Systematic Review In Medical Science: Methodological Issues, Bias, And Potential Impact Essay.

Provide specific detail on the types of participants, types of interventions, diagnostic tests or phenomenon of interest.

Outline the eligibility criterion: this sets out specifically which types of studies will be searched for and included, you should specifically state these as inclusion and exclusion criteria

.List the keywords and all possible derivatives of such words (eg oedema, ed ema)
.List all databases that will be searched
.State any potential limits to the search strategy eg, limited by year or language

Methodological issues in Systematic Reviews

Systematic reviews can be defined as a systematic presentation of literature reviews that considers a variety of research papers to formulate a comprehensive research finding. A systematic review vividly considers a set of relevant papers that are critically evaluated and appraised to gather secondary data that can help in further research within the similar field. According to Booth et al. (2016), systematic reviews help in the collection of relevant data from diverse research studies so as to present an overview about the research findings till date. Shamseer et al. (2015), in this regard has further compared the systematic reviews to an intensive summary that comprises of research evidences in favour of the devised research question. Further Korhonen et al. (2013), has mentioned that systematic reviews of randomised controlled trials serve as a key to formulate practice standards of evidence-based medicines. It can also be stated in this regard, that an intensive systematic review thus serves as a quick and feasible reference to the researchers who rely upon the traditional research methods to proceed with their research idea. It should further be crucially noted here that the conceptual understanding of the systematic reviews and its effective implementation is highly recommended in the field of health care studies. This is primarily because it serves as a spontaneous and affordable research method to embark upon a novel study. Systematic reviews are not just restricted to the field of health care studies but are also popular in the fields of application oriented subjects.

It should be noted that while conducting a systematic review a number of issues might be encountered. The complexity of these issues are directly dependent upon the type of data type that is being considered for the review along with the method that is being used for the rigorous analysis. It should further be noted that the analysis of systematic reviews is directly dependent upon the analysis of observational studies. While the consideration of observational studies generally contribute positively towards the synthesis of extensive research, on many instances it has been seen that the research studies generate results that overestimate the treatment and exposure effects on the target population (Shamseet et al. (2015). It is worth noting here that an effective systematic review is based upon several important considerations that include, an expansive research strategy, thorough research over multiple databases and broad inclusion or exclusion criteria consideration (Korhonen et al. 2013). An effective systematic review of the research studies should thus represent a clear reproducibility of the selection criteria along with the quality-assessment criteria to perform a rigorous analysis so as to formulate appropriate findings. The findings would subsequently help in the explanation of differences between the results obtained after analysing the relevant research studies. These considerations have been found ti be useful in determining the research protocol of future studies.

As has already been discussed in the previous sections of the assignment the concept of systematic review serves as an authentic research method that helps in the concise compilation of a set of relevant data. The systematic reviews present a set of information in a sequential manner that introduces a certain topic, summarises the critical issues and provides relevant examples that serve as a guideline for the researchers working in the similar area of interest (Moher et al. 2015).

Explore the concept of systematic review as a unique research method

The topic that has been chosen by me to conduct the systematic review involves an emerging topic in the field of medical science: what is the impact of graduated compression stockings to prevent Dvt in post operated orthopaedic patients?

A number of research studies have focused on the impact of graduated compression stockings for the prevention of Dvt in post-operated orthopaedic patients but there has not been a systematic review in this regard. Hence, this systematic review would aid the researchers in the following ways:

• It would serve as an authentic knowledge base that would include quality research evidence
• It would serve as a convenient protocol that would help researchers in conducting future studies
• The systematic review would represent explicit information that can be considered as a reliable source by the readers
• It would help in developing an overview about the present scenario of incidence of Dvt
• It would also help in determining the effect of graduated compression stockings on the standard of life of the post operated orthopaedic patients

Systematic review forms a research study design that has both been appreciated as well as critiqued by renowned researchers. It has been mentioned in this regard that although systematic reviews serve as a knowledge bank, one cannot be completely sure about the authenticity of the information provided by the review (Taylor et al. 2014). Another aspect that must be considered includes the critical specificationwith respect to the date of publication of the research studies. Researchers all over the word have agreed upon the fact that there must be set standards to conduct a vivid systematic review. Further, it should also be noted that researchers also hold the opinion that inclusion of resources beyond the major databases into grey literature would help in enhancing the effectiveness of the systematic reviews (Taylor et al. 2013).

According to Shamseer et al. (2015), it has been mentioned that systematic reviews conducted by Cochrane often contain biased reviews are extremely lengthy and are obsolete. Researchers have further criticized the study design in terms of inappropriate selection of studies and inclusion of low quality research journals (Moher et al. 2015). On the other hand, other primary research studies that involve qualitative or quantitative study design or randomized control is directed towards a specific target population and hence yield accurate results. However, it should also be mentioned here that systematic review yield an extensive synthesis on the basis of the relevant data available in the concerned field of research.

Systematic review presenta range of biasness on the basis of a number of sources. According to Taylor et al. (2014), a systematic review must be designed well on the basis of a standard protocol. The review should be made available on a public forum in order to facilitate critical review by the readers so as to include room for the scope of reporting biasness (Taylor et al. 2014). On an average a number of potential biasness are identified within the reviewed set of literatures. These include, time lag biasness, citation biasness, reporting outcome biasness, biasness in terms of multiple publications and language biasness. It should be noted here that an instance of evidence selection biasness occurs when there is a discrepancy in terms of the identification of available relevant data on a specific research topic. Instances of publication biasness have also been identified when data retrieved from statistically significant studies are published and studies including data that are not statistically significant are not published (Taylor et al. 2014). Biasness has also been identified in the discussion and critique of primary research findings that are appraised in a systematically appraised in a systematic review. Further, language biasness in literature review have also been critiqued by researchers as ideal systematic reviews should not use language as a constraint to filter and scrutinise relevant papers. Therefore, it should be highlighted that knowledge about potential bias in literatures can help researchers in the process of conducting an effective systematic review.

Discussion and comparison of strength and weaknesses of systematic review to research approaches

The hierarchy of evidences retrieved from research papers serves as a tool that helps in the effective appraisal of research papers. It should further be noted in this context, that the hierarchy presents an understanding about the latest advancements in the field of interest. For instance, while performing a systematic review it is appropriate to consider relevant literatures that are published within the time frame of 7 years from the year when the research is being conducted. It should further be noted that recent evidences facilitate easier understanding of the methodology procedures that consequently assist the process of critical decision making (Taylor et al. 2014). Also, in this regard it can be stated that recent studies present examples of latest evidences that can be compared and contrasted to a standard protocol and direct further research. It should also be noted that the hierarchy of evidences also help in developing an understanding about the historical background of the research study and recent advancements made through trial and error methods. It further helps in understanding the critical considerations that facilitate the process of appraising a research on the basis of the strength and weakness. The researcher clearly develops an insight about the potential factors that cause biasness within the studies and degrade the quality of the research. This understanding facilitates increased focus on the part of the researcher to avoid such discrepancies.

In order to conduct a systematic review a number of steps must stringently be followed. The primary step involves the identification of the area of research interest. The second step involves the designing of an appropriate research question. The third step involves devising an appropriate research-study design. Once this step is completed appropriately, the next step comprises of scanning popular research databases for relevant papers. It should be noted here that the papers are scanned on the basis of stringent inclusion and exclusion criteria (Moher et al. 2015). The inclusion and exclusion criteria might contain a series of considerations that are devised by the author. Once the relevant papers are retrieved, the duplicate papers and papers that have repetitive themes are rejected. Finally the papers that meet all the inclusion and exclusion criteria and do not present similar themes are short listed for the systematic review. It should be further noted here that the next steps involve discussion and data analysis. The method chosen for data analysis depends upon the type of data collected. It can either be discussed under themes or might be analysed through statistical analysis. After the retrieved data is analysed the findings are discussed and appraised so as to derive an exhaustive summary of the relevant research papers (Korhonen et al. 2013).

The proposed research question that would be answered through the systematic review is: what is the impact of graduated compressed stockings to prevent Dvt in the post-operated orthopaedic patients?

Prior to the in dept analysis of the research topic, the first segment of the paper would talk about the rationale behind the choice of the topic and devise the objectives of the research study. Dvt or deep vein thrombosis can be defined as a medical condition when there is a formation of a blood clot inside the deep veins of the body (Struijik-Mulder et al. 2013). It has usually been observed that this condition primarily arises within the veins of the leg Struijik-Mulder et al. 2013). Studies prove that deep vein thrombosis is often accompanied with inflammation and pain, however it should be noted that there are instances when the medical condition occurs without any symptoms (Berntsen et al. 2016); (Holmes et al. 2014). It should be critically noted here that the condition occurs on the basis of the nature of blood clot formation in an individual. Research studies reveal that the condition might also present itself in patients who have undergone accident surgeries (Roberts et al. 2013). Post operation, the movement of the patients is restricted for a long period of time. This leads to the possibility of developing Dvt. The condition of Dvt is dangerous as the blood clots formed in the body might travel to all major organs including the lungs and the heart and impair the normal physiological functioning of the organ system (Roberts et al. 2013). The most common symptoms associated with the disease condition include the following:

• Sensation of pain in the affected area
• Discolouration or the formation of reddened skin where the blood clot has formed
• Sensation of warmth within the affected region

Exploring areas of potential bias in literature

The rationale for conducting the research study includes critically analyzing the positive impact of graduated compression stocking to provide relief to the patients who have been diagnosed with deep vein thrombosis. This systematic review would help in analyzing the available literatures that suggest the use of graduated stockings to elicit a positive impact on the health of the patients. The systematic review intends to compile the best research papers dealing with the subject in order to devise a comprehensive summary that could be used by practitioners to help Dvt patients. Therefore, it can be said that the systematic review would serve as a guideline for the researchers who intend to perform research on the similar research area. In this regard it should be mentioned that the graduated compression stockings facilitate the ease of symptoms in the affected patients. The mechanism of the stockings is to apply pressure in order to prevent the worsening of the symptoms that include inflammation, accumulation of clot and pain (Struijik-Mulder et al. 2013). The stockings are designed in a manner that they are snug-fitting and stretchable and apply gentle pressure on the leg. The use of graduated compression stockings have been found to be extensively useful in alleviating the adverse symptoms association with the medical condition of deep vein thrombosis. This systematic review intends to validate the positive implication of using graduated compression stocking on the physical health of the patients.

  Therefore the devised research objectives of the systematic review would include the following:

• The incidence rate of deep vein thrombosis in relation to the global scenario
• The available options available as post-operative recovery options
• The impact of graduated compression stockings to provide relief to post-operated deep vein thrombosis patients
• The impact of the graduated compression stockings on the quality of life, morbidity and mortality rate among the target population

The systematic review would broadly be based upon the consideration of the objectives mentioned above. However it should be critically highlighted here that the primary objective would include the incidence of Deep vein thrombosis in the orthopaedic patients, post operation. The systematic review would critically include the global population as the target population. This is primarily because the study design of the research is a systematic review that would include the research papers that access the impact of graduated compression stockings on orthopaedic patients post operation. The research papers selected would not be country-specific and hence the target population for the research would not be area specific. In this regard it should also be mentioned that the secondary objective considered for the study would be to access and evaluate the impact of graduated compression stocking on the quality of life of the patients and the morbidity and mortality rate associated with the use of the graduates compression stocking in Deep vein thrombosis patients.

Target population considered in the research study:

The identified target population for the research study includes the post-operated orthopaedic patients who majorly face issues with deep vein thrombosis. According to research studies it should be noted that post surgery, patients are advised to rest and restrict their movement and mobilization for a long period of time. This is done primarily to allow time for recovery. According to the evidences revealed by research studies, it has been mentioned that the recovery period allows the dislocated or fractured bones to regain the proper orientation (Jayaraj and Meissner 2015). After a leg surgery, patients are often plastered and advised complete bed rest (Jayaraj and Meissner 2015). During the resting phase, the mobilization and movement is restricted to the maximum to allow time for the process of recovery and proper orientation of the bones (Ayhan et al. 2015). However, it should be noted that on account of the prolong time interval where the mobilization is restricted to the maximum, the circulation of blood is also affected. This leads to the formation of clots in and around the surrounding areas of the veins. The clots thus formed impede with the smooth circulation of blood and might reach up to major organs that include the lungs and the heart (Kahn et al. 2014); (Sachdeva et al. 2014). Accumulation of the clot enhances the probability to develop conditions such as haemorrhoids and infection (Lattimer et al. 2014). The use of graduated compression stockings have been the most prevalent remedy used by physicians to provide relief to patients, post-orthopaedic surgery (Wade et al. 2015). The pair of stockings typically make use of the pressure distribution mechanism and improve the circulation of blood within the leg region (Lim et al. 2014).

Understanding the potential for bias within studies and its impact on the quality of evidence

As has already been discussed in the previous sections above, the systematic review is based upon two major primary and secondary interests. The primary interest outcome includes, accessing the incidence of deep vein thrombosis in patients post orthopaedic surgery. At the same time, it should be mentioned here that the secondary research outcomes includes validating and analyzing the quality of life of the patients who have been using graduated compression stockings post surgery. It is expected that the designed interest outcomes would help in understanding the efficiency of the technique as a recovery process in the patients. Further, it should also be noted here that the broad interest outcomes would facilitate the consideration of a large number of papers for the process of systematic review. The broad synthesis of the findings would facilitate an exhaustive summary that could be utilized as a future reference for the future researchers.

According to Booth and Sutton (2016), it has been mentioned that a standard systematic review must be based upon the consideration of stringent exclusion and inclusion criteria. In this regard, it should also be noted that the exclusion and the inclusion criteria form the basis of the filters that help in the selection and short listing of the research papers. While the inclusion criteria includes the characteristics that must be critically considered while short listing a research article in the systematic review, the exclusion criteria forms the basis of the articles that are not included in the study. For this systematic review, the inclusion criteria comprised of the research articles that were published between the time frame of 2008 till the year 2017. Another aspect of the inclusion criteria included the research articles that were published in the English language. On the other hand, the exclusion criteria comprised of the articles that were published in foreign languages other than English and were published prior to the year 2008. It should be critically noted in this regard that the time frame was considered as a filter because papers that were published prior to the year 2008 are considered obsolete in the present day context. This is exclusively because papers published earlier lack the modern conceptual framework of intervention and medication prescribed to the orthopaedic patients post operation. In addition to this it should further be noted that the exclusion criteria would also comprise of the elimination of research studies that include paediatric and animal trials. The inclusion criteria thus would specifically comprise of the target audience that would include the middle aged and elderly individuals who have undergone an orthopaedic surgery.

The diagnostic tests and phenomenon that is used to diagnose patients who are suffering from deep vein thrombosis include critical consideration of the medical history of the patient. The first set of diagnosis includes a series of physical assessments that comprise of investigation of the blood pressure and evaluation of the major organs of the respiratory and the circulatory system (Holmes et al. 2014). The major organ includes, the heart and the lungs. Following the set of physical assessments the diagnostic tests are suggested to the patients who are suspected to be victims of deep vein thrombosis. It should be critically noted here that the most common methods of diagnostic tests that are used to access the condition of deep vein thrombosis include the ultrasound, A D-dimer test, Venography and other related medical tests. According to the research studies each of the methods used for the diagnosis of the medical health condition has been described in detail (Holmes et al. 2014); (Bernsten et al. 2016). The ultrasound test makes use of the ultrasound waves to form images of the blood flowing through the arteries and veins of the blood. On the other hand, the A-D dimer test typically measures a substance in the blood that is released naturally by the body to dissolve a blood clot (Roberts et al. 2013). If the test detects a higher amount of the substance inside the body, it indicates the presence of an increased amount of blood clots. However, the normal results predict a few risk factors but absence of severe clots inside the body. The method of venography is extremely popular and highly recommended to the patients if the ultrasound method does not provide clear results (Jayaraj and Meissner 2015). This process incorporates a dye inside a vein and following the same an X-ray is conducted. The X-ray clearly displays the speed of the blood circulation within the leg. The slower speed of the circulation indicates that there might be a presence of a blood clot. It should also be noted that other important medical tests include Magnetic Resonance Imaging and CT scan to detect the presence of the blood clots.

The eligibility criteria that would be followed for conducting the systematic review would include the exclusion and inclusion criteria. The inclusion criteria as has already been discussed would comprise of the research papers that were published in the recent years and in English Language. On the other hand the exclusion criteria would include papers that were published in languages other than English and published before 2008. In addition to this the inclusion criteria would also comprise short listing papers that contain the key words mentioned during the search and papers that follow both qualitative and quantitative research study design. This is primarily because, in order to fulfil the first interest outcome that deals with the evaluation of the incidence rate of deep vein thrombosis it is important to include papers on Dvt that follow a quantitative research design. In the same way, to satisfy the second interest papers that follow the qualitative approach would also be considered. The exclusion criteria would also comprise of papers that deal with deep vein thrombosis in paediatrics and animal trials. Further complete-text accessible papers would only be considered.

The search strategy would comprise of conducting a thorough search across popular databases that include CINAHL, GOOGLE SCHOLAR, PubMed, Medline and Cochrane Library. Following research, the relevant papers would be shortlisted applying the exclusion and inclusion criteria. Once the papers are short listed the papers would then be analyzed on the basis of thematic discussion and statistical analysis.

The keywords included while searching the databases include the following:

Keywords: Dvt, deep vein thrombosis, impact, incident, prevalence, post operation, orthopaedic patients, surgery, compression stocking, morbidity, mortality, quality of life

The databases that were searched included CINAHL, GOOGLE SCHOLAR, PUBmED, Medline and Cochrane library. In addition to this grey literary sources were also include that comprised browsing through the medical and wellness blogs, news articles and websites of popular health clinic.

The data collection method would comprise of gathering information from research papers across popular databases. The combines results obtained from the research papers would then be articulated together and discussed in an elaborate manner using the Preferred Reporting Items for systematic reviews popularly known as PRISMA by the author individually. The PRISMA method would serve as an excellent data reporting method that would allow the author to evaluate the benefits and harm associated with the use of graduated compression stocking on the concerned target population (Shamseer et al. 2015). Further, it should be noted that the obtained data would be analyzed on the basis of thematic discussion and statistical analysis to derive a standardized outcome by the author and his supervisor. The statistical data analysis methods that would be used would include odds ratio analysis and comparison on the basis of risk ratios (Shamseer et al. 2015). The data obtained would then be critically appraised with the use of CASP checklist tool in order to include appropriate findings. The quantitative, qualitative as well as mixed study CASP checklists would be considered to appraise the papers.

Conclusion and Recommendations:

Therefore to conclude it can be said that systematic reviews are robust research methods. It makes use of systematic search, critical appraisal and synthesis of the research findings. This method of research helps in combining the results of different research studies. However it should be noted that due to the lack of availability of ample research papers on the mentioned research topic, all relevant papers would be critically considered.

Hence it can be said that systematic reviews serve as a best research method to filter and present the cumulative results obtained from standard research studies. The findings of the systematic review would thus serve as a guideline for the effective designing of intervention for Dvt patients post surgery. In addition to this, it should also be stated that systematic reviews also highlight potential areas that require rigorous research in future.

References:

Ayhan, H., Iyigun, E., Ince, S., Can, M.F., Hatipoglu, S. and Saglam, M., 2015. A randomised clinical trial comparing the patient comfort and efficacy of three different graduated compression stockings in the prevention of postoperative deep vein thrombosis. Journal of clinical nursing, 24(15-16), pp.2247-2257.

Berntsen, C.F., Kristiansen, A., Akl, E.A., Sandset, P.M., Jacobsen, E.M., Guyatt, G. and Vandvik, P.O., 2016. Compression stockings for preventing the postthrombotic syndrome in patients with deep vein thrombosis. The American journal of medicine, 129(4), pp.447-e1.

Booth, A., Sutton, A. and Papaioannou, D., 2016. Systematic approaches to a successful literature review. Sage.

Holmes, C.E., Bambace, N.M., Lewis, P., Callas, P.W. and Cushman, M., 2014. Efficacy of a short course of complex lymphedema therapy or graduated compression stocking therapy in the treatment of post-thrombotic syndrome. Vascular Medicine, 19(1), pp.42-48.

Jayaraj, A. and Meissner, M., 2015. Impact of graduated compression stockings on the prevention of post-thrombotic syndrome-results of a randomized controlled trial. Phlebology, 30(8), pp.541-548.

Kahn, S.R., Shapiro, S., Ducruet, T., Wells, P.S., Rodger, M.A., Kovacs, M.J., Anderson, D., Tagalakis, V., Morrison, D.R., Solymoss, S. and Miron, M.J., 2014. Graduated compression stockings to treat acute leg pain associated with proximal DVT. Thrombosis and haemostasis, 111(06), pp.1137-1141.

Korhonen, A., Hakulinen?Viitanen, T., Jylhä, V. and Holopainen, A., 2013. Meta?synthesis and evidence?based health care–a method for systematic review. Scandinavian Journal of Caring Sciences, 27(4), pp.1027-1034.

Lattimer, C.R., Kalodiki, E., Kafeza, M., Azzam, M. and Geroulakos, G., 2014. Quantifying the degree graduated elastic compression stockings enhance venous emptying. European Journal of Vascular and Endovascular Surgery, 47(1), pp.75-80.

Lim, C.S. and Davies, A.H., 2014. Graduated compression stockings. Canadian Medical Association Journal, 186(10), pp.E391-E398.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.

Roberts, L.N., Patel, R.K., Chitongo, P.B., Bonner, L. and Arya, R., 2013. Presenting D?dimer and early symptom severity are independent predictors for post?thrombotic syndrome following a first deep vein thrombosis. British journal of haematology, 160(6), pp.817-824.

Sachdeva, A., Dalton, M., Amaragiri, S.V. and Lees, T., 2014. Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of Systematic Reviews, (12).

Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj, 349, p.g7647.

Struijk-Mulder, M.C., Ettema, H.B., Verheyen, C.C. and Büller, H.R., 2013. Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study of 100 patients. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 29(7), pp.1211-1216.

Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. and Reed, J.E., 2014. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf, 23(4), pp.290-298.

Wade, R., Sideris, E., Paton, F., Rice, S., Palmer, S., Fox, D., Woolacott, N. and Spackman, E., 2015. Graduated compression stockings for the prevention of deep-vein thrombosis in postoperative surgical patients: a systematic review and economic model with a value of information analysis.