRIs in terms of effectiveness. RESULTS: We included a total of 11 randomized controlled trials with good methodological quality enrolling 2,069 menopausal and post-menopausal women (follow-up 1-9 months, mean age 36-76 years, mean time since menopause 2.3-6.6 years). Compared with placebo, SSRIs were associated with a statistically significant decrease in hot flash frequency (difference in means −0.93; 95 % CI −1.46 to −0.37; I 2 = 21 %) and severity assessed by various scales (standardized difference in means −0.34; 95 % CI −0.59 to −0.10; I 2 = 47 %). Adverse events did not differ from placebo. Mixed treatment comparison analysis demonstrated the superiority of escitalopram compared to other SSRIs in terms of efficacy. CONCLUSION: SSRI use is associated with modest improvement in the severity and frequency of hot flashes but can also be associated with the typical profile of SSRI adverse effects.

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GRADE guidelines 6. Rating the quality of evidence—imprecision

Cited by 2,093 publications

References 26 publications

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Meta-analysis of negative-pressure wound therapy for closed surgical incisions

Preventive Pharmacologic Treatments for Episodic Migraine in Adults

SSRIs for Hot Flashes: A Systematic Review and Meta-Analysis of Randomized Trials

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