Critical Review Evidence.
PART 1: Completed PICO Worksheet
My situation of uncertainty of best practice related to a:
** Quantitative type of question: I have completed the PICO question ?
1. Use the following categories to help define your problem and what you are looking at in simple terms
PICO: Patient/Problem, Intervention, Comparison, and Outcome. (Quantitative situation)
(remember to use your readings to help you if you are unsure)
Patient/Problem: Adults patients with hypertension
Intervention: Effectiveness of Thiazides diuretics
Comparison: Alternative pharmacotherapy with CoQ10
Outcome: Clinically significant reduction of bloodpressure
2. Now use these terms from the question above to create your PICO research question so that you have a clear purpose for your search:
Inadult patients with hypertension, is the alternative pharmacotherapy with CoQ10 more effective in clinically significantly lowering blood pressure compared to the use of conventional first line treatment with thiazides diuretics?
3. What type of question do you think this PICO answers?
It answers questions relating to Therapy (efficacy)
4. The table below will help you to think of the other terms that you might also like to look up when searching for evidence to help you answer your question – this is part of basic planning for a research search.
Adults patients with hypertension
(not commonly used in actual database search strategy)
(not commonly used in actual database search strategy)
Decrease blood pressure
5. Is there a particular group of people that you want to look at? List here any inclusion criteria you might use to refine your search if you have too many papers:
Gender: ALL Age Range: ALL
Publication Dates: ALL Language: English
6. What kind of study do you think would best answer your question? Select here which type of article you might want to access. You can also use these to refine your search if you have a lot of papers.
? Systematic Review
? Randomized Controlled Trial (RCT)
Systematic Search Plan (this is what we call a Search Strategy)
7. Now that you have decided on WHAT you will be searching, you need to put down a plan of HOW you will search for your articles. This helps you and others to see how you got your evidence and how you made sure you got the best evidence to help you decide on your clinical action.
? Using the PICO terms in your table, enter each term in a row (group them together under the PICO categories).
? The next step is to combine similar terms using ‘OR’ so that you have all the papers on the same topic together
? The final step is to find papers which only talk about both the population AND the intervention. To do this you use ‘AND’ in the database.
2 Thiazides diuretics
4 Anti hypertensive medication
5 2 OR 3 OR 4
7 Coenzyme Q10
8 Alternative medication
9 Alternate medication
10 Complementary medication
11 6 OR 7 OR 8 OR 9 OR 10
12 Blood pressure
13 1 OR 12
14 5 AND 11 AND 13
16 5 OR 15
17 14 AND 16
8. The final step is to paste in a picture (screenshot/screen grab) of the search that you did in the database. The picture has to be readable!!!
Evidence Selection and Critical Appraisal using CASP Objectives
Systematic Review Appraisal Tool
Section A: Are the results of the review valid?
In adult patients with hypertension, is the alternative pharmacotherapy with CoQ10 more effective in clinically significantly lowering blood pressure compared to the use of conventional first line treatment with thiazides diuretics?
Rosenfeldt, F. L., Haas, S. J., Krum, H., Hadj, A., Ng, K., Leong, J., & Watts, G. F. (2007). Coenzyme Q10 in the treatment of hypertension: a meta-analysis of the clinical trials. Journal of human hypertension, 21(4), 297-306
Did the review address a clearly focused issue?
The main objective of the study was to make an assessment of overall efficacy and consistency of therapeutic action and incidence of side effects and to make a review of published trials of coenzyme Q10 for hypertension. Hypertension poses an increase in the burden of disease globally. The article starts by explaining the rationale behind conducting the study which makes it easier for readers to orient themselves (Parahoo 2014). The researchers indicate that hypertension has increased its threat as a global disease with the main management being the use of various medications. They point out that though they have effectiveness in the reduction of blood pressure, there are also various undesirable side effects like cardiac or renal dysfunction, depression and coughs.
Did the authors look for the right type of papers?
To introduce their study, they note the evidence of Coenzyme Q10 being used as therapeutic treatment in lowering blood pressure and improving glycaemic control. A wide range of recent literature is used by the researchers in their literature review. This is supported by previous literature on management of hypertension in clinical trials by use of CoQ10. In this article, Rosenfeldt et al. (2007) conducted a qualitative study with a meta-analysis in 12 clinical trials of 362 patients from three randomized control trials, eight open label studies and one crossover study. The main intervention plan for all the patients were the use of CoQ10 in the treatment of hypertension and the expected results were that there would be no adverse side effects when using CoQ10. Therefore, through this introduction, the research can be termed as valid as it considers the use of CoQ10 as an alternative pharmacotherapy in the treatment of hypertension to lower blood pressure.
Do you think the important, relevant studies were included?
The authors also looked for the right type of papers which considered all the aspects required in the meta-analysis. In making a review of published trials, the researchers began by carefully searching literature for identification of clinical trials of CoQ10 in hypertension therapy. Using an Evidence Based Medicine review, they included a variety of databases like American College of Physicians Journal Club, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Embase, Medline search (1966-2005), and PubMed (1966-2005). A consultation of the bibliographies of the selected articles was done and the search strategy including significant key words that had a relation to the trial design was utilized (including random allocation, double blind, placebo controlled, and randomized clinical trial), then cross-linked with terms that have a reference to CoQ10 and other terms like blood pressure and hypertension. The studies found address the review question adequately as all the key terms in the question are included in the search and thus, in the studies found. Therefore, the studies included were relevant to the study objectives.
Did the review’s authors do enough to assess the quality of the included studies?
In consideration of the rigour of the studies, the authors made a thorough analysis of the studies. This assessment was used to find the quality of the studies included. Using a meta-analysis, the results were pooled in the STATA v.8.2 software and the Cohen method of meta-analysis for weighted mean difference with regard to the continuous variables. These were presented as effect size with confidence limits of 95%. Each individual study is assigned a relative weight by the STATA in accordance to its contribution in the performance of the meta-analysis based on the treatment group’s size and the confidence level’s preciseness. The same weighting technique of inverse variance was used by Rosenfeldt et al. (2007), to calculate the before and after treatment mean values. Thus, the researchers used an appropriate study design by using a qualitative study. In the evaluation of interventions, they made sure to find randomized control trials. These trials would provide information in the determination of the existence of a cause-effect relation between treatment and outcome (Sibbald& Roland 1998). In making an assessment of overall efficacy and consistency of therapeutic action and incidence of side effects, they ensured that they effectively used the randomized controlled trials
If the results of the review have been combined, was it reasonable to do so?