Interventions for Age-Related Macular Degeneration: Are Practice Guidelines Based on Systematic Reviews?

PURPOSE: Are existing systematic reviews of interventions for age-related macular degeneration incorporated into clinical practice guidelines? DESIGN: High-quality systematic reviews should be used to underpin evidence-based clinical practice guidelines and clinical care. We examined the reliability of systematic reviews of interventions for age-related macular degeneration (AMD) and described the main findings of reliable reviews in relation to clinical practice guidelines. METHODS: Eligible publications were systematic reviews of the effectiveness of treatment interventions for AMD. We searched a database of systematic reviews in eyes and vision without language or date restrictions; the database was up to date as of May 6, 2014. Two authors independently screened records for eligibility and abstracted and assessed the characteristics and methods of each review. We classified reviews as reliable when they reported eligibility criteria, comprehensive searches, methodologic quality of included studies, appropriate statistical methods for meta-analysis, and conclusions based on results. We mapped treatment recommendations from the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for AMD to systematic reviews and citations of reliable systematic reviews to support each treatment recommendation. RESULTS: Of 1570 systematic reviews in our database, 47 met inclusion criteria; most targeted neovascular AMD and investigated anti-vascular endothelial growth factor (VEGF) interventions, dietary supplements, or photodynamic therapy. We classified 33 (70%) reviews as reliable. The quality of reporting varied, with criteria for reliable reporting met more often by Cochrane reviews and reviews whose authors disclosed conflicts of interest. Anti-VEGF agents and photodynamic therapy were the only interventions identified as effective by reliable reviews. Of 35 treatment recommendations extracted from the PPPs, 15 could have been supported with reliable systematic reviews; however, only 1 recommendation cited a reliable intervention systematic review. No reliable systematic review was identified for 20 treatment recommendations, highlighting areas of evidence gaps. CONCLUSIONS: For AMD, reliable systematic reviews exist for many treatment recommendations in the AAO PPPs and should be cited to support these recommendations. We also identified areas where no high-level evidence exists. Mapping clinical practice guidelines to existing systematic reviews is one way to highlight areas where evidence generation or evidence synthesis is either available or needed.

Community mass treatment with azithromycin for trachoma: Factors associated with change in participation of children from the first to the second round.

BACKGROUND: Mass drug administration (MDA) with azithromycin is an important part of trachoma control programs. Maintaining high participation among children is challenging. AIM: We assessed factors identifying households with a child who changed participation from the first MDA to the second MDA compared to households where all children participated at both MDAs. METHODS: Two case-control comparisons were conducted in 11 Tanzanian communities, which underwent MDA in 2008 and 2009. The first case group (n=165) was a random sample of households with a child who changed from a 2008 non-participant to a 2009 participant (delayed participant). The second case group (n=165) was a random sample of households with a child who went from a 2008 participant to a 2009 non-participant (change to non-participant). Controls (n=330) were a random sample of households where all children participated in both rounds. Risk factors were assessed using questionnaires asked of children's guardians. Logistic models with a random-intercept were used to estimate odds ratios and 95% confidence intervals. RESULTS: Households with delayed participation were more likely to be in communities with fewer treatment days (OR=2.98, 95% CI=1.80-4.92) and assigned to Community Treatment Assistants (CTA) with a wide area to cover (OR=1.88, 95% CI=1.09-3.23). Households with change to non-participation were more likely to live further from the distribution site (OR=3.17, 95% CI=1.19-8.46), have the guardian born outside the village with short-term residency (OR=2.64, 95% CI=1.32-5.31), and be assigned to a male CTA (OR=1.75, 95% CI=1.08-2.83). CONCLUSIONS: Factors related to program accessibility were associated with delayed participation and maintaining participation.

Azithromycin mass treatment for trachoma control: risk factors for non-participation of children in two treatment rounds.

BACKGROUND: Persistent non-participation of children in mass drug administration (MDAs) for trachoma may reduce program impact. Risk factors that identify families where participation is a problem or program characteristics that foster non-participation are poorly understood. We examined risk factors for households with at least one child who did not participate in two MDAs compared to households where all children participated in both MDAs. METHODS/PRINCIPAL FINDINGS: We conducted a case control study in 28 Tanzanian communities. Cases included all 152 households with at least one child who did not participate in the 2008 and 2009 MDAs with azithromycin. Controls consisted of a random sample of 460 households where all children participated in both MDAs. A questionnaire was asked of all families. Random-intercept logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), control for clustering, and adjust for community size. In total, 140 case households and 452 control households were included in the analyses. Compared to controls, guardians in case households had higher odds of reporting excellent health (OR 4.12 (CI 95% 1.57-10.86)), reporting a burden due to family health (OR 3.15 (95% CI 1.35-7.35)), reduced ability to rely on others for assistance (OR 1.66 (95% CI 1.01-2.75)), being in a two (versus five) days distribution program (OR 3.31 (95% CI 1.68-6.50)) and living in a community with < 2 community treatment assistants (CTAs)/1000 residents (OR 2.07 (95% CI 1.04-4.12). Furthermore, case households were more likely to have more children, younger guardians, unfamiliarity with CTAs, and CTAs with more travel time to their assigned households (p-values < 0.05). CONCLUSIONS/SIGNIFICANCE: Compared to full participation households, households with persistent non-participation had a higher burden of familial responsibility and seemed less connected in the community. Additional distribution days and lessening CTAs' travel time to their furthest assigned households may prevent non-participation.

Mass treatment with azithromycin for trachoma control: participation clusters in households.

BACKGROUND: Mass treatment to trachoma endemic communities is a critical part of the World Health Organization SAFE strategy. However, non-participation may not be at random, affecting coverage surveys and effectiveness if infection is differential. METHODOLOGY/PRINCIPAL FINDINGS: As part of the Partnership for Rapid Elimination of Trachoma (PRET), 32 communities in Tanzania, and 48 in The Gambia had a detailed census taken followed by mass treatment with azithromycin. The target coverage in each community was >80% of children ages <10 years. Community treatment assistants observed treatment and recorded compliance, thus coverage at the community, household, and individual level could be determined. Within each community, we determined the actual proportions of households where all, some, or none of the children were treated. Assuming the coverage in children <10 years of the community was as observed and non-participation was at random, we did 500 simulations to derive expected proportions of households where all, some, or none of the children were treated. Clustering of household treatment was detected comparing greater-than-expected proportions of households where none or all of children were treated, and the intraclass correlation (ICC) was calculated. Tanzanian and Gambian mass treatment coverages for children <10 years of age ranged from 82-100% and 62-99%, respectively. Clustering of households where all children were treated or no children were treated was greater than expected. Compared to model simulations, all Tanzanian communities and 44 of 48 (91.7%) Gambian communities had significantly higher proportions of households where all children were treated. Furthermore, 30 of 32 (93.8%) Tanzanian communities and 34 of 48 (70.8%) Gambian communities had a significantly elevated proportion of households compared to the expected proportion where no children were treated. The ICC for Tanzania was 0.77 (95% CI 0.74-0.81) and for The Gambia was 0.55 (95% CI 0.51-0.59). CONCLUSIONS/SIGNIFICANCE: In programs aiming for high coverage, complete compliance or non-compliance with mass treatment clusters within households. Non-compliance cannot be assumed to be at random.

Tamponade in surgery for retinal detachment associated with proliferative vitreoretinopathy.

BACKGROUND: Retinal detachment (RD) with proliferative vitreoretinopathy (PVR) often requires surgery. During surgery, a tamponade agent is needed to reduce the rate of recurrent retinal detachment. OBJECTIVES: The objective of this review was to evaluate the benefits and adverse outcomes of surgery with various tamponade agents. SEARCH STRATEGY: We searched the Cochrane Controlled Register (CENTRAL), MEDLINE, EMBASE, Latin America and Carribbean Health Sciences (LILACS) and the UK Clinical Trials Gateway (UKCTG). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 9 July 2009. SELECTION CRITERIA: We included randomized clinical trials comparing patients treated with various tamponade agents. DATA COLLECTION AND ANALYSIS: Two individuals screened the search results independently. One study with two trials was eligible for inclusion in the review. MAIN RESULTS: One study with two trials was included in the review. The first trial randomized 151 eyes to receive either silicone oil or sulfur hexafluoride (SF(6)) gas tamponades; the second trial randomized 271 eyes to receive either silicone oil or perfluropropane (C(3)F(8)) gas tamponades. In patients with RD associated with PVR, pars plana vitrectomy and infusion of either silicone oil or perfluropropane gas appear comparable for a broad variety of cases. Sulfur hexafluoride gas was associated with worse anatomic and visual outcomes than either silicone oil or perfluropropane gas. AUTHORS' CONCLUSIONS: The use of either C(3)F(8) or silicone oil appears reasonable for most patients with RD associated with PVR. Because there do not appear to be any major differences in outcomes between the two agents, the choice of a tamponade agent should be individualized for each patient.

Comparison of intraocular lens types for cataract surgery in eyes with uveitis.

This is the protocol for a review and there is no abstract. The objectives are as follows: The aim of this systematic review is to summarize the effects of different IOLs after cataract surgery in uveitis patients. Alternative types of IOLs include PMMA, silicone, acrylic with or without heparin-surface modification.

What do the JAMA editors say when they discuss manuscripts that they are considering for publication? Developing a schema for classifying the content of editorial discussion.

BACKGROUND: In an effort to identify previously unrecognized aspects of editorial decision-making, we explored the words and phrases that one group of editors used during their meetings. METHODS: We performed an observational study of discussions at manuscript meetings at JAMA, a major US general medical journal. One of us (KD) attended 12 editorial meetings in 2003 as a visitor and took notes recording phrases from discussion surrounding 102 manuscripts. In addition, editors attending the meetings completed a form for each manuscript considered, listing the reasons they were inclined to proceed to the next step in publication and reasons they were not (DR attended 4/12 meetings). We entered the spoken and written phrases into NVivo 2.0. We then developed a schema for classifying the editors' phrases, using an iterative approach. RESULTS: Our classification schema has three main themes: science, journalism, and writing. We considered 2,463 phrases, of which 87 related mainly to the manuscript topic and were not classified (total 2,376 classified). Phrases related to science predominated (1,274 or 54%). The editors, most of whom were physicians, also placed major weight on goals important to JAMA's mission (journalism goals) such as importance to medicine, strategic emphasis for the journal, interest to the readership, and results (729 or 31% of phrases). About 16% (n = 373) of the phrases used related to writing issues, such as clarity and responses to the referees' comments. CONCLUSION: Classification of editorial discourse provides insight into editorial decision making and concepts that need exploration in future studies.