Quality Of Supporting Evidence Research Articles

Advanced neuroimaging techniques to explore the effects of motor and cognitive rehabilitation in multiple sclerosis.

Progress in magnetic resonance imaging (MRI) technology and analyses is improving our comprehension of multiple sclerosis (MS) pathophysiology. These advancements, which enable the evaluation of atrophy, microstructural tissue abnormalities, and functional plasticity, are broadening our insights into the effectiveness and working mechanisms of motor and cognitive rehabilitative treatments. This narrative review with selected studies discusses findings derived from the application of advanced MRI techniques to evaluate structural and functional neuroplasticity modifications underlying the effects of motor and cognitive rehabilitative treatments in people with MS (PwMS). Current applications as outcome measure in longitudinal trials and observational studies, their interpretation and possible pitfalls and limitations in their use are covered. Finally, we examine how the use of these techniques could evolve in the future to improve monitoring of motor and cognitive rehabilitative treatments. Despite substantial variability in study design and participant characteristics in rehabilitative studies for PwMS, improvements in motor and cognitive functions accompanied by structural and functional brain modifications induced by rehabilitation can be observed. However, significant enhancements to refine rehabilitation strategies are needed. Future studies in this field should strive to implement standardized methodologies regarding MRI acquisition and processing, possibly integrating multimodal measures. This will help identifying relevant markers of treatment response in PwMS, thus improving the use of rehabilitative interventions at individual level. The combination of motor and cognitive strategies, longer periods of treatment, as well as adequate follow-up assessments will contribute to enhance the quality of evidence in support of their routine use.

Guidelines for the Evaluation of Pulmonary Nodules Detected Incidentally or by Screening: A Survey of Radiologist Awareness, Agreement, and Adherence From the Watch the Spot Trial.

The aim of this study was to examine radiologists' beliefs about existing guidelines for pulmonary nodule evaluation. A self-administered survey was developed to ascertain awareness of, agreement with, and adherence to published guidelines, including those from the Fleischner Society and the Lung CT Screening Reporting and Data System (Lung-RADS™). Surveys were distributed to 514 radiologists at 13 health care systems that are participating in a large, pragmatic trial of pulmonary nodule evaluation. Prespecified comparisons were made among groups defined by type of health system, years of experience, reader volume, and study arm. The response rate was 26.3%. Respondents were most familiar with guidelines from Fleischner (94%) and Lung-RADS (71%). For both incidental and screening-detected nodules, self-reported adherence to preferred guidelines was very high (97% and 94%, respectively), and most respondents believed that the benefits of adherence outweigh the harms (81% and 74%, respectively). Underlying evidence was thought to be high in quality by 68% of respondents for screening-detected nodules and 41% for incidental nodules. Approximately 70% of respondents believed that the frequency of recommended follow-up was "just right" for both guidelines. Radiologists who practice in nonintegrated health care systems were more likely to believe that the evidence was high in quality (79.5% versus 57.1%) and that the benefits of adherence outweigh the harms (85.1% versus 67.5%). Low-volume readers had lower awareness and self-reported adherence than higher volume readers. Radiologists reported high levels of familiarity and agreement with and adherence to guidelines for pulmonary nodule evaluation, but many overestimated the quality of evidence in support of the recommendations.

470 Nutritional Deficiencies in Irritable Bowel Syndrome: A North American Population-Based Study

INTRODUCTION: Irritable bowel syndrome (IBS) is common, affecting 12% of the population. However, the quality of evidence in support of current medical interventions has been rated as very low, and the majority of those with IBS report their symptoms as being unchanged or worsened over time. Diet is thought to play a significant role in IBS, and there is increasing focus on the therapeutic benefit of diet and supplementation. This study aims to compare dietary composition and serologic markers of nutritional status in those with and without IBS to determine potential targets for therapeutic supplementation. METHODS: All 17 national surveys between 1959 and 2019 were screened and only one, the Second National Health and Nutrition Examination Survey (NHANES II) (1976-1980), provided comprehensive data on IBS. We performed a cross-sectional analysis of serology and dietary composition of 12,295 individuals, aged 18 to 74 in NHANES II. Dietary composition was drawn from dietary recall questionnaires, and the diagnosis of IBS was based on self-reporting. RESULTS: Individuals with IBS had significantly higher copper-zinc ratios (1.70 versus 1.55, P = 0.048) and were more likely to have ratios above 1.8 (odds ratio 1.79, 95% confidence interval 1.02-3.13), suggestive of an underlying zinc deficiency. This deficiency may be due to their avoidance of milk, which was the largest source of dietary zinc in the study population. While they were significantly more likely to report dietary avoidances, they had no other serologic evidence of nutritional deficiencies. Additionally, dietary recall showed that they consumed significantly more daily calories (P = 0.02), were more likely to take vitamin supplements (P = 0.003) and that their macro and micronutrient intake was not significantly different. CONCLUSION: The findings suggest that individuals with IBS should be screened for zinc deficiency. Zinc deficiency may perpetuate the underlying pathophysiology of IBS and may contribute to the associated psychiatric conditions through zinc's role in the immune system, “brain-gut” axis, and gastrointestinal barrier integrity. This suggests that zinc supplementation may be a potential therapy both to mitigate underlying pathology as well as improve symptoms. Our findings should be confirmed in future studies, and the association of copper-zinc ratios with symptom severity, and the response of symptoms to supplementation could be investigated.

Testing validity inferences for Genetic Drift Inventory scores using Rasch modeling and item order analyses

BackgroundConcept inventories (CIs) are commonly used tools for assessing student understanding of scientific and naive ideas, yet the body of empirical evidence supporting the inferences drawn from CI scores is often limited in scope and remains deeply rooted in Classical Test Theory. The Genetic Drift Inventory (GeDI) is a relatively new CI designed for use in diagnosing undergraduate students’ conceptual understanding of genetic drift. This study seeks to expand the sources of evidence examining validity and reliability inferences produced by GeDI scores. Specifically, our research focused on: (1) GeDI instrument and item properties as revealed by Rasch modeling, (2) item order effects on response patterns, and (3) generalization to a new geographic sample.MethodsA sample of 336 advanced undergraduate biology majors completed four equivalent versions of the GeDI. Rasch analysis was used to examine instrument dimensionality, item fit properties, person and item reliability, and alignment of item difficulty with person ability. To investigate whether the presentation order of GeDI item suites influenced overall student performance, scores were compared from randomly assigned, equivalent test versions varying in item-suite presentation order. Scores from this sample were also compared with scores from similar but geographically distinct samples to examine generalizability of score patterns.ResultsRasch analysis indicated that the GeDI was unidimensional, with good fit to the Rasch model. Items had high reliability and were well matched to the ability of the sample. Person reliability was low. Rotating the GeDI’s item suites had no significant impact on scores, suggesting each suite functioned independently. Scores from our new sample from the NE United States were comparable to those from other geographic regions and provide evidence in support of score generalizability. Overall, most instrument features were robust. Suggestions for improvement include: (1) incorporation of additional items to differentiate high-ability persons and improve person reliability, and (2) re-examination of items with redundant or low difficulty levels.ConclusionsRasch analyses of the GEDI instrument and item order effects expand the range and quality of evidence in support of validity claims and illustrate changes that are likely to improve the quality of this (and other) evolution education instruments.

Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review

Study DesignSystematic review. IntroductionPatient adherence to orthosis wear and/or prescribed exercises improves functional outcome after acute injury and can prevent deformities, contractures, and reinjury of tissues. This is the first systematic review to review the evidence of the effectiveness of interventions to improve treatment adherence in children and adults with acute or chronic upper limb injuries or conditions. Purpose of the StudyThe purpose of this study is to establish the effectiveness of interventions to improve hand therapy adherence in people with upper limb conditions and to report on outcome measures used when reporting adherence. MethodsA literature search of MEDLINE (OVID), Embase (OVID), CENTRAL (OVID), CINAHL (EBSCO), and EmCare (OVID) (from inception to March 2017) was undertaken. Studies were selected if they met the following inclusion criteria: clinical trials; in adults or children with any injury or condition affecting the upper limb including acute trauma and injury; chronic and acquired musculoskeletal conditions; and neurological conditions. Two independent assessors rated the study quality and risk of bias using the Cochrane Collaboration tool for assessing the risk of bias. ResultsEight studies met the inclusion criteria. Study quality ranged from 3 to 6 out of 7 points on the Cochrane risk of bias tool. There were 4 categories of intervention for improving adherence: orthosis/cast material/design; orthosis wear schedule; patient education mode for home exercise programs; and behavioral approaches. Due to heterogeneity of condition acuity, interventions, and outcomes reported, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is weak evidence from a very small number of trials that orthosis/cast material has no influence on treatment adherence in acute or chronic conditions and mode of patient education (audio-visual vs written) has no effect in acute conditions. There is low-to-moderate quality of evidence in support of behavioral interventions for achieving treatment adherence in chronic rheumatoid arthritis. ConclusionBehavioral approaches that encourage self-efficacy are likely to be useful in achieving treatment adherence in populations with chronic upper limb conditions. There is insufficient evidence for other interventions aimed at improving adherence in acute upper limb injuries and conditions.

30 Patient experience of a telephone nodule follow-up clinic

The aim of this study was to examine radiologists’ beliefs about existing guidelines for pulmonary nodule evaluation.A self-administered survey was developed to ascertain awareness of, agreement with, and adherence to published guidelines, including those from the Fleischner Society and the Lung CT Screening Reporting and Data System (Lung-RADS™). Surveys were distributed to 514 radiologists at 13 health care systems that are participating in a large, pragmatic trial of pulmonary nodule evaluation. Prespecified comparisons were made among groups defined by type of health system, years of experience, reader volume, and study arm.The response rate was 26.3%. Respondents were most familiar with guidelines from Fleischner (94%) and Lung-RADS (71%). For both incidental and screening-detected nodules, self-reported adherence to preferred guidelines was very high (97% and 94%, respectively), and most respondents believed that the benefits of adherence outweigh the harms (81% and 74%, respectively). Underlying evidence was thought to be high in quality by 68% of respondents for screening-detected nodules and 41% for incidental nodules. Approximately 70% of respondents believed that the frequency of recommended follow-up was “just right” for both guidelines. Radiologists who practice in nonintegrated health care systems were more likely to believe that the evidence was high in quality (79.5% versus 57.1%) and that the benefits of adherence outweigh the harms (85.1% versus 67.5%). Low-volume readers had lower awareness and self-reported adherence than higher volume readers.Radiologists reported high levels of familiarity and agreement with and adherence to guidelines for pulmonary nodule evaluation, but many overestimated the quality of evidence in support of the recommendations.

ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR PROLIFERATIVE DIABETIC RETINOPATHY: A Systematic Review and Meta-Analysis.

To systematically review and perform meta-analysis on the available randomized controlled trial data for anti-vascular endothelial growth factor (anti-VEGF) agents in the management of proliferative diabetic retinopathy and its complications. The authors identified randomized controlled trials using anti-VEGF agents, either as stand-alone therapy or combined with other interventions, in the management of proliferative diabetic retinopathy. The primary outcome measures were change in best-corrected visual acuity and (in the context of vitrectomy) duration of surgery and postoperative vitreous hemorrhage. Secondary outcomes were change in central retinal thickness and (in the context of vitrectomy) intraoperative variables suggestive of complex surgery (retinal breaks, intraoperative bleeding, and endodiathermy applications). The quality of evidence for all outcomes was appraised using the GRADE criteria. Twenty-two studies involving 1,397 subjects met the criteria for inclusion in this study. One study compared intravitreal ranibizumab with saline, one compared intravitreal pegaptanib to pan-retinal photocoagulation (PRP), one compared intravitreal bevacizumab to PRP, 3 compared combined intravitreal ranibizumab/PRP to PRP, 5 compared combined intravitreal bevacizumab/PRP to PRP alone, and 11 compared combined intravitreal bevacizumab/PPV to PPV alone. When used in conjunction with PRP, there is a high-quality evidence to suggest that intravitreal ranibizumab is associated with superior visual acuity and central retinal thickness outcomes at 3 months to 4 months. In the context of PPV, there is moderate quality evidence to suggest that preoperative intravitreal bevacizumab results in a significant reduction in the duration of surgery, fewer retinal breaks, less intraoperative bleeding, and fewer endodiathermy applications. Although there is evidence to suggest occurrence of early postoperative vitreous hemorrhage is reduced, the quality of evidence in support of this finding is low. The use of anti-VEGF agents before PRP results in superior functional and structural outcomes at 3 months to 4 months. The use of anti-VEGF agents before PPV results in decreased duration of surgery, fewer breaks, and less intra-operative bleeding. Although there is evidence for a decreased incidence of early postoperative vitreous hemorrhage, the quality of evidence is low. The available data therefore support the use of anti-VEGF agents as adjuncts to PRP and PPV in patients with complicated proliferative diabetic retinopathy primarily as a means of facilitating, and potentially minimizing the iatrogenic damage resulting from, these procedures.

Evidence-based laparoscopic appendectomy practice requires national database studies

Dear Editor, As the article by Saia et al. [1] indicates, administrative databases are useful in comparing different surgical techniques: randomized, controlled trials are difficult to realize, require large sample sizes, and are mostly subject to blinding biases. The results demonstrated in this study contribute to the discussion around data published in two surveys concerning dissemination of laparoscopic appendectomy (LA) in Italy, commissioned by two different scientific surgical societies [2, 3]. The overview provided of the situation, 7 years after these initial results, confirm the increasing rate of LAs, particularly in fertile women. The use of LA is undoubtedly evidence based; no hard evidence confirms its application to subgroups different from premenopausal women, where the rate of differential diagnoses, after exploratory laparoscopy, is quite high. A Cochrane review by Sauerland et al. [4] emphasizes the poor quality of evidence in support of the advantages of an all-comers policy for LA. Similarly, the noted trend of performing fewer appendectomies can be due to the increasing application of antibiotic therapy to uncomplicated cases, which can be effective in most patients and can help avoid the need for surgery, as proved in a recent meta-analysis [5]. The major concern for the surgeon and the patient in the dissemination of LA has been the suspected increase in the rate of postoperative intra-abdominal abscesses, which might require a prolongation of the hospital stay or the need for a second surgery; thus, it would be interesting to retrieve from the Veneto regional database the number of readmissions, so as to ascertain the real entity of this problem and its trend over the 8-year period. More recent reports have downplayed this complication [6], but the problem remains unresolved. Today, surgical training and standardization of the technique seem of utmost importance. Surgeon training is a fundamental issue, and it must be analyzed, in the existing health care systems, on the basis of a single ward or practice. One of the above-mentioned national surveys demonstrated that LA is performed in more than 90 % of the hospitals, but in low numbers (30–60 % of appendectomies) and by a selected laparoscopic team (\30 % of the surgeons working in the same practice), and is not related to case volume [2]. One of the answers to the extreme regional variability in the number of LAs performed might be standardization of the surgical approach through the wide adoption of surgical evidence-based guidelines that must be realized, implemented, and controlled by national scientific societies in tandem with a central health institute. This has been accomplished in Italy with the drafting of evidence-based guidelines and their diffusion through the scientific literature [7, 8] and through the Italian Istituto Superiore di Sanita (http://www.snlg-iss.it/cms/files/LG_ACOI_appendicectomia_ %20laparoscopica.pdf). This correspondence is written on behalf of ACOI (Associazione Chirurghi Ospedalieri Italiani) and SICE (Societa Italiana Chirurgia Endoscopica e Nuove Tecnologie).

Recovery in mental health policy: good strategy or bad rhetoric?

This article explores current positions on ‘recovery’ in Scottish mental health policy and the practical limitations of these positions from a rhetorical perspective. It is not our intention to conduct a formal policy analysis but rather to open up an argumentative space for thinking critically about recovery. In adopting a rhetorical perspective, we are concerned not with the quality of evidence in support of recovery per se, but with the quality of the arguments and the manner in which these have been produced, reproduced and promulgated to support recovery in terms of its adoption in policy and practice within the Scottish context. We sketch the background to the ‘case for’ recovery in Scotland by drawing upon key policy documents, referring to the public mental health focus in Scotland's mental health policy, and indicate how policy and practice on recovery have been evaluated in that context. We then explore the value of critical dialogue by exploring the potential limitations of the case for recovery by considering hope and the medical model as examples of themes in recovery policy and practice. In light of this analysis, we argue that while the policy and its implementation might be understood as a good strategy for addressing major issues in mental health, it is bad rhetoric to the extent that it limits argument, and therefore practical deliberation, about recovery. In conclusion, we discuss the implications of our argument for mental health practitioners, for whom a critical stance on health policy is a necessary resource.

Quality and relevance of evidence in support of guideline recommendations for sleep laboratory investigations

As part of a review of guidelines for sleep laboratories, this study summarizes the quality and relevance of evidence cited in support of recommendations on investigations for individuals with sleep disorders. Quality of evidence in support of each recommendation was rated as A (from well-conducted, prospective controlled studies), B (from controlled studies and case series, with minor shortcomings), or C (from case series or case series plus controlled studies with substantial limitations). Relevance of the cited evidence was also rated from A to C, in decreasing order of merit. Of eighty-one recommendations from thirty-seven guidelines, forty-six were supported by evidence from primary studies. Six recommendations were supported by category A evidence, fifteen by category B, and twenty-five recommendations by category C. The cited evidence was highly relevant to eighteen recommendations, of some relevance for twenty-two and of little or no relevance to six. Four recommendations were informed by an absence of available evidence. For the other thirty-one, no evidence was provided in support. The approach used provided a concise overview of recommendations and supporting evidence for decision-makers. Guidelines on the use of sleep laboratory investigations contain much detailed information, but evidence supporting several recommendations is of limited quality and relevance. Furthermore, good-quality studies of many sleep laboratory applications are needed to assist both health policy formulation and clinical practice.

Teaching evidence-based medicine skills can change practice in a community hospital

Several studies have evaluated whether evidence-based medicine (EBM) training courses can improve skills such as literature searching and critical appraisal but to date, few data exist on whether teaching EBM skills and providing evidence-based resources result in change in behavior or clinical outcomes. This study was conducted to evaluate whether a multifaceted EBM intervention consisting of teaching EBM skills and provision of electronic evidence resources changed clinical practice. Before/after study. The medical inpatient units at a district general hospital. Thirty-five attending physicians and 12 medicine residents. A multicomponent EBM intervention was provided including an EBM training course of seven 1-hour sessions, an EBM syllabus and textbook, and provision of evidence-based resources on the hospital network. The primary outcome of the study was the quality of evidence in support of therapies initiated for the primary diagnoses in 483 consecutive patients admitted during the month before and the month after the intervention. Patients admitted after implementation of the EBM intervention were significantly more likely to receive therapies proven to be beneficial in randomized controlled trials (62% vs 49%; P= .016). Of these trial-proven therapies, those offered after the EBM intervention were significantly more likely to be based on high-quality randomized controlled trials (95% vs 87%; P= .023). A multifaceted intervention designed to teach and support EBM significantly improved evidence-based practice patterns in a district general hospital.

Development of guidelines to facilitate improved support of South Asian carers by primary health care teams

Background—Evidence based guidelines are regarded as an appropriate basis for providing effective health care, but few guidelines incorporate the views of users such as carers. Aim—To develop guidelines to assist...

Assessing the Quality of Evidence in Support of Resection of a Uterine Septum

Objectives: Though well entrenched as a recommended therapy in select circumstances, the rationale and strength for resection of a uterine septum remains unclear. The purpose of the present study was to evaluate the quality of evidence in support of resection of a uterine septum using an evidence based approach.

Need for evidence-based practice in prosthodontics

Statement Of Problem. Patients, their insurers, the courts, and the scientific community are demanding more evidence to support the effectiveness of health care strategies. Purpose. This article describes evidence-based practice, its origins, and value as a way of addressing the demand for evidence of treatment effectiveness in maxillofacial prosthetics. Material And Methods. A limited review of maxillofacial prosthetics literature was performed using Medline over the years 1966 to 1998. The retrieved articles were classified by methodologic design and assessed for the strength of their evidence. Results. Focused and speedy (but not necessarily comprehensive) literature searching methods are available. Critical appraisal skills are available and needed to assess the quality of evidence in support of a treatment and to maintain clinical skills. Conclusion. With appropriate skills and the availability of literature searching hardware and software, evidence-based practice is a powerful means for the practitioner to establish the effectiveness of individual patient treatment, and to prevent the diminution of clinical skills over the course of a career. These skills should be included in training programs. (J Prosthet Dent 2000;83:58-65.)