Jeanette Buckingham

RAMESES publication standards: realist syntheses

BackgroundThere is growing interest in realist synthesis as an alternative systematic review method. This approach offers the potential to expand the knowledge base in policy-relevant areas -for example, by explaining the success, failure or mixed fortunes of complex interventions. No previous publication standards exist for reporting realist syntheses. This standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The projects aim is to produce preliminary publication standards for realist systematic reviews.MethodsWe (a) collated and summarized existing literature on the principles of good practice in realist syntheses; (b) considered the extent to which these principles had been followed by published syntheses, thereby identifying how rigor may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, realist research, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing realist syntheses and the open-access RAMESES online discussion list so as to capture problems and questions as they arose; and (e) synthesized expert input, evidence syntheses and real-time problem analysis into a definitive set of standards.ResultsWe identified 35 published realist syntheses, provided real-time support to 9 on-going syntheses and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature and common questions and challenges into briefing materials for the Delphi panel, comprising 37 members. Within three rounds this panel had reached consensus on 19 key publication standards, with an overall response rate of 91%.ConclusionThis project used multiple sources to develop and draw together evidence and expertise in realist synthesis. For each item we have included an explanation for why it is important and guidance on how it might be reported. Realist synthesis is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of realist syntheses.To encourage dissemination of the RAMESES publication standards, this article is co-published in the Journal of Advanced Nursing and is freely accessible on Wiley Online Library (http://www.wileyonlinelibrary.com/journal/jan). Please see related article http://www.biomedcentral.com/1741-7015/11/20 and http://www.biomedcentral.com/1741-7015/11/22

Best practices for elderly hip fracture patients. A systematic overview of the evidence.

OBJECTIVES: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture. DATA SOURCES: MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004. REVIEW METHODS: Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations. RESULTS: Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even “multidisciplinary” care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. CONCLUSIONS: The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.

Strength of evidence for perioperative use of statins to reduce cardiovascular risk: systematic review of controlled studies

Objective To determine the strength of evidence underlying recommendations for use of statins during the perioperative period to reduce the risk of cardiovascular events. Design Systematic review of studies with concurrent control groups. Data sources Four electronic databases, the references of identified studies, international experts on perioperative medicine, and the authors of the primary studies. Review methods Two reviewers independently extracted data from studies that reported acute coronary syndromes or mortality in patients receiving or not receiving statins during the perioperative period. Main outcome measure Random effects summary odds ratios for death or acute coronary syndrome during the perioperative period. Results 18 studies—two randomised trials (n=177), 15 cohort studies (n=799 632), and one case-control study (n=480)—assessed whether statins provide perioperative cardiovascular protection; 12 studies enrolled patients undergoing non-cardiac vascular surgery, four enrolled patients undergoing coronary bypass surgery, and two enrolled patients undergoing various surgical procedures. In the randomised trials the summary odds ratio for death or acute coronary syndrome during the perioperative period with statin use was 0.26 (95% confidence interval 0.07 to 0.99) and the summary odds ratio in the cohort studies was 0.70 (0.57 to 0.87). Although the pooled cohort data provided a statistically significant result, statins were not randomly allocated, results in retrospective studies were larger (odds ratio 0.65, 0.50 to 0.84) than those in the prospective cohorts (0.91, 0.65 to 1.27), and dose, duration, and safety of statin use was not reported. Conclusion The evidence base for routine administration of statins to reduce perioperative cardiovascular risk is inadequate.

Assessing the Methodological Quality of Nonrandomized Intervention Studies

In many areas of health care, randomized controlled trials (the best evidence regarding the effectiveness of health care interventions) are lacking and decision-makers have to rely on evidence from nonrandomized studies (NRS). We conducted a Medline search to identify English-language articles describing instruments for assessing the quality of NRS of health care interventions. These instruments varied greatly in scope, in the number and types of items and in developmental rigor. Items commonly included were those related to specification of study questions, allocation method, comparability of groups, and blinding of outcome assessment. We do not support the development of a generic scale to evaluate the methodological quality of nonrandomized intervention studies. Instead, further study should be directed to investigate the degree to which, and the circumstances under which, different methodological characteristics are associated with bias. This information will assist researchers in identifying a priori which methodological characteristics need careful evaluation in particular studies.

Rehabilitation in Patients with Dementia Following Hip Fracture: A Systematic Review

PURPOSE Best rehabilitation practices after hip fracture for people with dementia have not been established. A systematic review was conducted to determine current evidence for rehabilitation in this population, including residents in continuing care. METHODS Standardized review methodology was used to search eight databases for literature on hip-fracture rehabilitation for people with dementia. Eligible studies included participants with dementia who had a hip fracture; performed a rehabilitation intervention; and evaluated one or more of function, ambulation, discharge location, or falls. The Newcastle-Ottawa Scale was used to assess validity. RESULTS A total of 13 studies were included: five randomized controlled trials (RCTs), seven prospective cohort series, and one retrospective cohort study. Average quality ratings for RCTs and cohort studies were good and fair respectively. Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia. Only one study examined the effect of rehabilitation among residents in continuing care. CONCLUSIONS People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture, similar to gains achieved by those without dementia. More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia, including those residing in continuing-care settings. Purpose: Best rehabilitation practices after hip fracture for people with dementia have not been established. A systematic review was conducted to determine current evidence for rehabilitation in this population, including residents in continuing care. Methods: Standardized review methodology was used to search eight databases for literature on hip-fracture rehabilitation for people with dementia. Eligible studies included participants with dementia who had a hip fracture; performed a rehabilitation intervention; and evaluated one or more of function, ambulation, discharge location, or falls. The Newcastle–Ottawa Scale was used to assess validity. Results: A total of 13 studies were included: five randomized controlled trials (RCTs), seven prospective cohort series, and one retrospective cohort study. Average quality ratings for RCTs and cohort studies were good and fair respectively. Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia. Only one study examined the effect of rehabilitation among residents in continuing care. Conclusions: People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture, similar to gains achieved by those without dementia. More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia, including those residing in continuing-care settings.

In search of quality evidence for lifestyle management and glycemic control in children and adolescents with type 2 diabetes: A systematic review

BackgroundOur purpose was to evaluate the impact of lifestyle behavior modification on glycemic control among children and youth with clinically defined Type 2 Diabetes (T2D).MethodsWe conducted a systematic review of studies (randomized trials, quasi-experimental studies) evaluating lifestyle (diet and/or physical activity) modification and glycemic control (HbA1c). Our data sources included bibliographic databases (EMBASE, CINAHL®, Cochrane Library, Medline®, PASCAL, PsycINFO®, and Sociological Abstracts), manual reference search, and contact with study authors. Two reviewers independently selected studies that included any intervention targeting diet and/or physical activity alone or in combination as a means to reduce HbA1c in children and youth under the age of 18 with T2D.ResultsOur search strategy generated 4,572 citations. The majority of citations were not relevant to the study objective. One study met inclusion criteria. In this retrospective study, morbidly obese youth with T2D were treated with a very low carbohydrate diet. This single study received a quality index score of < 11, indicating poor study quality and thus limiting confidence in the studys conclusions.ConclusionsThere is no high quality evidence to suggest lifestyle modification improves either short- or long-term glycemic control in children and youth with T2D. Additional research is clearly warranted to define optimal lifestyle behaviour strategies for young people with T2D.

Evidence-based urology in practice: the cochrane library

You are seeing a 59-year-old-woman in your clinic, with symptoms of recurrent cystitis. The patient reports recurrent dysuria, frequency and haematuria every 2–3 months; this is extremely bothersome to her. Urine cultures during these episodes have been consistent with UTIs, and her symptoms have responded promptly to short-course antibiotic treatment. The patient’s past medical history, a review of systems and a physical examination are otherwise not contributory.

Rehabilitation for Long-term Care Residents Following Hip Fracture: A Survey of Reported Rehabilitation Practices and Perceived Barriers to Delivery of Care

Background and Purpose:In Canada, residents of long-term care (LTC) facilities are frequently transferred back to their residential facilities to continue recovery 1 week following hip fractures. Limited evidence is available regarding rehabilitation services in LTC facilities following hip fracture or rehabilitation practices after hip fracture for persons with dementia. We previously performed a systematic review of the impact of rehabilitation after hip fractures on persons with dementia. The purpose of this project was to augment our systematic review findings and determine current reported rehabilitation practices of rehabilitation professionals working in LTC facilities with hip-fractured patients with dementia and examine perceived barriers to the delivery of rehabilitation. Methods:We performed a survey study of rehabilitation professionals working in LTC facilities in a Canadian province, using a modified Delphi Consensus approach and a Web-based survey format. The survey was constructed on the basis of our systematic literature review and through discussions with clinical experts. A 2-round modified Delphi consensus approach was used to attain consensus among respondents. Examination of agreement and disagreement among respondents in the areas of (1) current practice and (2) perceived barriers to care was undertaken. Results:A total of 42 respondents completed round 1 and 27 respondents completed round 2. Respondents were primarily female and working as physical therapists or occupational therapists. Most worked at facilities that employed at least 1 physical therapist and 1 occupational therapist. Treatment strategies for patients with hip fracture focused on return to independent ambulation and transfers. Although cognition was seen as a barrier to treatment, respondents implemented strategies to mitigate this barrier. Inadequate time and staffing were also seen as barriers to effective treatment. Discussion:Rehabilitation professionals working in LTC facilities reported that the residents with dementia can and should participate in rehabilitation following hip fractures; however, they identified time and staffing constraints in addition to cognitive impairment as barriers. Conclusions:Current research in LTC facilities is very sparse and little is known about the rehabilitation care provided in these facilities. Further research is needed to determine the most effective rehabilitation interventions following hip fractures for residents of LTC facilities with dementia.