Is Sacubitril/Valsartan a Superior Agent in Heart Failure With Reduced Ejection Fraction? A Review of Randomized Comparative Trials

Background: The PARADIGM HF trial showed sacubitril/valsartan (SV) to be superior to enalapril in patients with reduced ejection fraction (HFrEF). Since its publication, several other randomized trials have compared SV to either an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in HFrEF which showed conflicting results regarding mortality, hospitalizations, and quality of life scoring. Objective: To review randomized comparative trials of SV to either ACEI or ARB in patients with HFrEF. Methods: PubMed and Embase databases were used to identify randomized comparative trials. The text terms sacubitril, angiotensin neprilysin, and LCZ696 were used for both searches. Meta-analysis, retrospective, adhoc, and cohort studies were excluded. Results: 1476 and 3983 citations were reviewed on PubMed and Embase, respectively. Of these, 11 randomized comparative trials to either ACEI or ARB were included for analysis. The mortality/quality of life benefits of SV over enalapril in the PARADIGM HF were not corroborated in any of the other trials. The effect of hospitalizations for heart failure was inconsistent among trials. Exercise tolerance was not improved with SV versus enalapril. Conclusion: The results of the PARADIGM HF trial have largely not been confirmed in subsequent randomized comparative trials.

So how special is special K? A systematic review and meta-analysis of ketamine for PTSD RCTs

Background: PTSD is a significant mental health problem worldwide. Current evidence-based interventions suffer various limitations. Ketamine is a novel agent that is hoped to be incrementally better than extant interventions.Objective: Several randomized control trials (RCTs) of ketamine interventions for PTSD have now been published. We sought to systematically review and meta-analyse results from these trials to evaluate preliminary evidence for ketamine's incremental benefit above-and-beyond control interventions in PTSD treatment.Results: Omnibus findings from 52 effect sizes extracted across six studies (n = 221) yielded a small advantage for ketamine over control conditions at reducing PTSD symptoms (g = 0.27, 95% CI = 0.03, 0.51). However, bias-correction estimates attenuated this effect (adjusted g = 0.20, 95%, CI = -0.08, 0.48). Bias estimates indicated smaller studies reported larger effect sizes favouring ketamine. The only consistent timepoint assessed across RCTs was 24-hours post-initial infusion. Effects at 24-hours post-initial infusion suggest ketamine has a small relative advantage over controls (g = 0.35, 95% CI = 0.06, 0.64). Post-hoc analyses at 24-hours post-initial infusion indicated that ketamine was significantly better than passive controls (g = 0.44, 95% CI = 0.03, 0.85), but not active controls (g = 0.24, 95% CI = -0.30, 0.78). Comparisons one-week into intervention suggested no meaningful group differences (g = 0.24, 95% CI = 0.00, 0.48). No significant differences were evident for RCTs that examined effects two-weeks post initial infusion (g = 0.17, 95% CI = -0.10, 0.44).Conclusions: Altogether, ketamine-for-PTSD RCTs reveal a nominal initial therapeutic advantage relative to controls. However, bias and heterogeneity appear problematic. While rapid acting effects were observed, all control agents (including saline) also evidenced rapid acting effects. We argue blind penetration to be a serious concern, and that placebo is the likely mechanism behind reported therapeutic effects.

Histological Remission Placebo Rates in Ulcerative Colitis Trials: A Systematic Review and Meta-analysis

BACKGROUND

High histologic remission rates have been reported with placebos in randomized controlled trials (RCTs) evaluating ulcerative colitis (UC) therapies and have varied based on trial designs. We performed a systematic review and meta-analysis to quantify placebo histological remission rates and identify factors influencing those rates.

METHODS

MEDLINE, EMBASE, and the Cochrane library were searched from inception of the databases until December 2021. We included placebo-controlled RCTs of adult patients with UC treated with aminosalicylates, corticosteroids, immunosuppressives, biologics, and small molecules. We pooled estimates using a random-effects model and performed subgroup analysis and meta-regression to evaluate the effect of different covariates on placebo rates.

RESULTS

Thirty-three studies (30 induction and 3 maintenance) were included. The overall placebo histological remission rate was 15.7% (95% confidence interval, 12.9%-19%) across all 33 studies. High heterogeneity was observed among studies with I2 = 62.10%. The pooled estimate of histological remission was 15.8% in induction studies and 14.5% in maintenance studies. Subgroup analysis revealed statistically significant differences in placebo rates when accounting for background medications, the intervention drug class, and disease severity (P = .041, .025, and .025, respectively). There was no statistical difference between induction vs maintenance studies or between different histological scales (P = .771, and .075, respectively).

CONCLUSIONS

Placebo histological remission rates range from 13% to 19% in UC RCTs, but studies are highly heterogeneous. Factors found to influence placebo rates include presence of background medications, the drug used, and the disease severity. These observations inform future trial designs to minimize placebo rates and reduce heterogeneity.

The effect of expressive writing on Chinese cancer patients: A systematic review and meta-analysis of randomized control trails

Cancer patients in China encounter distinctive challenges stemming from cultural disparities and variations in the healthcare systems. This meta-analysis aimed to provide a synthesis of the expressive writing (EW) interventions delivered to Chinese cancer patients and assess the pooled effect of EW on their well-being. The review adheres to the latest PRISMA 2020 guidelines to ensure transparency and rigour. Randomized control trials (RCTs) published before 1 April 2023, and meeting the inclusion criteria were included. Keywords searching was performed in both English and Chinese electronic databases. Ten RCTs were identified and included in the analysis. The results showed that EW usually encompassed four to six writing sessions; the most common writing themes were 'emotional expression', 'cognitive appraisal', 'benefit finding', 'coping strategies' and 'looking to the future'. The meta-analysis suggested that EW had a substantial impact on reducing anxiety levels (Hedges' g = -1.22, 95% CI [-1.54, -0.90], I2 = 0.00%). It is worth noting that although the results of these studies could not be statistically synthesized, their individual findings suggest that EW may be beneficial in reducing anxiety, self-perceived burden and depressive symptoms, as well as increasing self-efficacy in Chinese cancer patients. In conclusion, this review highlights the importance and effectiveness of Ewin alleviating anxiety among Chinese cancer patients and underscores the potential benefits of incorporating EW into comprehensive care programmes for cancer patients in China. More RCTs are needed to explore the broader impact of EW in China.

Evidence-Based Surgery: What Can Intra-Operative Images Contribute?

Evidence-based medicine integrates results from randomized controlled trials (RCTs) and meta-analyses, combining the best external evidence with individual clinical expertise and patients' preferences. However, RCTs of surgery differ from those of medicine in that surgical performance is often assumed to be consistent. Yet, evaluating whether each surgery is performed to the same standard is quite challenging. As a primary issue, the novelty of this review is to emphasize-with a focus on orthopedic trauma-the advantage of having complete intra-operative image documentation, allowing the direct evaluation of the quality of the intra-operative technical performance. The absence of complete intra-operative image documentation leads to the inhomogeneity of case series, yielding inconsistent results due to the impossibility of a secondary analysis. Thus, comparisons and the reproduction of studies are difficult. Access to complete intra-operative image data in surgical RCTs allows not only secondary analysis but also comparisons with similar cases. Such complete data can be included in electronic papers. Offering these data to peers-in an accessible link-when presenting papers facilitates the selection process and improves publications for readers. Additionally, having access to the full set of image data for all presented cases serves as a rich resource for learning. It enables the reader to sift through the information and pinpoint the details that are most relevant to their individual needs, allowing them to potentially incorporate this knowledge into daily practice. A broad use of the concept of complete intra-operative image documentation is pivotal for bridging the gap between clinical research findings and real-world applications. Enhancing the quality of surgical RCTs would facilitate the equalization of evidence acquisition in both internal medicine and surgery. Joint effort by surgeons, scientific societies, publishers, and healthcare authorities is needed to support the ideas, implement economic requirements, and overcome the mental obstacles to its realization.

The paucity of high-level evidence for therapy in pediatric cardiology

Introduction

Clinical practice should be based on the highest quality of evidence available. Therefore, we aimed to classify publications in the field of pediatric cardiology in the year 2021 based on the level of scientific evidence.

Materials and Methods

A PubMed search was performed to identify pediatric cardiology articles published in the calendar year 2021. The abstract or manuscript of each study was reviewed. Each study was categorized as high, medium, or low level of evidence based on the study design. Disease investigated, treatment studied, and country of publication were recorded. Randomized control trials (RCTs) in similar fields of neonatology and adult cardiology were identified for comparison. Descriptive statistics were performed on the level of evidence, type of disease, country of publication, and therapeutic intervention.

Results

In 2021, 731 studies were identified. A decrease in prevalence for the level of evidence as a function of low, medium, and high was found (50.1%, 44.2%, and 5.8%, respectively). A low level of evidence studies was the majority for all types of cardiac disease identified, including acquired heart disease, arrhythmias, congenital heart disease, and heart failure, and for treatment modalities, including circulatory support, defibrillator, percutaneous intervention, medicine, and surgery. In a subgroup analysis, most high-level evidence studies were from the USA (31%), followed by China (26.2%) and India (14.3%). Comparing RCTs, 21 RCTs were identified in pediatric cardiology compared to 178 in neonatology and 413 in adult ischemic heart disease.

Conclusions

There is a great need for the conduct of studies that offer a high level of evidence in the discipline of pediatric cardiology.

How Has Statistical Testing in Orthopedics Changed Over Time? An Assessment of High Impact Journals Over 25 Years

BACKGROUND

It is important for physicians to be familiar with statistical techniques commonly used in published medical research. Statistical errors in medical literature are common, and there is a reported lack of understanding regarding statistical knowledge necessary for data interpretation and journal reading. As study design has become increasingly complex, peer-reviewed literature poorly addresses and explains the most common statistical methods utilized across leading orthopedic journals.

METHODS

Articles from 5 leading general and subspecialty orthopedic journals were compiled from 3 distinct time periods. After exclusions were applied, 9521 remained, and a random 5% sampling of these articles, balanced across journals and years, was conducted yielding 437 articles after additional exclusions. Information regarding the number of statistical tests used, power/sample size calculation, type of statistical tests used, level of evidence (LOE), study type, and study design was collected.

RESULTS

The mean number of statistical tests across all 5 orthopedic journals increased from 1.39 to 2.29 by 2018 (p = 0.007). The percentage of articles that reported power/sample size analyses was not found to differ by year, but the value has increased from 2.6% in 1994 to 21.6% in 2018 (p = 0.081). The most commonly used statistical test was the t-test which was present in 20.5% of articles, followed by chi-square test (13%), Mann-Whitney analysis (12.6%) and analysis of variance (ANOVA, 9.6%). The mean number of tests was generally greater in articles from higher impact factor journals (p = 0.013). Studies with a LOE of I used the highest mean number of statistical tests (3.23) compared to studies with lower LOE ratings (range 1.66-2.69, p < 0.001). Randomized control trials used the highest mean number of statistical test (3.31), while case series used the lowest mean number of tests (1.57, p < 0.001).

CONCLUSIONS

The mean number of statistical tests used per article has increased over the past 25 years with the t-test, chi-square test, Mann-Whitney analysis, and ANOVA being the most used statistical tests in leading orthopedic journals. Despite an increase in statistical tests it should be noted that there was a paucity in advance statistical testing within the orthopedic literature. This study displays important trends in data analysis and can serve as a guide to help clinicians and trainees better understand the statistics used in literature as well as identifying deficits within the literature that should be addressed to help progress the field of orthopedics.

Safety and Efficacy of Nemonoxacin vs Levofloxacin in Patients With Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Randomized Control Trials

Community-acquired pneumonia is a leading cause of morbidity and mortality throughout the world, which incurs significant healthcare costs. The aim of his meta-analysis is to assess the clinical efficacy and safety of a novel non-fluorinated quinolone, nemonoxacin, compared with levofloxacin in treating community-acquired pneumonia (CAP). A recursive literature search was conducted using PubMed, Google Scholar, and Scopus up to August 2022. All randomized clinical trials comparing nemonoxacin to levofloxacin for community-acquired pneumonia were included. The patients selected for this study had mild to moderate CAP. Each individual received treatment with either nemonoxacin (500 mg or 750 mg) or levofloxacin (500 mg) for a duration of 3-10 days. Four randomized control trials with a total of 1955 patients were included. Nemonoxacin and levofloxacin were found to have similar clinical cure rates in the treatment of CAP. There were no significant differences reported in the treatment-emergent adverse events between the two drugs (RR=0.95, 95% CI: 0.86, 1.08, I²=0%). However, the most frequent symptoms exhibited were gastrointestinal system-related. Both the dosages (500 mg and 750 mg) of nemonoxacin were found to have similar efficacy as that of levofloxacin. Our meta-analysis indicates that nemonoxacin is a well-tolerated and effective antibiotic therapy for the treatment of community-acquired pneumonia (CAP), with clinical success rates comparable to those of levofloxacin. Furthermore, the adverse effects associated with nemonoxacin are generally mild. Therefore, both the 500 mg and 750 mg dosages of nemonoxacin can be recommended as appropriate antibiotic therapy regimens for the treatment of CAP.

Effectiveness of Colorectal Cancer (CRC) Screening on All-Cause and CRC-Specific Mortality Reduction: A Systematic Review and Meta-Analysis

(1) Background: The aim of this study was to pool and compare all-cause and colorectal cancer (CRC) specific mortality reduction of CRC screening in randomized control trials (RCTs) and simulation models, and to determine factors that influence screening effectiveness. (2) Methods: PubMed, Embase, Web of Science and Cochrane library were searched for eligible studies. Multi-use simulation models or RCTs that compared the mortality of CRC screening with no screening in general population were included. CRC-specific and all-cause mortality rate ratios and 95% confidence intervals were calculated by a bivariate random model. (3) Results: 10 RCTs and 47 model studies were retrieved. The pooled CRC-specific mortality rate ratios in RCTs were 0.88 (0.80, 0.96) and 0.76 (0.68, 0.84) for guaiac-based fecal occult blood tests (gFOBT) and single flexible sigmoidoscopy (FS) screening, respectively. For the model studies, the rate ratios were 0.45 (0.39, 0.51) for biennial fecal immunochemical tests (FIT), 0.31 (0.28, 0.34) for biennial gFOBT, 0.61 (0.53, 0.72) for single FS, 0.27 (0.21, 0.35) for 10-yearly colonoscopy, and 0.35 (0.29, 0.42) for 5-yearly FS. The CRC-specific mortality reduction of gFOBT increased with higher adherence in both studies (RCT: 0.78 (0.68, 0.89) vs. 0.92 (0.87, 0.98), model: 0.30 (0.28, 0.33) vs. 0.92 (0.51, 1.63)). Model studies showed a 0.62-1.1% all-cause mortality reduction with single FS screening. (4) Conclusions: Based on RCTs and model studies, biennial FIT/gFOBT, single and 5-yearly FS, and 10-yearly colonoscopy screening significantly reduces CRC-specific mortality. The model estimates are much higher than in RCTs, because the simulated biennial gFOBT assumes higher adherence. The effectiveness of screening increases at younger screening initiation ages and higher adherences.

Evaluation of Immune Modulation by β-1,3; 1,6 D-Glucan Derived from Ganoderma lucidum in Healthy Adult Volunteers, A Randomized Controlled Trial

Fungi-derived β-glucan, a type of glucopolysaccharide, has been shown to possess immune-modulatory properties in clinical settings. Studies have indicated that β-glucan derived from Ganoderma lucidum (commonly known as Reishi) holds particular promise in this regard, both in laboratory and in vivo settings. To further investigate the efficacy and safety of Reishi β-glucan in human subjects, a randomized, double-blinded, placebo-controlled clinical trial was conducted among healthy adult volunteers aged 18 to 55. Participants were instructed to self-administer the interventions or placebos on a daily basis for 84 days, with bloodwork assessments conducted at the beginning and end of the study. The results of the trial showed that subjects in the intervention group, who received Reishi β-glucan, exhibited a significant enhancement in various immune cell populations, including CD3⁺, CD4⁺, CD8⁺ T-lymphocytes, as well as an improvement in the CD4/CD8 ratio and natural killer cell counts when compared to the placebo group. Additionally, a statistically significant difference was observed in serum immunoglobulin A levels and natural killer cell cytotoxicity between the intervention and placebo groups. Notably, the intervention was found to be safe and well tolerated, with no statistically significant changes observed in markers of kidney or liver function in either group. Overall, the study provides evidence for the ability of Reishi β-glucan to modulate immune responses in healthy adults, thereby potentially bolstering their defense against opportunistic infections.

Global Imbalances in Funding Sources for HIV Randomized Control Trials

Improving access to grant funding is a critical aspect of strengthening research capacity outside of higher income settings, particularly in HIV/AIDS where randomized control trials (RCTs) that require substantial resources are common. In this article, we assessed recent RCTs to examine variation in how studies were funded, depending on study location and the countries where publication authors were based. We conducted a PubMed literature review to identify RCTs with HIV status or viral load endpoints published in 2019 and 2020, then analyzed cross-tabulations of funding sources by study characteristics. One hundred sixteen publications met the inclusion criteria. Research in higher income countries was most likely to be funded by biotech/pharmaceutical companies, whereas research in lower- and middle-income countries was most likely to be funded by U.S. government sources. Overall, we found the distribution of funding sources differed significantly by study and author location (χ2 = 23, p < .001). Published RCTs with HIV status or viral load endpoints are financed differently based on where studies take place and where the authors are based. As part of future research, understanding why this variation exists is critical for assessing how funding contributes to global imbalances in scientific resources.

Assessment of risk of bias in randomized controlled trials published in Indian journals pertaining to pharmacology

Context

Number of trials in India shows an increasing trend. As these trials will shape clinical practice, their quality is of utmost importance. Among many tools to assess the quality of randomized control trials (RCTs), risk of bias (RoB) is most robust.

Aims

To understand the quality of trials being carried out in India in terms of RoB.

Settings and Design

We aimed to assess the RoB in a set of RCTs published in Indian pharmacology of randomized trials from journals pertaining to pharmacology.

Subjects and Methods

We used published journal articles as source of information for randomized clinical trials and evaluated them using Cochrane RoB tool 2.0.

Statistical Analysis Used

Descriptive statistics were used.

Results

158 trials published in seven journals were evaluated in six different domains. Overall evaluation for 97% (153) trials was "high risk," while 3% (5) were in "some concerns" category, with no trials categorized as "low risk. 74% articles showed a high risk of bias in the domain of 'selection of reported results. Nearly half articles scored "low risk" in domains of "missing data" and "deviations in assignment to intervention." The study results showed a slowly increasing trend of average RoB over the last 10 years.

Conclusions

The study shows concerning rise in RoB in various domains RCTs published in Pharmacology journals in India.

Recruitment and characteristics of participants in trials of physical activity for adults aged 45 years and above in general practice: a systematic review

BACKGROUND

General practice is well situated to promote physical activity (PA), but with PA levels declining after 45 years of age, often those who are most likely to benefit from interventions tend to be the least likely recruited to participate in research.

AIMS AND RATIONALE

The aim of this study was to investigate recruitment and reporting of participant demographics in PA trials for adults aged 45 years and above. Specific objectives were: (i) to examine the reporting of demographics of participants; (ii) to investigate the strategies used to recruit these participants; and, (iii) to examine the efficiency of recruitment strategies.

METHODS

Seven databases were searched, including: PubMed, CINAHL, the Cochrane Library Register of Controlled Trials, Embase, Scopus, PsycINFO, and Web of Science. Only randomized control trials involving adults 45 years old or older recruited through primary care were included. The PRISMA framework for systematic review was followed, which involved 2 researchers independently conducting title, abstract, and full article screening. Tools for data extraction and synthesis were adapted from previous work on inclusivity in recruitment.

RESULTS

The searches retrieved 3,491 studies of which 12 were included for review. Sample size of the studies ranged from 31 to 1,366, with a total of 6,042 participants of which 57% were female. Of 101 participating practices, 1 was reported as rural. Reporting of recruitment lacked detail-only 6 studies outlined how practices were recruited. 11/12 studies involved a database or chart review to identify participants that met the inclusion criteria, followed by a letter of invitation sent to those people. The studies with higher recruitment efficiency ratios each employed more than 1 recruitment strategy, e.g. opportunistic invitations and telephone calls.

CONCLUSION

This systematic review has presented deficits in the reporting of both demographics and recruitment. Future research should aim for a standardized approach to reporting.

Effect of Vitamin E on Clinical Outcomes in Patients With Non-alcoholic Fatty Liver Disease: A Meta-Analysis

The aim of the current meta-analysis was to assess the effects of vitamin E on clinical outcomes in individuals with non-alcoholic fatty liver disease (NAFLD). The current meta-analysis was planned, reported, and conducted per the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two authors systematically searched for all papers using PubMed, Cochrane Central Register, and Embase from inception to October 15, 2022. Outcomes assessed in the current meta-analysis included changes in alanine transaminase (ALT) and aspartate transaminase (AST) from baseline in IU/L. Other outcomes included a change in BMI (kg/cm2), a change in total cholesterol level from baseline (mg/l), and a fibrosis score. Total articles were included in the current meta-analysis, enrolling 569 patients (274 patients in the vitamin E group and 295 in the placebo group). The study found that reduction in ALT levels, AST levels, and BMI was significantly greater in patients in the vitamin E group compared to the placebo group. However, no significant differences were reported in terms of change in fibrosis score and total cholesterol.

Symptom Control Research

The need for symptom control research has never been greater. Yet, this is an underdeveloped area in hospice and palliative care. Expert symptom control researchers point out a number of issues that show the way forward over the next 25 years. Chief among them is the need to do the research, rather than being content with the evidence we have. A barrier is to have the self-discipline to honestly evaluate the state of the palliative care science where the gold standard of randomized controlled trials has not been used to establish current practice. Commitment to organized symptom control research groups and clinical trials networks is important. Combining symptom control research with disease-directed research is a promising way forward. Investing in training junior clinicians and researchers is critical. All palliative care fellows and clinicians must receive training in the basics of research methods so that they can effectively support and advance research and evidence-based best practices.

Combination of Acupoints for Alzheimer's Disease: An Association Rule Analysis

Background

Alzheimer's disease (AD) is an ongoing neurological degeneration characterized by amnesia and a decline in cognitive abilities. Hippocampal neurogenesis is the leading cause of AD. Mild cognitive impairment (MCI), a prodromal state of AD, is mainly due to the degradation of neuropsychiatric manifestations. Previous systematic reviews demonstrated that treatment with acupuncture with Chinese herbs is tolerable and effective in improving cognitive function in patients with AD. Our investigation aimed to discover the main acupoint combination for AD management based on a preceding systematic review and meta-analysis of randomized control trials (RCTs).

Materials and Methods

Our investigation was executed using association rule analysis, which is a common data mining technique accessible within R. Our study elucidated acupoint locations as binary data from 15 of the included studies using the Apriori algorithm.

Results

Thirty-two acupoints were selected from 15 RCTs. The 10 most frequent acupoints were selected. We inspected 503 association rules using the interpreted acupuncture data. The obtained results showed that {SP6, BI10} ≥ {HT7} and {HT7, BI10} ≥ {SP6} were the most associated rules in 15 RCTs.

Conclusion

The combination of acupoints ({SP6, BI10} ≥ {HT7} and {HT7, BI10} ≥ {SP6}) can be acknowledged as a core combination for future acupuncture regimens of AD.

An overview of systematic reviews on the pharmacological randomized controlled trials for reducing intracranial pressure after traumatic brain injury

BACKGROUND

There is a need for an overview of systematic reviews (SRs) examining randomized clinical trials (RCTs) of pharmacological interventions in the treatment of intracranial pressure (ICP) post-TBI.

OBJECTIVES

To summarize pharmacological effectiveness in decreasing ICP in SRs with RCTs and evaluate study quality.

METHODS

Comprehensive literature searches were conducted in MEDLINE, PubMed, EMBASE, PsycINFO, and Cochrane Library databases for English SRs through October 2020. Inclusion criteria were SRs with RCTs that examined pharmacological interventions to treat ICP in patients post-TBI. Data extracted were participant characteristics, pharmacological interventions, and ICP outcomes. Study quality was assessed with AMSTAR-2.

RESULTS

Eleven SRs between 2003 and 2020 were included. AMSTAR-2 ratings revealed 3/11 SRs of high quality. Pharmacological interventions included hyperosmolars, neuroprotectives, anesthetics, sedatives, and analgesics. Study samples ranged from 7 to 1282 patients. Hyperosmolar agents and sedatives were beneficial in lowering elevated ICP. High bolus dose opioids had a more deleterious effect on ICP. Neuroprotective agents did not show any effects in ICP management. RCT sample sizes and findings in the SRs varied. A lack of detailed data syntheses was noted. AMSTAR-2 analysis revealed moderate-to-high quality in most SRs. Future SRs may focus on streamlined reporting of dosing and clearer clinical recommendations.

CONCLUSIONS

PROSPERO-Registration: CRD42015017355.

Mono or Dual Antiplatelet Therapy for Treating Patients with Peripheral Artery Disease after Lower Extremity Revascularization: A Systematic Review and Meta-Analysis

The efficacy of dual antiplatelet therapy (DAPT) for patients with peripheral artery disease (PAD) after lower-limb intervention remains controversial. Currently, the prescription of DAPT after an intervention is not fully recommended in guidelines due to limited evidence. This study compares and analyzes the prognosis for symptomatic PAD patients receiving DAPT versus monotherapy after lower-limb revascularization. Up to November 2021, PubMed/MEDLINE, Embase, and Cochrane databases were searched to identify studies reporting the efficacy, duration, and bleeding complications when either DAPT or monotherapy were used to treat PAD patients after revascularization. Three randomized controlled trials and seven nonrandomized controlled trials were included in our study. In total, 74,651 patients made up these ten studies. DAPT in PAD patients after intervention was associated with lower rates of all-cause mortality (HR = 0.86; 95% CI, 0.79−0.94; p < 0.01), major adverse limb events (HR = 0.60; 95% CI, 0.47−0.78; p < 0.01), and major amputation (HR = 0.78; 95% CI, 0.64−0.96) when follow-up was for more than 1-year. DAPT was not associated with major bleeding events when compared with monotherapy (OR = 1.22; 95% CI, 0.69−2.18; p = 0.50) but was associated with a higher rate of minor bleeding as a complication (OR = 2.54; 95% CI, 1.59−4.08; p < 0.01). More prospective randomized studies are needed to provide further solid evidence regarding the important issue of prescribing DAPT.

Evidence That Selecting an Appropriate Item Response Theory-Based Approach to Scoring Surveys Can Help Avoid Biased Treatment Effect Estimates

Considerable thought is often put into designing randomized control trials (RCTs). From power analyses and complex sampling designs implemented preintervention to nuanced quasi-experimental models used to estimate treatment effects postintervention, RCT design can be quite complicated. Yet when psychological constructs measured using survey scales are the outcome of interest, measurement is often an afterthought, even in RCTs. The purpose of this study is to examine how choices about scoring and calibration of survey item responses affect recovery of true treatment effects. Specifically, simulation and empirical studies are used to compare the performance of sum scores, which are frequently used in RCTs in psychology and education, to that of approaches rooted in item response theory (IRT) that better account for the longitudinal, multigroup nature of the data. The results from this study indicate that selecting an IRT model that matches the nature of the data can significantly reduce bias in treatment effect estimates and reduce standard errors.

Comparison of Pharmacological Treatment Effects on Long-Time Outcomes in Heart Failure With Preserved Ejection Fraction: A Network Meta-analysis of Randomized Controlled Trials

Beneficial effects of therapeutic drugs are controversial for heart failure with preserved ejection fraction (HFpEF). This meta-analysis aimed to evaluate and compare the interactive effects of different therapeutic drugs and placebo in patients with HFpEF. A comprehensive search was conducted using PubMed, Google Scholar, and Cochrane Central Register to identify related articles published before March 2021. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular mortality, heart failure (HF) hospitalization, and worsening HF events. A total of 14 randomized controlled trials, comprising 19,573 patients (intervention group, n = 9,954; control group, n = 9,619) were included in this network meta-analysis. All-cause mortality, cardiovascular mortality, and worsening HF events among therapeutic drugs and placebo with follow-up of 0.5–4 years were not found to be significantly correlated. The angiotensin receptor neprilysin inhibitor (ARNI) and angiotensin-converting enzyme inhibitor (ACEI) significantly reduced the HF hospitalizations compared with placebo (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.60–0.87 and HR 0.64, 95% CI 0.43–0.96, respectively), without heterogeneity among studies. The ARNI was superior to angiotensin receptor blocker (ARB) in reducing HF hospitalizations (HR 0.80, 95% CI 0.71–0.91), and vericiguat 10 mg ranked worse than beta-blockers for reducing all-cause mortality in patients with HFpEF (HR 3.76, 95% CI 1.06–13.32). No therapeutic drugs can significantly reduce mortality, but the ARNI or ACEI is associated with the low risk of HF hospitalizations for patients with HFpEF.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42021247034

The hepatoprotective effect from ischemia-reperfusion injury of remote ischemic preconditioning in the liver related surgery: a meta-analysis

BACKGROUND

This study aimed to assess the hepatoprotective effect of remote ischemic preconditioning (RIPC) in the liver related surgery.

METHODS

Published articles in PubMed, Embase and Cochrane clinical trial databases were searched from the inception to May 2021. Randomized control trials (RCTs) comparing the RIPC with control or other conditionings were included for analysis. The postoperative liver synthetic function was used as the primary outcome.

RESULTS

A total of six RCTs were included the present meta-analysis. There were 216 patients underwent RIPC and 212 patients in the control group. The RIPC group had a significantly lower level of postoperative alanine transaminase and aspartate transaminase (p<0.001). The postoperative bilirubin level was also significant lower in the RIPC group than the control group (MD = -9.0, 95%CI, -13.94 to -4.03; p<0.001). ICG clearance was reduced in controls versus RIPC (p<0.001). There was no significant difference between the RIPC and control group in terms of the complication rate.

CONCLUSION

The RIPC was evaluated to have a strong hepatoprotective effect from ischemia-reperfusion injury in the liver related surgery.

Vocational Interventions to Improve Employment Participation of People with Psychosocial Disability, Autism and/or Intellectual Disability: A Systematic Review

Objective: To systematically review interventions aimed at improving employment participation of people with psychosocial disability, autism, and intellectual disability. Methods: We searched MEDLINE, Embase, PsycINFO, Web of Science, Scopus, CINAHL, ERIC, and ERC for studies published from 2010 to July 2020. Randomized controlled trials (RCTs) of interventions aimed at increasing participation in open/competitive or non-competitive employment were eligible for inclusion. We included studies with adults with psychosocial disability autism and/or intellectual disability. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias II Tool. Data were qualitatively synthesized. Our review was registered with PROSPERO (CRD42020219192). Results: We included 26 RCTs: 23 targeted people with psychosocial disabilities (n = 2465), 3 included people with autism (n = 214), and none included people with intellectual disability. Risk of bias was high in 8 studies, moderate for 18, and low for none. There was evidence for a beneficial effect of Individual Placement and Support compared to control conditions in 10/11 studies. Among young adults with autism, there was some evidence for the benefit of Project SEARCH and ASD supports on open employment. Discussion: Gaps in the availability of high-quality evidence remain, undermining comparability and investment decisions in vocational interventions. Future studies should focus on improving quality and consistent measurement, especially for interventions targeting people with autism and/or intellectual disability.

Adverse events of active and placebo groups in SARS-CoV-2 vaccine randomized trials: A systematic review

Background

For safety assessment in clinical trials, adverse events (AEs) are reported for the drug under evaluation and compared with AEs in the placebo group. Little is known about the nature of the AEs associated with clinical trials of SARS-CoV-2 vaccines and the extent to which these can be traced to nocebo effects, where negative treatment-related expectations favor their occurrence.

Methods

In our systematic review, we compared the rates of solicited AEs in the active and placebo groups of SARS-CoV-2 vaccines approved by the Western pharmaceutical regulatory agencies.We implemented a search strategy to identify trial-III studies of SARS-CoV-2 vaccines through the PubMed database. We adopted the PRISMA Statement to perform the study selection and the data collection and identified three trial: two mRNA-based (37590 participants) and one adenovirus type (6736 participants).

Findings

Relative risks showed that the occurrence of AEs reported in the vaccine groups was higher compared with the placebo groups. The most frequently AEs in both groups were fatigue, headache, local pain, as injection site reactions, and myalgia. In particular, for first doses in placebo recipients, fatigue was reported in 29% and 27% in BNT162b2 and mRNA-1273 groups, respectively, and in 21% of Ad26.COV2.S participants. Headache was reported in 27% in both mRNA groups and in 24% of Ad26.COV2.S recipients. Myalgia was reported in 10% and 14% in mRNA groups (BNT162b2 and mRNA-1273, respectively) and in 13% of Ad26.COV2.S participants. Local pain was reported in 12% and 17% in mRNA groups (BNT162b2 and mRNA-1273, respectively), and in 17% of Ad26.COV2.S recipients. These AEs are more common in the younger population and in the first dose of placebo recipients of the mRNA vaccines.

Interpretation

Our results are in agreement with the expectancy theory of nocebo effects and suggest that the AEs associated with COVID-19 vaccines may be related to the nocebo effect.

Funding

Fondazione CRT - Cassa di Risparmio di Torino, IT (grant number 66346, "GAIA-MENTE" 2019).

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

A Systematic Review Assessing Clinical Utility of Curcumin with a Focus on Cancer Prevention

SCOPE

There is extensive pre-clinical evidence for utility of curcuminoids across many diseases with a particular focus on cancer prevention, yet there remains a paucity of clinical evidence for its approved use. To assess current knowledge on the broader potential for clinical efficacy of curcumin and in particular, in cancer prevention strategies, this study undertook a systematic review determining the number and quality of randomized controlled trials (RCTs) undertaken across any pathology.

METHODS AND RESULTS

Search strategies for RCTs using a quantifiable amount of curcuminoids, are applied across Medline (Medical Literature Analysis and Retrieval System Online), Embase (Excerpta Medica dataBASE), Cochrane and clinicaltrials.gov. There are 314 curcuminoid-based RCTs, with 100 of these revealing significant within- and between-group changes relating to the primary outcome. Twenty three studies are conducted in a setting where there is an increased risk of cancer. Fifteen of these meet all prescribed quality criteria, and 10 reveal positive outcomes.

CONCLUSIONS

A substantial number of studies reveal positive outcomes following curcumin use. However, despite the vast array of preclinical data, there are relatively few RCTs conducted in the prevention setting. Future approaches to trials must deliver improved robustness and credibility of curcumin-related research to facilitate approvals for use in clinical settings.

Is Measurement Noninvariance a Threat to Inferences Drawn from Randomized Control Trials? Evidence From Empirical and Simulation Studies

Randomized control trials (RCTs) are considered the gold standard when evaluating the impact of psychological interventions, educational programs, and other treatments on outcomes of interest. However, few studies consider whether forms of measurement bias like noninvariance might impact estimated treatment effects from RCTs. Such bias may be more likely to occur when survey scales are utilized in studies and evaluations in ways not supported by validation evidence, which occurs in practice. This study consists of simulation and empirical studies examining whether measurement noninvariance impacts treatment effects from RCTs. Simulation study results demonstrate that bias in treatment effect estimates is mild when the noninvariance occurs between subgroups (e.g., male and female participants), but can be quite substantial when being assigned to control or treatment induces the noninvariance. Results from the empirical study show that surveys used in two federally funded evaluations of educational programs were noninvariant across student age groups.

Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias

Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.

Lessons learned from contemporary glioblastoma randomized clinical trials through systematic review and network meta-analysis: part 2 recurrent glioblastoma

BACKGROUND

There exists no consensus standard of treatment for patients with recurrent glioblastoma (GB). Here we used a network meta-analysis on treatments from randomized control trials (RCTs) to assess the effect on overall survival (OS) and progression-free survival (PFS) to determine if any consensus treatment can be determined for recurrent GB.

METHODS

We included all recurrent GB RCTs with at least 20 patients in each arm, and for whom patients underwent standard of care at the time of their GB initial diagnosis. Our primary outcome was OS, with secondary outcomes including PFS and adverse reactions. Hazard ratio (HR) and its 95% confidence interval (CI) of the comparison of study arms regarding OS and PFS were extracted from each paper. For comparative efficacy analysis, we utilized a frequentist network meta-analysis, an extension of the classic pair-wise meta-analysis. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Fifteen studies were included representing 29 separate treatment arms and 2194 patients. In our network meta-analysis, combination treatment with tumor-treating field and Vascular endothelial growth factor (VEGF) inhibitor ranked first in improving OS (P = .80). Concomitant anti-VEGF and Lomustine treatment was superior to Lomustine alone for extending PFS (HR 0.57, 95% CI 0.41-0.79) and ranked first in improving PFS compared to other included treatments (P = .86).

CONCLUSIONS

Our analysis highlights the numerous studies performed on recurrent GB, with no proven consensus treatment that is superior to the current SOC. Intertrial heterogeneity precludes drawing strong conclusions, and confidence analysis was low to very low. Further confirmation by future trials is recommended for our exploratory results.

Adjunctive bright light therapy for treating bipolar depression: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

Bright light therapy (BLT) was reported as an effective adjunctive treatment option for bipolar disorder. Previous meta-analytic study showed that augmentation treatment with light therapy significantly decreased the severity of bipolar depression. However, most of included studies were case-control studies and several of them focused on BLT that was provided in combination with sleep deprivation therapy.

METHODS

In this meta-analysis, we used several electronic databases to search the studies and included only randomized controlled trial (RCT) studies to compare BLT with control experimental groups for treating bipolar depression with pharmacological treatment to clarify the adjunctive efficacy of BLT. We searched the databases of EMBASE, MEDLINE, Scopus, The Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov for studies published in English until September 19, 2019. Two researchers conducted the literature screening, data extraction, and methodological quality assessment independently. The main outcome was the response rate and remission rate. We used the Review Manager 5.3 Software for the meta-analysis.

RESULTS

Four trials with a total of 190 participants (intervention: 94, control: 96) with bipolar depression were evaluated to gauge the effects of light therapy. The meta-analysis showed risk ratios of 1.78 (95% CI 1.24-2.56, p = .002; I2  = 17%) demonstrating a significant effect of light therapy in the response rate of bipolar disorder. The meta-analysis shows risk ratios of 2.03 (95% CI 0.48-8.59, p = .34; I2  = 67%) demonstrating no significant effect of light therapy in the remission rate of patients with bipolar disorder. None of the articles reported any serious adverse effects. Manic switch rate was 1.1% in the light therapy group and 1.2% in the control group.

CONCLUSIONS

Bright light therapy is an effective treatment for reducing depression symptoms among patients with bipolar depression.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018

BACKGROUND/OBJECTIVES

High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents.

DESIGN

The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident.

SETTING

Australian NHs.

PARTICIPANTS

Nursing home residents.

MEASUREMENTS

Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome.

RESULTS

Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6).

CONCLUSION

This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

Evaluation of 'spin' in the abstracts and articles of randomized controlled trials in pain literature and general anesthesia

Aim: To evaluate the abstracts and articles of randomized controlled trials (RCTs) in pain literature and general anesthesia for the evidence of spin. Materials & methods: Following a priori protocol, we used a PubMed search for RCTs from a 2-year period. Data extracted using the Boutron spin definition for criteria. Results: A total of 163 articles were identified as RCTs with clear primary and secondary end points. A total of 33 trials were identified with nonsignificant primary end points. An 18/33 were found to have spin (54.5%). The spin was identified in the results, title and conclusion 12/18, 3/18 and 3/18, respectively. Conclusion: Spin was found in 54% of pain RCTs. With sensitive clinical concerns, such as chronic pain, any misrepresentation of validity could prove to have significant clinical consequences.

Longitudinally adaptive assessment and instruction increase numerical skills of preschool children

Social inequality in mathematical skill is apparent at kindergarten entry and persists during elementary school. To level the playing field, we trained teachers to assess children's numerical and spatial skills every 10 wk. Each assessment provided teachers with information about a child's growth trajectory on each skill, information designed to help them evaluate their students' progress, reflect on past instruction, and strategize for the next phase of instruction. A key constraint is that teachers have limited time to assess individual students. To maximize the information provided by an assessment, we adapted the difficulty of each assessment based on each child's age and accumulated evidence about the child's skills. Children in classrooms of 24 trained teachers scored 0.29 SD higher on numerical skills at posttest than children in 25 randomly assigned control classrooms (P = 0.005). We observed no effect on spatial skills. The intervention also positively influenced children's verbal comprehension skills (0.28 SD higher at posttest, P < 0.001), but did not affect their print-literacy skills. We consider the potential contribution of this approach, in combination with similar regimes of assessment and instruction in elementary schools, to the reduction of social inequality in numerical skill and discuss possible explanations for the absence of an effect on spatial skills.

Prejudice Reduction: Progress and Challenges

The past decade has seen rapid growth in research that evaluates methods for reducing prejudice. This essay reviews 418 experiments reported in 309 manuscripts from 2007 to 2019 to assess which approaches work best and why. Our quantitative assessment uses meta-analysis to estimate average effects. Our qualitative assessment calls attention to landmark studies that are noteworthy for sustained interventions, imaginative measurement, and transparency. However, 76% of all studies evaluate light touch interventions, the long-term impact of which remains unclear. The modal intervention uses mentalizing as a salve for prejudice. Although these studies report optimistic conclusions, we identify troubling indications of publication bias that may exaggerate effects. Furthermore, landmark studies often find limited effects, which suggests the need for further theoretical innovation or synergies with other kinds of psychological or structural interventions. We conclude that much research effort is theoretically and empirically ill-suited to provide actionable, evidence-based recommendations for reducing prejudice.

Change in the Mindset of a Paediatric Exercise Physiologist: A Review of Fifty Years Research

In this review, the career of a pediatric exercise physiologist (HCGK) is given over a period of almost 50 years. His research was concentrated on the relationship of physical activity (physical education, sport, and daily physical activity) with health and fitness in teenagers in secondary schools. (1) His first experiment was an exercise test on a bicycle ergometer to measure aerobic fitness by estimating physical work capacity at a heart rate of 170 beats/minute (PWC₁₇₀). (2) Secondly, a randomized control trial (RCT) was performed with an intervention of more intensive physical education (PE) with circuit interval training during three lessons per week over a period of six weeks. (3) Thereafter, a second RCT was performed with an intervention of two extra PE lessons per week over a whole school year. The results of these two RCTs appeared to be small or nonsignificant, probably because the effects were confounded by differences in maturation and the habitual physical activity of these teenagers. (4) Therefore, the scope of the research was changed into the direction of a long-term longitudinal study (the Amsterdam Growth And Health Longitudinal Study). This study included male and female teenagers that were followed over many years to get insight into the individual changes in biological factors (growth, fitness, obesity, hypercholesterolemia, and hypertension) and lifestyle parameters such as nutrition, smoking, alcohol usage, and daily physical activity. With the help of new advanced statistical methods (generalized estimating equations, random coefficient analysis, and autoregression analysis) suitable for longitudinal data, research questions regarding repeated measurements, tracking, or stability were answered. New measurement techniques such as mineral bone density by means of dual-energy X-ray absorptiometry (DEXA) showed that bone can also be influenced by short bursts of mechanical load. This changed his mind: In children and adolescents, not only can daily aerobic exercise of at least 30 to 60 minutes duration increase the aerobic power of muscles, but very short highly intensive bursts of less than one minute per day can also increase the strength of their bones.

Therapeutic Potential of Ixekizumab in the Treatment of Ankylosing Spondylitis: A Review on the Emerging Clinical Data

Over the last 20 years, the greatly improved knowledges of underlying pathogenic mechanisms of AS, including the role of tumor necrosis factor (TNF), the interleukin 23/Th17 axis, and interleukin-17 (Il-17), constituted the rationale to develop biologics selectively inhibiting these pathways. For more than 10 years, anti-TNF biologics were successfully employed to treat AS, with marked improvement of signs and symptoms in around 60% of the patients. Recent knowledge of the pathophysiology of spondyloarthritis has highlighted the emerging role of the IL-17/IL-23 axis. New therapies with selective biological drugs have emerged in the treatment of this pathology. In this review, we evaluated the effects of ixekizumab, a new anti–IL-17A, that was licensed both by EMA and FDA in August 2019 for the treatment of ankylosing spondylitis. The review highlights the efficacy and safety data of the 3 randomized controlled trials (COAST V-COAST W-COAST X) and those of the extension to 52 weeks of COAST V and COAST W.

Efficacy and safety of elemene combined with chemotherapy in advanced gastric cancer: A Meta-analysis

BACKGROUND

Elemene is a natural compound extracted from Zingiberaceae plants, and is used in various cancer. However, the efficacy and safety elemene combined with chemotherapy in advanced gastric cancer (GC) are lack of systematic assessment.

METHODS

we searched the PubMed, EMBASE, Web of Science, Cochrane Library, China Academic Journals (CNKI), Chinese Science and Technology Journals (CQVIP) and Chinese Biomedical Literature databases. Randomized controlled trials (RCTs) comparing elemene plus chemotherapy with chemotherapy alone in participants with advanced GC and reporting at least one of the following outcomes were selected and assessed for inclusion. JADAD scale was used to assess the quality. Data was screened and extracted by two independent investigators. The primary clinical outcome was overall response rate (ORR); the secondary outcomes were quality of life (QOL) and adverse events (AEs). Analysis was performed using Review Manager 5.3.

RESULTS

Sixteen RCTs matched the selection criteria, which reported on 969 subjects. Risk ratios (RR) and corresponding 95% confidence intervals (CIs) were pooled for ORR, life quality based on KPS, and risk of AEs. Compared to chemotherapy alone, elemene combined with chemotherapy in the treatment of GC may increase the efficiency of ORR(RR: 1.41; 95% CI: 1.23-1.60; P < .0001), improve their life quality based on KPS (RR: 1.84; 95% CI: 1.45-2.34; P < .00001), and reduce the adverse reactions, including leukopenia(RR: 0.73; 95% CI: 0.62-0.85; P < .00001), neutropenia (RR: 0.75; 95% CI: 0.60-0.95; P = .02), anemia (RR: 0.76; 95% CI: 0.60-0.95; P = .02), thrombocytopenia (RR: 0.56; 95% CI: 0.43-0.73; P < .00001). Nausea and vomiting (RR: 0.84; 95% CI: 0.84-1.07; P = .39), diarrhea (RR: 0.69; 95% CI: 0.41-1.15; P = .15), neurotoxicity (RR: 0.77; 95% CI: 0.59-1.00; P = .05) and hepatic dysfunction (RR: 0.95; 95% CI: 0.58-1.54; P = .83) were similar between two groups.

CONCLUSIONS

Elemene may have the potential to improve the efficacy and reduce the AEs of chemotherapy for gastric cancer. However, the long-term, high-quality researches with a large sample size in different populations are required.

Comparison of kidney-tonifying and blood-activating medicinal herbs vs NSAIDs in patients with knee osteoarthritis: A protocol for a systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is one of the most common chronic muscular diseases in old people. In recent years, people are more and more interested in the use of Chinese herbal medicine (CHM) in the treatment of KOA, such as kidney-tonifying and blood-activating medicinal herbs (KTBAMs) in the treatment of KOA. Many studies have confirmed that KTBAMs are effective in the treatment of KOA. However, it is still unknown whether KTBAMs and NSAIDs are more effective in the treatment of KOA. Therefore, we evaluated the efficacy and safety of KTBAMs and NSAIDs in the treatment of KOA.

METHODS

Randomized controlled trials (RCTs) from online databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Data, and Chinese Biomedical Literature Database that compared the efficacy of KTBAMs and NSAIDs in the treatment of KOA were retrieved. The main outcomes included the evaluation of functional outcomes, pain and adverse effects. The Cochrane risk of bias (ROB) tool was used to assess methodological quality.

RESULTS

The literature will provide a high-quality analysis of the current evidence supporting KTBAMs for KOA based on various comprehensive assessments including the total effective rate, visual analog scale scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequence scores, Knee Society Scale (KSS) scores, and adverse effects.

CONCLUSION

This proposed systematic review will provide up-to-date evidence to assess the effect of KTBAMs in the treatment for patients with KOA. RESEARCH REGISTRY REGISTRATION NUMBER: : reviewregistry 783.

COMPASS: A Pilot Trial of an Early Palliative Care Intervention for Patients With End-Stage Liver Disease

CONTEXT

Palliative care interventions have shown promise in improving quality of life and reducing health-care utilization among patients with chronic organ failure.

OBJECTIVES

To evaluate the effect of a palliative care intervention for adults with end-stage liver disease.

METHODS

A randomized controlled trial of patients with end-stage liver disease admitted to the hepatology service at a tertiary referral center whose attending hepatologist indicated they would not be surprised if the patient died in the following year on a standardized questionnaire was performed. Control group patients received usual care. Intervention group patients received inpatient specialist palliative care consultations and outpatient phone follow-up by a palliative care nurse. The primary outcome was time until first readmission. Secondary outcomes included days alive outside the hospital, referral to hospice care, death, readmissions, patient quality of life, depression, anxiety, and quality of end-of-life care over 6 months.

RESULTS

The trial stopped early because of difficulties in accruing patients. Of 293 eligible patients, only 63 patients were enrolled, 31 in the intervention group and 32 in the control group. This pace of enrollment was only 25% of what the study had planned, and so it was deemed infeasible to complete. Despite stopping early, intervention group patients had a lower hazard of readmission (hazard ratio: 0.36, 95% confidence interval: 0.16-0.83, P = 0.017) and greater odds of having more days alive outside the hospital than control group patients (odds ratio: 3.97, 95% confidence interval: 1.14-13.84, P = 0.030). No other statistically significant differences were observed.

CONCLUSION

Logistical obstacles hindered completion of the trial as originally designed. Nevertheless, a preemptive palliative care intervention resulted in increased time to first readmission and more days alive outside the hospital in the first six months after study entry.

Metformin versus insulin for gestational diabetes: a systematic review and meta-analysis

BACKGROUND

Metformin is increasingly used in clinical practice for the treatment of gestational diabetes mellitus. However, its safety and long-term effects on fetuses exposed to metformin in uterus remain controversial.

METHODS

We systematically searched PubMed, Embase, and the Cochrane database (last search was updated on 1 May 2019) for randomized controlled trials comparing metformin with insulin. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model.

RESULTS

Twenty-four studies were included. Among these, seventeen RCTs (N = 2828 participants) were included for quantitative analyses and seven studies were included only for qualitative synthesis. Metformin lowered the risk of pregnancy-induced hypertension (p = .03; risk ratio (RR) = 0.64; confidence interval (95%CI) [0.44, 0.95]), large for gestational age babies (p = .04; RR = 0.82; 95% CI [0.68, 0.99]), macrosomia (p = .01; RR = 0.63; 95%CI [0.45, 0.90]), neonatal hypoglycemia (p = .001; RR = 0.72; 95%CI [0.59, 0.88]), and neonatal intensive care unit admission (p = .01; RR = 0.74; 95%CI [0.58, 0.94]). Metformin did not increase premature delivery (p = .11; RR = 1.28; 95%CI [0.95, 1.73]), preeclampsia (p = .45; RR = 0.89; 95%CI [0.65, 1.21]), caesarean delivery (p = .20; RR = 0.94; 95%CI [0.85, 1.04]), small for gestational age babies (p = .95; RR = 0.99; 95%CI [0.69, 1.42]). The long-term results seemed to have no adverse effect, but the information was still limited.

CONCLUSIONS

According to our review, metformin may have potential benefits for pregnant women and newborns with no obvious adverse effects. However, even more studies are needed to provide evidence for the future use of metformin.

A Failed Method? Reflections on Using Audio Diaries in Uganda With Young People Growing Up With HIV in the BREATHER Trial

In this article, we present a case study in which we consider our use of the audio diary method with young people (aged 10-24) living with HIV in Uganda in a longitudinal qualitative study conducted in a clinical randomized control trial. Despite initial enthusiasm for the method among participants to capture accounts of participants' experiences outside of the confines of the HIV clinic, the constraints the young people encountered in accessing sufficient privacy to confidently make recordings meant that no one elected to use them again in the study. Despite the insights the use of the method generated, the lack of acceptability led to its relative failure. This demonstrates that despite the call for innovation, there is an unwavering necessity when selecting methods that they align with the needs and preferences of our participants and with an attentive assessment of the local context in which illness narratives are produced.

Scalp acupuncture treatment for children's autism spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopment disorder without definitive cure. Previous studies have provided evidences for efficacy and safety of scalp acupuncture in children with ASD. However, the efficacy of scalp acupuncture treatment (SAT) in children with ASD has not been evaluated systematically. The objective of this study is to evaluate the efficacy of SAT in children with ASD.

METHODS

Information from 6 databases, including MEDLINE, EMBASE, Cochrane database, AMED, China National Knowledge Infrastructure, and Wanfang Data, were retrieved from the inception of each database from 1980 through September 2018. Randomized controlled trials evaluating the efficacy of SAT for patients with ASD were included. The primary outcome measures were the Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC). The secondary outcome measures were Psychoeducational Profile (Third Edition) (PEP-3) scores. Risk of bias assessment and data synthesis were conducted with Review Manager 5.3 software. Methodological quality was assessed with the Cochrane risk of bias tool.

RESULTS

Fourteen trials with 968 participants were conducted and 11 of the trials were suitable for meta-analysis. Compared with behavioral and educational interventions, SAT significantly decreased the overall CARS scores for children under 3 years old (mean difference (MD) = 3.08, 95% confidence interval (CI) [-3.96, -2.19], P < .001) and above 3 years old (MD = 5.29, 95% CI [-8.53, -2.06], P < .001), ABC scores (MD = 4.70, 95% CI [-6.94, -2.79], P < .001). Furthermore, SAT significantly improved PEP-3 scores in communication (MD = 3.61, 95% CI [2.85, 4.37], P < .001), physical ability (MD = 2.00, 95% CI [1.16, 2.84], P < .001), and behavior (MD = 2.76, 95% CI [1.80, 2.71], P < .001).

CONCLUSION

SAT may be an effective treatment for children with ASD. Given the heterogeneity and number of participants, randomized controlled trials of high quality and design are required before widespread application of this therapy.

The efficacy and safety of opening-wedge high tibial osteotomy in treating unicompartmental knee osteoarthritis: Protocol for a systematic review and meta-analysis

BACKGROUND

High tibial osteotomy (HTO) is an effective surgical technique that can stop or inhibit the progression of unicompartmental knee osteoarthritis (KOA) to avoid or postpone the need for knee arthroplasty in patients. Whether opening-wedge high tibial osteotomy (OWHTO) is superior to closing-wedge high tibial osteotomy (CWHTO) in treating unicompartmental KOA remains controversial.

METHODS

Databases (Cochrane Library, EMBASE, and PubMed) were searched from their establishment to July 1, 2018 for randomized controlled trials comparing the application of OWHTO to CWHTO in patients with unicompartmental KOA. The methodological quality of each included study was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions guideline. Review Manager 5.3.5 software (Cochrane Collaboration, Oxford, UK) was used to synthesize the final results.

RESULTS

The results will provide useful information about the effectiveness and safety of OWHTO in patients with unicompartmental KOA.

CONCLUSION

The findings of the study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD4201811805.

Comparison of platelet-rich plasma vs hyaluronic acid injections in patients with knee osteoarthritis: A protocol for a systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is a progressive joint disease involving intraarticular and periarticular structures. In recent years, there has been increasing interest in the use of autologous growth factors, such as intraarticular injections of platelet-rich plasma (PRP), to treat KOA. It is necessary to update the research and reevaluate the efficacy and safety of PRP to provide up-to-date evidence for KOA management. Therefore, we provide a protocol for a systematic review of PRP for KOA.

METHODS

The aim of this study was to retrieve papers on the topic of PRP treatment for KOA in electronic databases including PubMed, Embase, and the Cochrane Library. The search will include studies that were published from the time the databases were established until April 2018. The entire process will include study selection, data extraction, risk of bias assessment, and meta-analyses.

RESULTS

The literature will provide a high-quality analysis of the current evidence supporting PRP for KOA based on various comprehensive assessments including the Western Ontario and McMaster Universities Osteoarthritis Index, visual analog scale scores, International Knee Documentation Committee scores, Lequesne index scores, and adverse events.

CONCLUSION

This proposed systematic review will provide up-to-date evidence to assess the effect of PRP treatment for patients with KOA.

PROSPERO REGISTRATION NUMBER

CRD42018108825.

Implementation of Mass Cytometry as a Tool for Mechanism of Action Studies in Inflammatory Bowel Disease

Background

Novel therapeutics for inflammatory bowel disease (IBD) are under development, yet mechanistic readouts at the tissue level are lacking. Techniques to assess intestinal immune composition could represent a valuable tool for mechanism of action (MOA) studies of novel drugs. Mass cytometry enables analysis of intestinal inflammatory cell infiltrate and corresponding molecular fingerprints with unprecedented resolution. Here, we aimed to optimize the methodology for isolation and cryopreservation of cells from intestinal tissue to allow for the potential implementation of mass cytometry in MOA studies.

Methods

We investigated key technical issues, including minimal tissue requirements, cell isolation protocols, and cell storage, using intestinal biopsies and peripheral blood from healthy individuals. High-dimensional mass cytometry was employed for the analyses of biopsy-derived intestinal cellular subsets.

Results

Dithiothreitol and mechanical dissociation decreased epithelial cell contamination and allowed for isolation of adequate cell numbers from 2 to 4 colonic or ileal biopsies (6 × 104±2 × 104) after a 20-minute collagenase digestion, allowing for reliable detection of most major immune cell subsets. Biopsies and antibody-labeled mononuclear cells could be cryopreserved for later processing and acquisition (viability > 70%; P < 0.05).

Conclusions

Mass cytometry represents a unique tool for deep immunophenotyping intestinal cell composition. This technique has the potential to facilitate analysis of drug actions at the target tissue by identifying specific cellular subsets and their molecular signatures. Its widespread implementation may impact not only IBD research but also other gastrointestinal conditions where inflammatory cells play a role in pathogenesis.

Digital health interventions to help living with cancer: A systematic review of participants' engagement and psychosocial effects

OBJECTIVE

Digital health interventions (DI) open the possibility for cancer patients and survivors to manage the disease and its side effects when they return home after treatment. This study aims to highlight the components of DI, investigate patient engagement with DI, and explore the effects of DI on psychosocial variables.

METHODS

In September 2017, we performed a systematic review of studies focusing on DI which target cancer patients or survivors.

RESULTS

A total of 29 articles (24 studies) were reviewed. There was considerable heterogeneity in study methods, in outcome definitions, in measures for engagement with DI and in psychosocial variables assessed. Results from the studies showed a high level of engagement. Self-efficacy, psychological symptoms, and quality of life were the most commonly assessed psychosocial variables. However, results for the effect of DI on psychosocial variables were inconsistent. Regarding pain management, results were in line with what one would expect.

CONCLUSIONS

The present review showed that despite the heterogeneity in the studies assessed and inconsistent results, DI may constitute an excellent means to help cancer patients and survivors cope better with the disease and with treatment side effects, as they can improve self-management and wellbeing. In order to acquire a greater understanding of the mechanisms underlying cancer patients'/survivors' psychological and behavioral changes in terms of adopting DI, direct comparison between studies is needed. However, this can only come about if methodological and conceptual standardization of DI is implemented.

Is the combined application of both drain-clamping and tranexamic acid superior to the single use of either application in patients with total-knee arthroplasty?: A meta-analysis of randomized controlled trials

BACKGROUND

To compare the efficacy and safety of the combined application of both drain-clamping and tranexamic acid (TXA) versus the single use of either application in patients with total-knee arthroplasty (TKA).

METHODS

Databases (EMBASE, PubMed, Cochrane Library, Web of Sciences, the Google database, and the Ovid database) were searched from their inception through April 2018 for randomized controlled trials (RCTs) comparing the combined application of both drain-clamping and TXA versus single use of either application in patients with TKA. The Cochrane risk of bias (ROB) tool was used to assess the methodologic quality. The primary outcomes were blood loss in drainage, total blood loss, transfusion rate, and hemoglobin decline. The secondary outcomes were postoperative complications, the Knee Society Score (KSS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS

A total of five RCTs (479 participants) were included in our meta-analysis. The present meta-analysis indicated that significant differences existed in the total blood loss (mean difference [MD] = -145.86, 95% confidence interval [CI]: -228.64 to -63.08, P = .0006), blood loss in drainage (MD = -169.06, 95% CI: -248.56 to -89.57, P < .0001), hemoglobin decline (MD = -0.66, 95% CI: -1.00 to -0.33, P = .0001), and transfusion rate (MD = 0.44, 95% CI: 0.26-0.75, P = .002) between the groups. However, regarding postoperative complications, no significant differences were found between the 2 groups in the KSS and the WOMAC score (P > .05).

CONCLUSION

Combined application of both drain-clamping and TXA was associated with significant reductions in blood loss in drainage, total blood loss, hemoglobin decline, and the need for transfusion. However, high-quality, well-designed RCTs with long-term follow-up are still required.

Are large randomised controlled trials in severe sepsis and septic shock statistically disadvantaged by repeated inadvertent underestimates of required sample size?

OBJECTIVES

We sought to understand why randomised controlled trials in septic shock have failed to demonstrate effectiveness in the face of improving overall outcomes for patients and seemingly promising results of early phase trials of interventions.

DESIGN

We performed a retrospective analysis of large critical care trials of severe sepsis and septic shock. Data were collected from the primary trial manuscripts, prepublished statistical plans or by direct communication with corresponding authors.

SETTING

Critical care randomised control trials in severe sepsis and septic shock.

PARTICIPANTS

14 619 patients randomised in 13 trials published between 2005 and 2015, enrolling greater than 500 patients and powered to a primary outcome of mortality.

INTERVENTION

Multiple interventions including the evaluation of treatment strategies and novel therapeutics.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was the difference between the anticipated and actual control arm mortality. Secondary analysis examined the actual effect size and the anticipated effect size employed in sample size calculation.

RESULTS

In this post hoc analysis of 13 trials with 14 619 patients randomised, we highlight a global tendency to overestimate control arm mortality in estimating sample size (absolute difference 9.8%, 95% CI -14.7% to -5.0%, p<0.001). When we compared anticipated and actual effect size of a treatment, there was also a substantial overestimation in proposed values (absolute difference 7.4%, 95% CI -9.0% to -5.8%, p<0.0001).

CONCLUSIONS

An interpretation of our results is that trials are consistently underpowered in the planning phase by employing erroneous variables to calculate a satisfactory sample size. Our analysis cannot establish if, given a larger sample size, a trial would have had a positive result. It is disappointing so many promising phase II results have not translated into durable phase III outcomes. It is possible that our current framework has biased us towards discounting potentially life-saving treatments.

Simplifying "target" intraocular pressure for different stages of primary open-angle glaucoma and primary angle-closure glaucoma

Lowering of intraocular pressure is currently the only therapeutic measure for Glaucoma management. Many longterm, randomized trials have shown the efficacy of lowering IOP, either by a percentage of baseline, or to a specified level. This has lead to the concept of 'Target" IOP, a range of IOP on therapy, that would stabilize the Glaucoma/prevent further visual field loss, without significantly affecting a patient's quality of life. A clinical staging of Glaucoma by optic nerve head evaluation and perimetric parameters, allows a patient's eye to be categorized as having - mild, moderate or severe Glaucomatous damage. An initial attempt should be made to achieve the following IOP range for both POAG or PACG after an iridotomy. In mild glaucoma the initial target IOP range could be kept as 15-17 mmHg, for moderate glaucoma 12-15 mmHg and in the severe stage of glaucomatous damage 10-12 mmHg. Factoring in baseline IOP, age, vascular perfusion parameters, and change on perimetry or imaging during follow up, this range may be reassessed over 6 months to a year. "Target" IOP requires further lowering when the patient continues to progress or develops a systemic disease such as a TIA. Conversely, in the event of a very elderly or sick patient with stable nerve and visual field over time, the target IOP could be raised and medications reduced. An appropriate use of medications/laser/surgery to achieve such a "Target" IOP range in POAG or PACG can maintain visual fields and quality of life, preventing Glaucoma blindness.