Nonpharmacologic and pharmacologic treatments of adult patients with major depressive disorder: a systematic review and network meta-analysis for a clinical guideline by the American College of Physicians

Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD). To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants.

A web-survey assessed attitudes toward evidence-based practice among psychotherapists in Austria.

Evidence-based practice (EBP) means integrating the best available scientific evidence with clinical experience and patient values. Although perceived as important by many psychotherapists, there still seems to be reluctance to use empirically supported therapies in clinical practice. We aimed to assess the attitudes of psychotherapists in Austria toward EBP in psychotherapy as well as factors influencing the implementation of EBP. We conducted an online survey. To investigate attitudes toward EBP, we used two subscales ("Limitations" and "Balance") of a translated and validated short version of the Evidence-Based Practice Attitude Scale-36 (EBPAS-36). Participants provided perceived barriers and facilitators as answers to open-ended questions. We analyzed the responses mainly using descriptive statistics. Open answers were analyzed using a thematic analysis. In total, 238 psychotherapists completed our survey (mean age 51.0 years, standard deviation [SD] = 9.9, 76.9% female). Psychotherapists scored on average 2.62 (SD = 0.89) on the reversed EBPAS-36 subscale "Limitations," indicating that the majority do not perceive EBP as limiting their practice as psychotherapists. They scored 1.43 (SD = 0.69) on the reversed EBPAS-36 subscale "Balance," indicating that psychotherapists on average put a higher value on the art of psychotherapy than on evidence-based approaches. Organizational factors such as lack of time and access to research studies as well as negative attitudes toward research and a lack of skills and knowledge kept respondents from implementing EBP. Our study highlights that EBP is still not very popular within the psychotherapy community in Austria. The academization of psychotherapy training might change this in the future.

Resource use during systematic review production varies widely: a scoping review.

OBJECTIVE: We aimed to map the resource use during systematic review (SR) production and reasons why steps of the SR production are resource intensive to discover where the largest gain in improving efficiency might be possible. STUDY DESIGN AND SETTING: We conducted a scoping review. An information specialist searched multiple databases (e.g., Ovid MEDLINE, Scopus) and implemented citation-based and grey literature searching. We employed dual and independent screenings of records at the title/abstract and full-text levels and data extraction. RESULTS: We included 34 studies. Thirty-two reported on the resource use-mostly time; four described reasons why steps of the review process are resource intensive. Study selection, data extraction, and critical appraisal seem to be very resource intensive, while protocol development, literature search, or study retrieval take less time. Project management and administration required a large proportion of SR production time. Lack of experience, domain knowledge, use of collaborative and SR-tailored software, and good communication and management can be reasons why SR steps are resource intensive. CONCLUSION: Resource use during SR production varies widely. Areas with the largest resource use are administration and project management, study selection, data extraction, and critical appraisal of studies.

Restricting evidence syntheses of interventions to English-language publications is a viable methodological shortcut for most medical topics: a systematic review.

OBJECTIVES: To assess the impact of restricting systematic reviews of conventional or alternative medical treatments or diagnostic tests to English-language publications. STUDY DESIGN AND SETTING: We systematically searched MEDLINE (Ovid), the Science Citation Index Expanded (Web of Science), and Current Contents Connect (Web of Science) up to April 24, 2020. Eligible methods studies assessed the impact of restricting systematic reviews to English-language publications on effect estimates and conclusions. Two reviewers independently screened the literature; one investigator performed the data extraction, a second investigator checked for completeness and accuracy. We synthesized the findings narratively. RESULTS: Eight methods studies (10 publications) met the inclusion criteria; none addressed language restrictions in diagnostic test accuracy reviews. The included studies analyzed nine to 147 meta-analyses and/or systematic reviews. The proportions of non-English-language publications ranged from 2% to 100%. Based on five methods studies, restricting literature searches or inclusion criteria to English-language publications led to a change in statistical significance in 23/259 meta-analyses (9%). Most commonly, the statistical significance was lost, but had no impact on the conclusions of systematic reviews. CONCLUSION: Restricting systematic reviews to English-language publications appears to have little impact on the effect estimates and conclusions of systematic reviews.

Excluding non-English publications from evidence-syntheses did not change conclusions: a meta-epidemiological study.

OBJECTIVES: We aimed to assess whether limiting the inclusion criteria solely to English-language publications affected the overall conclusions of evidence syntheses. STUDY DESIGN AND SETTING: Our analyses used a dataset of a previous methods study that included 59 randomly selected Cochrane intervention reviews with no language restrictions. First, we ascertained the publication language of all 2,026 included publications. Next, we excluded studies based on the following criteria: (1) publication solely in non-English language, or (2) main publication (in case of multiple publications of the same study) in non-English language. We then re-calculated meta-analyses for outcomes that were presented in the main summary of findings tables of the Cochrane reports. If the direction of the effect estimate or the statistical significance changed, authors of the respective Cochrane reviews were consulted to assess whether the new evidence base would have changed their conclusions. The primary outcome of our analyses examined the proportion of conclusions that would change with the exclusion of non-English publications. We set the threshold for the approach as noninferior if the upper limit of the 95% confidence interval of the proportion of changed conclusions did not cross a margin of 10%. RESULTS: Across all 59 Cochrane reviews, 29 (49%) included 80 non-English publications. For 16 (27%) of these Cochrane reviews, the exclusion of non-English publications resulted in the exclusion of at least one study. In the remaining 13 Cochrane reviews, the non-English publications were not the only or main publication of the study or they did not contribute to the main summary of the findings table, so their exclusion did not result in an exclusion of the study. Overall, the exclusion of non-English publications led to the exclusion of 31 studies contributing to 40 outcomes. For 38 of the 40 outcomes, the exclusion of non-English studies did not markedly alter the size or direction of effect estimates or statistical significance. In two outcomes, the statistical significance changed, but authors would have still drawn the same conclusion, albeit with less certainty. Thus, the proportion of changed conclusions in our sample was 0.0% (95% CI 0.0-0.6), which indicated the noninferiority of the approach. However, the majority of excluded studies were small. CONCLUSION: Exclusion of non-English publications from systematic reviews on clinical interventions had a minimal effect on overall conclusions and could be a viable methodological shortcut, especially for rapid reviews.

[Assessment of risk of bias in controlled studies]. / Bewertung des Risikos für Bias in kontrollierten Studien.

BACKGROUND: Practicing physicians are faced with many medical decisions daily. These are mainly influenced by personal experience but should also consider patient preferences and the scientific evidence reflected by a constantly increasing number of medical publications and guidelines. With the objective of optimal medical treatment, the concept of evidence-based medicine is founded on these three aspects. It should be considered that there is a high risk of misinterpreting evidence, leading to medical errors and adverse effects without knowledge of the methodological background. OBJECTIVES: This article explains the concept of systematic error (bias) and its importance. Causes and effects as well as methods to minimize bias are discussed. This information should impart a deeper understanding, leading to a better assessment of studies and implementation of its recommendations in daily medical practice. CONCLUSION: Developed by the Cochrane Collaboration, the risk of bias (RoB) tool is an assessment instrument for the potential of bias in controlled trials. Good handling, short processing time, high transparency of judgements and a graphical presentation of findings that is easily comprehensible are among its strengths. Attached to this article the German translation of the RoB tool is published. This should facilitate the applicability for non-experts and moreover, support evidence-based medical decision-making.

[Kyphoplasty and vertebroplasty for the management of osteoporotic vertebral compression fractures: a systematic review]. / Kyphoplastie und Vertebroplastie bei osteoporotischen Wirbelkörperkompressionsfrakturen: Systematischer Review.

BACKGROUND: We evaluated the efficacy and safety of kyphoplasty and vertebroplasty using the data presented in recently published papers with respect to pain relief, function, complication rate, and incidence of new vertebral fractures. METHODS: Detailed searches for English-language and German-language articles published between 2002 and 2009 were performed in a number of electronic databases. Because of the large number of case series, we considered only systematic reviews and controlled studies. The internal validity of reviews and studies was judged by two authors independently. Data extraction was performed by one author, and extracted data were checked for completeness and correctness by a second author. RESULTS: A total of eight systematic reviews, primarily summarizing results from case series, and 11 controlled studies, two of which were randomized controlled trials (RCTs), were included. Both kyphoplasty and vertebroplasty significantly reduce pain in the majority of patients and can lead to short-term and possibly long-term improvement of function. Kyphoplasty induces fewer clinically relevant complications than vertebroplasty does, and there is presently stronger evidence for its efficacy compared with vertebroplasty. There is inconclusive evidence about the risk of new fractures after kyphoplasty and vertebroplasty. CONCLUSION: Both procedures seem to be equally effective, but kyphoplasty is safer than vertebroplasty. New results, specifically from RCTs comparing the two procedures, are needed to provide more definitive data.

[Rheopheresis for age-related macular degeneration]. / Rheopherese bei altersbedingter Makuladegeneration.

BACKGROUND: In Austria, Rheopheresis for non-exudative age-related macular degeneration (AMD) has been proposed for inclusion into the benefit catalogue. Decisions on the inclusion of new medical interventions in reimbursement schemes or benefit catalogues are increasingly based on systematic reviews of clinical studies and their patient-relevant results. MATERIAL AND METHODS: A systematic literature search in five databases identified two randomised clinical trials (RCTs). A systematic analysis of the evidence based on the critical appraisal of the RCTs was carried out. RESULTS: Both RCTs, having a total of 238 included patients, show that to date, evidence for the effectiveness of Rheopheresis for AMD is not available, and predictions for exact indications cannot be made. The bigger RCT showed no effect at all, and the smaller one showed a small effect with questionable clinical relevance. CONCLUSION: Available clinical data suggest considering Rheopheresis an experimental intervention. Its inclusion in the benefit catalogue is not recommended.