Coronavirus disease (COVID-19) pandemic: an overview of systematic reviews.

BACKGROUND: Navigating the rapidly growing body of scientific literature on the SARS-CoV-2 pandemic is challenging, and ongoing critical appraisal of this output is essential. We aimed to summarize and critically appraise systematic reviews of coronavirus disease (COVID-19) in humans that were available at the beginning of the pandemic. METHODS: Nine databases (Medline, EMBASE, Cochrane Library, CINAHL, Web of Sciences, PDQ-Evidence, WHO's Global Research, LILACS, and Epistemonikos) were searched from December 1, 2019, to March 24, 2020. Systematic reviews analyzing primary studies of COVID-19 were included. Two authors independently undertook screening, selection, extraction (data on clinical symptoms, prevalence, pharmacological and non-pharmacological interventions, diagnostic test assessment, laboratory, and radiological findings), and quality assessment (AMSTAR 2). A meta-analysis was performed of the prevalence of clinical outcomes. RESULTS: Eighteen systematic reviews were included; one was empty (did not identify any relevant study). Using AMSTAR 2, confidence in the results of all 18 reviews was rated as "critically low". Identified symptoms of COVID-19 were (range values of point estimates): fever (82-95%), cough with or without sputum (58-72%), dyspnea (26-59%), myalgia or muscle fatigue (29-51%), sore throat (10-13%), headache (8-12%) and gastrointestinal complaints (5-9%). Severe symptoms were more common in men. Elevated C-reactive protein and lactate dehydrogenase, and slightly elevated aspartate and alanine aminotransferase, were commonly described. Thrombocytopenia and elevated levels of procalcitonin and cardiac troponin I were associated with severe disease. A frequent finding on chest imaging was uni- or bilateral multilobar ground-glass opacity. A single review investigated the impact of medication (chloroquine) but found no verifiable clinical data. All-cause mortality ranged from 0.3 to 13.9%. CONCLUSIONS: In this overview of systematic reviews, we analyzed evidence from the first 18 systematic reviews that were published after the emergence of COVID-19. However, confidence in the results of all reviews was "critically low". Thus, systematic reviews that were published early on in the pandemic were of questionable usefulness. Even during public health emergencies, studies and systematic reviews should adhere to established methodological standards.

Cognitive levels in testing knowledge in evidence-based medicine: a cross sectional study.

BACKGROUND: Knowledge assessment in evidence-based medicine (EBM) is usually performed by the measurement of memorised facts, understanding of EBM concepts and application of learned knowledge in familiar situations, all of which are considered lower-level educational objectives. The aim of this study was to assess EBM knowledge both on higher and lower cognitive levels across EBM topics. METHODS: In order to assess knowledge on different EBM topics across learning levels, we created a knowledge test (Six Progressive Levels in Testing - SPLIT instrument), which consists of 36 multiple choice items and measures knowledge in EBM at six cognitive levels (Remembering, Understanding, Applying, Analysing, Evaluating and Creating) and addresses six EBM topics (Evidence-based practice, Internal validity, Clinical importance, Study design, Sources of evidence, Diagnostic studies). Three independent assessors defined the minimum passing score (MPS) for the overall test, based on the first-year course content and educational objectives. The instrument was assessed in a sample of first- (n = 119) and third-year medical students (n = 70) and EBM experts (n = 14). RESULTS: The MPS was 16 correct answers out of total 36 questions, and was achieved by 21 out of 119 first-year students, 14 out of 70 third-year students and 9 out of 14 EBM experts (χ2 = 13.3; P < 0.001, with significantly higher proportion of experts passing compared to students). Although experts had the highest scores overall, none of the groups outperformed others on individual cognitive levels, but the experts outperformed students in EBM topics of Study design and Sources of evidence (P = 0.002 and 0.004, respectively, Kruskal-Wallis test). First- and third-year students performed better on specific course topics taught in that study year (Diagnostic studies and Clinical relevance, respectively). CONCLUSION: EBM knowledge of students and experts differ according to the specificities of their education/expertise, but neither group had excellent knowledge in all areas. It may be difficult to develop a knowledge test that includes different EBM topics at different cognitive levels to follow the development of specific and general aspects of EBM knowledge.

Knowledge and attitudes of water polo coaches about sports-related dental injuries and dental emergency procedures.

BACKGROUND/AIMS: With the growing popularity of water polo across the world, there has been rising awareness of the risks for orofacial injures in water polo. The aim of this study was to evaluate knowledge and attitudes of water polo coaches regarding dental trauma, dental emergency procedures and awareness about prevention of such injuries. MATERIALS AND METHODS: A specific questionnaire comprising 25 questions regarding knowledge, experiences, and behaviors following dental trauma was distributed to 62 water polo coaches during the license renewal seminar held by the Croatian Water Polo Federation, in February 2018 in Split, Croatia. Chi-square with Yates correction when necessary, and Fisher's exact tests were used in statistical analysis, and the results were considered statistically significant when P < .05. RESULTS: There were 51 water polo coaches who participated in this study. Their ages ranged from 19 to 60 years. Most of the coaches (90.2%) have seen a dental injury in their players during their coaching careers. Concerning the procedure with handling an avulsed tooth, there were 68.6% coaches who would maintain the avulsed tooth in a handkerchief or gauze along with four coaches (7.8%) who would rinse the avulsed tooth under water and wrap it in a handkerchief or gauze afterward. Only one participant (2%) would maintain the avulsed tooth in saline solution before its replantation. None of the coaches would use milk for maintaining the avulsed tooth. Only seven coaches (13.7%) have previously had education about sports-related dental injuries, dental emergency procedures, and prevention of such injuries. CONCLUSIONS: The results of this study demonstrated poor level of knowledge of water polo coaches about dental injuries and dental emergency procedures. Their knowledge and attitudes could be improved by educational programs on dental injuries and dental emergency procedures, as well as sports-related dental injuries management.

What Patients, Students and Doctors Think About Permission to Publish Patient Photographs in Academic Journals: A Cross-Sectional Survey in Croatia.

Use of patient clinical photographs requires specific attention to confidentiality and privacy. Although there are policies and procedures for publishing clinical images, there is little systematic evidence about what patients and health professionals actually think about consent for publishing clinical images. We investigated the opinions of three stakeholder groups (patients, students and doctors) at 3 academic healthcare institutions and 37 private practices in Croatia (total 791 participants: 292 patients, 281 medical and dental students and 281 doctors of medicine or dental medicine). The questionnaire contained patient photographs with different levels of anonymization. All three respondent groups considered that more stringent forms of permission for were needed identifiable photographs than for those with higher levels of anonymization. When the entire face was presented in a photo only 33% of patients considered that written permission was required, compared with 88% of the students and 89% of the doctors. Opinions about publishing patient photographs differed among the three respondent samples: almost half of the patients thought no permission was necessary compared with one-third of students and doctors. These results show poor awareness of Croatian patients regarding the importance of written informed consent as well as unsatisfactory knowledge of health professionals about policies on the publication of patients' data in general. In conclusion, there is a need for increasing awareness of all stakeholders to achieve better protection of patient privacy rights in research and publication.

Promoting running as the best treatment for lower back pain in physiotherapy practice: a best practice implementation project.

OBJECTIVES: This project aimed to promote running as the best treatment for lower back pain (LBP) in an outpatient setting. INTRODUCTION: LBP is one of the most prevalent conditions worldwide. Sixty-two percent of all Germans experience episodes of non-specific back pain at least once a year, with one-fifth developing chronic conditions. Intervertebral disc (IVD) degeneration is a natural process, contributing to periods of acute LBP. However, the scientific literature and guidelines partially overlook the significance of water management in IVD. This implementation project sought to address this gap by educating patients about this process. Running and/or walking were chosen as general approaches for treatment rather than specific disease-related approaches. METHODS: This implementation project was conducted in an outpatient physiotherapy clinic in Brandenburg, Germany, utilizing the JBI Evidence Implementation Framework. An evidence-informed clinical audit and feedback strategy was used to measure compliance with ten audit criteria. Five physiotherapists and 20 patients took part in the audits. RESULTS: At baseline, only 20% of participating physiotherapists screened for yellow flags regarding psychological issues. However, after project implementation, this criterion scored 100% compliance. Some patients performed exercises independently, but confusion persisted regarding the choice of beneficial exercises. Patients continued running, but those who took a break due to pain expressed uncertainty about resuming. CONCLUSIONS: The project highlighted the effectiveness of collaborative efforts between patients and therapists to address the issue. The project team's conviction in action and solution strategies serves as the foundation for this collaboration. This implementation strategy provided "running" patients with the confidence to either resume or reintegrate running after an extended break. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A222.

How do network meta-analyses address intransitivity when assessing certainty of evidence: a systematic survey.

OBJECTIVES: To describe how systematic reviews with network meta-analyses (NMAs) that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) NMA approach addressed intransitivity when assessing certainty of evidence. DESIGN: Systematic survey. DATA SOURCES: Medline, Embase and Cochrane Database of Systematic Reviews from September 2014 to October 2022. ELIGIBILITY CRITERIA: Systematic reviews of randomised controlled trials with aggregate data NMAs that used the GRADE NMA approach for assessing certainty of evidence. DATA EXTRACTION AND SYNTHESIS: We documented how reviewers described methods for addressing intransitivity when assessing certainty of evidence, how often they rated down for intransitivity and their explanations for rating down. RESULTS: Of the 268 eligible systematic reviews, 44.8% (120/268) mentioned intransitivity when describing methods for assessing the certainty of evidence. Of these, 28.3% (34/120) considered effect modifiers and from this subset, 67.6% (23/34) specified the effect modifiers; however, no systematic review noted how they chose the effect modifiers. 15.0% (18/120) mentioned looking for differences between the direct comparisons that inform the indirect estimate. No review specified a threshold for difference in effect modifiers between the direct comparisons that would lead to rating down for intransitivity. Reviewers noted rating down indirect evidence for intransitivity in 33.1% of systematic reviews, and noted intransitivity for network estimates in 23.0% of reviews. Authors provided an explanation for rating down for intransitivity in 59.6% (31/52) of the cases in which they rated down. Of the 31 in which they provided an explanation, 74.2% (23/31) noted they detected differences in effect modifiers and 67.7% (21/31) specified in what effect modifiers they detected differences. CONCLUSIONS: A third of systematic reviews with NMAs using the GRADE approach rated down for intransitivity. Limitations in reporting of methods to address intransitivity proved considerable. Whether the problem is that reviewers neglected to address rating down for transitivity at all, or whether they did consider but not report, is not clear. At minimum systematic reviews with NMAs need to improve their reporting practices regarding intransitivity; it may well be that they need to improve their practice in transitivity assessment. How to best address intransitivity may remain unclear for many reviewers thus additional GRADE guidance providing practical instructions for addressing intransitivity may be desirable.

A systematic review of meta-research studies finds substantial methodological heterogeneity in citation analyses to monitor evidence-based research.

OBJECTIVES: This systematic review aimed to identify the characteristics and application of citation analyses in evaluating the justification, design, and placement of the research results of clinical health studies in the context of earlier similar studies. STUDY DESIGN AND SETTING: We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Methodology Register for meta-research studies. We included meta-research studies assessing whether researchers used earlier similar studies and/or systematic reviews of such studies to inform the justification or design of a new study, whether researchers used systematic reviews to inform the interpretation of new results, and meta-research studies assessing whether redundant studies were published within a specific area. The results are presented as a narrative synthesis. RESULTS: A total of 27 studies were included. How authors of citation analyses define their outcomes appears rather arbitrary, as does how the reference of a landmark review or adherence to reporting guidelines was expected to contribute to the initiation, justification, design, or contextualization of relevant clinical trials. CONCLUSION: Continued and improved efforts to promote evidence-based research are needed, including clearly defined and justified outcomes in meta-research studies to monitor the implementation of an evidence-based approach.

COVID-19 Vaccines Safety Tracking (CoVaST): Protocol of a Multi-Center Prospective Cohort Study for Active Surveillance of COVID-19 Vaccines' Side Effects.

BACKGROUND: Coronavirus disease (COVID-19) vaccine-related side effects have a determinant role in the public decision regarding vaccination. Therefore, this study has been designed to actively monitor the safety and effectiveness of COVID-19 vaccines globally. METHODS: A multi-country, three-phase study including a cross-sectional survey to test for the short-term side effects of COVID-19 vaccines among target population groups. In the second phase, we will monitor the booster doses' side effects, while in the third phase, the long-term safety and effectiveness will be investigated. A validated, self-administered questionnaire will be used to collect data from the target population; Results: The study protocol has been registered at ClinicalTrials.gov, with the identifier NCT04834869. CONCLUSIONS: CoVaST is the first independent study aiming to monitor the side effects of COVID-19 vaccines following booster doses, and the long-term safety and effectiveness of said vaccines.

Assessing risk of bias judgments for blinding of outcome assessors in Cochrane reviews.

Aim: Adequate judging of risk of bias (RoB) for blinding of outcome assessors (detection bias) is important for supporting highest level of evidence. Materials & methods: Judgments and supporting comments for detection bias were retrieved from RoB tables reported in Cochrane reviews. We categorized comments, and then compared judgment and supporting comment with instructions from the Cochrane Handbook. Results: We analyzed 8656 judgments for detection bias from 7626 trials included in 575 reviews. Overall, 1909 judgments (22%) were not in line with the Cochrane Handbook. In 9% of trials, the authors split the detection bias domain according to outcomes. Here, prevalence of inadequate judgments was 19%. Conclusion: Interventions to improve RoB assessments in systematic reviews should be explored.

Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Review and Meta-Analysis.

A growing body of literature on the 2019 novel coronavirus (SARS-CoV-2) is becoming available, but a synthesis of available data has not been conducted. We performed a scoping review of currently available clinical, epidemiological, laboratory, and chest imaging data related to the SARS-CoV-2 infection. We searched MEDLINE, Cochrane CENTRAL, EMBASE, Scopus and LILACS from 01 January 2019 to 24 February 2020. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. Qualitative synthesis and meta-analysis were conducted using the clinical and laboratory data, and random-effects models were applied to estimate pooled results. A total of 61 studies were included (59,254 patients). The most common disease-related symptoms were fever (82%, 95% confidence interval (CI) 56%-99%; n = 4410), cough (61%, 95% CI 39%-81%; n = 3985), muscle aches and/or fatigue (36%, 95% CI 18%-55%; n = 3778), dyspnea (26%, 95% CI 12%-41%; n = 3700), headache in 12% (95% CI 4%-23%, n = 3598 patients), sore throat in 10% (95% CI 5%-17%, n = 1387) and gastrointestinal symptoms in 9% (95% CI 3%-17%, n = 1744). Laboratory findings were described in a lower number of patients and revealed lymphopenia (0.93 × 109/L, 95% CI 0.83-1.03 × 109/L, n = 464) and abnormal C-reactive protein (33.72 mg/dL, 95% CI 21.54-45.91 mg/dL; n = 1637). Radiological findings varied, but mostly described ground-glass opacities and consolidation. Data on treatment options were limited. All-cause mortality was 0.3% (95% CI 0.0%-1.0%; n = 53,631). Epidemiological studies showed that mortality was higher in males and elderly patients. The majority of reported clinical symptoms and laboratory findings related to SARS-CoV-2 infection are non-specific. Clinical suspicion, accompanied by a relevant epidemiological history, should be followed by early imaging and virological assay.

Comparison of Open and Laparoscopic Appendectomy in Children: A 5-year Single Center Experience.

OBJECTIVE: To compare the outcomes of treatment in children with acute appendicitis between laparoscopic and open surgical approaches. Design: Retrospective study. SETTING: Division of Pediatric Surgery at a tertiary-care hospital in Croatia between January 2012 to December 2016. PATIENTS: 834 children [median (IQR) age 13 (11,15)] who underwent appendectomy; 301 in the laparoscopic group and 533 in the open group. MAIN OUTCOME MEASURES: Postoperative complications, duration of hospitalization, re-operation, and the quantity of analgesics used. RESULTS: The median length of hospital stay was 3 days in laparoscopic group compared to 6 days in open group (P<0.001). The amount of analgesics used was lower in patients with laparoscopic appendectomy compared to patients who underwent open procedure (P=0.042). Significantly higher number of wound infections was recorded in the open group (n=21; 3.9%) compared to laparoscopic group (n=3; 1%) (P=0.014). The frequency of re-operation in both groups was equal (1.3%). The median duration of surgery was shorter in the group of patients with laparoscopic appendectomy compared to the open approach (30 vs. 45 min; P<0.001). In five-year period, the proportion of laparoscopic appendectomies increased by 21.5%. CONCLUSIONS: Laparoscopic appendectomy was safe and effective in children. Advantages of laparoscopic approach were shorter hospital stay, lower number of wound infections and lower usage of analgesics.

In Cochrane reviews, risk of bias assessments for allocation concealment were frequently not in line with Cochrane's Handbook guidance.

OBJECTIVES: The aim of the article was to analyze whether the risk of bias (RoB) judgments for allocation concealment in Cochrane systematic reviews (CSRs) were in line with recommendations from the Cochrane Handbook. STUDY DESIGN AND SETTING: From CSR, we extracted data about judgments and supporting comments about allocation concealment for each included randomized controlled trial (RCT). We compared whether judgments for supporting comments were in line with Cochrane Handbook recommendations. RESULTS: We analyzed judgments and comments of 721 CSRs in which 10,280 RCTs were included. By following the Cochrane Handbook guidance, we found that judgments for allocation concealment were discrepant for 2,928 trials (29%). Most discrepancies were made for trials where RoB was judged as low (2,693 trials; 92%). Cochrane authors used 66 categories of comments describing envelopes as a method of allocation concealment. In 66 envelope-related categories, describing RoB assessments from 1,529 (15%) of the analyzed RCTs, most of the judgments were low RoB, although only one of those categories is associated with low RoB according to the Cochrane Handbook. Twenty categories of supporting comments, including 642 trials, were related to randomization, not allocation concealment. CONCLUSION: One-third of RoB judgments about allocation concealment in Cochrane reviews were discrepant from the Cochrane Handbook recommendations.

Methodological Quality of Systematic Reviews Addressing Orthodontic Interventions: Methodological Study

ABSTRACT Objective: To assess the methodological quality and characteristics of systematic reviews (SRs) of interventional studies in orthodontics and assess how the certainty of the evidence is reported using the GRADE approach. Material and Methods: Six electronic databases were searched, followed by a hand search of the reference lists of eligible studies (PROSPERO #CRD42020180852). The required study design was randomized and nonrandomized studies of interventions published between January 2019 and May 2020. The Assessing the Methodological Quality of Systematic Reviews (AMSTAR 2) tool was used for the quality appraisal of the included SRs. Paired reviewers independently screened the studies, extracted data, and appraised the methodological quality. Results: The study included 46 SRs; 19.5% had moderate to high methodological quality, and the remaining had low to critically low methodological quality. Fifty-four percent of the reviews assessed the certainty of evidence using the GRADE approach, and 34.8% followed all GRADE criteria. Conclusion: Most reviews had a good judgment of the AMSTAR2 items, although some critical items contributed to decreased overall quality. Half of the reviews used the GRADE approach to assess the certainty of the evidence, and this approach should be included in future systematic reviews of interventions.