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Division of Cardiothoracic Anesthesiology and Critical Care Medicine; Department of Anesthesiology; Duke University Medical Center; Durham, North Carolina; swami001{at}mc.duke.edu
In Response:
We agree with Bo et al.1 that meta-analyses of articles describing the results of well done randomized trials may represent valid evidence supporting treatment and are important contributions to the literature.2 The key here of course is the term "well done randomized trials." In addition, a limitation of meta-analysis is that the results of some trials may not be included in the meta-analysis, thus skewing the results.3,4 Our intention5 was not to minimize the importance of meta-analyses by relegating them to a position below validation and evaluation studies, and acknowledge that with the hierarchy we described, the importance of meta-analyses might be misconstrued by our readers. However, although we agree that it may have been appropriate to rank meta-analyses more on a par with randomized trials, even if our analyses had been performed using the suggested hierarchy, our results would have been unchanged.
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