Objective To evaluate the relevant systematic reviews/meta-analyses that focused on the prevention and treatment of complications after impacted tooth extraction. Methods The systematic reviews/meta-analyses on the prevention and treatment of complications after impacted tooth extraction were searched in PubMed, The Cochrane Library, CBM, CNKI and WanFang Data from inception to September 30th, 2012, and a total of 15 professional journals and the references of included studies were also retrieved manually. Two reviewers screened the literature according to the inclusion criteria and extracted the data. Then the AMSTAR was used to evaluate the quality of the included studies, and the GRADE system was used to evaluate the quality of evidence. Results A total of twelve relevant systematic reviews/meta-analyses were included, of which five focused on the prevention and treatment of dry socket, six on the prevention of swelling, seven on the prevention and treatment of pain, six on the prevention of limitation of mouth opening, two on the prevention of infection, three on the prevention of bleeding, and one on the treatment of nerve damage after tooth extraction. Based on AMSTAR, seven studies were minor limitations and five studies were moderate limitations. Based on GRADE system, two was high quality of evidence, twelve were moderate, nine were low, and seven were very low. Conclusion Currently, the systematic reviews/meta-analyses on the prevention and treatment of complications after impacted tooth extraction can provide some references for clinical practice, which should be combined with the real condition by clinical doctors when making an evidence-based decision. However, it also suggests performing more high quality and large sample studies to prove this conclusion.
The shortage of health workforce in rural and remote areas has been commonly concerned by every country around the word. It is one of world health issues, challenging the aspirations of achieving equity. In this regard, WHO developed the Global Policy Recommendations to improve the accessibility of the health workforce in rural and remote areas through improved retention. This article focuses on the key steps of the policy guideline developed from evidence-based medicine methodology and from angle of guideline development, mainly about background, issues, evidence retrieval and selection, quality grading of evidence, and the forming of recommendation plan, in order to further explore how to correctly understand, obtain, evaluate and apply currently available research evidence, and how to use the GRADE system to make scientific and feasible recommendations in the decision-making process, emphasizing the importance of evidence and the GRADE system in the evidence-based health decision-making.
We elaborated the reasons why systematic reviews need to use GRADE based on a couple of specific examples. Aiming to provide references to understand and use GRADE correctly, we also answered some frequently-asked questions and concerns about GRADE as follows: a) differentiating the uses of GRADE between its application in guidelines and in systematic reviews; b) how to determine the overall quality of evidence? c) can GRADE be used to access the quality of single study or not? d) different uses of GRADE between randomized controlled trials (RCTs) and observational studies; e) weight of GRADE items; and f) factors that might influence the results of GRADE and the balance between upgrading and downgrading.
Objective To systematically evaluate the efficacy and safety of montelukast in the treatment of acute asthma in adults.Methods Randomized controlled trials ( RCTs) of montelukast in the treatment of acute asthma compared with placebo were searched in Pubmed, Embase, OVID, and Cochrane Library. The quality of included RCTs was evaluated and the data were extracted. Meta-analyses were performed with RevMan 5. 1 software, and the GRADE system was applied to rate the level of evidence and strength of recommendation. Results Five RCTs ( n = 947) were included. Meta-analyses showed that montelukast could statistically improve peak expiratory flow ( PEF) ( MD = 10. 65 [ 2. 81, 18. 49] , P = 0. 008) , reduce the number of patients with oral corticosteroids ( RR=0. 75[ 0. 62, 0. 92] , NNT= 7[ 4, 46] , P =0. 005) , but there were no statistical differences in decreasing the number of patients with hospitalizations ( RR= 0. 78[ 0. 57, 1. 06] , NNT = 19[ 9, + ∞] , P = 0. 110) and treatment failure ( RR = 0. 85[ 0. 67, 1. 09] , NNT=17[ 9, +∞] , P =0. 314) compared with the placebo. Based on GRADE, the level of evidence was low or moderate, and the strength of recommendation was weak. Conclusion Our study suggests montelukast can improve the lung function and reduce the use of systematic corticosteroids in acute asthma, but the potency to reduce the number of patients with hospitalization and treatment failure need to be explored in future.
Objective To assess the effectiveness of sternocleidomastoid muscle (SCM) flap in preventing gustatory sweating syndrome following parotidectomy. Methods Databases including The Cochrane Library, MEDLINE, EMbase, CBM, CNKI, VIP and WanFang Data were searched from inception to March 2012 to retrieve randomized controlled trials (RCTs) about SCM flap in preventing gustatory sweating syndrome following parotidectomy. The data of studies meeting the inclusion criteria were extracted by two reviewers independently, the methodological quality was assessed and cross-checked, and meta-analysis was performed using the RevMan 5.1 software. Results A total of 10 RCTs involving 825 patients were included. The results of meta-analyses showed that compared with the blank control group, SCM flap could obviously decrease the subjective incidence of gustatory sweating syndrome by 78% (OR=0.22, 95%CI 0.08 to 0.59, P=0.003) and the objective incidence by 83% (OR=0.17, 95%CI 0.05 to 0.60, P=0.006). The sensitivity analysis indicated the above results were robust. The evidence based on GRADE system was of “low quality”. There was no obvious publication bias according to the tunnel chart. Conclusions Current evidence shows that SCM flap can obviously decrease both subjective and objective incidence of gustatory sweating syndrome following parotidectomy. Considering the limitation of the included studies, this conclusion still needs to be tested by more large-scale and high-quality RCTs taking SCM function as one of the outcome.
Objective To establish standards, methods and processes for evidence-based evaluation and selection of essential medicine that meet the needs of the 8 pilot township health centers in China. Methods A descriptive analysis was conducted to compare the similarities/differences and the advantages/disadvantages of the standards, methods and processes between the World Health Organization (WHO) essential medicines evaluation and selection, and the GRADE evidence quality and recommend intensity. In combination with the former outcomes of this series of study, the standards, methods and processes of evidence-based evaluation and selection of essential medicines in the domestic pilot township health centers were optimized, restructured and improved. Softwares such as GRADEprofiler were used to assess the quality of evidence. Results a) Localized standards, methods and processes for evidence-based evaluation and selection of essential medicine were established, and the evaluation tool was ascertained; and b) Disease and drug names, guidelines and searching processes for evaluation and selection of essential medicine were developed with standardized, systematic and transparent approaches. Conclusion a) Standards, methods and processes for searching, evaluating and recommending the best evidence are preliminarily established, through comparative analysis on the effectiveness, safety, cost-effectiveness and applicability of the candidate medicines for diagnosing, treating and preventing diseases in township health centers in China; b) Following the principle of “utilizing the best existing evidences and developing the urgently-needed but lacking evidence”, a good exploration was done for the localization, standardization and transparency of the standards, methods and processes of evidence-based evaluation and selection of essential medicine for pilot township health centers.
Objective To evaluate the effectiveness and safety of Endostar combined with chemotherapy for non-small cell lung cancer (NSCLC). Methods Randomized controlled trials (RCTs) on Endostar combined with chemotherapy for NSCLC were searched in The Cochrane Library, MEDLINE, EMbase, VIP, CNKI, CBMdisc and other electronic databases. The quality of RCTs meeting inclusion criteria was evaluated and the data were extracted; meta-analyses were performed with RevMan 5.1 software, and then the GRADE System was used to rate the level of evidence and strength of recommendation. Results Among the 18 RCTs involving 1 825 cases included, 1 816 cases met the inclusion criteria. Meta-analyses showed that: compared with the single chemotherapy, Endostar combined with chemotherapy could increase the total effective rate (RR=1.85, 95%CI 1.56 to 2.11, Plt;0.000 01), and the clinical benefit response (RR=1.21, 95%CI 1.14 to 1.29, Plt;0.000 01), but decrease the incidence risk of leukopenia (RR=0.89, 95%CI 0.82 to 0.97, P=0.006). There were no signficant differences between the two groups in decreasing thrombocytopenia (RR=0.87, 95%CI 0.74 to 1.03, P=0.10), impaired renal function (RR=0.96, 95%CI 0.69 to 1.34, P=0.82), nausea and vomiting (RR=0.92, 95%CI 0.84 to 1.01, P=0.08) and other side effects. Based on GRADE, the level of evidence was Grade C, and the strength of recommendation was 2. Conclusion The present results of clinical trials show that Endostar combined with chemotherapy for NSCLC is a safe and effective therapy without increasing the toxic reaction and side effects; and based on GRADE, the level of evidence was Grade 2C, and the strength of recommendation was 2. However, in view of the limitations of this study, it is suggested that large-scale, high-quality researches on basic and clinical fields should be performed to further verify the above conclusion by critical outcome indicators.
Evidence is the core of Evidence-Based Medcine; the Grades of Recommendations Assessment, Development and Evaluation (GRADE System) is a milestone in the history of evidence development. This paper outlines the GRADE System and GRADEpro 3.2 software, and briefly explores the right and wrong application which was published in the Chinese Journal of Evidence-Based Medicine. The GRADEpro 3.2 software is easy to operate, but for evaluating the reasons of upgrade and downgrade, and the importance of the parameters of outcomes, it needs to comprehensively and systematically understand the knowledge of relevant background, and to construct a solid foundation in clinical epidemiology and systematic review. In view of this paper based on the current GRADE System, there may be some discrepancy to the later content with the GRADE System constant improvement. Therefore, it is bly recommended that readers should keep constant learning and improving.
The approaches of rating the quality of evidence of systematic reviews of diagnostic accuracy tests are different from systematic reviews of interventional studies. This article systematically introduces the application of GRADE in systematic reviews of diagnostic accuracy tests by a case interpretation and analysis. In this article we present rating workflow in systematic reviews of diagnostic accuracy tests and introduce how to use the GDT website to display the rating results, and interpret the conclusion of systematic reviews based on GRADE results.
Depending on different designs of original studies, systematic reviews of diagnostic studies could be categorized into two kinds:one is based on diagnostic randomized controlled trials, of which the GRADE rating approach is similar to that of interventional systematic reviews; and the other is based on diagnostic accuracy tests, of which the GRADE rating approach is introduced in this article. This article explains the application of GRADE in systematic reviews of diagnostic accuracy tests mainly from the angle of theoretical analysis, including rationales, methods, and challenges.