levels of evidence
Recently Published Documents

There is a growing concern about the multi-resistant capabilities presented by microorganisms to antimicrobials. Society is harmed by the redirection of financial resources from other areas, also lacking the population, to purchase more potent antimicrobials and in larger quantities. This study describes the consumption of antimicrobial drugs and their impact generated through a systematic review, following the recommendations of the Prisma method. Searches were performed in four databases (Portal BVS, PubMed, Embase and Science Direct). A total of 196 articles were found, 11 of which were selected after applying the eligibility criteria. A prospective study showed that the difference in expenditures can reach $31.17 patients/day between prophylactics and those with nosocomial infections. Studies have shown that the increase in costs is related to the increase in the length of stay. Mortality and admission to the ICU also increased. Further studies with high levels of evidence are recommended.

ABSTRACT Objectives To investigate the masticatory (masticatory performance, bite force, swallowing threshold, muscle activity, and questionnaires) and nutritional (nutrient intake) impacts of the activation and/or installation of different orthodontic appliances (fixed labial, lingual appliances, and clear aligners). Materials and Methods Six electronic databases and gray literature were searched (up to May 2021) for relevant studies evaluating mastication and nutrition after activation/installation of orthodontic appliances. This review followed PRISMA guidelines and was registered at PROSPERO (CRD42020199510). The risk of bias (RoB 2 and ROBINS-I) and evidence quality Grading of Recommendations Assessment, Development, and Evaluation were analyzed. Results Of 4226 recorded and screened, 15 studies were finally included. Masticatory performance (standardized mean difference [SMD]: 1.069; 95% coefficient interval [CI]: 0.619 to 1.518) and bite force (SMD: -2.542; 95% CI: -4.867 to -0.217) reduced in the first 24 to 48 hours of fixed labial appliance installation/activation, but they were both normalized after 30 days (P > .05). The swallowing threshold remained constant (P > .05). Nutritional intake was rarely reported but showed copper (P = .002) and manganese (P = .016) reductions, with higher calorie and fat intake (P < .05). Lingual appliances impacted chewing more than labial, and clear aligner wearers reported fewer chewing problems (P < .001). Low to very low levels of evidence were found. Conclusions Based on low to very low levels of evidence, mastication was reduced during the first 24 to 48 hours of fixed labial appliance activation/installation, but it was transitory (up to 30 days). Due to insufficient data, the nutritional impact of orthodontic appliances was not conclusive.

Critical appraisal of the evidence is the third step in the evidence-based practice process. This column, the first in a multipart series to describe the critical appraisal process, defines and provides examples of the levels of evidence and tools to begin the appraisal process using a rapid critical appraisal technique.

Abstract Background Cannabis has been rapidly legalized in North America; however, limited evidence exists around its side effects. Health Canada defines side effect as a harmful and unintended response to a health product. Given drug safety concerns, this study’s purpose was to review the unintended side effects of cannabis in otolaryngology. Methods The Preferred Reporting Items For Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) protocol was used to conduct a scoping review of the MEDLINE, EMBASE, CINAHL, and CENTRAL databases. (PROSPERO: CRD42020153022). English studies in adults were included from inception to the end of 2019. In-vitro, animal, and studies with n < 5 were excluded. Primary outcome was defined as unintended side effects (defined as any Otolaryngology symptom or diagnosis) following cannabis use. Oxford Centre for Evidence-Based Medicine: Levels of Evidence and risk of bias using the Risk of Bias in randomized trials (RoB 2) and Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tools were assessed.. Two authors independently reviewed all studies; the senior author settled any discrepancies. Results Five hundred and twenty-one studies were screened; 48 studies were analysed. Subspecialties comprised: Head and Neck (32), Otology (8), Rhinology (5), Airway (5), Laryngology (1). Cannabis use was associated with unintended tinnitus, vertigo, hearing loss, infection, malignancy, sinusitis, allergic rhinitis, thyroid dysfunction, and dyspnea. About half (54.1%) of studies showed increased side effects, or no change in symptoms following cannabis use. Oxford Levels of Evidence was 2–4 with substantial heterogeneity. Risk of bias assessment with RoB2 was low to high and ROBINS-1 was moderate to critical. Conclusion This was the first comprehensive scoping review of unintended side effects of cannabis in Otolaryngology. The current literature is limited and lacks high-quality research Future randomized studies are needed to focus on therapeutic effects of cannabis in otolaryngology. Substantial work remains to guide clinicians to suggest safe, evidence-based choices for cannabis use. Graphic abstract

Background &amp; Aims: Nonalcoholic fatty liver disease (NAFLD) is the most common liver injury. We performed this umbrella review of meta-analyses to summarize the evidence on the associations of nutritional, lifestyle, and metabolic factors with NAFLD.Methods: We searched the PubMed, Embase, and Web of Science databases from inception until July 2, 2020, to identify meta-analyses of observational studies which explored the associations of nutritional, lifestyle, and metabolic factors with NAFLD. Evidence levels were assessed using summary effect sizes, 95% prediction intervals, between-study heterogeneity, evidence of small-study effects, and evidence of excess significance bias for each meta-analysis. (No. of PROSPERO, CRD42020200124).Results: Twenty two risk or protective factors from 10 published meta-analyses were included and studied. Three risk factors (sugar-sweetened beverage consumption, serum fetuin-A, and waist circumference) with highly suggestive levels of evidence and three risk factors (soft drink consumption, former smoking, and body mass index) with suggestive levels of evidence were identified. Only two protective factors (physical activity and serum vitamin D level [among adults in Western countries]) with suggestive levels of evidence were identified. Furthermore, other six risk factors and two protective factors with weak levels of evidence were identified.Conclusions: We found varying levels of evidence of associations of nutritional, lifestyle, and metabolic factors and NAFLD. The results suggest that nutritional and lifestyle management should be considered as a major primary preventive strategy for NAFLD. Moreover, considering the low quality of included meta-analyses and limited area of research topics, future high-quality original studies and meta-analyses should be performed to study these associations.

Background: Commercially available products used in knee cartilage reconstructive and restorative surgical practices fall under unique US Food and Drug Administration (FDA) regulatory pathways that determine the level of evidence required to market each product. Purpose: To evaluate the levels of evidence in the literature supporting commercially available cartilage repair procedures stratified by FDA regulatory pathway (section 351 vs section 361 of “Human Cells, Tissues, and Cellular and Tissue-Based Products” [HCT/P] in the Code of Federal Regulation) with the hypothesis that products requiring approval under a stringent regulatory pathway (351 HCT/P) have higher levels of evidence in the literature supporting use and that products with a less stringent regulatory pathway (361 HCT/P) have a higher number of products available for use in the United States. Study Design: Systematic review; Level of evidence, 4. Methods: A search of the PubMed database was performed to identify all peer-reviewed articles pertaining to either allograft or autologous cartilage repair technologies. Predefined inclusion and exclusion criteria were used to find clinical, preclinical, and laboratory studies while excluding duplicates, systematic reviews, and products not available in the United States. Articles were categorized by regulatory pathway (351 and 361 HCT/P), and variables including publication year, type of publication, level of evidence, and number of publications were analyzed. Results: After application of predefined criteria, 470 of 1924 articles were included in this study. The 351 HCT/P group was composed entirely of autologous chondrocyte implantation (ACI) technology; 94% of the 361 HCT/P group was composed of osteochondral allografts (OCA). The articles regarding 351 HCT/P were more likely to be clinical in nature than the articles on 361 HCT/P (80% vs 48%, respectively; P = .0001) and entailed significantly more level 1 studies (25 vs 0, respectively; P < .0001). Twice as many articles in the 351 HCT/P group were published in the American Journal of Sports Medicine compared with the 361 HCT/P group (71 vs 38, respectively; P = .18). Conclusion: Both ACI and OCA have robust evidence supporting their use, whereas the remaining regulated products have little or no supporting evidence. Technologies regulated by 351 HCT/P were more likely to be level 1 clinical studies and published in the highest impact journal. The 361 HCT/P pathway regulated many more products, with fewer articles supporting their use.