Alexander Tsertsvadze - Academia.edu (original) (raw)

Papers by Alexander Tsertsvadze

Research paper thumbnail of A systematic review of economic models used to assess the cost-effectiveness of strategies for identifying latent tuberculosis in high-risk groups

Tuberculosis (Edinburgh, Scotland), 2016

Timely diagnosis and treatment of latent tuberculosis infection (LTBI) through screening remains ... more Timely diagnosis and treatment of latent tuberculosis infection (LTBI) through screening remains a key public health priority. Although globally it is recommended to screen people at high risk of developing TB, the economic evidence underpinning these recommendations is limited. This review critically appraised studies that had used a decision-analytical modelling framework to estimate the cost-effectiveness of interferon gamma release assays (IGRAs) compared to tuberculin skin test (TST) for detecting LTBI in high risk populations. A comprehensive search of MEDLINE, EMBASE, NHS-EED was undertaken from 2009 up to June 2015. Studies were screened and extracted by independent reviewers. The study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and the Philips' checklist, respectively. A narrative synthesis of the included studies was undertaken. Ten studies were included in this review. Two economic evaluations were conducted in ...

Research paper thumbnail of Summary of Glaucoma Diagnostic Testing Accuracy: An Evidence-Based Meta-Analysis

Journal of Clinical Medicine Research, 2016

New glaucoma diagnostic technologies are penetrating clinical care and are changing rapidly. Havi... more New glaucoma diagnostic technologies are penetrating clinical care and are changing rapidly. Having a systematic review of these technologies will help clinicians and decision makers and help identify gaps that need to be addressed. This systematic review studied five glaucoma technologies compared to the gold standard of white on white perimetry for glaucoma detection. OVID(®) interface: MEDLINE(®) (In-Process & Other Non-Indexed Citations), EMBASE(®), BIOSIS Previews(®), CINAHL(®), PubMed, and the Cochrane Library were searched. A gray literature search was also performed. A technical expert panel, information specialists, systematic review method experts and biostatisticians were used. A PRISMA flow diagram was created and a random effect meta-analysis was performed. A total of 2,474 articles were screened. The greatest accuracy was found with frequency doubling technology (FDT) (diagnostic odds ratio (DOR): 57.7) followed by blue on yellow perimetry (DOR: 46.7), optical coherence tomography (OCT) (DOR: 41.8), GDx (DOR: 32.4) and Heidelberg retina tomography (HRT) (DOR: 17.8). Of greatest concern is that tests for heterogeneity were all above 50%, indicating that cutoffs used in these newer technologies were all very varied and not uniform across studies. Glaucoma content experts need to establish uniform cutoffs for these newer technologies, so that studies that compare these technologies can be interpreted more uniformly. Nevertheless, synthesized data at this time demonstrate that amongst the newest technologies, OCT has the highest glaucoma diagnostic accuracy followed by GDx and then HRT.

Research paper thumbnail of Systematic Review: Comparative Effectiveness and Harms of Combinations of Lipid-Modifying Agents and High-Dose Statin Monotherapy

Annals of Internal Medicine, Sep 1, 2009

Statin therapy effectively prevents vascular disease, but treatment targets are often not achieve... more Statin therapy effectively prevents vascular disease, but treatment targets are often not achieved. To compare the benefits and harms of high-dose statin monotherapy with those of combination therapy in adults at high risk for coronary disease. English-language records from MEDLINE (1966 to 2009), EMBASE (1980 to 2009), and the Cochrane Library (third quarter of 2008). A reviewer screened records, and a second reviewer verified selection of randomized, controlled trials in adult patients that compared combinations of statins and bile-acid sequestrants, fibrates, ezetimibe, niacin, or omega-3 fatty acids with statin monotherapy, as well as nonrandomized comparative studies that were longer than 24 weeks and reported clinical and harms outcomes. Data were abstracted for studies by using standardized forms, and study quality was rated with a standardized scale and strength of evidence by using the Grading of Recommendations Assessment, Development, and Evaluation approach. 102 studies met eligibility criteria. The main analysis compared combination therapy with high-dose statin monotherapy in high-risk patients. Very-low-strength evidence showed that statin-ezetimibe (2 trials; n = 439) and statin-fibrate (1 trial; n = 166) combinations did not reduce mortality more than high-dose statin monotherapy. No trials compared the effect of combination therapy versus high-dose statin monotherapy on the incidence of myocardial infarction, stroke, or revascularization procedures. Two statin-ezetimibe trials (n = 295) demonstrated higher low-density lipoprotein cholesterol goal attainment with combination therapy (odds ratio, 7.21 [95% CI, 4.30 to 12.08]). Trials in lower-risk patients did not show a difference in mortality. Studies were generally short, focused on surrogate outcomes, and were heterogeneous in the sample's risk for coronary disease. Few studies examined treatment combinations other than statin-ezetimibe. Limited evidence suggests that combinations of lipid-lowering agents do not improve clinical outcomes more than high-dose statin monotherapy. Very-low-quality evidence favors statin-ezetimibe treatment for attainment of low-density lipoprotein cholesterol goals. Agency for Healthcare Research and Quality.

Research paper thumbnail of Accurate diagnosis of latent tuberculosis in children, people who are immunocompromised or at risk from immunosuppression and recent arrivals from countries with a high incidence of tuberculosis: systematic review and economic evaluation

Health technology assessment (Winchester, England), 2016

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB) [(Zopf 1883) Lehmann and Neumann 18... more Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB) [(Zopf 1883) Lehmann and Neumann 1896], is a major cause of morbidity and mortality. Nearly one-third of the world's population is infected with MTB; TB has an annual incidence of 9 million new cases and each year causes 2 million deaths worldwide. To investigate the clinical effectiveness and cost-effectiveness of screening tests [interferon-gamma release assays (IGRAs) and tuberculin skin tests (TSTs)] in latent tuberculosis infection (LTBI) diagnosis to support National Institute for Health and Care Excellence (NICE) guideline development for three population groups: children, immunocompromised people and those who have recently arrived in the UK from high-incidence countries. All of these groups are at higher risk of progression from LTBI to active TB. Electronic databases including MEDLINE, EMBASE, The Cochrane Library and Current Controlled Trials were searched from December 2009 up to December 2014. English-lan...

Research paper thumbnail of Updating Comparative Effectiveness Reviews

Research paper thumbnail of The Effectiveness of Housing Interventions and Housing and Service Interventions on Ending Family Homelessness: A Systematic Review

American Journal of Orthopsychiatry, Sep 1, 2014

Family homelessness has become a growing public health problem over the last 3 decades. Despite t... more Family homelessness has become a growing public health problem over the last 3 decades. Despite this trend, few studies have explored the effectiveness of housing interventions and housing and service interventions. The purpose of this systematic review is to appraise and synthesize evidence on effective interventions addressing family homelessness. We searched 10 major electronic databases from 2007 to 2013. Empirical studies investigating effectiveness of housing interventions and housing and service interventions for American homeless families regardless of publication status were eligible for inclusion. Outcomes included housing status, employment, parental trauma and mental health and substance use, children's behavioral and academic status, and family reunification. Study quality was appraised using the Effective Public Health Practice Project tool. Six studies were included in this review. Overall, there was some postintervention improvement in housing and employment, but ongoing residential and work stability were not achieved. Methodological limitations, poor reporting quality, and inconsistent definitions across outcomes hindered between-study comparisons. Substantial limitations in research underscore the insufficiency of our current knowledge base for ending homelessness. Although many families were no longer literally homeless, long-term residential stability and employment at a livable wage were not ensured. Developing and implementing evidence-based approaches for addressing homelessness are long overdue.

Research paper thumbnail of Effectiveness and safety of vitamin D in relation to bone health

Evidence Report Technology Assessment, Aug 1, 2007

OBJECTIVES: To review and synthesize the literature in the following areas: the association of sp... more OBJECTIVES: To review and synthesize the literature in the following areas: the association of specific circulating 25(OH)D concentrations with bone health outcomes in children, women of reproductive age, postmenopausal women and elderly men; the effect of dietary intakes (foods fortified with vitamin D and/or vitamin D supplementation) and sun exposure on serum 25(OH)D; the effect of vitamin D on bone mineral density (BMD) and fracture or fall risk; and the identification of potential harms of vitamin D above current reference intakes.DATA SOURCES: MEDLINE(R) (1966-June Week 3 2006); Embase (2002-2006 Week 25); CINAHL (1982-June Week 4, 2006); AMED (1985 to June 2006); Biological Abstracts (1990-February 2005); and the Cochrane Central Register of Controlled Trials (2nd Quarter 2006).REVIEW METHODS: Two independent reviewers completed a multi-level process of screening the literature to identify eligible studies (title and abstract, followed by full text review, and categorization of study design per key question). To minimize bias, study design was limited to randomized controlled trials (RCTs) wherever possible. Study criteria for question one were broadened to include observational studies due to a paucity of available RCTs, and question four was restricted to systematic reviews to limit scope. Data were abstracted in duplicate and study quality assessed. Differences in opinion were resolved through consensus or adjudication. If clinically relevant and statistically feasible, meta-analyses of RCTs on vitamin D supplementation and bone health outcomes were conducted, with exploration of heterogeneity. When meta-analysis was not feasible, a qualitative systematic review of eligible studies was conducted.RESULTS: 167 studies met our eligibility criteria (112 RCTs, 19 prospective cohorts, 30 case-controls and six before-after studies). The largest body of evidence on vitamin D status and bone health was in older adults with a lack of studies in premenopausal women and infants, children and adolescents. The quality of RCTs was highest in the vitamin D efficacy trials for prevention of falls and/or fractures in older adults. There was fair evidence of an association between low circulating 25(OH)D concentrations and established rickets. However, the specific 25(OH)D concentrations associated with rickets is uncertain, given the lack of studies in populations with dietary calcium intakes similar to North American diets and the different methods used to determine 25(OH)D concentrations. There was inconsistent evidence of an association of circulating 25(OH)D with bone mineral content in infants, and fair evidence that serum 25(OH)D is inversely associated with serum PTH. In adolescents, there was fair evidence for an association between 25(OH)D levels and changes in BMD. There were very few studies in pregnant and lactating women, and insufficient evidence for an association between serum 25(OH)D and changes in BMD during lactation, and fair evidence of an inverse correlation with PTH. In older adults, there was fair evidence that serum 25(OH)D is inversely associated with falls, fair evidence for a positive association with BMD, and inconsistent evidence for an association with fractures. The imprecision of 25(OH)D assays may have contributed to the variable thresholds of 25(OH)D below which the risk of fractures, falls or bone loss was increased. There was good evidence that intakes from vitamin D-fortified foods (11 RCTs) consistently increased serum 25(OH)D in both young and older adults. Eight randomized trials of ultraviolet (UV)-B radiation (artificial and solar exposure) were small and heterogeneous with respect to determination of the exact UV-B dose and 25(OH)D assay but there was a positive effect on serum 25(OH)D concentrations. It was not possible to determine how 25(OH)D levels varied by ethnicity, sunscreen use or latitude. Seventy-four trials examined the effect of vitamin D(3) or D(2) on 25(OH)D concentrations. Most trials used vitamin D(3), and the majority enrolled older adults. In three trials, there was a greater response of serum 25(OH)D concentrations to vitamin D(3) compared to vitamin D(2), which may have been due to more rapid clearance of vitamin D(2) in addition to other mechanisms. Meta-analysis of 16 trials of vitamin D(3) was consistent with a dose-response effect on serum 25(OH)D when comparing daily doses of <400 IU to doses >/= 400 IU. An exploratory analysis of the heterogeneity demonstrated a significant positive association comparable to an increase of 1 - 2 nmol/L in serum 25(OH)D for every 100 additional units of vitamin D although heterogeneity remained after adjusting for dose. Vitamin D(3) in combination with calcium results in small increases in BMD compared to placebo in older adults although quantitative synthesis was limited due to variable treatment durations and BMD sites. The evidence for fracture reduction with vitamin D supplementation was inconsistent across 15 trials. The combined results of trials using vitamin D(3) (700 - 800 IU daily) with calcium (500 - 1,200 mg) was consistent with a benefit on fractures although in a subgroup analysis by setting, benefit was primarily in elderly institutionalized women (fair evidence from two trials). There was inconsistent evidence across 14 RCTs of a benefit on fall risk. However, a subgroup analysis showed a benefit of vitamin D in postmenopausal women, and in trials that used vitamin D(3) plus calcium. In addition, there was a reduction in fall risk with vitamin D when six trials that adequately ascertained falls were combined. Limitations of the fall and fracture trials included poor compliance with vitamin D supplementation, incomplete assessment of vitamin D status and large losses to follow-up. We did not find any systematic reviews that addressed the question on the level of sunlight exposure that is sufficient to maintain serum 25(OH)D concentrations but minimizes risk of melanoma and non-melanoma skin cancer. There is little evidence from existing trials that vitamin D above current reference intakes is harmful. In most trials, reports of hypercalcemia and hypercalciuria were not associated with clinically relevant events. The Women's Health Initiative study did report a small increase in kidney stones in postmenopausal women aged 50 to 79 years whose daily vitamin D(3) intake was 400 IU (the reference intake for 50 to 70 years, and below the reference intake for > 70 years) combined with 1000 mg calcium. The increase in renal stones corresponded to 5.7 events per 10,000 person-years of exposure. The women in this trial had higher calcium intakes than is seen in most post-menopausal women.CONCLUSIONS: The results highlight the need for additional high quality studies in infants, children, premenopausal women, and diverse racial or ethnic groups. There was fair evidence from studies of an association between circulating 25(OH)D concentrations with some bone health outcomes (established rickets, PTH, falls, BMD). However, the evidence for an association was inconsistent for other outcomes (e.g., BMC in infants and fractures in adults). It was difficult to define specific thresholds of circulating 25(OH)D for optimal bone health due to the imprecision of different 25(OH)D assays. Standard reference preparations are needed so that serum 25(OH)D can be accurately and reliably measured, and validated. In most trials, the effects of vitamin D and calcium could not be separated. Vitamin D(3) (>700 IU/day) with calcium supplementation compared to placebo has a small beneficial effect on BMD, and reduces the risk of fractures and falls although benefit may be confined to specific subgroups. Vitamin D intake above current dietary reference intakes was not reported to be associated with an increased risk of adverse events. However, most trials of higher doses of vitamin D were not adequately designed to assess long-term harms.

Research paper thumbnail of Community-onset sepsis and its public health burden: protocol of a systematic review

Systematic reviews, 2015

Sepsis is a life-threatening condition and major contributor of public health and economic burden... more Sepsis is a life-threatening condition and major contributor of public health and economic burden in the industrialised world. The heterogeneity, absence of more specific definition, and difficulties in accurate diagnosis lead to great variability in the estimates of sepsis incidence. There has been uncertainty regarding the incidence and risk factors attributable to community-onset as opposed to hospital-acquired sepsis. Community-onset sepsis has distinct host characteristics, risk factors, pathogens, and prognosis. A systematic assessment of recent evidence is warranted in light of secular changes in epidemiology, pathogens, and the uncertainties around the incidence and risk factors of community-onset sepsis. This protocol describes a systematic review which aims to synthesise the recent empirical evidence on the incidence and risk factors of community-onset sepsis, severe sepsis, and septic shock in high-income countries. English-language publications of cohort and case-control...

Research paper thumbnail of Clinical effectiveness and cost-effectiveness of elemental nutrition for the maintenance of remission in Crohn's disease: a systematic review and meta-analysis

Health technology assessment (Winchester, England), 2015

Although enteral nutrition has been shown to be a viable treatment option for the management of a... more Although enteral nutrition has been shown to be a viable treatment option for the management of active Crohn's disease (CD), the evidence regarding its clinical benefits compared with standard treatments (e.g. steroids) for maintaining remission in patients with CD has been inconsistent. If enteral nutrition was to be effective, the use of drugs such as steroids and immunosuppressive drugs could be reduced, thereby reducing the likelihood of adverse events associated with these medications. This systematic review aimed to assess the clinical effectiveness and cost-effectiveness of elemental nutrition (a type of enteral nutrition) for maintenance of remission in patients with CD. Major bibliographic databases (e.g. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) were searched from inception to August/September 2013. Searches were not limited by study design, language or publication date. Websites for relevant organisations and references of included studies were checked...

Research paper thumbnail of The prevalence of mental illness in homeless children: a systematic review and meta-analysis

Journal of the American Academy of Child and Adolescent Psychiatry, 2015

The numbers of children experiencing homelessness have increased. To develop responsive intervent... more The numbers of children experiencing homelessness have increased. To develop responsive interventions, we must understand their mental health/behavioral needs. The purpose of this systematic review was to update the evidence base by identifying, appraising, and summarizing studies on the prevalence of mental health issues among homeless children, comparing these individuals to low-income-housed children, and discussing research, practice, and policy implications. We searched 3 electronic databases and included empirical studies investigating the prevalence of mental illness in homeless children in the United States (1990-2014). Retrieved publications were screened, data extracted, and study quality appraised by independent reviewers. Evidence synthesis was based on qualitative and quantitative analyses. Prevalence odds ratios (OR) of individual studies were pooled using an inverse-variance random effects model. Twelve studies were included and reviewed. Overall, 10% to 26% of homele...

Research paper thumbnail of Extending the diabetic retinopathy screening interval beyond 1 year: systematic review

The British journal of ophthalmology, Jan 13, 2015

To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK c... more To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14 013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262 541 patients of whom at least 228 649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference betwee...

Research paper thumbnail of The effectiveness of housing interventions and housing and service interventions on ending family homelessness: a systematic review

The American journal of orthopsychiatry, 2014

Family homelessness has become a growing public health problem over the last 3 decades. Despite t... more Family homelessness has become a growing public health problem over the last 3 decades. Despite this trend, few studies have explored the effectiveness of housing interventions and housing and service interventions. The purpose of this systematic review is to appraise and synthesize evidence on effective interventions addressing family homelessness. We searched 10 major electronic databases from 2007 to 2013. Empirical studies investigating effectiveness of housing interventions and housing and service interventions for American homeless families regardless of publication status were eligible for inclusion. Outcomes included housing status, employment, parental trauma and mental health and substance use, children's behavioral and academic status, and family reunification. Study quality was appraised using the Effective Public Health Practice Project tool. Six studies were included in this review. Overall, there was some postintervention improvement in housing and employment, but...

Research paper thumbnail of Acupuncture for (sub)acute non-specific low-back pain

Research paper thumbnail of Assessing the risk of bias of individual studies in systematic reviews of health care interventions

Research paper thumbnail of A surveillance system to assess the need for updating systematic reviews

Systematic Reviews, 2013

Background: Systematic reviews (SRs) can become outdated as new evidence emerges over time. Organ... more Background: Systematic reviews (SRs) can become outdated as new evidence emerges over time. Organizations that produce SRs need a surveillance method to determine when reviews are likely to require updating. This report describes the development and initial results of a surveillance system to assess SRs produced by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program. Methods: Twenty-four SRs were assessed using existing methods that incorporate limited literature searches, expert opinion, and quantitative methods for the presence of signals triggering the need for updating. The system was designed to begin surveillance six months after the release of the original review, and thenceforth every six months for any review not classified as being a high priority for updating. The outcome of each round of surveillance was a classification of the SR as being low, medium or high priority for updating. Results: Twenty-four SRs underwent surveillance at least once, and ten underwent surveillance a second time during the 18 months of the program. Two SRs were classified as high, five as medium, and 17 as low priority for updating. The time lapse between the searches conducted for the original reports and the updated searches (search time lapse -STL) ranged from 11 months to 62 months: The STL for the high priority reports were 29 months and 54 months; those for medium priority reports ranged from 19 to 62 months; and those for low priority reports ranged from 11 to 33 months. Neither the STL nor the number of new relevant articles was perfectly associated with a signal for updating. Challenges of implementing the surveillance system included determining what constituted the actual conclusions of an SR that required assessing; and sometimes poor response rates of experts.

Research paper thumbnail of Total hip replacement for the treatment of end stage arthritis of the hip: A systematic review and meta-analysis

Background: Evolvements in the design, fixation methods, size, and bearing surface of implants fo... more Background: Evolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement (THR) have led to a variety of options for healthcare professionals to consider. The need to determine the most optimal combinations of THR implant is warranted. This systematic review evaluated the clinical effectiveness of different types of THR used for the treatment of end stage arthritis of the hip.

Research paper thumbnail of Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials

Objectives: The purpose of this study was to systematically review trial-based economic evaluatio... more Objectives: The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions. Methods: A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases. Results: Twenty-five publications were included (11 trial-based economic evaluations). The studies compared costeffectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain. Conclusions: Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients. (J Manipulative Physiol Ther 2014;37:343-362)

Research paper thumbnail of Interactions of commonly used dietary supplements with cardiovascular drugs: a systematic review

Systematic Reviews, 2012

Background: The objective of this systematic review was to examine the benefits, harms and pharma... more Background: The objective of this systematic review was to examine the benefits, harms and pharmacokinetic interactions arising from the co-administration of commonly used dietary supplements with cardiovascular drugs. Many patients on cardiovascular drugs take dietary supplements for presumed benefits and may be at risk for adverse supplement-drug interactions.

Research paper thumbnail of Blinded versus unblinded assessments of risk-of-bias in studies included in a systematic review

Protocols, 1996

The importance of appraising the risk of bias of studies included in systematic reviews is well-e... more The importance of appraising the risk of bias of studies included in systematic reviews is well-established. However, uncertainty remains surrounding the method by which risk of bias assessments should be conducted. Specifically, no summary of evidence exists as to whether blinded (i.e. the assessor is unaware of the study author&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s name, institution, sponsorship, journal, etc.) versus unblinded assessments of risk of bias yield systematically different assessments in a systematic review. To determine whether blinded versus unblinded assessments of risk of bias yield systematically different assessments in a systematic review. We searched MEDLINE (1966 to September week 4 2009), CINAHL (1982 to May week 3 2008), All EBM Reviews (inception to 6 October 2009), EMBASE (1980 to 2009 week 40) and HealthStar (1966 to September week 4 2009) (all Ovid interface). We applied no restrictions regarding language of publication, publication status or study design. We examined reference lists of included studies and contacted experts for potentially relevant literature. We included any study that examined blinded versus unblinded assessments of risk of bias included within a systematic review. We extracted information from each of the included studies using a pre-specified 16-item form. We summarized the level of agreement between blinded and unblinded assessments of risk of bias descriptively. We calculated the standardized mean difference whenever possible. We included six randomized controlled trials (RCTs). Four studies had unclear risk of bias and two had high risk of bias. The results of these RCTs were not consistent; two demonstrated no differences between blinded and unblinded assessments, two found that blinded assessments had significantly lower quality scores, and another observed significantly higher quality scores for blinded assessments. The remaining study did not report the level of significance. We pooled five studies reporting sufficient information in a meta-analysis. We observed no statistically significant difference in risk of bias assessments between blinded or unblinded assessments (standardized mean difference -0.13, 95% confidence interval -0.42 to 0.16). The mean difference might be slightly inaccurate, as we did not adjust for clustering in our meta-analysis. We observed inconsistency of results visually and noted statistical heterogeneity. Our review highlights that discordance exists between studies examining blinded versus unblinded risk of bias assessments at the systematic review level. The best approach to risk of bias assessment remains unclear, however, given the increased time and resources required to conceal reports effectively, it may not be necessary for risk of bias assessments to be conducted under blinded conditions in a systematic review.

Research paper thumbnail of When and how to update systematic reviews

Reviews, 1996

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and... more This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2008, Issue 2 http://www.thecochranelibrary.com ... When and how to update systematic reviews (Review) Copyright © 2008 The Cochrane ...

Research paper thumbnail of A systematic review of economic models used to assess the cost-effectiveness of strategies for identifying latent tuberculosis in high-risk groups

Tuberculosis (Edinburgh, Scotland), 2016

Timely diagnosis and treatment of latent tuberculosis infection (LTBI) through screening remains ... more Timely diagnosis and treatment of latent tuberculosis infection (LTBI) through screening remains a key public health priority. Although globally it is recommended to screen people at high risk of developing TB, the economic evidence underpinning these recommendations is limited. This review critically appraised studies that had used a decision-analytical modelling framework to estimate the cost-effectiveness of interferon gamma release assays (IGRAs) compared to tuberculin skin test (TST) for detecting LTBI in high risk populations. A comprehensive search of MEDLINE, EMBASE, NHS-EED was undertaken from 2009 up to June 2015. Studies were screened and extracted by independent reviewers. The study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and the Philips' checklist, respectively. A narrative synthesis of the included studies was undertaken. Ten studies were included in this review. Two economic evaluations were conducted in ...

Research paper thumbnail of Summary of Glaucoma Diagnostic Testing Accuracy: An Evidence-Based Meta-Analysis

Journal of Clinical Medicine Research, 2016

New glaucoma diagnostic technologies are penetrating clinical care and are changing rapidly. Havi... more New glaucoma diagnostic technologies are penetrating clinical care and are changing rapidly. Having a systematic review of these technologies will help clinicians and decision makers and help identify gaps that need to be addressed. This systematic review studied five glaucoma technologies compared to the gold standard of white on white perimetry for glaucoma detection. OVID(®) interface: MEDLINE(®) (In-Process &amp;amp;amp; Other Non-Indexed Citations), EMBASE(®), BIOSIS Previews(®), CINAHL(®), PubMed, and the Cochrane Library were searched. A gray literature search was also performed. A technical expert panel, information specialists, systematic review method experts and biostatisticians were used. A PRISMA flow diagram was created and a random effect meta-analysis was performed. A total of 2,474 articles were screened. The greatest accuracy was found with frequency doubling technology (FDT) (diagnostic odds ratio (DOR): 57.7) followed by blue on yellow perimetry (DOR: 46.7), optical coherence tomography (OCT) (DOR: 41.8), GDx (DOR: 32.4) and Heidelberg retina tomography (HRT) (DOR: 17.8). Of greatest concern is that tests for heterogeneity were all above 50%, indicating that cutoffs used in these newer technologies were all very varied and not uniform across studies. Glaucoma content experts need to establish uniform cutoffs for these newer technologies, so that studies that compare these technologies can be interpreted more uniformly. Nevertheless, synthesized data at this time demonstrate that amongst the newest technologies, OCT has the highest glaucoma diagnostic accuracy followed by GDx and then HRT.

Research paper thumbnail of Systematic Review: Comparative Effectiveness and Harms of Combinations of Lipid-Modifying Agents and High-Dose Statin Monotherapy

Annals of Internal Medicine, Sep 1, 2009

Statin therapy effectively prevents vascular disease, but treatment targets are often not achieve... more Statin therapy effectively prevents vascular disease, but treatment targets are often not achieved. To compare the benefits and harms of high-dose statin monotherapy with those of combination therapy in adults at high risk for coronary disease. English-language records from MEDLINE (1966 to 2009), EMBASE (1980 to 2009), and the Cochrane Library (third quarter of 2008). A reviewer screened records, and a second reviewer verified selection of randomized, controlled trials in adult patients that compared combinations of statins and bile-acid sequestrants, fibrates, ezetimibe, niacin, or omega-3 fatty acids with statin monotherapy, as well as nonrandomized comparative studies that were longer than 24 weeks and reported clinical and harms outcomes. Data were abstracted for studies by using standardized forms, and study quality was rated with a standardized scale and strength of evidence by using the Grading of Recommendations Assessment, Development, and Evaluation approach. 102 studies met eligibility criteria. The main analysis compared combination therapy with high-dose statin monotherapy in high-risk patients. Very-low-strength evidence showed that statin-ezetimibe (2 trials; n = 439) and statin-fibrate (1 trial; n = 166) combinations did not reduce mortality more than high-dose statin monotherapy. No trials compared the effect of combination therapy versus high-dose statin monotherapy on the incidence of myocardial infarction, stroke, or revascularization procedures. Two statin-ezetimibe trials (n = 295) demonstrated higher low-density lipoprotein cholesterol goal attainment with combination therapy (odds ratio, 7.21 [95% CI, 4.30 to 12.08]). Trials in lower-risk patients did not show a difference in mortality. Studies were generally short, focused on surrogate outcomes, and were heterogeneous in the sample&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s risk for coronary disease. Few studies examined treatment combinations other than statin-ezetimibe. Limited evidence suggests that combinations of lipid-lowering agents do not improve clinical outcomes more than high-dose statin monotherapy. Very-low-quality evidence favors statin-ezetimibe treatment for attainment of low-density lipoprotein cholesterol goals. Agency for Healthcare Research and Quality.

Research paper thumbnail of Accurate diagnosis of latent tuberculosis in children, people who are immunocompromised or at risk from immunosuppression and recent arrivals from countries with a high incidence of tuberculosis: systematic review and economic evaluation

Health technology assessment (Winchester, England), 2016

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB) [(Zopf 1883) Lehmann and Neumann 18... more Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB) [(Zopf 1883) Lehmann and Neumann 1896], is a major cause of morbidity and mortality. Nearly one-third of the world's population is infected with MTB; TB has an annual incidence of 9 million new cases and each year causes 2 million deaths worldwide. To investigate the clinical effectiveness and cost-effectiveness of screening tests [interferon-gamma release assays (IGRAs) and tuberculin skin tests (TSTs)] in latent tuberculosis infection (LTBI) diagnosis to support National Institute for Health and Care Excellence (NICE) guideline development for three population groups: children, immunocompromised people and those who have recently arrived in the UK from high-incidence countries. All of these groups are at higher risk of progression from LTBI to active TB. Electronic databases including MEDLINE, EMBASE, The Cochrane Library and Current Controlled Trials were searched from December 2009 up to December 2014. English-lan...

Research paper thumbnail of Updating Comparative Effectiveness Reviews

Research paper thumbnail of The Effectiveness of Housing Interventions and Housing and Service Interventions on Ending Family Homelessness: A Systematic Review

American Journal of Orthopsychiatry, Sep 1, 2014

Family homelessness has become a growing public health problem over the last 3 decades. Despite t... more Family homelessness has become a growing public health problem over the last 3 decades. Despite this trend, few studies have explored the effectiveness of housing interventions and housing and service interventions. The purpose of this systematic review is to appraise and synthesize evidence on effective interventions addressing family homelessness. We searched 10 major electronic databases from 2007 to 2013. Empirical studies investigating effectiveness of housing interventions and housing and service interventions for American homeless families regardless of publication status were eligible for inclusion. Outcomes included housing status, employment, parental trauma and mental health and substance use, children's behavioral and academic status, and family reunification. Study quality was appraised using the Effective Public Health Practice Project tool. Six studies were included in this review. Overall, there was some postintervention improvement in housing and employment, but ongoing residential and work stability were not achieved. Methodological limitations, poor reporting quality, and inconsistent definitions across outcomes hindered between-study comparisons. Substantial limitations in research underscore the insufficiency of our current knowledge base for ending homelessness. Although many families were no longer literally homeless, long-term residential stability and employment at a livable wage were not ensured. Developing and implementing evidence-based approaches for addressing homelessness are long overdue.

Research paper thumbnail of Effectiveness and safety of vitamin D in relation to bone health

Evidence Report Technology Assessment, Aug 1, 2007

OBJECTIVES: To review and synthesize the literature in the following areas: the association of sp... more OBJECTIVES: To review and synthesize the literature in the following areas: the association of specific circulating 25(OH)D concentrations with bone health outcomes in children, women of reproductive age, postmenopausal women and elderly men; the effect of dietary intakes (foods fortified with vitamin D and/or vitamin D supplementation) and sun exposure on serum 25(OH)D; the effect of vitamin D on bone mineral density (BMD) and fracture or fall risk; and the identification of potential harms of vitamin D above current reference intakes.DATA SOURCES: MEDLINE(R) (1966-June Week 3 2006); Embase (2002-2006 Week 25); CINAHL (1982-June Week 4, 2006); AMED (1985 to June 2006); Biological Abstracts (1990-February 2005); and the Cochrane Central Register of Controlled Trials (2nd Quarter 2006).REVIEW METHODS: Two independent reviewers completed a multi-level process of screening the literature to identify eligible studies (title and abstract, followed by full text review, and categorization of study design per key question). To minimize bias, study design was limited to randomized controlled trials (RCTs) wherever possible. Study criteria for question one were broadened to include observational studies due to a paucity of available RCTs, and question four was restricted to systematic reviews to limit scope. Data were abstracted in duplicate and study quality assessed. Differences in opinion were resolved through consensus or adjudication. If clinically relevant and statistically feasible, meta-analyses of RCTs on vitamin D supplementation and bone health outcomes were conducted, with exploration of heterogeneity. When meta-analysis was not feasible, a qualitative systematic review of eligible studies was conducted.RESULTS: 167 studies met our eligibility criteria (112 RCTs, 19 prospective cohorts, 30 case-controls and six before-after studies). The largest body of evidence on vitamin D status and bone health was in older adults with a lack of studies in premenopausal women and infants, children and adolescents. The quality of RCTs was highest in the vitamin D efficacy trials for prevention of falls and/or fractures in older adults. There was fair evidence of an association between low circulating 25(OH)D concentrations and established rickets. However, the specific 25(OH)D concentrations associated with rickets is uncertain, given the lack of studies in populations with dietary calcium intakes similar to North American diets and the different methods used to determine 25(OH)D concentrations. There was inconsistent evidence of an association of circulating 25(OH)D with bone mineral content in infants, and fair evidence that serum 25(OH)D is inversely associated with serum PTH. In adolescents, there was fair evidence for an association between 25(OH)D levels and changes in BMD. There were very few studies in pregnant and lactating women, and insufficient evidence for an association between serum 25(OH)D and changes in BMD during lactation, and fair evidence of an inverse correlation with PTH. In older adults, there was fair evidence that serum 25(OH)D is inversely associated with falls, fair evidence for a positive association with BMD, and inconsistent evidence for an association with fractures. The imprecision of 25(OH)D assays may have contributed to the variable thresholds of 25(OH)D below which the risk of fractures, falls or bone loss was increased. There was good evidence that intakes from vitamin D-fortified foods (11 RCTs) consistently increased serum 25(OH)D in both young and older adults. Eight randomized trials of ultraviolet (UV)-B radiation (artificial and solar exposure) were small and heterogeneous with respect to determination of the exact UV-B dose and 25(OH)D assay but there was a positive effect on serum 25(OH)D concentrations. It was not possible to determine how 25(OH)D levels varied by ethnicity, sunscreen use or latitude. Seventy-four trials examined the effect of vitamin D(3) or D(2) on 25(OH)D concentrations. Most trials used vitamin D(3), and the majority enrolled older adults. In three trials, there was a greater response of serum 25(OH)D concentrations to vitamin D(3) compared to vitamin D(2), which may have been due to more rapid clearance of vitamin D(2) in addition to other mechanisms. Meta-analysis of 16 trials of vitamin D(3) was consistent with a dose-response effect on serum 25(OH)D when comparing daily doses of <400 IU to doses >/= 400 IU. An exploratory analysis of the heterogeneity demonstrated a significant positive association comparable to an increase of 1 - 2 nmol/L in serum 25(OH)D for every 100 additional units of vitamin D although heterogeneity remained after adjusting for dose. Vitamin D(3) in combination with calcium results in small increases in BMD compared to placebo in older adults although quantitative synthesis was limited due to variable treatment durations and BMD sites. The evidence for fracture reduction with vitamin D supplementation was inconsistent across 15 trials. The combined results of trials using vitamin D(3) (700 - 800 IU daily) with calcium (500 - 1,200 mg) was consistent with a benefit on fractures although in a subgroup analysis by setting, benefit was primarily in elderly institutionalized women (fair evidence from two trials). There was inconsistent evidence across 14 RCTs of a benefit on fall risk. However, a subgroup analysis showed a benefit of vitamin D in postmenopausal women, and in trials that used vitamin D(3) plus calcium. In addition, there was a reduction in fall risk with vitamin D when six trials that adequately ascertained falls were combined. Limitations of the fall and fracture trials included poor compliance with vitamin D supplementation, incomplete assessment of vitamin D status and large losses to follow-up. We did not find any systematic reviews that addressed the question on the level of sunlight exposure that is sufficient to maintain serum 25(OH)D concentrations but minimizes risk of melanoma and non-melanoma skin cancer. There is little evidence from existing trials that vitamin D above current reference intakes is harmful. In most trials, reports of hypercalcemia and hypercalciuria were not associated with clinically relevant events. The Women's Health Initiative study did report a small increase in kidney stones in postmenopausal women aged 50 to 79 years whose daily vitamin D(3) intake was 400 IU (the reference intake for 50 to 70 years, and below the reference intake for > 70 years) combined with 1000 mg calcium. The increase in renal stones corresponded to 5.7 events per 10,000 person-years of exposure. The women in this trial had higher calcium intakes than is seen in most post-menopausal women.CONCLUSIONS: The results highlight the need for additional high quality studies in infants, children, premenopausal women, and diverse racial or ethnic groups. There was fair evidence from studies of an association between circulating 25(OH)D concentrations with some bone health outcomes (established rickets, PTH, falls, BMD). However, the evidence for an association was inconsistent for other outcomes (e.g., BMC in infants and fractures in adults). It was difficult to define specific thresholds of circulating 25(OH)D for optimal bone health due to the imprecision of different 25(OH)D assays. Standard reference preparations are needed so that serum 25(OH)D can be accurately and reliably measured, and validated. In most trials, the effects of vitamin D and calcium could not be separated. Vitamin D(3) (>700 IU/day) with calcium supplementation compared to placebo has a small beneficial effect on BMD, and reduces the risk of fractures and falls although benefit may be confined to specific subgroups. Vitamin D intake above current dietary reference intakes was not reported to be associated with an increased risk of adverse events. However, most trials of higher doses of vitamin D were not adequately designed to assess long-term harms.

Research paper thumbnail of Community-onset sepsis and its public health burden: protocol of a systematic review

Systematic reviews, 2015

Sepsis is a life-threatening condition and major contributor of public health and economic burden... more Sepsis is a life-threatening condition and major contributor of public health and economic burden in the industrialised world. The heterogeneity, absence of more specific definition, and difficulties in accurate diagnosis lead to great variability in the estimates of sepsis incidence. There has been uncertainty regarding the incidence and risk factors attributable to community-onset as opposed to hospital-acquired sepsis. Community-onset sepsis has distinct host characteristics, risk factors, pathogens, and prognosis. A systematic assessment of recent evidence is warranted in light of secular changes in epidemiology, pathogens, and the uncertainties around the incidence and risk factors of community-onset sepsis. This protocol describes a systematic review which aims to synthesise the recent empirical evidence on the incidence and risk factors of community-onset sepsis, severe sepsis, and septic shock in high-income countries. English-language publications of cohort and case-control...

Research paper thumbnail of Clinical effectiveness and cost-effectiveness of elemental nutrition for the maintenance of remission in Crohn's disease: a systematic review and meta-analysis

Health technology assessment (Winchester, England), 2015

Although enteral nutrition has been shown to be a viable treatment option for the management of a... more Although enteral nutrition has been shown to be a viable treatment option for the management of active Crohn's disease (CD), the evidence regarding its clinical benefits compared with standard treatments (e.g. steroids) for maintaining remission in patients with CD has been inconsistent. If enteral nutrition was to be effective, the use of drugs such as steroids and immunosuppressive drugs could be reduced, thereby reducing the likelihood of adverse events associated with these medications. This systematic review aimed to assess the clinical effectiveness and cost-effectiveness of elemental nutrition (a type of enteral nutrition) for maintenance of remission in patients with CD. Major bibliographic databases (e.g. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) were searched from inception to August/September 2013. Searches were not limited by study design, language or publication date. Websites for relevant organisations and references of included studies were checked...

Research paper thumbnail of The prevalence of mental illness in homeless children: a systematic review and meta-analysis

Journal of the American Academy of Child and Adolescent Psychiatry, 2015

The numbers of children experiencing homelessness have increased. To develop responsive intervent... more The numbers of children experiencing homelessness have increased. To develop responsive interventions, we must understand their mental health/behavioral needs. The purpose of this systematic review was to update the evidence base by identifying, appraising, and summarizing studies on the prevalence of mental health issues among homeless children, comparing these individuals to low-income-housed children, and discussing research, practice, and policy implications. We searched 3 electronic databases and included empirical studies investigating the prevalence of mental illness in homeless children in the United States (1990-2014). Retrieved publications were screened, data extracted, and study quality appraised by independent reviewers. Evidence synthesis was based on qualitative and quantitative analyses. Prevalence odds ratios (OR) of individual studies were pooled using an inverse-variance random effects model. Twelve studies were included and reviewed. Overall, 10% to 26% of homele...

Research paper thumbnail of Extending the diabetic retinopathy screening interval beyond 1 year: systematic review

The British journal of ophthalmology, Jan 13, 2015

To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK c... more To determine whether the recommended screening interval for diabetic retinopathy (DR) in the UK can safely be extended beyond 1 year. Systematic review of clinical and cost-effectiveness studies. Nine databases were searched with no date restrictions. Randomised controlled trials (RCTs), cohort studies, prognostic or economic modelling studies which described the incidence and progression of DR in populations with type 1 diabetes mellitus or type 2 diabetes mellitus of either sex and of any age reporting incidence and progression of DR in relation to screening interval (vs annual screening interval) and/or prognostic factors were included. Narrative synthesis was undertaken. 14 013 papers were identified, of which 11 observational studies, 5 risk stratification modelling studies and 9 economic studies were included. Data were available for 262 541 patients of whom at least 228 649 (87%) had type 2 diabetes. There were no RCTs. Studies concluded that there is little difference betwee...

Research paper thumbnail of The effectiveness of housing interventions and housing and service interventions on ending family homelessness: a systematic review

The American journal of orthopsychiatry, 2014

Family homelessness has become a growing public health problem over the last 3 decades. Despite t... more Family homelessness has become a growing public health problem over the last 3 decades. Despite this trend, few studies have explored the effectiveness of housing interventions and housing and service interventions. The purpose of this systematic review is to appraise and synthesize evidence on effective interventions addressing family homelessness. We searched 10 major electronic databases from 2007 to 2013. Empirical studies investigating effectiveness of housing interventions and housing and service interventions for American homeless families regardless of publication status were eligible for inclusion. Outcomes included housing status, employment, parental trauma and mental health and substance use, children's behavioral and academic status, and family reunification. Study quality was appraised using the Effective Public Health Practice Project tool. Six studies were included in this review. Overall, there was some postintervention improvement in housing and employment, but...

Research paper thumbnail of Acupuncture for (sub)acute non-specific low-back pain

Research paper thumbnail of Assessing the risk of bias of individual studies in systematic reviews of health care interventions

Research paper thumbnail of A surveillance system to assess the need for updating systematic reviews

Systematic Reviews, 2013

Background: Systematic reviews (SRs) can become outdated as new evidence emerges over time. Organ... more Background: Systematic reviews (SRs) can become outdated as new evidence emerges over time. Organizations that produce SRs need a surveillance method to determine when reviews are likely to require updating. This report describes the development and initial results of a surveillance system to assess SRs produced by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program. Methods: Twenty-four SRs were assessed using existing methods that incorporate limited literature searches, expert opinion, and quantitative methods for the presence of signals triggering the need for updating. The system was designed to begin surveillance six months after the release of the original review, and thenceforth every six months for any review not classified as being a high priority for updating. The outcome of each round of surveillance was a classification of the SR as being low, medium or high priority for updating. Results: Twenty-four SRs underwent surveillance at least once, and ten underwent surveillance a second time during the 18 months of the program. Two SRs were classified as high, five as medium, and 17 as low priority for updating. The time lapse between the searches conducted for the original reports and the updated searches (search time lapse -STL) ranged from 11 months to 62 months: The STL for the high priority reports were 29 months and 54 months; those for medium priority reports ranged from 19 to 62 months; and those for low priority reports ranged from 11 to 33 months. Neither the STL nor the number of new relevant articles was perfectly associated with a signal for updating. Challenges of implementing the surveillance system included determining what constituted the actual conclusions of an SR that required assessing; and sometimes poor response rates of experts.

Research paper thumbnail of Total hip replacement for the treatment of end stage arthritis of the hip: A systematic review and meta-analysis

Background: Evolvements in the design, fixation methods, size, and bearing surface of implants fo... more Background: Evolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement (THR) have led to a variety of options for healthcare professionals to consider. The need to determine the most optimal combinations of THR implant is warranted. This systematic review evaluated the clinical effectiveness of different types of THR used for the treatment of end stage arthritis of the hip.

Research paper thumbnail of Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials

Objectives: The purpose of this study was to systematically review trial-based economic evaluatio... more Objectives: The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions. Methods: A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases. Results: Twenty-five publications were included (11 trial-based economic evaluations). The studies compared costeffectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain. Conclusions: Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients. (J Manipulative Physiol Ther 2014;37:343-362)

Research paper thumbnail of Interactions of commonly used dietary supplements with cardiovascular drugs: a systematic review

Systematic Reviews, 2012

Background: The objective of this systematic review was to examine the benefits, harms and pharma... more Background: The objective of this systematic review was to examine the benefits, harms and pharmacokinetic interactions arising from the co-administration of commonly used dietary supplements with cardiovascular drugs. Many patients on cardiovascular drugs take dietary supplements for presumed benefits and may be at risk for adverse supplement-drug interactions.

Research paper thumbnail of Blinded versus unblinded assessments of risk-of-bias in studies included in a systematic review

Protocols, 1996

The importance of appraising the risk of bias of studies included in systematic reviews is well-e... more The importance of appraising the risk of bias of studies included in systematic reviews is well-established. However, uncertainty remains surrounding the method by which risk of bias assessments should be conducted. Specifically, no summary of evidence exists as to whether blinded (i.e. the assessor is unaware of the study author&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s name, institution, sponsorship, journal, etc.) versus unblinded assessments of risk of bias yield systematically different assessments in a systematic review. To determine whether blinded versus unblinded assessments of risk of bias yield systematically different assessments in a systematic review. We searched MEDLINE (1966 to September week 4 2009), CINAHL (1982 to May week 3 2008), All EBM Reviews (inception to 6 October 2009), EMBASE (1980 to 2009 week 40) and HealthStar (1966 to September week 4 2009) (all Ovid interface). We applied no restrictions regarding language of publication, publication status or study design. We examined reference lists of included studies and contacted experts for potentially relevant literature. We included any study that examined blinded versus unblinded assessments of risk of bias included within a systematic review. We extracted information from each of the included studies using a pre-specified 16-item form. We summarized the level of agreement between blinded and unblinded assessments of risk of bias descriptively. We calculated the standardized mean difference whenever possible. We included six randomized controlled trials (RCTs). Four studies had unclear risk of bias and two had high risk of bias. The results of these RCTs were not consistent; two demonstrated no differences between blinded and unblinded assessments, two found that blinded assessments had significantly lower quality scores, and another observed significantly higher quality scores for blinded assessments. The remaining study did not report the level of significance. We pooled five studies reporting sufficient information in a meta-analysis. We observed no statistically significant difference in risk of bias assessments between blinded or unblinded assessments (standardized mean difference -0.13, 95% confidence interval -0.42 to 0.16). The mean difference might be slightly inaccurate, as we did not adjust for clustering in our meta-analysis. We observed inconsistency of results visually and noted statistical heterogeneity. Our review highlights that discordance exists between studies examining blinded versus unblinded risk of bias assessments at the systematic review level. The best approach to risk of bias assessment remains unclear, however, given the increased time and resources required to conceal reports effectively, it may not be necessary for risk of bias assessments to be conducted under blinded conditions in a systematic review.

Research paper thumbnail of When and how to update systematic reviews

Reviews, 1996

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and... more This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2008, Issue 2 http://www.thecochranelibrary.com ... When and how to update systematic reviews (Review) Copyright © 2008 The Cochrane ...