Evidence Pyramid Research Articles

Validity of data extraction in acupuncture meta-analysis: a reproducibility study protocol

IntroductionSystematic review and meta-analysis occupy the apex of the evidence pyramid, serving as the most comprehensive and reliable form of evidence-based assessment. Data extraction is a crucial juncture in meta-analysis,...

Best evidence summary of prevention and management of lower limb ischemia in patients with veno-arterial extracorporeal membrane oxygenation

To provide evidence-based recommendations for the prevention and management of lower limb ischemia in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) patients during treatment according to search, evaluate, and summarize the best evidence on the prevention and management of lower limb ischemia in patients with VA-ECMO. Based on the PIPOST framework (population, intervention, professional, outcome, setting, and type of evidence), an evidence-based question was formulated. A systematic search was conducted according to the "6S" evidence pyramid model in both domestic and international databases, as well as professional association websites, for all evidence related to the prevention and management of lower limb ischemia in VA-ECMO patients (aged ≥18 years). The types of evidence included clinical decisions, guidelines, expert consensus, systematic reviews, evidence summaries, and original studies. The search was conducted from the construction of the databases to February 2024. Two researchers independently conducted a literature quality evaluation, extracted and summarized evidence from the studies that met the quality criteria. A total of 13 articles were included, consisting of 3 clinical decisions, 3 guidelines, 3 expert consensus, 3 systematic reviews, and 1 randomized controlled trial. A total of 18 pieces of evidence in 7 dimensions were summarized, including risk factors of VA-ECMO lower limb ischemia, evaluation before catheterization, evaluation and monitoring during treatment, prevention of lower limb ischemia, treatment of lower limb ischemia, management of distal perfusion catheter (DPC), and monitoring after VA-ECMO weaning. This evidence summary provides evidence-based recommendations for the prevention and management of lower limb ischemia in VA-ECMO patients, aiming to assist clinical healthcare professionals in developing tailored strategies for the prevention and management of lower limb ischemia based on during VA-ECMO support.

Leveraging ChatGPT for systematic reviews: how accurate is it for screening by title and abstract?

Abstract Background Systematic reviews are at the top of the evidence pyramid, but the whole process can be labor-intensive, especially in the screening by title and abstract of retrieved records. Large language models (LLMs), such as ChatGPT, are proficient in natural language processing tasks and offer potential for accelerating this phase. The aim of this study is to assess ChatGPT’s performance in screening records for an already published systematic review (doi: 10.1080/21645515.2023.2300848). Methods 1601 records with title and abstract were evaluated with ChatGPT 4, using two different prompts to instruct the model: one asking the model to classify each record as included or excluded (Prompt A), and one asking the model to rate each record from 1 to 5 based on inclusion confidence (Prompt B), to compute the model’s performance metrics. Results The review included 64 records after title and abstract screening, of which 18 after full text screening. Using records included by title and abstract as a reference, prompt B with a rating cut-off of 3 provided 82% sensitivity, 88% specificity and 99% negative predictive value (NPV). With articles included by full text as a reference, 100% sensitivity, 86% specificity, and 100% NPV. An 85% workload saving was reached. Prompts A showed higher workload savings (∼93%), high NPVs (∼100%) and specificity (∼96%), but lower sensitivity (62-72%). Conclusions Prompts with a rating cut-off of 3 achieved a better performance, and still relevant workload savings compared to binary classification prompts. These findings can inform prompt-engineering strategies to instruct LLMs and reach both high sensitivity and workload savings. Key messages • Systematic reviews provide evidence synthesis to guide policy and decision-making in healthcare and public health. Such process can be time-consuming, and need for timely evidence is often stringent. • LLMs can help reduce workload and speed up the title and abstract screening phase of a systematic review, which is considered a major bottleneck in the review process.

In adult dogs is supplementary tryptophan in the diet effective in reducing signs of anxiety?

Question In adult dogs, is dietary supplementation with tryptophan compared with no dietary tryptophan supplement effective in reducing signs of anxiety? Clinical bottom line The category of research question was: Treatment. The number and type of study designs that were critically appraised were: Two studies were found to be considered appropriate in the level of hierarchy of evidence pyramid. One study was a randomised double-blinded, placebo-controlled study and the other was a single-blind, placebo-controlled study. Critical appraisal of the selected papers meeting the inclusion criteria collectively provide zero/weak/moderate/strong evidence in terms of their experimental design and implementation: Moderate. The outcomes reported are summarised as follows… One study found no overall significant influence of tryptophan in the diet as an aid in reducing anxiety and fear-related behaviour in anxious dogs in household conditions. In contrast, the second study reported lower anxiety-related behaviour in dogs by owners but did not find significant differences in cortisol levels based on urine cortisol-to-creatinine ratio. In view of the strength of evidence and the outcomes from the studies the following conclusion is made… Current evidence reveals two studies that have evaluated the effectiveness of tryptophan as a supplement to the diets of anxious canines for pet owners. One study conducted did not find a significant effect or interaction in reducing anxiety-related behaviour whilst the second study reported lower anxiety-related behaviour in dogs by owners but did not find significant differences in cortisol levels based on urine cortisol-to-creatinine ratios. The use of tryptophan as a supplementary component in the diet is thus not enough as a sole treatment to assist in reducing anxiety in anxious adult dogs.

Erratum] Brain Imaging and neurostimulation in health and disorders: status report

INTRODUCTION: Despite being considered least important for clinical practice in the pyramid of evidence for recommendations, sometimes scientists' expert opinions could help to better understand the summarization of updated publications. OBJECTIVE: To provide a major summarized update about brain imaging and stimulation of the nervous system in health and disease. METHODS: Comprehensive review developed by experts in each subarea of knowledge in neuroimaging and non-invasive stimulation of the nervous system. A team of researchers and clinic experts was invited to present an update on their area of expertise. RESULTS: In basics on brain imaging techniques, we approach general and quantitative electroencephalography, functional magnetic resonance imaging, functional near-infrared spectroscopy, and experimental paradigms in brain imaging studies. Were included associations between transcranial magnetic stimulation and electromyography, electroencephalography, and functional near-infrared stimulation to evaluate brain activity. Furthermore, we showed several actualized central and peripheral neuromodulation techniques. And finally, we presented different clinical and performance uses of non-invasive neuromodulation. CONCLUSION: To our knowledge, this is a major summarized and concentrated update about brain imaging and stimulation that can benefit neuroscience researchers and clinicians from different levels of experience.

Fortifying the Evidence Pyramid in Anesthesiology and Perioperative Medicine: From Cornerstone to Capstone.

Fortifying the Evidence Pyramid in Anesthesiology and Perioperative Medicine: From Cornerstone to Capstone.

Does the holy grail of the evidence pyramid vindicate the controversial practice of endometrial scratching or is there room for healthy skepticism?

Does the holy grail of the evidence pyramid vindicate the controversial practice of endometrial scratching or is there room for healthy skepticism?

Acupressure, a promising intervention for fatigue, within the European nursing care pathways (ENP): An integrative review.

The aim of this study is to test whether acupressure for patients with fatigue is an efficient nursing intervention and if it can be implemented into the European nursing care pathways (ENP) nursing classification system. Previously, interventions for acupressure were included nonspecifically in ENP and therefore were not available for standardized nursing documentation in an electronic health record (EHR). Acupressure is a nursing intervention that is increasingly used in specific settings. ENP is a nursing classification system that provides evidence-based nursing interventions for nursing diagnoses. A systematic international literature search was conducted from May 2021 to December 2021. An iterative, hierarchical search process according to the 6S evidence pyramid was chosen. The results were reported following the PRISMA statement. Findings of 49 included publications that studied a total of 1,716 patients indicate that certain acupressure points may be efficient in treating fatigue. Acupressure is a useful nursing intervention and can really help patients experiencing fatigue. It is illustrated how the findings have been implemented in the development of ENP nursing interventions to document acupressure. The acupressure points most frequently used on the ear with positive effects in improving fatigue are Shen Men, liver, spleen, subcortex, endocrine, heart, and sympathetic, while the most common points on the body are ST 36, SP 6, LI 4, HT 7, KID 1, Ex-HN 3, Ex-HN, and KID 3. In the future, nurses will be able to use ENP to quickly and easily document acupressure interventions for fatigue in the EHR. In the EHR, the documentation of the nursing process with ENP could help to promote research into evidence-based approaches to fatigue by generating mass data on the different concepts of acupressure, which could lead to a clearer determination of the evidence and contribute to the safety of care and patients.

Summary of the best evidence for the prevention and management of myasthenic crisis after thymectomy.

Myasthenic crisis (MC) may occur after thymectomy in patients with myasthenia gravis (MG), but effective preventive interventions can reduce the occurrence of this complication. Previous research on MC focused on risk factors, emergency treatment, etc., which was relatively scattered and did not form a comprehensive management framework. This study sought to retrieve and summarize the relevant evidence on the prevention and management of postoperative MC to provide a theoretical reference for clinical medical staff. According to the evidence pyramid model, relevant articles were retrieved from UpToDate, British Medical Journal (BMJ) Best Practice, World Health Organization (WHO), Scottish Intercollegiate Guidelines Network (SIGN), Guidelines International Network (GIN), Australian Joanna Briggs Institute (JBI) Healthcare Database, Medlive, PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang. The types of evidence included clinical guidelines, expert consensus articles, clinical decisions, systematic reviews, and randomized controlled trials (RCTs). The quality evaluations were conducted using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation tool for guidelines, the Australian JBI Evidence-Based Healthcare Center evaluation tool for expert consensus articles, the Critical Appraisal for Summaries of Evidence (CASE) evaluation tool for clinical decisions, the Assessment of Multiple Systematic Reviews (AMSTAR) evaluation tool for systematic reviews, and the Cochrane risk-of-bias tool for RCTs. A total of 12 articles were included in this study, including three clinical guidelines, three expert consensus articles, three clinical decisions, two systematic reviews, and one RCT. From these articles, we summarized 39 pieces of evidence on the prevention and management of postoperative MC. This study summarized the best evidence on the prevention and management of postoperative MC and provided to clinical staffs evidence-based clinical approaches to help reduce the incidence of this complication.

Is meta-analysis the "top of the evidence pyramid" in cardiology?

The author comments on the significance and place of meta-analyses in modern evidence-based medicine, primarily in cardiology. The history of meta-analyses is briefly described. The main limitations of meta-analyses are reviewed. Examples are given where meta-analyses on the same problem had directly opposite results. The importance of meta-analyses in identifying side effects of drugs is discussed. The possibility of manipulating the results of meta-analyses is demonstrated. The significance of meta-analyses is currently being assessed through the example of the coronavirus pandemic, when different meta-analyses assessed the effectiveness and safety of the same drugs differently.The author concludes that meta-analyses should be excluded from level I evidence and given a more modest role in the hierarchy of evidence.

An umbrella review and meta-analysis of meta-analyses of the impact of Ramadan fasting on the metabolic syndrome components

Abstract Context Ramadan is a holy month of fasting, spiritual reflection, and worship for Muslims worldwide. However, the Ramadan fast – which involves abstaining from all food and drink, sunrise to sunset for 29 days–30 days annually – may also influence physical health outcomes, especially relating to the risk of metabolic syndrome. Objective The literature from the top of the pyramid of evidence was gathered and synthesized for this comprehensive umbrella review and meta-analysis of meta-analyses in order to provide an overall conclusion on the impact of Ramadan fasting with regard to metabolic syndrome components. Data Extraction Eleven systematic reviews and meta-analyses were included in the current umbrella review. Nine components, including waist circumference, body weight), high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure), and fasting blood plasma glucose were analyzed. Data Analysis The random-effects meta-analysis results revealed standard mean differences as follows: waist circumference –0.30 (95% confidence interval [CI] –0.33 to –0.27), body weight –0.34 (95% CI –0.39 to –0.29), high-density lipoprotein 0.20 (95% CI 0.10 to 0.30), low-density lipoprotein –0.10 (95% CI –0.13 to –0.07), total cholesterol –0.15 (95% CI –0.21 to –0.09), triglycerides –0.16 (95% CI –0.24 to –0.08), systolic blood pressure –0.20 (95% CI –0.23 to –0.17), diastolic blood pressure –0.20 (95% CI –0.22 to –0.18), fasting blood plasma glucose –0.10 (95% CI –0.12 to –0.08). Conclusion Ramadan fasting appears to benefit body weight, lipid profile, blood pressure, and fasting blood glucose levels. Therefore, engaging in fasting during Ramadan may contribute to weight reduction, decreased cardiovascular disease risk, improved blood pressure, and enhanced glycemic control. Nevertheless, the methodological quality of the included reviews ranged from low to critically low, necessitating cautious interpretation of conclusions drawn from these data. Systematic Review Registration Open Science Framework Identifier: DOI 10.17605/OSF.IO/9WVJZ.

Systematic review and meta-analysis: a critical examination of the methodology

Nowadays, the pyramid of evidence is the main model of decision-making for healthcare professionals. According to this concept, data from randomized clinical trials (RCTs) are considered lower in hierarchy than data obtained from systematic reviews (SRs) and meta-analyses (MAs). However, it заменить на:is not established whether it is appropriate to rate large RCTs with hard endpoints lower than SRs and MAs that combine data from smaller RCTs of questionable quality, or even from prospective or retrospective observational studies. It is also important to consider that in addition to assessing the quality of the studies included in the SRs and MAs, it is necessary to assess the accuracy of the SRs and MAs themselves. If not rigorously conducted, they can also contain systematic errors, leading to increased risks of data manipulation. The publication covers the main stages and principles of preparing SRs and MAs, common types of systematic errors that can arise at each stage, and methods to minimize them. We believe that the tools, knowledge, and skills we offer will help practicing doctors and healthcare professionals critically assess the results obtained from SRs and MAs in terms of methodology and the mitigation of potential data manipulation risks.

Brain Imaging and neurostimulation in health and disorders: status report

INTRODUCTION: Despite being considered least important for clinical practice in the pyramid of evidence for recommendations, sometimes scientists' expert opinions could help to better understand the summarization of updated publications. OBJECTIVE: To provide a major summarized update about brain imaging and stimulation of the nervous system in health and disease. METHODS: Comprehensive review developed by experts in each subarea of knowledge in neuroimaging and non-invasive stimulation of the nervous system. A team of researchers and clinic experts was invited to present an update on their area of expertise. RESULTS: In basics on brain imaging techniques, we approach general and quantitative electroencephalography, functional magnetic resonance imaging, functional near-infrared spectroscopy, and experimental paradigms in brain imaging studies. Were included associations between transcranial magnetic stimulation and electromyography, electroencephalography, and functional near-infrared stimulation to evaluate brain activity. Furthermore, we showed several actualized central and peripheral neuromodulation techniques. And finally, we presented different clinical and performance uses of non-invasive neuromodulation. CONCLUSION: To our knowledge, this is a major summarized and concentrated update about brain imaging and stimulation that can benefit neuroscience researchers and clinicians from different levels of experience.

A proof of concept that experience-based management of endometriosis can complement evidence-based guidelines.

Management of endometriosis should be based on the best available evidence. The pyramid of evidence reflects unbiased observations analysed with traditional statistics. Evidence-based medicine (EBM) is the clinical interpretation of these data by experts. Unfortunately, traditional statistical inference can refute but cannot confirm a hypothesis and clinical experience is considered a personal opinion. A proof of concept to document clinical experience by considering each diagnosis and treatment as an experiment with an outcome, which is used to update subsequent management. Experience and knowledge-based questions were answered on a 0 to 10 visual analogue scale (VAS) by surgery-oriented clinicians with experience of > 50 surgeries for endometriosis. The answers reflect the collective clinical experience of managing >10.000 women with endometriosis. Experience-based management was overall comparable as approved by >75% of answers rated ≥ 8/10 VAS. Knowledge-based management was more variable, reflecting debated issues and differences between experts and non-experts. The collective experience-based management of those with endometriosis is similar for surgery-oriented clinicians. Results do not conflict with EBM and are a Bayesian prior, to be confirmed, refuted or updated by further observations. Collective experience-based management can be measured and is more than a personal opinion. This might extend EBM trial results to the entire population and add data difficult to obtain in RCTs, such as many aspects of surgery.

Common misunderstandings of evidence-based medicine.

Currently, most evidence assessments in guidelines or health technology assessments (HTAs) rely on the assumption that arandomized controlled trial (RCT) is always the best source of evidence. However, if the outcome in acontrol group is certain, e.g. death within ashort time with an almost 100% chance, or if an event can only occur in the treatment group, there is no need for arandomized control group; the evidence cannot be improved by acontrol group, nor by an RCT design. If acause-effect relationship is certain ("primary or direct evidence"), atherapeutic effect can be diluted in the population of an RCT by cross-over, etc. This can lead to serious misinterpretations of the effect. While experts such as the GRADE group or Cochrane institutes recommend using all available evidence, the leading approach in many guidelines and HTAs is assessing "the best available trials", i.e. RCTs. But since RCTs only deliver probabilities of cause-effect relationships, it is not appropriate to demand RCTs for certain effects. Acontrol group can only diminish the net value of atreatment since the outcome in the control group is subtracted from the outcome in the treatment group. Therefore, under identical circumstances, an RCT will always show lower effect rates compared to asingle arm study of the same quality, for desired as well as for adverse effects. Considering these inconsistencies in evidence-based medicine interpretation, the evidence pyramid with RCTs at the top is not always areliable indicator for the best quality of evidence.

Choosing the Best Design in Surgical Research.

Choosing the Best Design in Surgical Research.

Response to Arendt-Nielsen et al. (Methodology considerations for the paper by Hosted et al. 2023).

Response to Arendt-Nielsen et al. (Methodology considerations for the paper by Hosted et al. 2023).

Outcome Comparison of Drug-Resistant Trigeminal Neuralgia Surgical Treatments—An Umbrella Review of Meta-Analyses and Systematic Reviews

Medical treatment for trigeminal neuralgia (TN) is not always a feasible option due to a lack of full response or adverse effects. Open surgery or percutaneous procedures are advocated in these cases. Several articles have compared the results among different techniques. Nevertheless, the findings of these studies are heterogeneous. Umbrella reviews are studies sitting at the peak of the evidence pyramid. With this umbrella review, we provided a systematic review of the outcomes of the surgical procedures used for TN treatment. Only systematic reviews and meta-analyses were included following the PRISMA guidelines. Ten articles were enrolled for qualitative and quantitative assessment. Level of evidence was quantified using a specific tool (AMSTAR-2). Results were heterogenous in terms of outcome and measurements. Microvascular decompression (MVD) appeared to be the most effective procedure both in the short-term (pain relief in 85-96.6% of cases) and long-term follow-up (pain relief in 64-79% of cases), although showed the highest rate of complications. The results of percutaneous techniques were similar but radiosurgery showed the highest variation in term of pain relief and a higher rate of delayed responses. The use of the AMSTAR-2 tool to quantify the evidence level scored three studies as critically low and seven studies as low-level, revealing a lack of good quality studies on this topic. Our umbrella review evidenced the need of well-designed comparative studies and the utilization of validated scales in order to provide more homogenous data for pooled-analyses and meta-analyses in the field of TN surgical treatment.

Patient-oriented research and the shiny object syndrome.

Patient-oriented research and the shiny object syndrome.

The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema.

Evidence-based medicine uses the current best evidence for decisions about patient care. Lymphedema is a chronic debilitating medical condition caused by a dysfunctional lymphatic system. This study analyzes the most cited articles, including the levels of evidence, for the surgical treatment of lymphedema. The Web of Science Sci-Expanded Index was utilized to search for surgical treatment of lymphedema. Articles were examined by three independent reviewers and the top 100 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed. Since 1970, the top 100 articles have been cited 7,300 times. The average citation count was 68 and standard deviation was 55. The majority was case series (71), followed by retrospective cohort (8), prospective cohort (7), retrospective case-control (5), and randomized controlled trials (2). Based on the "Level of Evidence Pyramid," 71 articles were level IV, 13 articles were level III, and 9 articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation Scale, there were 71 articles with "very low," 20 articles with "low," and 2 articles with "moderate" quality of evidence. The top 100 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of lymphedema will continue to improve.