GRADE guidelines: 8. Rating the quality of evidence—indirectness

Guyatt, Gordon; Oxman, Andrew D; Kunz, Regina; Woodcock, James; Brožek, Jan; Helfand, Mark; Alonso‐Coello, Pablo; Falck‐Ytter, Yngve; Jaeschke, Roman; Vist, Gunn Elisabeth; Akl, Elie A.; Post, Piet N.; Norris, Susan L.; Meerpohl, Joerg J; Shukla, Vijay Kumar; Nasser, Mona; Schünemann, Holger J.

doi:10.1016/j.jclinepi.2011.04.014

Cited by 1,479 publications

(853 citation statements)

References 16 publications

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“…0·47 to 1·01; I 2 = 37·3 per cent). Owing to inconsistency in the direction of effect on wound dehiscence and a moderate risk of bias, the quality of evidence was downgraded to low43. The NNT to avoid wound dehiscence was 17; as the treatment effect was not significant, the 95 per cent c.i.…”

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

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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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“…Network meta-analyses, also called multiple-treatment comparison meta-analyses, provide an approach to simultaneous consideration of the relative effectiveness of multiple treatment alternatives [17,23,29]. The benefit of a network meta-analysis includes the potential for providing indirect evidence, which refers to the determination of relative treatment effects between two treatments when head-to-head trials (ie, direct evidence) are not available [29].…”

Section: Introductionmentioning

confidence: 99%

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

Foote

Guyatt

Vignesh

et al. 2015

Clinical Orthopaedics &Amp; Related Research

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Background Open tibial shaft fractures are one of the most devastating orthopaedic injuries. Surgical treatment options include reamed or unreamed nailing, plating, Ender nails, Ilizarov fixation, and external fixation. Using a network meta-analysis allows comparison and facilitates pooling of a diverse population of randomized trials across these approaches in ways that a traditional meta-analysis does not. Questions/purposes Our aim was to perform a network meta-analysis using evidence from randomized trials on the relative effect of alternative approaches on the risk of unplanned reoperation after open fractures of the tibial diaphysis. Our secondary study endpoints included malunion, deep infection, and superficial infection. Methods A network meta-analysis allows for simultaneous consideration of the relative effectiveness of multiple treatment alternatives. To do this on the subject of surgical treatments for open tibial fractures, we began with systematic searches of databases (including EMBASE and MEDLINE) and performed hand searches of orthopaedic journals, bibliographies, abstracts from orthopaedic conferences, and orthopaedic textbooks, for all relevant material published between 1980 and 2013. Two authors independently screened abstracts and manuscripts and extracted the data, three evaluated the risk of bias in individual studies, and two applied Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria to bodies of evidence. We included all randomized and quasirandomized trials comparing two (or more) surgical treatment options for open tibial shaft fractures in predominantly (ie, [ 80%) adult patients. We calculated pooled estimates for all direct comparisons and conducted a network meta-analysis combining direct and indirect evidence for all 15 comparisons between six stabilization strategies. Fourteen trials published between Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. This study was performed at

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GRADE guidelines: 8. Rating the quality of evidence—indirectness

Cited by 1,479 publications

References 16 publications

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

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

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

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

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