CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials

Randomized clinical trials on Eastern-Western integrative medicine for health care in Korean literature: a systematic review

OBJECTIVE

To summarize and critically evaluate the evidence for and against the effectiveness of Eastern-Western integrative medicine (EWIM) for health care compared to Eastern medicine (EM) or Western medicine (WM) alone.

METHODS

Systematic searches were conducted on five Korean medical databases. Manual searches were also conducted through nine major Korean medical journals. Prospective randomized clinical trials (RCTs) were included if EWIM was tested for any type of conditions compared to EM or WM.

RESULTS

There were one hundred forty-one possibly relevant studies were identified, and seven RCTs were included. The risk of bias was high in most studies. The EWIM methods were compared with EM or WM in patients with pain conditions in four studies. These studies showed favorable effects of EWIM on pain reduction in patients with shoulder pain and chronic headache compared with EM, while the other RCTs failed to do so in traffic injury patients. Two studies tested EWIM in patients with Bell's palsy compared with EM and found acute functional improvement. An RCT comparing EWIM with WM in patients with acne showed a significant difference.

CONCLUSION

The results of our systematic review suggest that there is limited evidence for the superiority of EWIM over EM or WM in the treatment of pain and acute symptom improvement in patients with Bell's palsy. The evidence from our analysis was limited from the low number of RCTs included and the high risk of bias. Future RCTs appear to be warranted.

Intravenous immunoglobulins for epilepsy

BACKGROUND

Epilepsy is a common neurological condition, with an estimated incidence of 50 per 100,000 persons. People with epilepsy may present with various types of immunological abnormalities, such as low serum IgA level, lack of IgG subclass and identification of certain types of antibodies. Intravenous immunoglobulin (IVIg) treatment may represent a valuable approach and its efficacy has important implications for epilepsy management.

OBJECTIVES

To examine the effects of IVIg on the frequency and duration of seizures, quality of life and adverse effects, when used as monotherapy or as add-on treatment for people with epilepsy.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group Specialized Register (14 June 2010), the Cochrane Central Register of Controlled Trials (Issue 2 of 4, The Cochrane Library, 2010), MEDLINE (1950 to June 2010), Web of Science (14 June 2010), Current Controlled Trials (11 June 2010), the National Research Register (NRR) archive (11 June 2010), the US National Institutes of Health (Clinicaltrials.gov) (11 June 2010) and reference lists of articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of IVIg as monotherapy or add-on treatment in people with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials for inclusion and extracted data. We contacted study authors for additional information. Outcomes included percentage of people rendered seizure-free, 50% or greater reduction in seizure frequency, adverse effects, treatment withdrawal and quality of life.

MAIN RESULTS

We included one study (61 patients). We found no randomized controlled trials that investigated the effects of IVIg monotherapy for epilepsy. The included study was a randomized, double-blind, placebo-controlled, multi-center trial which compared the treatment efficacy of IVIg as an add-on with a placebo add-on in patients with refractory epilepsy. There was no significant difference between IVIg and placebo in 50% or greater reduction in seizure frequency. The study reported a statistically significant effect for global assessment in favor of IVIg. No adverse effects were demonstrated.

AUTHORS' CONCLUSIONS

No reliable conclusions can be drawn regarding the efficacy of IVIg as a treatment for epilepsy. Further randomized controlled trials are needed.

Ginseng for cognition

BACKGROUND

Ginseng is a herbal medicine in widespread use throughout the world. Its effect on the brain and nervous system has been investigated. It has been suggested, on the basis of both laboratory and clinical studies, that it may have beneficial effects on cognitive performance.

OBJECTIVES

To evaluate the efficacy and adverse effects of ginseng given to improve cognitive performance in healthy participants, participants with cognitive impairment or dementia.To highlight the quality and quantity of research evidence available.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources were searched on 24 February 2009 using the following terms: ginseng* OR panax OR ginsan OR "Jen Shen"OR shinseng OR Renshen OR schinseng OR ninjin OR gingilone OR panaxoside* OR ginsenoside* OR protopanaxa* OR protopanaxadiol OR protopanaxatriol OR panaxagin OR ginsenol OR ginsenine and terms for dementia and cognition. The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many clinical trials registries and grey literature sources.

SELECTION CRITERIA

All double-blind and single-blind randomized, placebo controlled trials assessing the effects of ginseng on cognitive function were eligible for inclusion. Interventions were considered to be ginseng if they were compounds containing ginseng or active agents of the Panax genus as the major component.

DATA COLLECTION AND ANALYSIS

Characteristics of each included trial were extracted independently by two reviewers using a self-developed data extraction form and entered into RevMan 5.0 software. Authors of identified trials were contacted for additional information and unpublished data. The effects of ginseng in healthy participants, participants with cognitive impairment or dementia were addressed independently.

MAIN RESULTS

Nine randomized, double-blind, placebo controlled trials meeting the inclusion criteria were identified. Eight trials enrolled healthy participants, and one was of subjects with age-associated memory impairment (AAMI).Only five of the identified trials had extractable information and were included in the analysis. Four studies investigated the effects of ginseng extract and one assessed the efficacy of ginseng compound HT008-1. All of these trials investigated the effects of ginseng on healthy participants. Pooling the data was impossible owing to heterogeneity in outcome measures, trial duration, and ginseng dosage. Results of the analysis suggested improvement of some aspects of cognitive function, behavior and quality of life. No serious adverse events associated with ginseng were found.

AUTHORS' CONCLUSIONS

Currently, there is a lack of convincing evidence to show a cognitive enhancing effect of Panax ginseng in healthy participants and no high quality evidence about its efficacy in patients with dementia. Randomized, double-blind, placebo-controlled, parallel group trials with large sample sizes are needed to further investigate the effect of ginseng on cognition in different populations, including dementia patients.

Does moxibustion work? An overview of systematic reviews

Background

Several systematic reviews (SRs) have assessed the effectiveness of moxibustion for a range of conditions, often with contradictory conclusions. Our aim was to provide a critical evaluation and summary of these data.

Methods

Electronic searches were conducted to locate all SRs of moxibustion for any condition. Data were extracted by two authors according to predefined criteria.

Results

Ten SRs met our inclusion criteria, which related to the following conditions: cancer, ulcerative colitis, stroke rehabilitation, constipation, hypertension, pain conditions and breech presentation. Their conclusions were contradictory in several instances. Relatively clear evidence emerged to suggest that moxibustion is effective for breech presentation.

Conclusions

Based on evidence from the currently available SRs, the effectiveness of moxibustion has been demonstrated for several conditions; however, due to the poor quality of the primary studies, there remains considerable uncertainty.

Cellulite and extracorporeal Shockwave therapy (CelluShock-2009)--a randomized trial

BACKGROUND

Cellulite is a widespread problem involving females' buttocks and thighs based on the female specific anatomy. Given the higher number of fat cells stored in female fatty tissue in contrast to males, and the aging process of connective tissue leads to an imbalance between lipogenesis and lipolysis with subsequent large fat cells bulging the skin. In addition, microcirculatory changes have been suggested, however remain largely unknown in a controlled clinical setting. We hypothesize that the combination of extracorporeal shockwave and a daily gluteal muscle strength program is superior to the gluteal muscle strength program alone in cellulite.

METHODS/DESIGN

STUDY DESIGN

Randomized-controlled trial. IRB approval was granted at Hannover Medical School, Germany on May 22, 2009. For allocation of participants, a 1:1 ratio randomization was performed using opaque envelopes for the concealment of allocation. Reporting: according to CONSORT 2010. Eligible patients were females aged 18 or over and 65 or younger with cellulite with documented cellulite 1°-4° according to the Nürnberger score. Exclusion criteria were suspected or evident pregnancy, no cellulite, no informed consent or age under 18 years or above 65 years. Patients were recruited by advertisements in local regional newspapers and via the Internet.

ANALYSIS

Intention-to-treat.

OUTCOME PARAMETERS

a) Photonumeric severity scale, b) Nürnberger Score, c) circumference measurements, d) capillary blood flow, e) tissue oxygen saturation, f) postcapillary venous blood flow. Intervention group: Six sessions of extracorporeal focused shock wave for six sessions (2000 impulses, 0,25 mJ/m2 every 1-2 weeks) at both gluteal and thigh regions plus a specific gluteal strength exercise training.

CONTROL GROUP

Six sessions of sham extracorporeal focused shock wave for six sessions (2000 impulses, 0,01 mJ/m2 every 1-2 weeks) at both gluteal and thigh regions plus a specific gluteal strength exercise training.

FOLLOW-UP

12 weeks. Blinding was achieved for all participants enrolled in the trial, the photograph taking the digital images for the primary outcome measure, the two assessors of the outcome measures, all additional health care providers and for the analyst from the biometrical department. Only one researcher (BJ) was aware of the group assignment performing the randomisation and the extracorporeal shock wave therapy.

DISCUSSION

This randomised-controlled trial will provide much needed evidence on the clinical effectiveness of focused extracorporal shock wave therapy as an adjunct to gluteal strength training in females suffering cellulite.

A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework

Background

The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations.

Methods

We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus.

Results

Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.'

Conclusions

While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

Evidence at a glance: error matrix approach for overviewing available evidence

BACKGROUND

Clinical evidence continues to expand and is increasingly difficult to overview. We aimed at conceptualizing a visual assessment tool, i.e., a matrix for overviewing studies and their data in order to assess the clinical evidence at a glance.

METHODS

A four-step matrix was constructed using the three dimensions of systematic error, random error, and design error. Matrix step I ranks the identified studies according to the dimensions of systematic errors and random errors. Matrix step II orders the studies according to the design errors. Matrix step III assesses the three dimensions of errors in studies. Matrix step IV assesses the size and direction of the intervention effect.

RESULTS

The application of this four-step matrix is illustrated with two examples: peri-operative beta-blockade initialized in relation to surgery versus placebo for major non-cardiac surgery, and antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. When clinical evidence is deemed both internally and externally valid, the size of the intervention effect is to be assessed.

CONCLUSION

The error matrix provides an overview of the validity of the available evidence at a glance, and may assist in deciding which interventions to use in clinical practice.

LICAVAL: combination therapy in acute and maintenance treatment of bipolar disorder

BACKGROUND

The challenge of Bipolar Disorder (BD) treatment is due to the complexity of the disease. Current guidelines represent an effort to help clinicians in their everyday practice but still have limitations, specially concerning to long term treatment. LICAVAL (efficacy and tolerability of the combination of LIthium and CArbamazepine compared to lithium and VALproic acid in the treatment of young bipolar patients) study aim to evaluate acute and maintenance phase of BD treatment with two combined drugs.

METHODS

LICAVAL is a single site, parallel group, randomized, outcome assessor blinded trial. BD I patients according to the DSM-IV-TR, in depressive, manic,/hypomanic or mixed episode, aged 18 to 35 years are eligible. After the diagnostic assessments, the patients are allocated for one of the groups of treatment (lithium + valproic acid or lithium + carbamazepine). Patients will be followed up for 8 weeks in phase I (acute treatment), 6 months in phase II (continuation treatment) and 12 months in phase III (maintenance treatment). Outcome assessors are blind to the treatment. The main outcome is the evaluation of changes in mean scores on CGI-BP-M between baseline and endpoint at the end of each phase of the study.

RESULTS

LICAVAL is currently in progress, with patients in phase I, II or III. It will extended until august 2012.

CONCLUSIONS

Trials comparing specific treatments efficacy in BD (head to head) can show relevant information in clinical practice. Long term treatment is an issue of great important and should be evaluated carefully in more studies as long as BD is a chronic disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00976794.

Chiropractic and children: Is more research enough?

Many health science research and review articles end with the words: "More research is needed". However, when it comes to research, it is not as much a question of quantity as of quality. There are a number of important prerequisites before research should be initiated. The three pillars, relevance, quality and ethics should be respected but for a project to be meaningful, it must also be based on plausible rationale.

In evidence-based (informed) practice, one takes into account not only research-based evidence but also clinical expertise and the patients' perspectives. In this paper, we briefly discuss how this should be handled in clinical practice is briefly discussed, using the concept of "traffic lights" (red, yellow, green). We explain how the combination of evidence and plausibility can be used to reach a decision as to whether a treatment or diagnostic procedure is suitable, possible, or unsuitable.

In this thematic series of Chiropractic & Osteopathy a number of reviews are presented, in which the research status of pediatric chiropractic is scrutinized and found wanting. Two important aspects were studied in these reviews: the effect of treatment and safety issues. Two types of problems were identified: the lack of research in general and the lack of research using the appropriate study designs and methodology in particular. Therefore, we discuss the meager research noted in the areas of chiropractic care in children and the clinical consequences this should have. The prerequisites for "more research" are scrutinized and an example given of suitable research programs.

Finally, the important issue of implementation of research findings is covered, emphasizing the responsibility of all stakeholders involved at both the undergraduate and the postgraduate level, within professional associations, and on an individual level.

Illustrating risk difference and number needed to treat from a randomized controlled trial of spinal manipulation for cervicogenic headache

BACKGROUND

The number needed to treat (NNT) for one participant to benefit is considered a useful, clinically meaningful way of reporting binary outcomes from randomized trials. Analysis of continuous data from our randomized controlled trial has previously demonstrated a significant and clinically important difference favoring spinal manipulation over a light massage control.

METHODS

Eighty participants were randomized to receive spinal manipulation or a light massage control (n = 40/group). Improvements in cervicogenic headache pain (primary outcome), disability, and number in prior four weeks were dichotomized into binary outcomes at two thresholds: 30% representing minimal clinically important change and 50% representing clinical success. Groups were compared at 12 and 24-week follow-up using binomial regression (generalized linear models) to compute the adjusted risk difference (RD) between groups and number needed to treat (NNT) after adjusting for baseline differences between groups. Results were compared to logistic regression results.

RESULTS

For headache pain, clinically important improvement (30% or 50%) was more likely for spinal manipulation: adjusted RD = 17% to 27% and NNT = 3.8 to 5.8 (p = .005 to .028). Some statistically significant results favoring manipulation were found for headache disability and number.

CONCLUSION

Spinal manipulation demonstrated a benefit in terms of a clinically important improvement of cervicogenic headache pain. The use of adjusted NNT is recommended; however, adjusted RD may be easier to interpret than NNT. The study demonstrated how results may depend on the threshold for dichotomizing variables into binary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NLM identifier NCT00246350.