Flawed, futile, and fabricated-features that limit confidence in clinical research in pain and anaesthesia: a narrative review

Glial-modulating agents for the treatment of pain: a systematic review

ABSTRACT

Preclinical research supports a critical role for nervous system glia in pain pathophysiology. This systematic review of human trials of potential glia-modulating drugs for the prevention or treatment of pain followed a predefined search strategy and protocol registration. We searched for English language, randomized, double-blind trials comparing putative glia-modulating drugs to placebo or other comparators. The primary outcomes included validated participant-reported measures of pain intensity or relief and, in studies of opioid administration, measures of opioid consumption and/or opioid-related adverse effects. Twenty-six trials (2132 participants) of glial modulators (12 minocycline, 11 pentoxifylline, and 3 ibudilast) were included. Because of clinical heterogeneity related to study drug, participant population, outcome measures, and trial design, no meta-analysis was possible. Only 6 trials reported a positive effect of the treatment (pentoxifylline-4 trials; minocycline-2 trials), whereas 11 trials reported mixed results and 9 trials reported no effect. This review does not provide convincing evidence of efficacy of current pharmacological targets of nervous system glial function for pain treatment or prevention. However, in light of ample preclinical evidence of the importance of neuroimmune signalling and glial functions in pain pathophysiology, continued strategic human research is anticipated to identify (1) drugs with maximal activity as selectively targeted glial modulators, (2) the necessary timing and duration of pharmacological glial modulation needed for pain prevention or treatment for specific injuries or pain conditions, and (3) the best design of future clinical trials of glial-targeted drugs for pain treatment and/or prevention.

The importance of rigor in pharmacy research: Challenges and solutions

Scientific rigor broadly refers to upholding basic principles within the conduct of research. Various threats associated with rigor exist in today's research environment, such as the replication crisis, the increasing prevalence of misconduct, and a loss of public trust in regulatory and educational institutions. The purpose of this commentary is to identify problems and solutions associated with research rigor, with a focus on pharmacy research. Problems exist at many levels, including within variable research training/funding, institutional pressures associated with career advancement, and norms associated with academic publishing. However, solutions are possible as methods of harm reduction, including (but not limited to) focused initiatives supporting rigor, team-based approaches to research that include diverse interested parties, and a reimagining of what constitutes value within science. Pharmacists and pharmacy researchers are called upon to uphold research rigor as a professional and ethical responsibility.

Pain, quality of life, and function in chronic intractable leg pain were substantially improved with 10kHz spinal cord stimulation in a multicentre European study

PURPOSE

This prospective, single-arm, multicentre study evaluated the effectiveness of 10 kHz spinal cord stimulation (SCS) in relieving pain and improving function and quality of life in patients with chronic intractable leg pain in routine clinical practice.

METHODS

Patients with leg pain refractory to conservative therapy and scoring ≥ 5 cm on a 10-cm visual analog scale (VAS) were enrolled at 12 centres. Those who achieved ≥ 50% leg pain relief during a temporary trial underwent permanent implantation and were followed for 12 months. Outcomes collected included the proportion of patients who achieved ≥ 50% reduction in leg pain VAS score, health-related quality-of-life (EQ-5D-5 L, functional disability [ODI]), opioid use, sleep quality (PSQ-3), global impression of change (GIC), and patient satisfaction.

RESULTS

Of 121 patients trialed, 118 completed the trial and 95 proceeded to implant. At 3 months, 61/95 (64.2%) of all implanted patients were responders to therapy (≥ 50% VAS reduction), which remained stable at 64.2% through 12 months. EQ-5D-5 L, ODI, and PSQ-3 showed clinically important and sustained improvement over 12 months (repeated measures ANOVA, p < 0.001). Patients also reduced opioid dosage on average (p = 0.022). The safety profile was consistent with previous reports using 10 kHz SCS.

CONCLUSION

This study supports 10 kHz SCS as an effective and safe therapeutic option to reduce pain and disability while improving health-related quality of life in patients with chronic intractable leg pain. 10 kHz SCS appears to be effective in significantly improving the severe disability and poor quality of life experienced by patients with chronic intractable leg pain.

STUDY REGISTERED

ISRCTN Registry - ISRCTN11180496.

Effectiveness of pharmacological therapies for fibromyalgia syndrome in adults: an overview of Cochrane Reviews

OBJECTIVES

To summarise and evaluate Cochrane reviews of pharmacological therapies for adults with fibromyalgia syndrome (FMS) pain.

METHODS

Systematic search of Cochrane Database of Systematic Reviews to May 2024. Generic quality assessment used AMSTAR-2 criteria, validity checks of potentially critical factors in evaluation of analgesic efficacy, and assessment of susceptibility of results to publication bias. Pain outcomes were participant-reported pain relief of ≥ 30% or ≥ 50%, or PGIC much or very much improved.

RESULTS

Twenty-one reviews (87 trials, 17,631 patients) were included. All rated moderate (15) or high-quality (6) using AMSTAR-2 and at least seven of eight critical pain criteria were met by 13 of 21 reviews. Diagnosis of FMS used recognised criteria. Seven reviews found no trials (carbamazepine, clonazepam, lamotrigine, phenytoin, oxycodone, topiramate, or valproate), seven had limited and inadequate data (antipsychotics, cannabinoids, combination therapy, gabapentin, lacosamide, monoamine oxidase inhibitors, NSAIDs), and two were subject to publication bias (amitriptyline, SSRI). Mirtazapine had moderate evidence of no effect. Duloxetine, milnacipran, and pregabalin had moderate/good evidence of substantial pain relief for 4-12 weeks in around 1 in 10 adults with moderate or severe FMS pain, without evidence of efficacy beyond six months. Serious adverse events were no more common than with placebo. There was no evidence about who might benefit or experience adverse events. There was no substantial efficacy evidence for other medicines.

CONCLUSIONS

Duloxetine, milnacipran, and pregabalin had good evidence that about 1 person in 10 with moderate or severe pain experienced pain intensity reduction by at least 50%.

Associations between biomarkers and skeletal muscle function in individuals with osteoarthritis: a systematic review and meta-analysis

OBJECTIVES

Skeletal muscle dysfunction is the primary cause of functional limitations in osteoarthritis, associated biomarkers have the potential as targets for early disease identification, diagnosis, and prevention of osteoarthritis disability. This review aimed to identify associations between biomarkers and lower limb skeletal muscle function in individuals with osteoarthritis.

METHODS

A systematic literature review and meta-analysis conducted in PubMed, MEDLINE, CINAHL, EMBASE, Scopus, SPORTDiscus and Web of Science databases from inception to 8th August 2023. Two independent reviewers performed the title, abstract, full-text screening, data extraction and methodological quality assessment. A meta-analysis was undertaken based on the available data.

RESULTS

Twenty-four studies with 4101 participants with osteoarthritis were included (females: 78%; age range; 49 to 71 years). One study reported muscle-specific biomarkers (n = 3), whilst six studies reported osteoarthritis-specific markers (n = 5). Overall, 93 biomarkers were reported, predominately characterised as inflammatory (n = 35), metabolic (n = 15), and hormones (n = 10). Muscle strength and vitamin D reported a significant association (Hedge's g: 0.58 (Standard Error (SE): 0.27; P = 0.03), k = 3 studies). Walking speed and high-sensitivity C-reactive protein reported no significant associations (Hedge's g: -0.02 (SE: 0.05; P = 0.73), k = 3 studies).

CONCLUSION

Associations between biomarkers and lower limb skeletal muscle function in individuals with osteoarthritis was limited, the few studies exploring lower limb muscle measures were mainly secondary outcomes. Furthermore, biomarkers were largely related to overall health, with a lack of muscle specific biomarkers. As such, the mechanistic pathways through which these associations occur are less evident, and difficult to draw clear conclusions on these relationships.

TRIAL REGISTRATION

Registered on PROSPERO (CRD42022359405).

Use of patient-reported global assessment measures in clinical trials of chronic pain treatments: ACTTION systematic review and considerations

ABSTRACT

Establishing clinically meaningful changes in pain experiences remains important for clinical trials of chronic pain treatments. Regulatory guidance and pain measurement initiatives have recommended including patient-reported global assessment measures (eg, Patient-Global Impression of Change [PGIC]) to aid interpretation of within-patient differences in domain-specific clinical trial outcomes (eg, pain intensity). The objectives of this systematic review were to determine the frequency of global assessment measures inclusion, types of measures, domains assessed, number and types of response options, and how measures were analyzed. Of 4172 abstracts screened across 6 pain specialty journals, we reviewed 96 clinical trials of chronic pain treatments. Fifty-two (54.2%) studies included a global assessment measure. The PGIC was most common (n = 28; 53.8%), with relatively infrequent use of other measures. The majority of studies that used a global assessment measure (n = 31; 59.6%) assessed change or improvement in an unspecified domain. Others assessed overall condition severity (n = 9; 17.3%), satisfaction (n = 8; 15.4%), or overall health status/recovery (n = 5; 9.6%). The number, range, and type of response options were variable and frequently not reported. Response options and reference periods even differed within the PGIC. Global assessment measures were most commonly analyzed as continuous variables (n = 24; 46.2%) or as dichotomous variables with positive categories combined to calculate the proportion of participants with a positive response to treatment (n = 18; 34.6%). This review highlights the substantial work necessary to clarify measurement and use of patient global assessment in chronic pain trials and provides short- and long-term considerations for measure selection, reporting and analysis, and measure development.

Major mistakes or errors in the use of trial sequential analysis in systematic reviews or meta-analyses - the METSA systematic review

BACKGROUND

Systematic reviews and data synthesis of randomised clinical trials play a crucial role in clinical practice, research, and health policy. Trial sequential analysis can be used in systematic reviews to control type I and type II errors, but methodological errors including lack of protocols and transparency are cause for concern. We assessed the reporting of trial sequential analysis.

METHODS

We searched Medline and the Cochrane Database of Systematic Reviews from 1 January 2018 to 31 December 2021 for systematic reviews and meta-analysis reports that include a trial sequential analysis. Only studies with at least two randomised clinical trials analysed in a forest plot and a trial sequential analysis were included. Two independent investigators assessed the studies. We evaluated protocolisation, reporting, and interpretation of the analyses, including their effect on any GRADE evaluation of imprecision.

RESULTS

We included 270 systematic reviews and 274 meta-analysis reports and extracted data from 624 trial sequential analyses. Only 134/270 (50%) systematic reviews planned the trial sequential analysis in the protocol. For analyses on dichotomous outcomes, the proportion of events in the control group was missing in 181/439 (41%), relative risk reduction in 105/439 (24%), alpha in 30/439 (7%), beta in 128/439 (29%), and heterogeneity in 232/439 (53%). For analyses on continuous outcomes, the minimally relevant difference was missing in 125/185 (68%), variance (or standard deviation) in 144/185 (78%), alpha in 23/185 (12%), beta in 63/185 (34%), and heterogeneity in 105/185 (57%). Graphical illustration of the trial sequential analysis was present in 93% of the analyses, however, the Z-curve was wrongly displayed in 135/624 (22%) and 227/624 (36%) did not include futility boundaries. The overall transparency of all 624 analyses was very poor in 236 (38%) and poor in 173 (28%).

CONCLUSIONS

The majority of trial sequential analyses are not transparent when preparing or presenting the required parameters, partly due to missing or poorly conducted protocols. This hampers interpretation, reproducibility, and validity.

STUDY REGISTRATION

PROSPERO CRD42021273811.

Is it premature to formulate recommendations for policy and practice, based on culture and health research? A robust critique of the CultureForHealth (2022) report

Introduction

Arts and health practice and research has expanded rapidly since the turn of the millennium. A World Health Organization scoping review of a large body of evidence claims positive health benefits from arts participation and makes recommendations for policy and implementation of arts for health initiatives. A more recent scoping review (CultureForHealth) also claims that current evidence is sufficient to form recommendations for policy and practice. However, scoping reviews of arts and health research-without critical appraisal of included studies-do not provide a sound basis for recommendations on the wider implantation of healthcare interventions.

Methods

We performed a detailed assessment of 18 Randomised Controlled Trials (RCTs) on arts-based interventions included in Section 1 of the CultureForHealth report using the Joanna Briggs Institute Critical Appraisal Tool for RCTs (2023).

Results

The 18 RCTs included demonstrated considerable risks of bias regarding internal and statistical conclusion validity. Moreover, the trials are substantially heterogeneous with respect to settings, health-issues, interventions, and outcomes, which limits their external validity, reliability, and generalisability.

Conclusions

The absence of a critical appraisal of studies included in the CultureForHealth report leads to an overinterpretation and overstatement of the health outcomes of arts-based interventions. As such, the CultureForHealth review is not a suitable foundation for policy recommendations, nor for formulating guidance on implementation of arts-based interventions for health.

Narrative bias ("spin") is common in randomised trials and systematic reviews of cannabinoids for pain

ABSTRACT

We define narrative bias as a tendency to interpret information as part of a larger story or pattern, regardless of whether the facts support the full narrative. Narrative bias in title and abstract means that results reported in the title and abstract of an article are done so in a way that could distort their interpretation and mislead readers who had not read the whole article. Narrative bias is often referred to as "spin." It is prevalent in abstracts of scientific papers and is impactful because abstracts are often the only part of an article read. We found no extant narrative bias instrument suitable for exploring both efficacy and safety statements in randomized trials and systematic reviews of pain. We constructed a 6-point instrument with clear instructions and tested it on randomised trials and systematic reviews of cannabinoids and cannabis-based medicines for pain, with updated searches to April 2021. The instrument detected moderate or severe narrative bias in the title and abstract of 24% (8 of 34) of randomised controlled trials and 17% (11 of 64) of systematic reviews; narrative bias for efficacy and safety occurred equally. There was no significant or meaningful association between narrative bias and study characteristics in correlation or cluster analyses. Bias was always in favour of the experimental cannabinoid or cannabis-based medicine. Put simply, reading title and abstract only could give an incorrect impression of efficacy or safety in about 1 in 5 papers reporting on these products.

Appraisal methods and outcomes of AMSTAR 2 assessments in overviews of systematic reviews of interventions in the cardiovascular field: A methodological study

This study aimed to assess the methods and outcomes of The Measurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisals in overviews of reviews (overviews) of interventions in the cardiovascular field and identify factors that are associated with these outcomes. MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews were searched until November 2022. Eligible were overviews of cardiovascular interventions, analyzing systematic reviews (SRs) of randomized controlled trials (RCTs). Extracted data included characteristics of overviews and SRs and AMSTAR 2 appraisal methods and outcomes. Data were synthesized using descriptive statistics and logistic regression to explore potential associations between the characteristics of SRs and extracted AMSTAR 2 overall ratings ("High-Moderate" vs. "Low-Critically low"). The original results on individual AMSTAR 2 items were entered into the official AMSTAR 2 online tool and the recalculated overall confidence ratings were compared to those provided in overviews. All 34 overviews identified were published between 2019 and 2022. Rating of overall confidence following the algorithm suggested by AMSTAR 2 developers was noted in 74% of overviews. The 679 unique included SRs were mainly of "Critically low" (53%) or "Low" (18.7%) confidence and underperformed in items 2 (Protocol, no = 65.2%) and 7 (List of excluded studies, no = 84%). The following characteristics of SRs were significantly associated with higher overall ratings: Cochrane origin, pharmacological interventions, including exclusively RCTs, citation of methodological and reporting guidelines, protocol, absence of funding and publication after AMSTAR 2 release. Generally, overviews' authors tended to deviate from the original rating scheme and ascribe higher ratings to SRs compared to the official AMSTAR 2 online tool. Most SRs included in overviews of cardiovascular interventions have critically low or low confidence in their results. Overviews' authors should be more transparent about the methods used to derive the overall confidence in SRs.

The need for robust critique of arts and health research: the treatment of the Gene Cohen et al. (2006) paper on singing, wellbeing and health in subsequent evidence reviews

BACKGROUND

This paper considers weaknesses in a study by Cohen et al. (2006) on the impacts of community singing on health. These include high demand characteristics, lack of attention to attrition, flawed statistical analysis, and measurement. Nevertheless, the study is uncritically cited, in evidence reviews, with findings taken at face value.

METHODS

Google Scholar, SCOPUS and BASE citation functions for Cohen et al. identified 32 evidence reviews in peer-reviewed journals. Eleven of these reviews, published between 2010 and 2023, focused on creative arts interventions.

RESULTS

We demonstrate limitations in the Cohen et al. research which undermine the conclusions they reach regarding the health benefits of group singing. Subsequent evidence reviews take the findings at face value and offer little critical commentary.

DISCUSSION

We consider what is needed to improve evidence reviews in the field of creative arts and health research.

CONCLUSIONS

A more robust approach is needed in reviewing research evidence in the field of arts and health. The Cohen et al. paper is not suitable for inclusion in future evidence reviews.

Effectiveness of non-pharmacological interventions for fibromyalgia and quality of review methods: an overview of Cochrane Reviews

BACKGROUND

Fibromyalgia syndrome (FMS) is defined as chronic widespread pain associated with sleep disorders, cognitive dysfunction, and somatic symptoms present for at least three months and cannot be better explained by another diagnosis.

OBJECTIVES

To examine efficacy and safety of non-pharmacological interventions for FMS in adults reported in Cochrane Reviews, and reporting quality of reviews.

METHODS

Systematic reviews of randomised controlled trials (RCTs) of non-pharmacological interventions for FMS were identified from the Cochrane Database of Systematic Reviews (CDSR 2022, Issue 3 and CDSR 2023 Issue 6). Methodological quality was assessed using the AMSTAR-2 tool and a set of methodological criteria critical for analgesic effects. The primary efficacy outcomes of interest were clinically relevant pain relief, improvement in health-related quality of life (HRQoL), acceptability, safety, and reduction of mobility difficulties as reported by study participants. No pooled analyses were planned. We assumed a clinically relevant improvement was a minimal clinically important difference (MCID) between interventions and controls of 15%, or a SMD of more than 0.2, or a MD of more than 0.5, on a 0 to 10 scale.

RESULTS

Ten Cochrane reviews were eligible, reporting 181 randomized or quasi- randomized trials (11,917 participants, average trial size 66 participants). The reviews examined exercise training, acupuncture, transcutaneous electrical nerve stimulation, and psychological therapies. One review was rated moderate according to AMSTAR 2, seven were rated low and two were rated critically low. All reviews met most of the additional methodological quality criteria. All reviews included studies with patient-reported outcomes for pain. We found low certainty evidence of clinically relevant positive effects of aerobic and mixed exercise training and for cognitive behavioural therapies (CBTs) at reducing mobility difficulties and for mixed exercise training and CBTs for improving HRQoL at the end of the intervention. Number needed to treat for an additional beneficial outcome (NNTB) values for a MCID of 15% ranged between 4 and 9. We found low certainty evidence that was clinically relevant for mixed exercise and CBTs for reducing mobility difficulties at an average follow up of 24 weeks. We found low certainty evidence of clinically relevant positive effects of mixed exercise on HRQoL at an average follow up of 24 weeks. NNTB values for a MCID of 15% ranged from 5 to 11. The certainty of evidence of the acceptability (measured by dropouts) of the different non-pharmacological interventions ranged from very low to moderate and the dropout rate for any reason did not differ across the interventions or the controls, except for biofeedback and movement therapies. All the systematic reviews stated that the reporting of adverse events was inconsistent in the studies analysed (very low certainty evidence).

AUTHORS' CONCLUSIONS

There is low certainty evidence of clinically relevant reduction of mobility difficulties and of improvement of HRQoL among individuals with FMS by aerobic and mixed exercise training and by CBTs at the end of the intervention. There is low certainty evidence that CBTs and mixed exercise training reduces mobility difficulties post-treatment and that mixed exercise training improves HRQoL at follow-up by clinically meaningful scores.

PROSPECT methodology for developing procedure-specific pain management recommendations: an update

The procedure-specific postoperative pain management (PROSPECT) working group develops evidence-based pain management recommendations. PROSPECT methodology is unique and rigorous. However, several limitations were recognised that needed to be addressed, and several new factors were identified that improved PROSPECT methodology. The aim of this article is to present updated PROSPECT methodology for development of recommendations for procedure-specific pain management, focusing on the methodological revisions we will implement. In future, included randomised clinical trials will need to be prospectively registered on a publicly accessible clinical trials database and the study design, including the primary outcome in the registration, should coincide with that in the published manuscript. Placebo-controlled studies in which the analgesic intervention of interest is solely paracetamol, non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors or opioids will not be included. Studies comparing one drug in a particular class with another in the same class will also not be included. Future projects will use the Cochrane Collaboration risk of bias tool for quality of reporting of methodology and results. A modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach will be used for grading of level of evidence and strength of recommendations. Finally, the updated PROSPECT methodology addresses several other limitations and implements new factors that all add rigour and transparency to developing procedure-specific pain management recommendations.

Perspective on salutogenic approaches to persistent pain with a focus on mindfulness interventions

In this article, we provide a unique perspective on the use of mindfulness interventions in a whole health framework embedded within the theory of salutogenesis and the concept of painogenic environments. We argue that mindfulness is a valuable tool to bridge exploration of inner experiences of bodily pain with socio-ecological influences on thoughts and emotions. We outline research from neuroimaging studies that mindfulness techniques mediate neural processing and neuroplastic changes that alleviate pain and related symptoms. We also review evidence examining behavioural changes associated with mindfulness meditation providing evidence that it promotes self-regulatory activity, including the regulation and control of emotion and catalysation of health behaviour changes; both of which are important in chronic illness. Our viewpoint is that mindfulness could be a core element of salutogenic approaches to promote health and well-being for people living with pain because it rebuilds a fractured sense of cohesion. Mindfulness empowers people in pain to embrace their existence; shifting the focus away from pain and giving their lives meaning. We propose that integrating mindfulness into activities of daily living and individual or community-based activities will promote living well in the modern world, with or without pain; thus, promoting individual potential for fulfilment. Future research should consider the effects of mindfulness on people with pain in real-life settings, considering social, environmental, and economic factors using a broader set of outcomes, including self-efficacy, sense of coherence and quality of life.

Pain through the perspective of art and creativity: insights from the Unmasking Pain project

People struggle to tell their story of living with pain and when they do it is articulated in a way that may not be understood, heard or taken seriously. Unmasking Pain is an artist-led project that explored creative approaches to tell stories of life with pain. The project was led by a dance theatre company that specialises in storytelling and emotional experiences for players and audiences. The project involved artists and people living with ongoing pain co-creating activities and environments to curiously explore "oneself", through imagination and creative expression. This article discusses insights and perspectives emerging from the project. The project revealed the power of art to make-sense of oneself with or without pain, and how art facilitates expression of complex inner experience and personal stories. People described Unmasking Pain as "explorative joy despite pain", and "a new set of rules" that contrasts with those experienced during clinical encounters. We discuss how art has the potential to improve clinical encounters and promote health and well-being, and whether artist-led activities are an intervention, therapy, or something else. Pain rehabilitation specialists from the project described Unmasking Pain as "freeing-up thinking", allowing conceptual thought beyond the biopsychosocial model of pain. We conclude that art has the potential to shift people living with pain from "I can't do, I am not willing to do it" to "Perhaps I can, I'll give it a go, I enjoyed".

Non-opioid analgesics for the prevention of chronic postsurgical pain: a systematic review and network meta-analysis

BACKGROUND

Chronic postsurgical pain is common after surgery. Identification of non-opioid analgesics with potential for preventing chronic postsurgical pain is important, although trials are often underpowered. Network meta-analysis offers an opportunity to improve power and to identify the most promising therapy for clinical use and future studies.

METHODS

We conducted a PRISMA-NMA-compliant systematic review and network meta-analysis of randomised controlled trials of non-opioid analgesics for chronic postsurgical pain. Outcomes included incidence and severity of chronic postsurgical pain, serious adverse events, and chronic opioid use.

RESULTS

We included 132 randomised controlled trials with 23 902 participants. In order of efficacy, i.v. lidocaine (odds ratio [OR] 0.32; 95% credible interval [CrI] 0.17-0.58), ketamine (OR 0.64; 95% CrI 0.44-0.92), gabapentinoids (OR 0.67; 95% CrI 0.47-0.92), and possibly dexmedetomidine (OR 0.36; 95% CrI 0.12-1.00) reduced the incidence of chronic postsurgical pain at ≤6 months. There was little available evidence for chronic postsurgical pain at >6 months, combinations agents, chronic opioid use, and serious adverse events. Variable baseline risk was identified as a potential violation to the network meta-analysis transitivity assumption, so results are reported from a fixed value of this, with analgesics more effective at higher baseline risk. The confidence in these findings was low because of problems with risk of bias and imprecision.

CONCLUSIONS

Lidocaine (most effective), ketamine, and gabapentinoids could be effective in reducing chronic postsurgical pain ≤6 months although confidence is low. Moreover, variable baseline risk might violate transitivity in network meta-analysis of analgesics; this recommends use of our methods in future network meta-analyses.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021269642.

Spin and fragility in anaesthesia studies: when sirens sing into anaesthetists' ears

Spin and fragility are common in randomised controlled trials published in anaesthesia journals. Staying with the facts and addressing only the primary endpoint in the conclusion of clinical research reports might help reduce spin. Routinely reporting the fragility index, in turn, could deliver information about robustness, enhancing the transparency of positive dichotomous results. It is in the best interest of clinical research that authors, reviewers, and journals come together to reduce spin and address the fragility of randomised controlled trials.