Ornella Clavisi

Living Systematic Reviews: An Emerging Opportunity to Narrow the Evidence-Practice Gap

Julian Elliott and colleagues discuss how the current inability to keep systematic reviews up-to-date hampers the translation of knowledge into action. They propose living systematic reviews as a contribution to evidence synthesis to enhance the accuracy and utility of health evidence.

Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults.

Reason for withdrawal from publication July 2016 Owing to the age, retraction of studies (Lehmann 2001; Lehmann 2002; Triem 2006), and possible errors in the conversion of dose for the purpose of analysis the decision has been reached to withdraw the review from the CDSR pending update and amendment of the review.

Effective stakeholder participation in setting research priorities using a Global Evidence Mapping approach.

OBJECTIVE We present a multistep process for identifying priority research areas in rehabilitation and long-term care of traumatic brain-injured (TBI) patients. In particular, we aimed to (1) identify which stakeholders should be involved; (2) identify what methods are appropriate; (3) examine different criteria for the generation of research priority areas; and (4) test the feasibility of linkage and exchange among researchers, decision makers, and other potential users of the research. STUDY DESIGN AND SETTING Potential research questions were identified and developed using an initial scoping meeting and preliminary literature search, followed by a facilitated mapping workshop and an online survey. Identified research questions were then prioritized against specific criteria (clinical importance, novelty, and controversy). Existing evidence was then mapped to the high-priority questions using usual processes for search, screening, and selection. A broad range of stakeholders were then brought together at a forum to identify priority research themes for future research investment. Using clinical and research leaders, smaller targeted planning workshops prioritized specific research projects for each of the identified themes. RESULTS Twenty-six specific questions about TBI rehabilitation were generated, 14 of which were high priority. No one method identified all high-priority questions. Methods that relied solely on the views of clinicians and researchers identified fewer high-priority questions compared with methods that used broader stakeholder engagement. Evidence maps of these high-priority questions yielded a number of evidence gaps. Priority questions and evidence maps were then used to inform a research forum, which identified 12 priority themes for future research. CONCLUSION Our research demonstrates the value of a multistep and multimethod process involving many different types of stakeholders for prioritizing research to improve the rehabilitation outcomes of people who have suffered TBI. Enhancing stakeholder representation can be augmented using a combination of methods and a process of linkage and exchange. This process can inform decisions about prioritization of research areas.

Review article: Prehospital fluid management in traumatic brain injury

The early management of patients who have sustained traumatic brain injury is aimed at preventing secondary brain injury through avoidance of cerebral hypoxia and hypoperfusion. Especially in hypotensive patients, it has been postulated that hypertonic crystalloids and colloids might support mean arterial pressure more effectively by expanding intravascular volume without causing problematic cerebral oedema. We conducted a systematic review to investigate if hypertonic saline or colloids result in better outcomes than isotonic crystalloid solutions, as well as to determine the safety of minimal volume resuscitation, or delayed versus immediate fluid resuscitation during prehospital care for patients with traumatic brain injury. We identified nine randomized controlled trials and one cohort study examined the effects of hypertonic solutions (with or without colloid added) for prehospital fluid resuscitation. None has reported better survival and functional outcomes over the use of isotonic crystalloids. The only trial of restrictive resuscitation strategies was underpowered to demonstrate its safety compared with aggressive early fluid resuscitation in head injured patients, and maintenance of cerebral perfusion remains the top priority.

Searches for evidence mapping: effective, shorter, cheaper.

An evidence map is an overview of a broad research field that describes the volume, nature, and characteristics of research in that field [1]. Evidence maps can indicate research links, gaps, and strengths in a broad clinical context, while systematic reviews focus on a single clinical question [2, 3]. Maps complement systematic reviews by engaging stakeholders to identify and prioritize questions that may be informed by research evidence, highlighting the applicability of research evidence to different populations and contexts, and identifying important gaps that can inform further primary research or systematic reviews [3]. Evidence mapping can be a labor-intensive process, as it must provide an overview of the nature and characteristics of all research in any given field (Figure 1, online only). There are many more potentially useful references to review when mapping a topic area than when answering a specific clinical question, as in a systematic review. The searching challenges for evidence mapping are similar to those of a rapid review, which also needs to produce high-quality evidence with reduced resources. In the case of the rapid review, the time needed is limited [4]. The Global Evidence Mapping (GEM) Initiative was funded in 2007 by the Victorian Neurotrauma Initiative (Australia) to map the research addressing important questions about treatments, diagnostic tests, prognosis, and cost effectiveness in the broad clinical areas of traumatic brain injury (TBI) and spinal cord injury (SCI). The project involved identifying the scope of clinical issues in pre-hospital, acute, and rehabilitation (long-term care) for TBI and SCI; identifying key questions in the area; and developing evidence maps to support strategic allocation of research funds. Although a number of sources, including, but not confined to, electronic databases [5, 6], were routinely checked as part of this project, this paper describes an evaluation of just the electronic database-searching procedures and methodologies that were developed to populate the evidence maps. Pragmatic changes to otherwise rigorous and accepted procedures were done only after consideration of time and benefit. At the end of the project, a newly developed evidence mapping search method was compared with highly sensitive systematic review searches using PubMed MEDLINE as the test searching platform. The evaluation of the effectiveness of these two methods was based on the following parameters: yield, sensitivity, time requirements, and resource use.

Pharmacological interventions in traumatic brain injury: Can we rely on systematic reviews for evidence?

INTRODUCTION Providing current, reliable and evidence based information for clinicians and researchers in a synthesised and summarised way can be challenging particularly in the area of traumatic brain injury where a vast number of reviews exists. These reviews vary in their methodological quality and are scattered across varying sources. In this paper, we present an overview of systematic reviews that evaluate the pharmacological interventions in traumatic brain injury (TBI). By doing this, we aim to evaluate the existing evidence for improved outcomes in TBI with pharmacological interventions, and to identify gaps in the literature to inform future research. METHODS We searched the Neurotrauma Evidence Map on systematic reviews relating to pharmacological interventions for managing TBI in acute phase. Two reviewers independently screened search results and appraised each systematic review using the validated AMSTAR tool and extracted data from the review. RESULTS A total of 288 systematic reviews relating to TBI were available on the Neurotrauma Evidence Map at the time of this study. We identified 19 systematic reviews on pharmacological management for acute TBI with publications dates ranging from 1998 to 2014. The studies were of varying methodological quality, with a mean AMSTAR score of 7.78 (range 2-11]. CONCLUSION The evidence from high quality systematic reviews show that there is currently insufficient evidence for the use of magnesium, monoaminergic and dopamine agonists, progesterone, aminosteroids, excitatory amino acid inhibitors, haemostatic and antifibrinolytic drugs in TBI. Anti-convulsants are only effective in reducing early seizures with no significant difference between phenytoin and leviteracetam. There is no difference between propofol and midazolam for sedation in TBI patients and ketamine may not cause increased ICP. Overviews of systematic review provide informative and powerful summaries of evidence based research.

Target-Controlled Infusion Versus Manually-Controlled Infusion of Propofol for General Anaesthesia or Sedation in Adults

BACKGROUND: Continuous infusions of the IV anesthetic propofol are commonly used to induce and maintain sedation and general anesthesia. Infusion devices can be manually controlled (MCI) where the anesthesiologist makes each change to the infusion rate or target-controlled (TCI) where the anesthesiologist sets a target blood or effect-site concentration and the computerized infusion device makes the necessary changes to the infusion rate. Randomized trials have explored the differences in quality of anesthesia, adverse event rate and cost between TCI and MCI but the effectiveness of TCI compared with MCI remains controversial. As TCI is in widespread international use, and potentially may be more expensive without added benefit, a systematic review of randomized, controlled trials comparing TCI and MCI is warranted. OBJECTIVES: We assessed whether TCI of propofol is as effective as MCI of propofol with respect to quality of anesthesia or sedation, adverse events and propofol drug cost. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 3); PubMED (1950 to July week 2 2007); and EMBASE via OVID (1980 to week 28 2007). We also searched LILACS, CINAHL, ISI Web Knowledge, Panteleimon, KoreaMed, and IndMed. We searched for ongoing trials via the National Research Register and metaRegister of Controlled Trials. SELECTION CRITERIA: We planned to include all published and unpublished randomized, controlled trials that compared TCI of propofol with MCI of propofol for general anesthesia or sedation in adult surgical patients. Only published studies were included as no unpublished studies were identified. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted outcome data. We contacted study authors and the pharmaceutical industry for additional information. MAIN RESULTS: Twenty trials of poor quality that involved 1759 patients were included. Heterogeneity was high (that is, the trials did not compare the same things). TCI was associated with higher total doses of propofol than was MCI resulting in marginally higher propofol drug costs. However, fewer interventions were required by the anesthesiologist during the use of TCI compared with MCI. No clinically significant differences were demonstrated in terms of quality of anesthesia or adverse events. AUTHORS’ CONCLUSIONS: This systematic review does not provide sufficient evidence for us to make firm recommendations about the use of TCI versus MCI in clinical anesthetic practice. The full review is available: Leslie K, Clavisi O, Hargrove J. Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults. Cochrane Database Syst Rev 2008, Issue 3. Art. No.: CD006059. DOI: 10.1002/14651858.CD006059.pub2. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review (see www.thecochranelibrary.com for information). Peribulbar Versus Retrobulbar Anaesthesia for Cataract Surgery

Title and Abstract Screening and Evaluation in Systematic Reviews (TASER): a pilot randomised controlled trial of title and abstract screening by medical students

BackgroundThe production of high quality systematic reviews requires rigorous methods that are time-consuming and resource intensive. Citation screening is a key step in the systematic review process. An opportunity to improve the efficiency of systematic review production involves the use of non-expert groups and new technologies for citation screening. We performed a pilot study of citation screening by medical students using four screening methods and compared students’ performance to experienced review authors.MethodsThe aims of this pilot randomised controlled trial were to provide preliminary data on the accuracy of title and abstract screening by medical students, and on the effect of screening modality on screening accuracy and efficiency. Medical students were randomly allocated to title and abstract screening using one of the four modalities and required to screen 650 citations from a single systematic review update. The four screening modalities were a reference management software program (EndNote), Paper, a web-based systematic review workflow platform (ReGroup) and a mobile screening application (Screen2Go). Screening sensitivity and specificity were analysed in a complete case analysis using a chi-squared test and Kruskal-Wallis rank sum test according to screening modality and compared to a final set of included citations selected by expert review authors.ResultsSensitivity of medical students’ screening decisions ranged from 46.7% to 66.7%, with students using the web-based platform performing significantly better than the paper-based group. Specificity ranged from 93.2% to 97.4% with the lowest specificity seen with the web-based platform. There was no significant difference in performance between the other three modalities.ConclusionsMedical students are a feasible population to engage in citation screening. Future studies should investigate the effect of incentive systems, training and support and analytical methods on screening performance.Systematic review registrationCochrane Database CD001048

The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map

Objective To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). Methods We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as ‘current’ when it included the most recently published RCT we found on their topic, and ‘complete’ when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). Findings We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. Conclusion A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.