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Wuytack F, Regan M, Biesty L, Meskell P, Lutomski JE, O'Donnell M, Treweek S, Devane D. Risk of bias assessment of sequence generation: a study of 100 systematic reviews of trials. Syst Rev 2019; 8:13. [PMID: 30621793 PMCID: PMC6323681 DOI: 10.1186/s13643-018-0924-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/18/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Systematic reviews of randomised trials guide policy and healthcare decisions. Yet, we observed that some reviews judge randomised trials as high or unclear risk of bias (ROB) for sequence generation, potentially introducing bias. However, to date, the extent of this issue has not been well examined. We evaluated the consistency in the ROB assessment for sequence generation of randomised trials in Cochrane and non-Cochrane reviews, and explored the reviewers' judgement of the quality of evidence for the related outcomes. METHODS Cochrane intervention reviews (01/01/2017-31/03/2017) were retrieved from the Cochrane Database of Systematic Reviews. We also searched for systematic reviews in ten general medical journals with highest impact factors (01/01/2016-31/03/2017). We examined the proportion of reviews that rated the sequence generation domain as high, low or unclear risk of selection bias. For reviews that had rated any randomised trials as high or unclear risk of bias, we examined the proportion that had assessed the quality of evidence. RESULTS Overall, 100 systematic reviews were included in our analysis. We evaluated 64 Cochrane reviews which comprised of 984 randomised trials; 0.8% (n = 8) and 52.2% (n = 514) were rated as high and unclear ROB for sequence generation respectively. We further evaluated 36 non-Cochrane reviews which comprised of 1376 trials; 5.8% (n = 80) and 39.6% (n = 545) were rated as high and unclear ROB respectively. Ninety percent (n = 10) of non-Cochrane reviews which rated randomised trials as high ROB for sequence generation did not report an underlying reason. All Cochrane reviews assessed the quality of evidence (GRADE). For the non-Cochrane reviews, only just over half had assessed the quality of evidence. CONCLUSION Systematic reviews of interventions frequently rate randomised trials as high or unclear ROB for sequence generation. In general, Cochrane reviews were more transparent than non-Cochrane reviews in ROB and quality of evidence assessment. The scientific community should more strongly promote consistent ROB assessment for sequence generation to minimise selection bias and support transparent quality of evidence assessment. Consistency ensures that appropriate conclusions are drawn from the data.
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Affiliation(s)
- Francesca Wuytack
- School of Nursing & Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Maria Regan
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Linda Biesty
- HRB-Trials Methodology Research Network/School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Pauline Meskell
- Department of Nursing & Midwifery, Health Sciences Building, University of Limerick, Limerick, Ireland
| | - Jennifer E Lutomski
- Radboud Biobank, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA, Nijmegen, The Netherlands
| | - Martin O'Donnell
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Declan Devane
- HRB-Trials Methodology Research Network/School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
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Zingarelli B, Coopersmith CM, Drechsler S, Efron P, Marshall JC, Moldawer L, Wiersinga WJ, Xiao X, Osuchowski MF, Thiemermann C. Part I: Minimum Quality Threshold in Preclinical Sepsis Studies (MQTiPSS) for Study Design and Humane Modeling Endpoints. Shock 2019; 51:10-22. [PMID: 30106874 PMCID: PMC6296871 DOI: 10.1097/shk.0000000000001243] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Preclinical animal studies are mandatory before new treatments can be tested in clinical trials. However, their use in developing new therapies for sepsis has been controversial because of limitations of the models and inconsistencies with the clinical conditions. In consideration of the revised definition for clinical sepsis and septic shock (Sepsis-3), a Wiggers-Bernard Conference was held in Vienna in May 2017 to propose standardized guidelines on preclinical sepsis modeling. The participants conducted a literature review of 260 most highly cited scientific articles on sepsis models published between 2003 and 2012. The review showed, for example, that mice were used in 79% and euthanasia criteria were defined in 9% of the studies. Part I of this report details the recommendations for study design and humane modeling endpoints that should be addressed in sepsis models. The first recommendation is that survival follow-up should reflect the clinical time course of the infectious agent used in the sepsis model. Furthermore, it is recommended that therapeutic interventions should be initiated after the septic insult replicating clinical care. To define an unbiased and reproducible association between a new treatment and outcome, a randomization and blinding of treatments as well as inclusion of all methodological details in scientific publications is essential. In all preclinical sepsis studies, the high standards of animal welfare must be implemented. Therefore, development and validation of specific criteria for monitoring pain and distress, and euthanasia of septic animals, as well as the use of analgesics are recommended. A set of four considerations is also proposed to enhance translation potential of sepsis models. Relevant biological variables and comorbidities should be included in the study design and sepsis modeling should be extended to mammalian species other than rodents. In addition, the need for source control (in case of a defined infection focus) should be considered. These recommendations and considerations are proposed as "best practices" for animal models of sepsis that should be implemented.
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Affiliation(s)
- Basilia Zingarelli
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Susanne Drechsler
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Philip Efron
- Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - John C Marshall
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Lyle Moldawer
- Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida
| | - W Joost Wiersinga
- Division of Infectious Diseases, Center for Experimental and Molecular Medicine, The Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Xianzhong Xiao
- Xiangya School of Medicine, Central South University, Chagnsha, Hunan, China
| | - Marcin F Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Christoph Thiemermann
- The William Harvey Research Institute, Barts and London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
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53
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Duckham RL, Tait JL, Nowson CA, Sanders KM, Taaffe DR, Hill KD, Daly RM. Strategies and challenges associated with recruiting retirement village communities and residents into a group exercise intervention. BMC Med Res Methodol 2018; 18:173. [PMID: 30572835 PMCID: PMC6302307 DOI: 10.1186/s12874-018-0633-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/30/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) provide the highest level of scientific evidence, but successful participant recruitment is critical to ensure the external and internal validity of results. This study describes the strategies associated with recruiting older adults at increased falls risk residing in retirement villages into an 18-month cluster RCT designed to evaluate the effects of a dual-task exercise program on falls and physical and cognitive function. METHODS Recruitment of adults aged ≥65 at increased falls risk residing within retirement villages (size 60-350 residents) was initially designed to occur over 12 months using two distinct cohorts (C). Recruitment occurred via a three-stage approach that included liaising with: 1) village operators, 2) independent village managers, and 3) residents. To recruit residents, a variety of different approaches were used, including distribution of information pack, on-site presentations, free muscle and functional testing, and posters displayed in common areas. RESULTS Due to challenges with recruitment, three cohorts were established between February 2014 and April 2015 (14 months). Sixty retirement villages were initially invited, of which 32 declined or did not respond, leaving 28 villages that expressed interest. A total of 3947 individual letters of invitation were subsequently distributed to residents of these villages, from which 517 (13.1%) expressions of interest (EOI) were received. Across three cohorts with different recruitment strategies adopted there were only modest differences in the number of EOI received (10.5 to 15.3%), which suggests that no particular recruitment approach was most effective. Following the initial screening of these residents, 398 (77.0%) participants were deemed eligible to participate, but a final sample of 300 (58.0% of the 517 EOI) consented and was randomized; 7.6% of the 3947 residents invited. Principal reasons for not participating, despite being eligible, were poor health, lack of time and no GP approval. CONCLUSION This study highlights that there are significant challenges associated with recruiting sufficient numbers of older adults from independent living retirement villages into an exercise intervention designed to improve health and well-being. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12613001 161718 . Date registered 23rd October 2013.
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Affiliation(s)
- Rachel L Duckham
- Institute for Physical Activity and Nutrition, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
- Australian Institute for Musculoskeletal Sciences (AIMSS), St. Albans, Melbourne, Australia.
| | - Jamie L Tait
- Institute for Physical Activity and Nutrition, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Caryl A Nowson
- Institute for Physical Activity and Nutrition, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Kerrie M Sanders
- Department of Medicine, Western Health, Department of Medicine, University of Melbourne, Sunshine Hospital, St Albans, Victoria, Australia
- Australian Institute for Musculoskeletal Sciences (AIMSS), University of Melbourne and Western Health, Melbourne, St. Albans, Australia
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Keith D Hill
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Robin M Daly
- Institute for Physical Activity and Nutrition, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
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Day S, Jonker AH, Lau LPL, Hilgers RD, Irony I, Larsson K, Roes KC, Stallard N. Recommendations for the design of small population clinical trials. Orphanet J Rare Dis 2018; 13:195. [PMID: 30400970 PMCID: PMC6219020 DOI: 10.1186/s13023-018-0931-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023] Open
Abstract
Background Orphan drug development faces numerous challenges, including low disease prevalence, patient population heterogeneity, and strong presence of paediatric patient populations. Consequently, clinical trials for orphan drugs are often smaller than those of non-orphan drugs, and they require the development of efficient trial designs relevant to small populations to gain the most information from the available data. The International Rare Diseases Research Consortium (IRDiRC) is aimed at promoting international collaboration and advance rare diseases research worldwide, and has as one of its goals to contribute to 1000 new therapies for rare diseases. IRDiRC set up a Small Population Clinical Trials (SPCT) Task Force in order to address the shortcomings of our understanding in carrying out clinical trials in rare diseases. Results The IRDiRC SPCT Task Force met in March 2016 to discuss challenges faced in the design of small studies for rare diseases and present their recommendations, structured around six topics: different study methods/designs and their relation to different characteristics of medical conditions, adequate safety data, multi-arm trial designs, decision analytic approaches and rational approaches to adjusting levels of evidence, extrapolation, and patients’ engagement in study design. Conclusions Recommendations have been issued based on discussions of the Small Population Clinical Trials Task Force that aim to contribute towards successful therapy development and clinical use. While randomised clinical trials are still considered the gold standard, it is recommended to systematically take into consideration alternative trial design options when studying treatments for a rare disease. Combining different sources of safety data is important to give a fuller picture of a therapy’s safety profile. Multi-arm trials should be considered an opportunity for rare diseases therapy development, and funders are encouraged to support such trial design via international networks. Patient engagement is critical in trial design and therapy development, a process which sponsors are encouraged to incorporate when conducting trials and clinical studies. Input from multiple regulatory agencies is recommended early and throughout clinical development. Regulators are often supportive of new clinical trial designs, provided they are well thought through and justified, and they also welcome discussions and questions on this topic. Parallel advice for multiregional development programs should also be considered.
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Affiliation(s)
- Simon Day
- Clinical Trials Consulting & Training Limited, 53 Portway, North Marston, Buckingham, Buckinghamshire, MK18 3PL, UK.
| | | | | | | | - Ilan Irony
- Center for Biologics Evaluation and Research/ Office of Tissues and Advanced Therapies, US Food and Drug Administration, Silver Spring, USA
| | | | - Kit Cb Roes
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Nigel Stallard
- Statistics and Epidemiology, Warwick Medical School, University of Warwick, Coventry, UK
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Byrne RA, Capodanno D, Mahfoud F, Fajadet J, Windecker S, Jüni P, Baumbach A, Wijns W, Haude M. Evaluating the importance of sham-controlled trials in the investigation of medical devices in interventional cardiology. EUROINTERVENTION 2018; 14:708-715. [PMID: 29786535 DOI: 10.4244/eij-d-18-00481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiovascular medicine is one of the specialties that has relied most heavily on evidence from randomised clinical trials in determining best practice for the management of common disease conditions. When comparing treatment approaches, trials incorporating random allocation are the most appropriate method for protecting against treatment allocation bias. In order to protect against performance and ascertainment bias, trial designs including placebo control are preferable where feasible. In contrast to testing of medicines, treatments based on procedures or use of medical devices are more challenging to assess, as sham procedures are necessary to facilitate blinding of participants. However, in many cases, ethical concerns exist, as individual patients allocated to sham procedure are exposed only to risk without potential for benefit. Accordingly, the potential benefits to the general patient population must be carefully weighed against the risks of the exposed individuals. For this reason, trial design and study conduct are critically important to ensure that the investigation has the best chance of answering the study question at hand. In the current manuscript, we aim to review issues relating to the conduct of sham-controlled trials and discuss a number of recent examples in the field of interventional cardiology.
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Affiliation(s)
- Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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Tonin FS, Steimbach LM, Leonart LP, Ferreira VL, Borba HH, Piazza T, Araújo AG, Fernandez-Llimos F, Pontarolo R, Wiens A. Discontinuation of non-anti-TNF drugs for rheumatoid arthritis in interventional versus observational studies: a systematic review and meta-analysis. Eur J Clin Pharmacol 2018; 74:1513-1521. [PMID: 30022333 DOI: 10.1007/s00228-018-2524-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/11/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Although randomized controlled trials (RCTs) are the gold standard for the assessment of clinical outcomes, long-term extension trials (LTEs) and observational cohorts may help generate evidence. Our goal was to compare the discontinuation rates of abatacept, rituximab, and tocilizumab in rheumatoid arthritis (RA) reported in different study designs. METHODS A systematic review was conducted with searches in PubMed, Scopus, and the Cochrane Library, plus a manual search, for RCTs, LTEs, and observational cohorts reporting discontinuation rates by any of three causes (all-cause, inefficacy, adverse events). Meta-analyses with sensitivity analyses and meta-regressions were conducted. RESULTS Of the 111 studies included, 74 were RCTs (n = 55) or LTEs (n = 17) reporting data on abatacept (n = 33), rituximab (n = 10), and tocilizumab (n = 31) and 37 were observational cohort studies (abatacept = 11, rituximab = 8, tocilizumab = 18). The follow-up duration did not differ among the study designs. Discontinuation rates were similar among the drugs but varied among the study designs. Discontinuation rates were significantly higher in cohort studies than those in interventional studies for the three drugs. Sensitivity analyses could not identify patient characteristics associated with these differences. Meta-regression analyses demonstrated no correlation between study follow-up duration and discontinuation rates. CONCLUSIONS The discontinuation rates reported for non-anti-TNF drugs varied relative to the study design in which they were investigated. Regulatory agencies, price-setting entities, and evidence-gathering researchers should consider the effect of the real-life environment in their decisions and conclusions.
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Affiliation(s)
| | | | | | | | - Helena H Borba
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil
| | - Thais Piazza
- Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Department of Social Pharmacy, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Roberto Pontarolo
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil
| | - Astrid Wiens
- Department of Pharmacy, Universidade Federal do Paraná, Av. Pref. Lothário Meissner, 632, Curitiba, Paraná, Brazil.
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Beer-Borst S, Luta X, Hayoz S, Sommerhalder K, Krause CG, Eisenblätter J, Jent S, Siegenthaler S, Aubert R, Haldimann M, Strazzullo P. Study design and baseline characteristics of a combined educational and environmental intervention trial to lower sodium intake in Swiss employees. BMC Public Health 2018; 18:421. [PMID: 29606103 PMCID: PMC5879608 DOI: 10.1186/s12889-018-5366-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/22/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Blood pressure is a primary cardiovascular disease risk factor. Population-wide governmental strategies aim to reduce lifestyle and dietary risk factors for hypertension, one of which is an unbalanced diet with high sodium and low potassium intakes. Nutrition interventions in the workplace are considered a promising approach in encouraging health-promoting behaviors. We developed and conducted the health promoting sodium reduction trial "Healthful & Tasty: Sure!" in worksites in the German-speaking part of Switzerland from May 2015 to Nov 2016, for which we present the study protocol and baseline characteristics. METHODS Healthful & Tasty, a cluster nonrandomized single-arm trial with calibration arm, aimed to demonstrate the effectiveness of a combined educational and environmental intervention in the workplace in reducing employees' average daily sodium/salt intake by 15%. To this end, health and food literacy of employees and guideline compliance among the catering facility team needed to be improved. The primary outcome measure was sodium/salt intake estimated from sodium excretion in a 24-h urine sample. Secondary outcome measures included changes in the overall qualitative diet composition, blood pressure, anthropometric indices, and health and food literacy. Of eight organizations with catering facilities, seven organizations took part in the nutrition education and catering salt reduction interventions, and one organization participated as a control. Overall, 145 consenting employees were included in the staggered, one-year four-phase trial, of which 132 participated in the intervention group. In addition to catering surveys and food sampling, the trial included five follow-up health assessments including questionnaires, blood pressure measurements, anthropometrics, and sodium, potassium, and iodine intake measurements obtained from 24-h and spot urine samples, and a food record checklist. Exploratory and hypothesis generating baseline statistical analysis included 141 participants with adequate 24-h urine samples. DISCUSSION Despite practice-driven limitations to the study design and small cluster and participant numbers, this trial has methodological strength and will provide important insights into the effectiveness of a combined educational and environmental intervention to reduce salt intake among female and male Swiss employees. TRIAL REGISTRATION German Clinical Trials Register, DRKS00006790 . Registered 23 September 2014.
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Affiliation(s)
- Sigrid Beer-Borst
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.
| | - Xhyljeta Luta
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Stefanie Hayoz
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Kathrin Sommerhalder
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - Corinna Gréa Krause
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Julia Eisenblätter
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - Sandra Jent
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - Stefan Siegenthaler
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008, Bern, Switzerland
| | - Rafael Aubert
- Federal Food Safety and Veterinary Office, Division of Risk Assessment, Laboratories, Schwarzenburgstrasse 155, 3003, Bern, Switzerland
| | - Max Haldimann
- Federal Food Safety and Veterinary Office, Division of Risk Assessment, Laboratories, Schwarzenburgstrasse 155, 3003, Bern, Switzerland
| | - Pasquale Strazzullo
- Department of Clinical Medicine & Surgery, Federico II University of Naples Medical School, via S. Pansini 5, 80131, Naples, Italy
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Assy Z, Brand HS. A systematic review of the effects of acupuncture on xerostomia and hyposalivation. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 18:57. [PMID: 29439690 PMCID: PMC5811978 DOI: 10.1186/s12906-018-2124-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 02/05/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Saliva is fundamental to our oral health and our well-being. Many factors can impair saliva secretion, such as adverse effects of prescribed medication, auto-immune diseases (for example Sjögren's syndrome) and radiotherapy for head and neck cancers. Several studies have suggested a positive effect of acupuncture on oral dryness. METHODS Pubmed and Web of Science were electronically searched. Reference lists of the included studies and relevant reviews were manually searched. Studies that met the inclusion criteria were systematically evaluated. Two reviewers assessed each of the included studies to confirm eligibility and assessing the risk of bias. RESULTS Ten randomized controlled trials investigating the effect of acupuncture were included. Five trials compared acupuncture to sham/placebo acupuncture. Four trials compared acupuncture to oral hygiene/usual care. Only one clinical trial used oral care sessions as control group. For all the included studies, the quality for all the main outcomes has been assessed as low. Although some publications suggest a positive effect of acupuncture on either salivary flow rate or subjective dry mouth feeling, the studies are inconclusive about the potential effects of acupuncture. CONCLUSIONS Insufficient evidence is available to conclude whether acupuncture is an evidence-based treatment option for xerostomia/hyposalivation. Further well-designed, larger, double blinded trials are required to determine the potential benefit of acupuncture. Sample size calculations should be performed before before initiating these studies.
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Affiliation(s)
- Zainab Assy
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), room 12N-37, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands
| | - Henk S. Brand
- Department of Oral Biochemistry, Academic Centre for Dentistry Amsterdam (ACTA), room 12N-37, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, The Netherlands
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Chalmers I, Oxman AD, Austvoll-Dahlgren A, Ryan-Vig S, Pannell S, Sewankambo N, Semakula D, Nsangi A, Albarqouni L, Glasziou P, Mahtani K, Nunan D, Heneghan C, Badenoch D. Key Concepts for Informed Health Choices: a framework for helping people learn how to assess treatment claims and make informed choices. BMJ Evid Based Med 2018; 23:29-33. [PMID: 29367324 DOI: 10.1136/ebmed-2017-110829] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2017] [Indexed: 12/16/2022]
Abstract
Many claims about the effects of treatments, though well intentioned, are wrong. Indeed, they are sometimes deliberately misleading to serve interests other than the well-being of patients and the public. People need to know how to spot unreliable treatment claims so that they can protect themselves and others from harm. The ability to assess the trustworthiness of treatment claims is often lacking. Acquiring this ability depends on being familiar with, and correctly applying, some key concepts, for example, that' association is not the same as causation.' The Informed Health Choices (IHC) Project has identified 36 such concepts and shown that people can be taught to use them in decision making. A randomised trial in Uganda, for example, showed that primary school children with poor reading skills could be taught to apply 12 of the IHC Key Concepts. The list of IHC Key Concepts has proven to be effective in providing a framework for developing and evaluating IHC resources to help children to think critically about treatment claims. The list also provides a framework for retrieving, coding and organising other teaching and learning materials for learners of any age. It should help teachers, researchers, clinicians, and patients to structure critical thinking about the trustworthiness of claims about treatment effects.
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Affiliation(s)
- Iain Chalmers
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- The James Lind Initiative, National Institute for Health Research, Oxford, UK
| | - Andrew D Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
| | | | | | - Sarah Pannell
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Nelson Sewankambo
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Makerere University College of Medicine, Makerere University, Kampala, Uganda
| | - Daniel Semakula
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Makerere University College of Medicine, Makerere University, Kampala, Uganda
| | - Allen Nsangi
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
- Makerere University College of Medicine, Makerere University, Kampala, Uganda
| | - Loai Albarqouni
- Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Kamal Mahtani
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - David Nunan
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Douglas Badenoch
- The James Lind Initiative, National Institute for Health Research, Oxford, UK
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Abstract
This article is part of a series of articles featuring the Catalogue of Bias introduced in this volume of BMJ Evidence-Based Medicine that describes allocation bias and outlines its potential impact on research studies and the preventive steps to minimise its risk. Allocation bias is a type of selection bias and is relevant to clinical trials of interventions. Knowledge of interventions prior to group allocation can result in systematic differences in important characteristics that could influence study findings. Allocation bias can overestimate effect size by up to 30%-40%. Sequentially numbered, opaque, sealed envelopes; containers; pharmacy-controlled randomisation and central computer randomisation are methods to minimise allocation bias.
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Affiliation(s)
- David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth A Spencer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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McGuire W, Halliday HL. The Research Cycle: Improving Care and Outcomes for Newborn Infants. Neonatology 2018; 114:2-6. [PMID: 29566381 DOI: 10.1159/000487990] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/17/2018] [Indexed: 11/19/2022]
Abstract
Ensuring that policies and practice in perinatal care are informed by evidence from high-quality research is fundamental to improving outcomes for newborn infants and their families. Effective interventions in the perinatal period can have a life-long impact disproportionate to their costs. Many of the major advances in care that have transformed outcomes for preterm and sick newborn infants have been informed by empirical and applied health research. Conversely, there are examples of life-long adverse consequences for infants and families that are a legacy of practices based on poor-quality evidence. The challenge in the 21st century is to maintain the trajectory of improvements in care and outcomes. This will most likely be achieved via marginal gains from new or improved care practices underpinned by a range of research approaches, from preclinical and laboratory-based empirical studies that uncover pathogenic pathways or therapeutic mechanisms, to large-scale, applied research such as multicentre, randomised controlled trials. This will involve the coordination and collaboration of research efforts globally. Strategies to develop and prioritise research questions need to involve parents and families. Given the context in which much perinatal research is conducted, particularly in emergency situations around the time of birth, robust and transparent ethics and governance frameworks are essential to maintain the trust and engagement of communities. An ethical imperative exists to ensure that research output is disseminated effectively, and that effective and cost-effective interventions are implemented and integrated within a cycle that audits and benchmarks good practice and outcomes, and informs research evidence-based continuous quality improvement. This is the first in a series of articles on research methodology in neonatal medicine to be published in Neonatology, in response to a request from trainee researchers. We introduce the series by describing the research cycle, in particular how it is applied in neonatal medicine. Subsequent articles will cover translational research, clinical trials, diagnostic tests, global challenges, and the ethical issues relating to neonatal/perinatal research.
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Affiliation(s)
- William McGuire
- Centre for Reviews and Dissemination and Hull York Medical School (HYMS), University of York, York, United Kingdom
| | - Henry L Halliday
- Retired Professor of Child Health, Queen's University of Belfast, Belfast, United Kingdom
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Wood S, Rabi Y, Tang S, Brant R, Ross S. Progesterone in women with arrested premature labor, a report of a randomised clinical trial and updated meta-analysis. BMC Pregnancy Childbirth 2017; 17:258. [PMID: 28768474 PMCID: PMC5541428 DOI: 10.1186/s12884-017-1400-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progesterone may be effective in prevention of premature birth in some high risk populations. Women with arrested premature labor are at risk of recurrent labor and maintenance therapy with standard tocolytics has not been successful. METHODS Randomized double blinded clinical trial of daily treatment with 200 mg vaginal progesterone in women with arrested premature labor and an updated meta-analysis. RESULTS The clinical trial was terminated early after 41 women were enrolled. Vaginal progesterone treatment did not change the median gestational age at delivery: 36+2 weeks versus 36+4 weeks, p = .865 nor increase the mean latency to delivery: 44.5 days versus 46.6 days, p = .841. In the updated meta-analysis, progesterone treatment did reduce delivery <37 weeks gestation and increase latency to delivery, but this treatment effect was not evident in the high quality trials: (OR 1.23, 95% CI 0.91, 1.67) and (-0.95 days, 95% CI -5.54, 3.64) respectively. CONCLUSION Progesterone is not effective for preventing preterm birth following arrested preterm labor.
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Affiliation(s)
- Stephen Wood
- Department of Obstetrics and Gynaecology, University of Calgary, 4th Floor, North Tower, Foothills Medical Centre 1441 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Yacov Rabi
- Alberta Children’s Hospital Research Institute, Foothills Medical Centre, Room, rm C211 1403 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Selphee Tang
- Department of Obstetrics and Gynaecology, University of Calgary, 4th Floor, North Tower, Foothills Medical Centre 1441 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Rollin Brant
- Department of Statistics, University of British Columbia, ESB rm 3146, 2207 Main Mall F512-4480 Oak Street, Vancouver, BC Canada
| | - Susan Ross
- Obstetrics & Gynecology, University of Alberta, 5S141 Lois Hole Hosp/Robbins Pav/RAH, Edmonton, AB T5H 3V9 Canada
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Murad MH, Wang Z. Guidelines for reporting meta-epidemiological methodology research. ACTA ACUST UNITED AC 2017; 22:139-142. [PMID: 28701372 PMCID: PMC5537553 DOI: 10.1136/ebmed-2017-110713] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2017] [Indexed: 12/15/2022]
Abstract
Published research should be reported to evidence users with clarity and transparency that facilitate optimal appraisal and use of evidence and allow replication by other researchers. Guidelines for such reporting are available for several types of studies but not for meta-epidemiological methodology studies. Meta-epidemiological studies adopt a systematic review or meta-analysis approach to examine the impact of certain characteristics of clinical studies on the observed effect and provide empirical evidence for hypothesised associations. The unit of analysis in meta-epidemiological studies is a study, not a patient. The outcomes of meta-epidemiological studies are usually not clinical outcomes. In this guideline, we adapt items from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) to fit the context of meta-epidemiological studies.
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Affiliation(s)
| | - Zhen Wang
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
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Sandercock PAG, Leong TS. Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke. Cochrane Database Syst Rev 2017; 4:CD000119. [PMID: 28374884 PMCID: PMC6478133 DOI: 10.1002/14651858.cd000119.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Low-molecular-weight heparins (LMWHs) and heparinoids are anticoagulants that may have more powerful antithrombotic effects than standard unfractionated heparin (UFH) but a lower risk of bleeding complications. This is an update of the original Cochrane Review of these agents, first published in 2001 and last updated in 2008. OBJECTIVES To determine whether antithrombotic therapy with LMWHs or heparinoids is associated with a reduction in the proportion of people who are dead or dependent for activities in daily living compared with UFH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library Issue 1, 2017), MEDLINE (1966 to February 2017), and Embase (1980 to February 2017). We also searched trials registers to February 2017: ClinicalTrials.gov, EU Clinical Trials Register, Stroke Trials Registry, ISRCTN Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA Unconfounded randomised trials comparing LMWH or heparinoids with standard UFH in people with acute ischaemic stroke, in which participants were recruited within 14 days of stroke onset. DATA COLLECTION AND ANALYSIS Two review authors independently chose studies for inclusion, assessed risk of bias and trial quality, extracted and analysed the data. Differences were resolved by discussion. MAIN RESULTS We included nine trials involving 3137 participants. We did not identify any new trials for inclusion in this updated review. None of the studies reported data on the primary outcome in sufficient detail to enable analysis for the review. Overall, there was a moderate risk of bias in the included studies. Compared with UFH, there was no evidence of an effect of LMWH or heparinoids on death from all causes during the treatment period (96/1616 allocated LMWH/heparinoid versus 78/1486 allocated UFH; odds ratio (OR) 1.06, 95% CI 0.78 to 1.47; 8 trials, 3102 participants, low quality evidence). LMWH or heparinoid were associated with a significant reduction in deep vein thrombosis (DVT) compared with UFH (OR 0.55, 95% CI 0.44 to 0.70, 7 trials, 2585 participants, low quality evidence). However, the number of the major clinical events such as pulmonary embolism (PE) and intracranial haemorrhage was too small to provide a reliable estimate of the effects. AUTHORS' CONCLUSIONS Treatment with a LMWH or heparinoid after acute ischaemic stroke appears to decrease the occurrence of DVT compared with standard UFH, but there are too few data to provide reliable information on their effects on other important outcomes, including functional outcome, death and intracranial haemorrhage.
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Affiliation(s)
- Peter AG Sandercock
- University of EdinburghCentre for Clinical Brain Sciences (CCBS)The Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
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Cross ELA, Tolfree R, Kipping R. Systematic review of public-targeted communication interventions to improve antibiotic use. J Antimicrob Chemother 2017; 72:975-987. [PMID: 27999058 PMCID: PMC7263825 DOI: 10.1093/jac/dkw520] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/19/2016] [Accepted: 11/07/2016] [Indexed: 01/14/2023] Open
Abstract
Background Excessive use of antibiotics accelerates the acquisition/spread of antimicrobial resistance. A systematic review was conducted to identify the components of successful communication interventions targeted at the general public to improve antibiotic use. Methods The databases MEDLINE, EMBASE, CINAHL, Web of Science and Cochrane Library were searched. Search terms were related to the population (public, community), intervention (campaign, mass media) and outcomes (antibiotic, antimicrobial resistance). References were screened for inclusion by one author with a random subset of 10% screened by a second author. No date restrictions were applied and only articles in the English language were considered. Studies had to have a control group or be an interrupted time-series. Outcomes had to measure change in antibiotic-related prescribing/consumption and/or the public's knowledge, attitudes or behaviour. Two reviewers assessed the quality of studies. Narrative synthesis was performed. Results Fourteen studies were included with an estimated 74-75 million participants. Most studies were conducted in the United States or Europe and targeted both the general public and clinicians. Twelve of the studies measured changes in antibiotic prescribing. There was quite strong ( P < 0·05 to ≥ 0·01) to very strong ( P < 0·001) evidence that interventions that targeted prescribing for RTIs were associated with decreases in antibiotic prescribing; the majority of these studies reported reductions of greater than -14% with the largest effect size reaching -30%. Conclusion Multi-faceted communication interventions that target both the general public and clinicians can reduce antibiotic prescribing in high-income countries but the sustainability of reductions in antibiotic prescribing is unclear.
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Affiliation(s)
| | - Robert Tolfree
- Public Health Team, Somerset Council, County Hall, Taunton, TA1 4DY, UK
| | - Ruth Kipping
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Strand LB, Clarke P, Graves N, Barnett AG. Time to publication for publicly funded clinical trials in Australia: an observational study. BMJ Open 2017; 7:e012212. [PMID: 28336734 PMCID: PMC5372122 DOI: 10.1136/bmjopen-2016-012212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To examine the length of time between receiving funding and publishing the protocol and main paper for randomised controlled trials. DESIGN An observational study using survival analysis. SETTING Publicly funded health and medical research in Australia. PARTICIPANTS Randomised controlled trials funded by the National Health and Medical Research Council of Australia between 2008 and 2010. MAIN OUTCOME MEASURES Time from funding to the protocol paper and main results paper. Multiple variable survival models examining whether study characteristics predicted publication times. RESULTS We found 77 studies with a total funding of $A59 million. The median time to publication of the protocol paper was 6.4 years after funding (95% CI 4.1 to 8.1). The proportion with a published protocol paper 8 years after funding was 0.61 (95% CI 0.48 to 0.74). The median time to publication of the main results paper was 7.1 years after funding (95% CI 6.3 to 7.6). The proportion with a published main results paper 8 years after funding was 0.72 (95% CI 0.56 to 0.87). The HRs for how study characteristics might influence timing were generally close to one with narrow CIs, the notable exception was that a longer study length lengthened the time to the main paper (HR=0.62 per extra study year, 95% CI 0.43 to 0.89). CONCLUSIONS Despite the widespread registration of clinical trials, there remain serious concerns of trial results not being published or being published with a long delay. We have found that these same concerns apply to protocol papers, which should be publishable soon after funding. Funding agencies could set a target of publishing the protocol paper within 18 months of funding.
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Affiliation(s)
- Linn Beate Strand
- Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Philip Clarke
- Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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Tektonidou MG, Ward MM. Methodological Quality of Studies of Endstage Renal Disease in Lupus Nephritis, 1970 to 2015. J Rheumatol 2017; 44:626-630. [PMID: 28202746 DOI: 10.3899/jrheum.160546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine trends in methodological quality of studies of endstage renal disease risk in lupus nephritis, 1970-2015. METHODS We assessed quality using the Newcastle-Ottawa scale for observational studies, and the Cochrane Collaboration's risk-of-bias tool for trials. RESULTS In observational studies, description of enrollment criteria was high but decreased over time. Adequacy of followup was low but improved. Inception cohorts and community-based studies were uncommon. Trials had low risk of bias in blinding and selective outcome reporting but most had unclear risks in sequence generation and allocation concealment. CONCLUSION Methodological quality was mixed, with limited improvement over time.
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Affiliation(s)
- Maria G Tektonidou
- From the Rheumatology Unit, First Department of Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, Maryland, USA.,M.G. Tektonidou, MD, Assistant Professor of Rheumatology, Head of Rheumatology Unit, First Department of Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens; M.M. Ward, MD, MPH, Senior Investigator, NIAMS, NIH
| | - Michael M Ward
- From the Rheumatology Unit, First Department of Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health (NIH), Bethesda, Maryland, USA. .,M.G. Tektonidou, MD, Assistant Professor of Rheumatology, Head of Rheumatology Unit, First Department of Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens; M.M. Ward, MD, MPH, Senior Investigator, NIAMS, NIH.
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Brockhaus AC, Sauerland S, Saad S. Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease: a systematic review, meta-analysis and assessment of the evidence. BMC Surg 2016; 16:71. [PMID: 27756272 PMCID: PMC5070079 DOI: 10.1186/s12893-016-0187-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/12/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Single-incision laparoscopic colectomy (SILC) requires only one umbilical port site and (depending on technique) a specimen extraction site. The aim of this study was the assessment of the available evidence for the comparison of SILC to conventional multi-port laparoscopic colectomy (MLC) in adult patients, in whom elective colectomy is indicated because of malignant or benign disease. First, previous meta-analyses on this topic were assessed. Secondly, a systematic review and meta-analysis of randomised controlled trials, was performed. METHODS Electronic literature searches (CENTRAL, MEDLINE and EMBASE; up to March 2016) were performed. Additionally, we searched clinical trials registries and abstracts from surgical society meetings. For meta-analysis, risk ratios (RR) or mean differences (MD) with 95 % confidence intervals were calculated and pooled. The quality of previous meta-analyses was evaluated against established criteria (AMSTAR) and their reported results were investigated for consistency. RESULTS We identified 6 previous meta-analyses of mostly low methodological quality (AMSTAR total score: 2 - 5 out of 11 items). To fill the evidence gaps, all these meta-analyses had included non-randomised studies, but usually without assessing their risk of bias. In our systematic review and meta-analysis of randomised controlled trials exclusively, we included two randomised controlled trials with a total of 82 colorectal cancer patients. There was insufficient evidence to clarify whether SILC leads to less local complications (RR = 0.52, 95 % CI 0.14 - 1.94) or lower mortality (1 death per treatment group). Length of hospital stay was significantly shorter in the SILC group (MD = -1.20 days, 95 % CI -1.95 to -0.44). One of the two studies found postoperative pain intensity to be lower at the first day. We also identified 7 ongoing trials with a total sample size of over 1000 patients. CONCLUSION The currently available study results are too sparse to detect (or rule out) relevant differences between SILC and MLC. The quality of the current evidence is low, and the additional analysis of non-randomised data attempts, but does not solve this problem. SILC should still be considered as an experimental procedure, since the evidence of well-designed randomised controlled trials is too sparse to allow any recommendation.
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Affiliation(s)
- Anne Catharina Brockhaus
- Department of Medical Biometry, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany. .,Institute for Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
| | - Stefan Sauerland
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Stefan Saad
- Department of General, Abdominal, Vascular and Thoracic Surgery, Academic Hospital University Cologne, Cologne, Germany
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Paludan-Müller A, Teindl Laursen DR, Hróbjartsson A. Mechanisms and direction of allocation bias in randomised clinical trials. BMC Med Res Methodol 2016; 16:133. [PMID: 27717321 PMCID: PMC5055724 DOI: 10.1186/s12874-016-0235-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/27/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Selective allocation of patients into the compared groups of a randomised trial may cause allocation bias, but the mechanisms behind the bias and its directionality are incompletely understood. We therefore analysed the mechanisms and directionality of allocation bias in randomised clinical trials. METHODS Two systematic reviews and a theoretical analysis. We conducted one systematic review of empirical studies of motives/methods for deciphering patient allocation sequences; and another review of methods publications commenting on allocation bias. We theoretically analysed the mechanisms of allocation bias and hypothesised which main factors predicts its direction. RESULTS Three empirical studies addressed motives/methods for deciphering allocation sequences. Main motives included ensuring best care for patients and ensuring best outcome for the trial. Main methods included various manipulations with randomisation envelopes. Out of 57 methods publications 11 (19 %) mentioned explicitly that allocation bias can go in either direction. We hypothesised that the direction of allocation bias is mainly decided by the interaction between the patient allocators' motives and treatment preference. CONCLUSION Inadequate allocation concealment may exaggerate treatment effects in some trials while underestimate effects in others. Our hypothesis provides a theoretical overview of the main factors responsible for the direction of allocation bias.
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Affiliation(s)
| | | | - Asbjørn Hróbjartsson
- The Nordic Cochrane Centre, Rigshospitalet 7811, Copenhagen, Denmark
- Centre for Evidence-Based Medicine, University of Southern Denmark and Odense University Hospital, Odense, Denmark
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Kalankesh LR, Pourasghar F, Nicholson L, Ahmadi S, Hosseini M. Effect of Telehealth Interventions on Hospitalization Indicators: A Systematic Review. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2016; 13:1h. [PMID: 27843425 PMCID: PMC5075236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Telehealth has been defined as the remote delivery of healthcare services using information and communication technology. Where resource-limited health systems face challenges caused by the increasing burden of chronic diseases and an aging global population, telehealth has been advocated as a solution for changing and improving the paradigm of healthcare delivery to cope with these issues. The aim of this systematic review is to investigate the effect of telehealth interventions on two indicators: hospitalization rate and length of stay. MATERIALS AND METHODS The reviewers searched the PubMed, ScienceDirect, and Springer electronic databases from January 2005 to November 2013. A search strategy was developed using a combination of the following search keywords: impact, effect, telehealth, telemedicine, telecare, hospitalization, length of stay, and resource utilization. Both randomized controlled trials and observational studies were included in the review. To be included in the review, articles had to be written in English. The results of study were compiled, reviewed, and analyzed on the basis of the review aims. RESULTS This systematic review examined 22 existing studies with a total population of 19,086 patients. The effect of telehealth on all-cause hospitalization was statistically significant in 40 percent of the related studies, whereas it was not statistically significant in 60 percent. Similarly, the effect of telehealth on the all-cause length of stay was statistically significant in 36 percent of the studies and nonsignificant in 64 percent. CONCLUSION Considering the fact that hospitalization rate and length of stay can be confounded by factors other than telehealth intervention, studies examining the effect of the intervention on these indicators must take into account all other factors influencing them. Otherwise any judgment on the effect of telehealth on these indicators cannot be valid.
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Affiliation(s)
- Leila R Kalankesh
- Medical informatics and health information technology in School of Management and Medical Informatics and researcher at Tabriz Health Services Management Research Center in Tabriz, Iran
| | - Faramarz Pourasghar
- Medical informatics in School of Management and Medical Informatics at the Tabriz University of Medical Sciences in Tabriz, Iran
| | - Lorraine Nicholson
- IFHIMA (2007-2010), Independent HIM Consultant, Rochdale OL11 2XE, Lancashire, UK
| | - Shamim Ahmadi
- Health information technology at Iran University of Medical Sciences in Tehran, Iran
| | - Mohsen Hosseini
- Health information technology at the School of Management and Medical Informatics at Tabriz University of Medical Sciences in Tabriz, Iran
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Ramasubbu RA, Ramasubbu BM. Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail - which method is optimal? Indian J Orthop 2016; 50:455-463. [PMID: 27746486 PMCID: PMC5017165 DOI: 10.4103/0019-5413.189613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. MATERIALS AND METHODS MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): "open tibia fracture," "fracture fixation," "external fixation," "intramedullary," and "bone nail." Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. RESULTS Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. CONCLUSION There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.
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Affiliation(s)
- Rohan A Ramasubbu
- Department of Clinical Anatomy, School of Medicine, University of St. Andrews, Fife, Scotland,Address for correspondence: Mr. Rohan A Ramasubbu, 13/2 Gilmore Place, Edinburgh, EH3 9NE, Scotland. E-mail:
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Gardner HR, Fraser C, MacLennan G, Treweek S. A protocol for a systematic review of non-randomised evaluations of strategies to improve participant recruitment to randomised controlled trials. Syst Rev 2016; 5:131. [PMID: 27485111 PMCID: PMC4971680 DOI: 10.1186/s13643-016-0308-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 06/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Randomised controlled trials guard against selection bias and therefore offer the fairest way of evaluating healthcare interventions such as medicinal products, devices and services. Recruitment to trials can be extremely difficult, and poor recruitment can lead to extensions to both time and budget and may result in an underpowered study which does not satisfactorily answer the original research question. In the worst cases, a trial may be abandoned, causing huge waste. The evidence to support the choice of recruitment interventions is currently weak. Non-randomised evaluations of recruitment interventions are currently rejected on grounds of poor methodological quality, but systematic evaluation and assessment of this substantial body of work (using Grading of Recommendations Assessment, Development and Evaluation (GRADE) where possible) may provide useful information to support and inform the recruitment decisions of trialists and the research priorities of methodology researchers. METHODS The following databases will be searched for relevant studies: Cochrane Methodology Register, MEDLINE, EMBASE, CINAHL and PsycINFO. Any non-randomised study that includes a comparison of two or more interventions to improve recruitment to randomised controlled trials will be included. We will not apply any restrictions on publication date, language or journal. The primary outcome will be the number of individuals or centres recruited into a randomised controlled trial. The secondary outcome will be cost per recruit. Two reviewers will independently screen abstracts for eligible studies, and then, full texts of potentially relevant records will be reviewed. Disagreements will be resolved through discussion. The methodological quality of studies will be assessed using the Cochrane risk of bias tool for non-randomised studies, and the GRADE system will be used if studies are pooled. DISCUSSION This review aims to summarise the evidence on methods used to improve recruitment to randomised controlled trials. Carrying out a systematic review including only data from non-randomised studies is a novel approach, and one which some may argue is futile. However, we believe that the systematic evaluation of what is likely to be a substantial amount of research activity is necessary, worthwhile, and will yield valuable results for the clinical trials community regardless of whether the outcomes find in favour of one or more interventions. Should the results of this review suggest that non-randomised evaluations do have something to offer trialists planning their recruitment strategies, the review may be combined in the future with the Cochrane review of randomised evaluations to produce a full review of recruitment strategies encompassing both randomised and non-randomised evaluation methods. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016037718.
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Affiliation(s)
- Heidi R Gardner
- Health Services Research Unit, University of Aberdeen, Foresterhill Health Campus, Health Sciences Building, Aberdeen, Scotland, UK.
| | - Cynthia Fraser
- Health Services Research Unit, University of Aberdeen, Foresterhill Health Campus, Health Sciences Building, Aberdeen, Scotland, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Foresterhill Health Campus, Health Sciences Building, Aberdeen, Scotland, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Foresterhill Health Campus, Health Sciences Building, Aberdeen, Scotland, UK
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Madden K, Middleton P, Cyna AM, Matthewson M, Jones L. Hypnosis for pain management during labour and childbirth. Cochrane Database Syst Rev 2016; 2016:CD009356. [PMID: 27192949 PMCID: PMC7120324 DOI: 10.1002/14651858.cd009356.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND This review is one in a series of Cochrane reviews investigating pain management for childbirth. These reviews all contribute to an overview of systematic reviews of pain management for women in labour, and share a generic protocol. This review updates an earlier version of the review of the same title. OBJECTIVES To examine the effectiveness and safety of hypnosis for pain management during labour and childbirth. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and the reference lists of primary studies and review articles. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTS comparing preparation for labour using hypnosis and/or use of hypnosis during labour, with or without concurrent use of pharmacological or non-pharmacological pain relief methods versus placebo, no treatment or any analgesic drug or technique. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. Where possible we contacted study authors seeking additional information about data and methodology. MAIN RESULTS We included nine trials randomising a total of 2954 women. The risk of bias in trials was variable, there were several well-designed large trials and some trials where little was reported about trial design. Although eight of the nine trials assessed antenatal hypnotherapy, there were considerable differences between these trials in timing and technique. One trial provided hypnotherapy during labour. In this updated review we compared hypnosis interventions with all control groups (main comparison) and also with specific control conditions: standard care (nine RCTs), supportive counselling (two RCTs) and relaxation training (two RCTs).In the main comparison, women in the hypnosis group were less likely to use pharmacological pain relief or analgesia than those in the control groups, (average risk ratio (RR) 0.73, 95% CI 0.57 to 0.94, eight studies, 2916 women; very low-quality evidence; random-effects model). There were no clear differences between women in the hypnosis group and those in the control groups for most of the other primary outcomes. There were no clear differences for sense of coping with labour (MD 0.22, 95% CI -0.14 to 0.58, one study, 420 women; low-quality evidence) or spontaneous vaginal birth (average RR 1.12, 95% CI 0.96 to 1.32, six studies, 2361 women; low-quality evidence; random-effects model). There were no clear differences for satisfaction with pain relief (measured on a seven-point scale two weeks postnatally) for women in the hypnosis group who also received pethidine (MD 0.41, 95% CI -0.45 to 1.27; one study, 72 women), Entonox (MD 0.19, 95% CI -0.19 to 0.57; one study, 357 women), self-hypnosis (MD 0.28, 95% CI -0.32 to 0.88; one study, 160 women), or epidural (MD -0.03, 95% CI -0.40 to 0.34; one study, 127 women), but a slight benefit in favour of hypnosis was seen for women who received water immersion (MD 0.52, 95% CI 0.04 to 1.00; one study, 174 women (all low-quality evidence). There were no clear differences for satisfaction with pain relief when it was measured as the number of women who reported they had adequate pain relief (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.94 to 1.20, one study, 264 women; low-quality evidence). It should be noted that for pharmacological pain relief and spontaneous vaginal birth, there was evidence of considerable statistical heterogeneity, which could not be fully explained by subgroup analysis.For this review's secondary outcomes, no clear differences were found between women in the hypnosis group and women in the control groups for most outcomes where data were available. There was mixed evidence regarding benefits for women in the hypnosis group compared with all control groups for pain intensity, satisfaction with childbirth experience and postnatal depression. For each of these outcomes, data from more than one trial were available for analysis but could not be combined due to differences in measurement methods. There was evidence that fewer women in the hypnosis group stayed in hospital for more than two days after the birth but this finding was based on one small study (RR 0.11, 95% CI 0.02 to 0.83). No clear differences between women in the hypnosis group and the control groups were found for the other secondary outcomes where data were available.In the comparisons of hypnosis with specific types of control conditions: standard care, supportive counselling and relaxation training, there were no clear differences found between women in the hypnosis group and those in the standard care control groups or the relaxation control groups for the primary outcomes. Compared with the women in the supportive counselling control group, women in the hypnosis group were less likely to use pharmacological analgesia (average RR 0.48, 95% CI 0.32 to 0.73, two studies, 562 women). They were also more likely to have a spontaneous vaginal birth (RR 2.42, 95% CI 1.43 to 4.07), although this finding was based on the results of one small study. Overall these new comparisons displayed much less statistical heterogeneity than the comparison including all control groups. AUTHORS' CONCLUSIONS There are still only a relatively small number of studies assessing the use of hypnosis for labour and childbirth. Hypnosis may reduce the overall use of analgesia during labour, but not epidural use. No clear differences were found between women in the hypnosis group and those in the control groups for satisfaction with pain relief, sense of coping with labour or spontaneous vaginal birth. Not enough evidence currently exists regarding satisfaction with pain relief or sense of coping with labour and we would encourage any future research to prioritise the measurement of these outcomes. The evidence for the main comparison was assessed using GRADE as being of low quality for all the primary outcomes with downgrading decisions due to concerns regarding inconsistency of the evidence, limitations in design and imprecision. Further research is needed in the form of large, well-designed randomised controlled trials to assess whether hypnosis is of value for pain management during labour and childbirth.
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Affiliation(s)
- Kelly Madden
- St Helen's Private Hospital186 Macquarie StreetHobartTasmaniaAustralia7000
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSAAustralia
| | - Allan M Cyna
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Mandy Matthewson
- University of TasmaniaSchool of PsychologyPrivate Bag 30HobartTasmaniaAustralia7001
| | - Leanne Jones
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Galvao TF, Zimmermann IR, da Mota LMH, Silva MT, Pereira MG. Withdrawal of biologic agents in rheumatoid arthritis: a systematic review and meta-analysis. Clin Rheumatol 2016; 35:1659-68. [DOI: 10.1007/s10067-016-3285-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 12/11/2022]
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Abstract
BACKGROUND Various rehabilitation treatments may be offered following carpal tunnel syndrome (CTS) surgery. The effectiveness of these interventions remains unclear. This is the first update of a review first published in 2013. OBJECTIVES To review the effectiveness and safety of rehabilitation interventions following CTS surgery compared with no treatment, placebo, or another intervention. SEARCH METHODS On 29 September 2015, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, AMED, LILACS, and PsycINFO. We also searched PEDro (3 December 2015) and clinical trials registers (3 December 2015). SELECTION CRITERIA Randomised or quasi-randomised clinical trials that compared any postoperative rehabilitation intervention with either no intervention, placebo, or another postoperative rehabilitation intervention in individuals who had undergone CTS surgery. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias, and assessed the quality of the body of evidence for primary outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach according to standard Cochrane methodology. MAIN RESULTS In this review we included 22 trials with a total of 1521 participants. Two of the trials were newly identified at this update. We studied different rehabilitation treatments including immobilisation using a wrist orthosis, dressings, exercise, controlled cold therapy, ice therapy, multi-modal hand rehabilitation, laser therapy, electrical modalities, scar desensitisation, and arnica. Three trials compared a rehabilitation treatment to a placebo, four compared rehabilitation to a no treatment control, three compared rehabilitation to standard care, and 15 compared various rehabilitation treatments to one another.Overall, the included studies were very low in quality. Thirteen trials explicitly reported random sequence generation; of these, five adequately concealed the allocation sequence. Four trials achieved blinding of both participants and outcome assessors. Five were at high risk of bias from incompleteness of outcome data at one or more time intervals, and eight had high risk of selective reporting bias.These trials were heterogeneous in terms of treatments provided, duration of interventions, the nature and timing of outcomes measured, and setting. Therefore, we were not able to pool results across trials.Four trials reported our primary outcome, change in self reported functional ability at three months or more. Of these, three trials provided sufficient outcome data for inclusion in this review. One small high-quality trial studied a desensitisation programme compared with standard treatment and revealed no statistically significant functional benefit based on the Boston Carpal Tunnel Questionnaire (BCTQ) (mean difference (MD) -0.03, 95% confidence interval (CI) -0.39 to 0.33). One low-quality trial assessed participants six months post surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and found no significant difference between a no formal therapy group and a group given a two-week course of multi-modal therapy commenced at five to seven days post surgery (MD 1.00, 95% CI -4.44 to 6.44). One very low-quality quasi-randomised trial found no statistically significant difference in function on the BCTQ at three months post surgery with early immobilisation (plaster wrist orthosis worn until suture removal) compared with a splint and late mobilisation (MD 0.39, 95% CI -0.45 to 1.23).Differences between treatments for secondary outcome measures (change in self reported functional ability measured at less than three months; change in CTS symptoms; change in CTS-related impairment measures; presence of iatrogenic symptoms from surgery; return to work or occupation; and change in neurophysiological parameters) were generally small and not statistically significant. Few studies reported adverse events. AUTHORS' CONCLUSIONS There is limited and, in general, low quality evidence for the benefit of the reviewed interventions. People who have undergone CTS surgery should be informed about the limited evidence of effectiveness of postoperative rehabilitation interventions. Until researchers provide results of more high-quality trials that assess the effectiveness and safety of various rehabilitation treatments, the decision to provide rehabilitation following CTS surgery should be based on the clinician's expertise, the patient's preferences and the context of the rehabilitation environment. It is important for researchers to identify patients who respond to a particular treatment and those who do not, and to undertake high-quality studies that evaluate the severity of iatrogenic symptoms from surgery, measure function and return-to-work rates, and control for confounding variables.
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Affiliation(s)
- Susan Peters
- The University of QueenslandDivision of Occupational Therapy, School of Health and Rehabilitation SciencesBrisbaneAustralia
- Brisbane Hand and Upper Limb Research InstituteLevel 9, 259 Wickham TerraceBrisbaneQueenslandAustraliaQLD 4000
| | - Matthew J Page
- Monash UniversitySchool of Public Health & Preventive MedicineLevel 1, 549 St Kilda RoadMelbourneVictoriaAustralia3004
- University of BristolSchool of Social and Community MedicineCanynge Hall, 39 Whatley RoadBristolUKBS8 2PS
| | - Michel W Coppieters
- Vrije Universiteit AmsterdamMOVE Research Institute Amsterdam, Department of Human Movement Sciences, Faculty of Behavioural and Movement SciencesVan der Boechorststraat 9AmsterdamNetherlands1081BT
- The University of QueenslandDivision of Physiotherapy, School of Health and Rehabilitation SciencesBrisbaneAustralia
| | - Mark Ross
- Brisbane Hand and Upper Limb Research InstituteLevel 9, 259 Wickham TerraceBrisbaneQueenslandAustraliaQLD 4000
- The University of QueenslandDivision of Orthopaedic Surgery, School of MedicineBrisbaneQueenslandAustralia
- Princess Alexandra HospitalOrthopaedic DepartmentWoolloongabbaBrisbaneAustralia
| | - Venerina Johnston
- The University of QueenslandDivision of Physiotherapy, School of Health and Rehabilitation SciencesBrisbaneAustralia
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Ban JW, Emparanza JI, Urreta I, Burls A. Design Characteristics Influence Performance of Clinical Prediction Rules in Validation: A Meta-Epidemiological Study. PLoS One 2016; 11:e0145779. [PMID: 26730980 PMCID: PMC4701404 DOI: 10.1371/journal.pone.0145779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 12/08/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Many new clinical prediction rules are derived and validated. But the design and reporting quality of clinical prediction research has been less than optimal. We aimed to assess whether design characteristics of validation studies were associated with the overestimation of clinical prediction rules' performance. We also aimed to evaluate whether validation studies clearly reported important methodological characteristics. METHODS Electronic databases were searched for systematic reviews of clinical prediction rule studies published between 2006 and 2010. Data were extracted from the eligible validation studies included in the systematic reviews. A meta-analytic meta-epidemiological approach was used to assess the influence of design characteristics on predictive performance. From each validation study, it was assessed whether 7 design and 7 reporting characteristics were properly described. RESULTS A total of 287 validation studies of clinical prediction rule were collected from 15 systematic reviews (31 meta-analyses). Validation studies using case-control design produced a summary diagnostic odds ratio (DOR) 2.2 times (95% CI: 1.2-4.3) larger than validation studies using cohort design and unclear design. When differential verification was used, the summary DOR was overestimated by twofold (95% CI: 1.2 -3.1) compared to complete, partial and unclear verification. The summary RDOR of validation studies with inadequate sample size was 1.9 (95% CI: 1.2 -3.1) compared to studies with adequate sample size. Study site, reliability, and clinical prediction rule was adequately described in 10.1%, 9.4%, and 7.0% of validation studies respectively. CONCLUSION Validation studies with design shortcomings may overestimate the performance of clinical prediction rules. The quality of reporting among studies validating clinical prediction rules needs to be improved.
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Affiliation(s)
- Jong-Wook Ban
- Evidence-Based Health Care Programme, Department of Continuing Education, Kellogg College, University of Oxford, Oxford, United Kingdom
| | - José Ignacio Emparanza
- CASPe, CIBER-ESP, Clinical Epidemiology Unit, Hospital Universitario Donostia, San Sebastian, Spain
| | - Iratxe Urreta
- CASPe, CIBER-ESP, Clinical Epidemiology Unit, Hospital Universitario Donostia, San Sebastian, Spain
| | - Amanda Burls
- School of Health Sciences, City University London, London, United Kingdom
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Seshia SS. A 'reluctant' critical review: 'Manual for evidence-based clinical practice (2015)'. J Eval Clin Pract 2015; 21:995-1005. [PMID: 26726034 DOI: 10.1111/jep.12509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Users' Guides to the Medical Literature Manual has been a major influence on the teaching and practice of health care globally. METHODS The 3rd edition of the multi-authored Manual was reviewed using the principles outlined in Evidence-based Medicine (EBM) texts. One 'clinical scenario' was selected for critical appraisal, as were several chapters; objectivity was enhanced by citing references to support opinions. RESULTS (SUMMARY OF THE APPRAISAL): (1) Strengths: Clinical pearls, too numerous to list. EXAMPLES (i) evidence is never enough to drive clinical decision making; (ii) do not rush to adopt new interventions; and (iii) question efficacy data based only on surrogate markers. (2) Weaknesses: The Manual shares shortcomings of textbooks discussed by Straus et al.: (i) references may not be current, important ones may be excluded and citations may be selective; (ii) often, opinion-based; and (iii) delays between revisions. (3) Notable omissions: Little or no discussion of: (i) important segments of the population: those <18 years of age, >65 years of age and those with multimorbidity; (ii) surgical disciplines; (iii) Greenhalgh et al.'s essay on EBM; (iv) alternate views on the hierarchy of evidence; and (vi) critical thinking. (4) Additional issues: (i) Omission of important references on dabigatran (clinical scenario: chapter 13.1); (ii) authors' advice (Chapter 13.3) to 'bypass the discussion section of published research'; and (iii) the advocacy of pre-appraised sources of evidence and network meta-analysis without warnings about limitations, are critiqued. CONCLUSION The Manual has several clinical pearls but readers should also be aware of shortcomings.
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Affiliation(s)
- Shashi S Seshia
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Carcas AJ, Abad Santos F, Sánchez Perruca L, Dal-Ré R. [Electronic medical record in clinical trials of effectiveness of drugs integrated in clinical practice]. Med Clin (Barc) 2015; 145:452-7. [PMID: 25913907 DOI: 10.1016/j.medcli.2015.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/29/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Antonio J Carcas
- Servicio de Farmacología Clínica, Hospital Universitario La Paz, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | - Francisco Abad Santos
- Servicio de Farmacología Clínica, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IP), Madrid, España
| | - Luis Sánchez Perruca
- Dirección Técnica de Sistemas de Información Sanitaria, Gerencia Adjunta de Planificación y Calidad, Gerencia de Atención Primaria, Consejería de Salud de la Comunidad Autónoma de Madrid, Madrid, España
| | - Rafael Dal-Ré
- Investigación Clínica, Programa BUC (Biociencias UAM+CSIC), Centro de Excelencia Internacional, Universidad Autónoma de Madrid, Madrid, España.
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Kahan BC, Rehal S, Cro S. Risk of selection bias in randomised trials. Trials 2015; 16:405. [PMID: 26357929 PMCID: PMC4566301 DOI: 10.1186/s13063-015-0920-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 08/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Selection bias occurs when recruiters selectively enrol patients into the trial based on what the next treatment allocation is likely to be. This can occur even if appropriate allocation concealment is used if recruiters can guess the next treatment assignment with some degree of accuracy. This typically occurs in unblinded trials when restricted randomisation is implemented to force the number of patients in each arm or within each centre to be the same. Several methods to reduce the risk of selection bias have been suggested; however, it is unclear how often these techniques are used in practice. METHODS We performed a review of published trials which were not blinded to assess whether they utilised methods for reducing the risk of selection bias. We assessed the following techniques: (a) blinding of recruiters; (b) use of simple randomisation; (c) avoidance of stratification by site when restricted randomisation is used; (d) avoidance of permuted blocks if stratification by site is used; and (e) incorporation of prognostic covariates into the randomisation procedure when restricted randomisation is used. We included parallel group, individually randomised phase III trials published in four general medical journals (BMJ, Journal of the American Medical Association, The Lancet, and New England Journal of Medicine) in 2010. RESULTS We identified 152 eligible trials. Most trials (98%) provided no information on whether recruiters were blind to previous treatment allocations. Only 3% of trials used simple randomisation; 63% used some form of restricted randomisation, and 35% did not state the method of randomisation. Overall, 44% of trials were stratified by site of recruitment; 27% were not, and 29% did not report this information. Most trials that did stratify by site of recruitment used permuted blocks (58%), and only 15% reported using random block sizes. Many trials that used restricted randomisation also included prognostic covariates in the randomisation procedure (56%). CONCLUSIONS The risk of selection bias could not be ascertained for most trials due to poor reporting. Many trials which did provide details on the randomisation procedure were at risk of selection bias due to a poorly chosen randomisation methods. Techniques to reduce the risk of selection bias should be more widely implemented.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, E1 2AB, London, UK.
| | - Sunita Rehal
- MRC Clinical Trials Unit at UCL, WC2B 6NH, London, UK.
| | - Suzie Cro
- MRC Clinical Trials Unit at UCL, WC2B 6NH, London, UK.
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Peinemann F, Kleijnen J. Development of an algorithm to provide awareness in choosing study designs for inclusion in systematic reviews of healthcare interventions: a method study. BMJ Open 2015; 5:e007540. [PMID: 26289450 PMCID: PMC4550722 DOI: 10.1136/bmjopen-2014-007540] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 05/25/2015] [Accepted: 06/16/2015] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To develop an algorithm that aims to provide guidance and awareness for choosing multiple study designs in systematic reviews of healthcare interventions. DESIGN Method study: (1) To summarise the literature base on the topic. (2) To apply the integration of various study types in systematic reviews. (3) To devise decision points and outline a pragmatic decision tree. (4) To check the plausibility of the algorithm by backtracking its pathways in four systematic reviews. RESULTS (1) The results of our systematic review of the published literature have already been published. (2) We recaptured the experience from our four previously conducted systematic reviews that required the integration of various study types. (3) We chose length of follow-up (long, short), frequency of events (rare, frequent) and types of outcome as decision points (death, disease, discomfort, disability, dissatisfaction) and aligned the study design labels according to the Cochrane Handbook. We also considered practical or ethical concerns, and the problem of unavailable high-quality evidence. While applying the algorithm, disease-specific circumstances and aims of interventions should be considered. (4) We confirmed the plausibility of the pathways of the algorithm. CONCLUSIONS We propose that the algorithm can assist to bring seminal features of a systematic review with multiple study designs to the attention of anyone who is planning to conduct a systematic review. It aims to increase awareness and we think that it may reduce the time burden on review authors and may contribute to the production of a higher quality review.
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Affiliation(s)
- Frank Peinemann
- Maastricht University, School for Public Health and Primary Care, Maastricht, The Netherlands
- Children's Hospital, University of Cologne, Cologne, Germany
| | - Jos Kleijnen
- Maastricht University, School for Public Health and Primary Care, Maastricht, The Netherlands
- Kleijnen Systematic Reviews Ltd, York, UK
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O'Connor SR, Tully MA, Ryan B, Bradley JM, Baxter GD, McDonough SM. Failure of a numerical quality assessment scale to identify potential risk of bias in a systematic review: a comparison study. BMC Res Notes 2015; 8:224. [PMID: 26048813 PMCID: PMC4467625 DOI: 10.1186/s13104-015-1181-1] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 05/20/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Assessing methodological quality of primary studies is an essential component of systematic reviews. Following a systematic review which used a domain based system [United States Preventative Services Task Force (USPSTF)] to assess methodological quality, a commonly used numerical rating scale (Downs and Black) was also used to evaluate the included studies and comparisons were made between quality ratings assigned using the two different methods. Both tools were used to assess the 20 randomized and quasi-randomized controlled trials examining an exercise intervention for chronic musculoskeletal pain which were included in the review. Inter-rater reliability and levels of agreement were determined using intraclass correlation coefficients (ICC). Influence of quality on pooled effect size was examined by calculating the between group standardized mean difference (SMD). RESULTS Inter-rater reliability indicated at least substantial levels of agreement for the USPSTF system (ICC 0.85; 95% CI 0.66, 0.94) and Downs and Black scale (ICC 0.94; 95% CI 0.84, 0.97). Overall level of agreement between tools (ICC 0.80; 95% CI 0.57, 0.92) was also good. However, the USPSTF system identified a number of studies (n = 3/20) as "poor" due to potential risks of bias. Analysis revealed substantially greater pooled effect sizes in these studies (SMD -2.51; 95% CI -4.21, -0.82) compared to those rated as "fair" (SMD -0.45; 95% CI -0.65, -0.25) or "good" (SMD -0.38; 95% CI -0.69, -0.08). CONCLUSIONS In this example, use of a numerical rating scale failed to identify studies at increased risk of bias, and could have potentially led to imprecise estimates of treatment effect. Although based on a small number of included studies within an existing systematic review, we found the domain based system provided a more structured framework by which qualitative decisions concerning overall quality could be made, and was useful for detecting potential sources of bias in the available evidence.
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Affiliation(s)
- Seán R O'Connor
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Belfast, UK.
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, School of Health Sciences, University of Ulster, Belfast, UK.
| | - Mark A Tully
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Belfast, UK.
| | - Brigid Ryan
- Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand.
| | - Judy M Bradley
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, School of Health Sciences, University of Ulster, Belfast, UK.
| | - George D Baxter
- Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand.
| | - Suzanne M McDonough
- UKCRC Centre of Excellence for Public Health (Northern Ireland), Belfast, UK.
- Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health Research, School of Health Sciences, University of Ulster, Belfast, UK.
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Al Halabi S, Qintar M, Hussein A, Alraies MC, Jones DG, Wong T, MacDonald MR, Petrie MC, Cantillon D, Tarakji KG, Kanj M, Bhargava M, Varma N, Baranowski B, Wilkoff BL, Wazni O, Callahan T, Saliba W, Chung MK. Catheter Ablation for Atrial Fibrillation in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials. JACC Clin Electrophysiol 2015; 1:200-209. [PMID: 26258174 DOI: 10.1016/j.jacep.2015.02.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rhythm control with antiarrhythmic drugs (AADs) is not superior to rate control in patients with heart failure (HF) and atrial fibrillation (AF), but AF ablation may be more successful at achieving rhythm control than AADs. However, risks for both ablation and AADs are likely higher and success rates lower in patients with HF. OBJECTIVE To compare rate control versus AF catheter ablation strategies in patients with AF and HF. METHODS We conducted a meta-analysis of trials which randomized HF patients (LVEF<50%) with AF to a rate control or AF catheter ablation strategy and reported change in LVEF, quality of life, 6-minute walk test, or peak oxygen consumption. Study quality and heterogenity were assessed using Jadad scores and Cochran's Q statistics, respectively. Mantel Haenszel relative risks and mean differences were calculated using random effect models. RESULTS Four trials (N=224) met inclusion criteria; 82.5% (n=185) had persistent AF. AF ablation was associated with an increase in LVEF (mean difference 8.5%; 95%CI 6.4,10.7%; P<0.001) compared to rate control. AF ablation was superior in improving quality of life by Minnesota Living with Heart Failure (MLWHF) questionnaire scores (mean difference -11.9; 95%CI -17.1, -6.6; P<0.001). Peak oxygen consumption and 6-minute walk distance increased in AF ablation compared to rate control patients (mean difference 3.2; 95%CI 1.1,5.2; P=0.003; mean difference 34.8; 95%CI 2.9, 66.7; P = 0.03, respectively). In the persistent AF subgroup LVEF and MLWHF were significantly improved with AF ablation. Major adverse event rates (RR 1.3; 95% CI, 0.4, 3.9; p=0.64) were not significantly different. No significant heterogeneity was evident. CONCLUSIONS In patients with HF and AF, AF catheter ablation is superior to rate control in improving LVEF, quality of life and functional capacity. Prior to accepting a rate control strategy in HF patients with persistent or drug refractory AF, consideration should be given to AF ablation.
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Affiliation(s)
- Shadi Al Halabi
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Mohammed Qintar
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Ayman Hussein
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - M Chadi Alraies
- The Department of Cardiology, University of Minnesota, Minneapolis, MN
| | - David G Jones
- Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Tom Wong
- Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Mark C Petrie
- Golden Jubilee National Hospital, Glasgow, Scotland, United Kingdom
| | - Daniel Cantillon
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Khaldoun G Tarakji
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Mohamed Kanj
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Mandeep Bhargava
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Niraj Varma
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Bryan Baranowski
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Bruce L Wilkoff
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Oussama Wazni
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Thomas Callahan
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Walid Saliba
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Mina K Chung
- The Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH
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Hubbard G, Campbell A, Davies Z, Munro J, Ireland AV, Leslie S, Watson AJ, Treweek S. Experiences of recruiting to a pilot trial of Cardiac Rehabilitation In patients with Bowel cancer (CRIB) with an embedded process evaluation: lessons learned to improve recruitment. Pilot Feasibility Stud 2015; 1:15. [PMID: 27965794 PMCID: PMC5154094 DOI: 10.1186/s40814-015-0009-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/24/2015] [Indexed: 11/10/2022] Open
Abstract
Background Recruitment to randomised controlled trials (RCTs) is a perennial problem. Calls have been made for trialists to make recruitment performance publicly available. This article presents our experience of recruiting to a pilot RCT of cardiac rehabilitation for patients with bowel cancer with an embedded process evaluation. Methods Recruitment took place at three UK hospitals. Recruitment figures were based on the following: i) estimated number of patient admissions, ii) number of patients likely to meet inclusion criteria from clinician input and iii) recruitment rates in previous studies. The following recruitment procedure was used:Nurse assessed patients for eligibility. Patients signed a screening form indicating interest in and agreement to be approached by a researcher about the study. An appointment was made at which the patient signed a consent form and was randomised to the intervention or control group.
Information about all patients considered for the study and subsequently included or excluded at each stage of the recruitment process and reasons given were recorded. Results There were variations in the time taken to award Research Management approval to run the study at the three sites (45–359 days). Sixty-two percent of the original recruitment estimate was reached. The main reason for under-recruitment was due to over-estimation of the number of patient admissions; other reasons were i) not assessing all patients for eligibility, ii) not completing a screening form for eligible patients and iii) patients who signed a screening form being lost to the study before consenting and randomisation. Conclusions Pilot trials should not simply aim to improve recruitment estimates but should also identify factors likely to influence recruitment performance in a future trial and inform the development of that trial’s recruitment strategies. Pilot trials are a crucial part of RCT design. Nevertheless, pilot trials are likely to be small scale, involving only a small number of sites, and contextual differences between sites are likely to impact recruitment performance in any future trial. This means that ongoing monitoring and evaluation in trials are likely to be required. Trial registration ISRCTN63510637; UKCRN id 14092.
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Affiliation(s)
- Gill Hubbard
- Cancer Care Research Centre, School of Health Sciences, University of Stirling, Highland Campus, Old Perth Road, Inverness, IV2 3JH UK
| | - Anna Campbell
- Faculty of Life Science, Sport and Social Sciences, Edinburgh Napier University, Sighthill Campus, Edinburgh, EH11 4BN UK
| | - Zoe Davies
- Cancer Trials Unit, Tower Block 2, Room 20, UHW, Heath Park, Cardiff, CF14 4XW UK
| | - Julie Munro
- Cancer Care Research Centre, School of Health Sciences, University of Stirling, Highland Campus, Old Perth Road, Inverness, IV2 3JH UK
| | - Aileen V Ireland
- Cancer Care Research Centre, School of Health Sciences, University of Stirling, Stirling, FK9 4LA UK
| | - Stephen Leslie
- Cardiac Unit, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ UK
| | - Angus Jm Watson
- NHS Highland, Inverness, IV2 3BW UK ; Colorectal Surgery, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
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Abstract
BACKGROUND Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Clot prevention with anticoagulants might improve outcomes if bleeding risks are low. This is an update of a Cochrane review first published in 1995, with recent updates in 2004 and 2008. OBJECTIVES To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) in people with acute presumed or confirmed ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA) (The Cochrane Library 2014 Issue 6), MEDLINE (2008 to June 2014) and EMBASE (2008 to June 2014). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies. SELECTION CRITERIA Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data. MAIN RESULTS We included 24 trials involving 23,748 participants. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence relates to the effects of anticoagulant therapy initiated within the first 48 hours of onset. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow-up. Similarly, based on eight trials (22,125 participants), there was no evidence that early anticoagulation reduced the odds of being dead or dependent at the end of follow-up (OR 0.99; 95% CI 0.93 to 1.04). Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99). AUTHORS' CONCLUSIONS Since the last version of the review, no new relevant studies have been published and so there is no additional information to change the conclusions. Early anticoagulant therapy is not associated with net short- or long-term benefit in people with acute ischaemic stroke. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any of the currently available anticoagulants in acute ischaemic stroke.
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Affiliation(s)
- Peter AG Sandercock
- University of EdinburghCentre for Clinical Brain Sciences (CCBS)The Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Carl Counsell
- University of AberdeenDivision of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
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85
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Fretheim A, Zhang F, Ross-Degnan D, Oxman AD, Cheyne H, Foy R, Goodacre S, Herrin J, Kerse N, McKinlay RJ, Wright A, Soumerai SB. A reanalysis of cluster randomized trials showed interrupted time-series studies were valuable in health system evaluation. J Clin Epidemiol 2015; 68:324-33. [DOI: 10.1016/j.jclinepi.2014.10.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 10/10/2014] [Accepted: 10/17/2014] [Indexed: 10/24/2022]
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Howick J, Mebius A. In search of justification for the unpredictability paradox. Trials 2014; 15:480. [PMID: 25490908 PMCID: PMC4295227 DOI: 10.1186/1745-6215-15-480] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 11/24/2014] [Indexed: 11/21/2022] Open
Abstract
A 2011 Cochrane Review found that adequately randomized trials sometimes revealed larger, sometimes smaller, and often similar effect sizes to inadequately randomized trials. However, they found no average statistically significant difference in effect sizes between the two study types. Yet instead of concluding that adequate randomization had no effect the review authors postulated the “unpredictability paradox”, which states that randomized and non-randomized studies differ, but in an unpredictable direction. However, stipulating the unpredictability paradox is problematic for several reasons: 1) it makes the authors’ conclusion that adequate randomization makes a difference unfalsifiable—if it turned out that adequately randomized trials had significantly different average results from inadequately randomized trials the authors could have pooled the results and concluded that adequate randomization protected against bias; 2) it leaves other authors of reviews with similar results confused about whether or not to pool results (and hence which conclusions to draw); 3) it discourages researchers from investigating the conditions under which adequate randomization over- or under-exaggerates apparent treatment benefits; and 4) it could obscure the relative importance of allocation concealment and blinding which may be more important than adequate randomization.
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Affiliation(s)
- Jeremy Howick
- Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, 2nd floor, Oxford OX2 6NW, UK.
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87
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Martin A, Ogilvie D, Suhrcke M. Evaluating causal relationships between urban built environment characteristics and obesity: a methodological review of observational studies. Int J Behav Nutr Phys Act 2014; 11:142. [PMID: 25406733 PMCID: PMC4253618 DOI: 10.1186/s12966-014-0142-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 11/04/2014] [Indexed: 01/11/2023] Open
Abstract
Background Existing reviews identify numerous studies of the relationship between urban built environment characteristics and obesity. These reviews do not generally distinguish between cross-sectional observational studies using single equation analytical techniques and other studies that may support more robust causal inferences. More advanced analytical techniques, including the use of instrumental variables and regression discontinuity designs, can help mitigate biases that arise from differences in observable and unobservable characteristics between intervention and control groups, and may represent a realistic alternative to scarcely-used randomised experiments. This review sought first to identify, and second to compare the results of analyses from, studies using more advanced analytical techniques or study designs. Methods In March 2013, studies of the relationship between urban built environment characteristics and obesity were identified that incorporated (i) more advanced analytical techniques specified in recent UK Medical Research Council guidance on evaluating natural experiments, or (ii) other relevant methodological approaches including randomised experiments, structural equation modelling or fixed effects panel data analysis. Results Two randomised experimental studies and twelve observational studies were identified. Within-study comparisons of results, where authors had undertaken at least two analyses using different techniques, indicated that effect sizes were often critically affected by the method employed, and did not support the commonly held view that cross-sectional, single equation analyses systematically overestimate the strength of association. Conclusions Overall, the use of more advanced methods of analysis does not appear necessarily to undermine the observed strength of association between urban built environment characteristics and obesity when compared to more commonly-used cross-sectional, single equation analyses. Given observed differences in the results of studies using different techniques, further consideration should be given to how evidence gathered from studies using different analytical approaches is appraised, compared and aggregated in evidence synthesis.
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Affiliation(s)
- Adam Martin
- Health Economics Group and UKCRC Centre for Diet and Activity Research (CEDAR), Norwich Medical School, University of East Anglia, Norwich, UK.
| | - David Ogilvie
- MRC Epidemiology Unit and UKCRC Centre for Diet and Activity Research (CEDAR), University of Cambridge, Cambridge, UK.
| | - Marc Suhrcke
- Health Economics Group and UKCRC Centre for Diet and Activity Research (CEDAR), Norwich Medical School, University of East Anglia, Norwich, UK. .,Centre for Health Economics, University of York, York, UK.
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Madan A, Tracy S, Reid R, Henry A. Recruitment difficulties in obstetric trials: a case study and review. Aust N Z J Obstet Gynaecol 2014; 54:546-52. [PMID: 25350684 DOI: 10.1111/ajo.12233] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/29/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND The CONSORT statement calls for complete data on flow of participants, including all losses and exclusions. Incomplete reporting of flow into trials versus flow through trials is not uncommon. Where complete data exist in obstetric trials, poor recruitment seems a recurring theme. AIMS To explore difficulties in recruitment and differences between assessed-but-not-recruited and included women to improve future trial participation, using a case study of a recently published randomised trial of outpatient Foley catheter versus inpatient PGE2 gel for cervical ripening. MATERIALS & METHODS The assessed-but-not-recruited population of an obstetric trial (ACTRN:12609000420246) was prospectively studied for reasons for noninclusion, demographic data and pregnancy outcome. Women assessed-but-not-recruited due to declined consent or obstetrician declined participation were compared to included women. Main outcome measures included demographic and outcome differences associated with trial participation. RESULTS Of 468 assessed participants, 220 (47%) were not eligible by exclusion criteria (potential 'trial factor' recruitment difficulties), 147 (31%) declined consent (n = 100, 'participant factor') or their obstetrician declined participation (n = 47, 'clinician factor') and 101 (22%) were included. Declining women were more likely than participants to be parous (24 vs 10%, P < 0.05), induced for nonmedical reasons (18 vs 4%, P < 0.001), privately admitted (31 vs 3%, P < 0.001) and have longer inpatient stay (4.9 vs 4.2 days, P < 0.05). CONCLUSION The high assessed-but-not-recruited rate highlights important issues with external validity and feasibility when conducting obstetric trials, including recruitment difficulties related to participant, clinician and trial factors. Assessed: recruited ratios and demographic and outcome differences need consideration in planning and interpretation of randomised trials.
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Affiliation(s)
- Arushi Madan
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Randwick, New South Wales, Australia
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89
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Mickenautsch S, Fu B, Gudehithlu S, Berger VW. Accuracy of the Berger-Exner test for detecting third-order selection bias in randomised controlled trials: a simulation-based investigation. BMC Med Res Methodol 2014; 14:114. [PMID: 25283963 PMCID: PMC4209086 DOI: 10.1186/1471-2288-14-114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 09/23/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCT) are highly influential upon medical decisions. Thus RCTs must not distort the truth. One threat to internal trial validity is the correct prediction of future allocations (selection bias). The Berger-Exner test detects such bias but has not been widely utilized in practice. One reason for this non-utilisation may be a lack of information regarding its test accuracy. The objective of this study is to assess the accuracy of the Berger-Exner test on the basis of relevant simulations for RCTs with dichotomous outcomes. METHODS Simulated RCTs with various parameter settings were generated, using R software, and subjected to bias-free and selection bias scenarios. The effect size inflation due to bias was quantified. The test was applied in both scenarios and the pooled sensitivity and specificity, with 95% confidence intervals for alpha levels of 1%, 5%, and 20%, were computed. Summary ROC curves were generated and the relationships of parameters with test accuracy were explored. RESULTS An effect size inflation of 71% - 99% was established. Test sensitivity was 1.00 (95% CI: 0.99 - 1.00) for alpha level 1%, 5%, and 20%; test specificity was 0.94 (95% CI: 0.93 - 0.96); 0.82 (95% CI: 0.80 - 0.84), and 0.56 (95% CI: 0.54 - 0.58) for alpha 1%, 5%, and 20%, respectively. Test accuracy was best with the maximal procedure used with a maximum tolerated imbalance (MTI) = 2 as the randomisation method at alpha 1%. CONCLUSIONS The results of this simulation study suggest that the Berger-Exner test is generally accurate for identifying third-order selection bias.
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Affiliation(s)
- Steffen Mickenautsch
- />SYSTEM Initiative/Department of Community Dentistry, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd., Parktown, Johannesburg, 2193 South Africa
| | - Bo Fu
- />Department of Biostatistics, GSPH, University of Pittsburgh, Pittsburgh, PA USA
| | - Sheila Gudehithlu
- />National Cancer Institute, National Institute of Health, Rockville, MD USA
- />Department of Statistics, University of Illinois at Urbana-Champaign, Champaign, IL USA
| | - Vance W Berger
- />National Cancer Institute, National Institute of Health, Rockville, MD USA
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90
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Donald F, Kilpatrick K, Reid K, Carter N, Martin-Misener R, Bryant-Lukosius D, Harbman P, Kaasalainen S, Marshall DA, Charbonneau-Smith R, Donald EE, Lloyd M, Wickson-Griffiths A, Yost J, Baxter P, Sangster-Gormley E, Hubley P, Laflamme C, Campbell–Yeo M, Price S, Boyko J, DiCenso A. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract 2014; 2014:896587. [PMID: 25258683 PMCID: PMC4167459 DOI: 10.1155/2014/896587] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 12/25/2022] Open
Abstract
Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal and Research Centre of Hôpital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121, 5415 boulevard l'Assomption, Montréal, QC, Canada H1T 2M4
| | - Kim Reid
- KJ Research, Rosemere, QC, Canada J7A 4N8
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8
| | - Patricia Harbman
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Deborah A. Marshall
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6
| | | | - Erin E. Donald
- Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1
| | - Monique Lloyd
- International Affairs and Best Practice Guidelines Centre, Registered Nurses' Association of Ontario, 158 Pearl Street, Toronto, ON, Canada M5H 1L3
| | | | - Jennifer Yost
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Pamela Baxter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Esther Sangster-Gormley
- School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2
| | - Pamela Hubley
- The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue, Toronto, ON, Canada M5G 1X8
| | - Célyne Laflamme
- Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent, Suite 101, Ottawa, ON, Canada K1G 5Z3
| | - Marsha Campbell–Yeo
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Sheri Price
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Jennifer Boyko
- School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9
| | - Alba DiCenso
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
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The need for randomization in animal trials: an overview of systematic reviews. PLoS One 2014; 9:e98856. [PMID: 24906117 PMCID: PMC4048216 DOI: 10.1371/journal.pone.0098856] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/07/2014] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives Randomization, allocation concealment, and blind outcome assessment have been shown to reduce bias in human studies. Authors from the Collaborative Approach to Meta Analysis and Review of Animal Data from Experimental Studies (CAMARADES) collaboration recently found that these features protect against bias in animal stroke studies. We extended the scope the work from CAMARADES to include investigations of treatments for any condition. Methods We conducted an overview of systematic reviews. We searched Medline and Embase for systematic reviews of animal studies testing any intervention (against any control) and we included any disease area and outcome. We included reviews comparing randomized versus not randomized (but otherwise controlled), concealed versus unconcealed treatment allocation, or blinded versus unblinded outcome assessment. Results Thirty-one systematic reviews met our inclusion criteria: 20 investigated treatments for experimental stroke, 4 reviews investigated treatments for spinal cord diseases, while 1 review each investigated treatments for bone cancer, intracerebral hemorrhage, glioma, multiple sclerosis, Parkinson's disease, and treatments used in emergency medicine. In our sample 29% of studies reported randomization, 15% of studies reported allocation concealment, and 35% of studies reported blinded outcome assessment. We pooled the results in a meta-analysis, and in our primary analysis found that failure to randomize significantly increased effect sizes, whereas allocation concealment and blinding did not. In our secondary analyses we found that randomization, allocation concealment, and blinding reduced effect sizes, especially where outcomes were subjective. Conclusions Our study demonstrates the need for randomization, allocation concealment, and blind outcome assessment in animal research across a wide range of outcomes and disease areas. Since human studies are often justified based on results from animal studies, our results suggest that unduly biased animal studies should not be allowed to constitute part of the rationale for human trials.
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Ankarfeldt MZ. Comment on "Limitations of observational evidence: implications for evidence-based dietary recommendations". Adv Nutr 2014; 5:293. [PMID: 24829477 PMCID: PMC4013183 DOI: 10.3945/an.114.005777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mikkel Zöllner Ankarfeldt
- Institute of Preventive Medicine, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark; andFaculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Anglemyer A, Horvath HT, Bero L. Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev 2014; 2014:MR000034. [PMID: 24782322 PMCID: PMC8191367 DOI: 10.1002/14651858.mr000034.pub2] [Citation(s) in RCA: 229] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Researchers and organizations often use evidence from randomized controlled trials (RCTs) to determine the efficacy of a treatment or intervention under ideal conditions. Studies of observational designs are often used to measure the effectiveness of an intervention in 'real world' scenarios. Numerous study designs and modifications of existing designs, including both randomized and observational, are used for comparative effectiveness research in an attempt to give an unbiased estimate of whether one treatment is more effective or safer than another for a particular population.A systematic analysis of study design features, risk of bias, parameter interpretation, and effect size for all types of randomized and non-experimental observational studies is needed to identify specific differences in design types and potential biases. This review summarizes the results of methodological reviews that compare the outcomes of observational studies with randomized trials addressing the same question, as well as methodological reviews that compare the outcomes of different types of observational studies. OBJECTIVES To assess the impact of study design (including RCTs versus observational study designs) on the effect measures estimated.To explore methodological variables that might explain any differences identified.To identify gaps in the existing research comparing study designs. SEARCH METHODS We searched seven electronic databases, from January 1990 to December 2013.Along with MeSH terms and relevant keywords, we used the sensitivity-specificity balanced version of a validated strategy to identify reviews in PubMed, augmented with one term ("review" in article titles) so that it better targeted narrative reviews. No language restrictions were applied. SELECTION CRITERIA We examined systematic reviews that were designed as methodological reviews to compare quantitative effect size estimates measuring efficacy or effectiveness of interventions tested in trials with those tested in observational studies. Comparisons included RCTs versus observational studies (including retrospective cohorts, prospective cohorts, case-control designs, and cross-sectional designs). Reviews were not eligible if they compared randomized trials with other studies that had used some form of concurrent allocation. DATA COLLECTION AND ANALYSIS In general, outcome measures included relative risks or rate ratios (RR), odds ratios (OR), hazard ratios (HR). Using results from observational studies as the reference group, we examined the published estimates to see whether there was a relative larger or smaller effect in the ratio of odds ratios (ROR).Within each identified review, if an estimate comparing results from observational studies with RCTs was not provided, we pooled the estimates for observational studies and RCTs. Then, we estimated the ratio of ratios (risk ratio or odds ratio) for each identified review using observational studies as the reference category. Across all reviews, we synthesized these ratios to get a pooled ROR comparing results from RCTs with results from observational studies. MAIN RESULTS Our initial search yielded 4406 unique references. Fifteen reviews met our inclusion criteria; 14 of which were included in the quantitative analysis.The included reviews analyzed data from 1583 meta-analyses that covered 228 different medical conditions. The mean number of included studies per paper was 178 (range 19 to 530).Eleven (73%) reviews had low risk of bias for explicit criteria for study selection, nine (60%) were low risk of bias for investigators' agreement for study selection, five (33%) included a complete sample of studies, seven (47%) assessed the risk of bias of their included studies,Seven (47%) reviews controlled for methodological differences between studies,Eight (53%) reviews controlled for heterogeneity among studies, nine (60%) analyzed similar outcome measures, and four (27%) were judged to be at low risk of reporting bias.Our primary quantitative analysis, including 14 reviews, showed that the pooled ROR comparing effects from RCTs with effects from observational studies was 1.08 (95% confidence interval (CI) 0.96 to 1.22). Of 14 reviews included in this analysis, 11 (79%) found no significant difference between observational studies and RCTs. One review suggested observational studies had larger effects of interest, and two reviews suggested observational studies had smaller effects of interest.Similar to the effect across all included reviews, effects from reviews comparing RCTs with cohort studies had a pooled ROR of 1.04 (95% CI 0.89 to 1.21), with substantial heterogeneity (I(2) = 68%). Three reviews compared effects of RCTs and case-control designs (pooled ROR: 1.11 (95% CI 0.91 to 1.35)).No significant difference in point estimates across heterogeneity, pharmacological intervention, or propensity score adjustment subgroups were noted. No reviews had compared RCTs with observational studies that used two of the most common causal inference methods, instrumental variables and marginal structural models. AUTHORS' CONCLUSIONS Our results across all reviews (pooled ROR 1.08) are very similar to results reported by similarly conducted reviews. As such, we have reached similar conclusions; on average, there is little evidence for significant effect estimate differences between observational studies and RCTs, regardless of specific observational study design, heterogeneity, or inclusion of studies of pharmacological interventions. Factors other than study design per se need to be considered when exploring reasons for a lack of agreement between results of RCTs and observational studies. Our results underscore that it is important for review authors to consider not only study design, but the level of heterogeneity in meta-analyses of RCTs or observational studies. A better understanding of how these factors influence study effects might yield estimates reflective of true effectiveness.
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Affiliation(s)
- Andrew Anglemyer
- University of California, San FranciscoGlobal Health SciencesSan FranciscoCaliforniaUSA94105
| | - Hacsi T Horvath
- University of California, San FranciscoGlobal Health SciencesSan FranciscoCaliforniaUSA94105
| | - Lisa Bero
- University of California San FranciscoDepartment of Clinical Pharmacy and Institute for Health Policy StudiesSuite 420, Box 06133333 California StreetSan FranciscoCaliforniaUSA94143‐0613
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Clark CE, Horvath IA, Taylor RS, Campbell JL. Doctors record higher blood pressures than nurses: systematic review and meta-analysis. Br J Gen Pract 2014; 64:e223-32. [PMID: 24686887 PMCID: PMC3964448 DOI: 10.3399/bjgp14x677851] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/11/2013] [Accepted: 12/20/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The magnitude of the 'white coat effect', the alerting rise in blood pressure, is greater for doctors than nurses. This could bias interpretation of studies on nurse-led care in hypertension, and risks overestimating or overtreating high blood pressure by doctors in clinical practice. AIM To quantify differences between blood pressure measurements made by doctors and nurses. DESIGN AND SETTING Systematic review and meta-analysis using searches of MEDLINE, CENTRAL, CINAHL, Embase, journal collections, and conference abstracts. METHOD Studies in adults reporting mean blood pressures measured by doctors and nurses at the same visit were selected, and mean blood pressures extracted, by two reviewers. Study risk of bias was assessed using modified Cochrane criteria. Outcomes were pooled across studies using random effects meta-analysis. RESULTS In total, 15 studies (11 hypertensive; four mixed hypertensive and normotensive populations) were included from 1899 unique citations. Compared with doctors' measurements, nurse-measured blood pressures were lower (weighted mean differences: systolic -7.0 [95% confidence interval {CI} = -4.7 to -9.2] mmHg, diastolic -3.8 [95% CI = -2.2 to -5.4] mmHg). For studies at low risk of bias, differences were lower: systolic -4.6 (95% CI = -1.9 to -7.3) mmHg; diastolic -1.7 (95% CI = -0.1 to -3.2) mmHg. White coat hypertension was diagnosed more frequently based on doctors' than on nurses' readings: relative risk 1.6 (95% CI =1.2 to 2.1). CONCLUSIONS The white coat effect is smaller for blood pressure measurements made by nurses than by doctors. This systematic difference has implications for hypertension diagnosis and management. Caution is required in pooling data from studies using both nurse- and doctor-measured blood pressures.
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Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, UK
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Abstract
BACKGROUND In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES To assess the efficacy and safety of immediate oral antiplatelet therapy (that is started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 16 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2013), MEDLINE (June 1998 to May 2013), and EMBASE (June 1998 to May 2013). In 1998, for a previous version of this review, we searched the register of the Antiplatelet Trialists' Collaboration, MedStrategy and contacted relevant drug companies. SELECTION CRITERIA Randomised trials comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. MAIN RESULTS We included eight trials involving 41,483 participants. No new trials have been added since the last update.Two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 98% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a significant decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat 79). Antiplatelet therapy was associated with a small but definite excess of symptomatic intracranial haemorrhages, but this small hazard was significantly outnumbered by the benefit, the reduction in recurrent ischaemic stroke and pulmonary embolus. AUTHORS' CONCLUSIONS Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.
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Affiliation(s)
- Peter AG Sandercock
- University of EdinburghCentre for Clinical Brain Sciences (CCBS)The Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Carl Counsell
- University of AberdeenDivision of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Mei‐Chiun Tseng
- National Sun Yat‐Sen UniversityDepartment of Business Management70 Lien‐Hai RoadKaohsiung, TaiwanChina804
| | - Emanuela Cecconi
- University of EdinburghDivision of Clinical NeurosciencesWestern General HospitalCrewe RoadEdinburghUKEH4 2XU
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Peinemann F, Tushabe DA, Kleijnen J. Using multiple types of studies in systematic reviews of health care interventions--a systematic review. PLoS One 2013; 8:e85035. [PMID: 24416098 PMCID: PMC3887134 DOI: 10.1371/journal.pone.0085035] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/23/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A systematic review may evaluate different aspects of a health care intervention. To accommodate the evaluation of various research questions, the inclusion of more than one study design may be necessary. One aim of this study is to find and describe articles on methodological issues concerning the incorporation of multiple types of study designs in systematic reviews on health care interventions. Another aim is to evaluate methods studies that have assessed whether reported effects differ by study types. METHODS AND FINDINGS We searched PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Methodology Register on 31 March 2012 and identified 42 articles that reported on the integration of single or multiple study designs in systematic reviews. We summarized the contents of the articles qualitatively and assessed theoretical and empirical evidence. We found that many examples of reviews incorporating multiple types of studies exist and that every study design can serve a specific purpose. The clinical questions of a systematic review determine the types of design that are necessary or sufficient to provide the best possible answers. In a second independent search, we identified 49 studies, 31 systematic reviews and 18 trials that compared the effect sizes between randomized and nonrandomized controlled trials, which were statistically different in 35%, and not different in 53%. Twelve percent of studies reported both, different and non-different effect sizes. CONCLUSIONS Different study designs addressing the same question yielded varying results, with differences in about half of all examples. The risk of presenting uncertain results without knowing for sure the direction and magnitude of the effect holds true for both nonrandomized and randomized controlled trials. The integration of multiple study designs in systematic reviews is required if patients should be informed on the many facets of patient relevant issues of health care interventions.
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Affiliation(s)
- Frank Peinemann
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Children's Hospital, University of Cologne, Cologne, Germany
- * E-mail:
| | - Doreen Allen Tushabe
- University of Birmingham, Department of Public Health, Epidemiology & Biostatistics, Birmingham, United Kingdom
| | - Jos Kleijnen
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Kleijnen Systematic Reviews Ltd, York, United Kingdom
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Treweek S, Wilkie E, Craigie AM, Caswell S, Thompson J, Steele RJC, Stead M, Anderson AS. Meeting the challenges of recruitment to multicentre, community-based, lifestyle-change trials: a case study of the BeWEL trial. Trials 2013; 14:436. [PMID: 24351063 PMCID: PMC3880418 DOI: 10.1186/1745-6215-14-436] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 12/03/2013] [Indexed: 11/10/2022] Open
Abstract
Background Recruiting participants to multicentre, community-based trials is a challenge. This case study describes how this challenge was met for the BeWEL trial, which evaluated the impact of a diet and physical activity intervention on body weight in people who had had pre-cancerous bowel polyps. Methods The BeWEL trial was a community-based trial, involving centres linked to the Scottish National Health Service (NHS) colorectal cancer screening programme. BeWEL had a recruitment target of 316 and its primary recruitment route was the colonoscopy clinics of the Scottish Bowel Screening Programme. Results BeWEL exceeded its recruitment target but needed a 6-month no-cost extension from the funder to achieve this. The major causes of delay were lower consent rates (49% as opposed to 70% estimated from earlier work), the time taken for NHS research and development department approvals and the inclusion of two additional sites to increase recruitment, for which there were substantial bureaucratic delays. A range of specific interventions to increase recruitment, for example, telephone reminders and a shorter participant information leaflet, helped to increase the proportion of eligible individuals consenting and being randomized. Conclusions Recruitment to multicentre trials is a challenge but can be successfully achieved with a committed team. In a UK context, NHS research and development approval can be a substantial source of delay. Investigators should be cautious when estimating consent rates. If consent rates are less than expected, qualitative analysis might be beneficial, to try and identify the reason. Finally, investigators should select trial sites on the basis of a formal assessment of a site’s past performance and the likelihood of success in the trial being planned. Trial registration Current Controlled Trials ISRCTN53033856
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Affiliation(s)
- Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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Cipriani A, Reid K, Young AH, Macritchie K, Geddes J. Valproic acid, valproate and divalproex in the maintenance treatment of bipolar disorder. Cochrane Database Syst Rev 2013; 2013:CD003196. [PMID: 24132760 PMCID: PMC6599863 DOI: 10.1002/14651858.cd003196.pub2] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Bipolar disorder is a recurrent illness that is amongst the top 30 causes of disability worldwide and is associated with significant healthcare costs. In the past, emphasis was placed solely on the treatment of acute episodes of bipolar disorder; recently, the importance of episode prevention and of minimisation of iatrogenicity has been recognised. For many years, lithium was the only mood stabiliser in common use, and it remains an agent of first choice in the preventative treatment of bipolar disorder. However, an estimated 20% to 40% of patients may not respond adequately to lithium. Valproate is an anticonvulsant drug that has been shown to be effective in acute mania and is frequently used in maintenance treatment of bipolar disorder. When the acceptability of long-term treatment is considered, together with efficacy, the adverse event profile of a medication is also important. This is an update of a Cochrane review first published in 2001 and last updated in 2009. OBJECTIVES 1. To determine the efficacy of valproate continuation and maintenance treatment:a) in preventing or attenuating manic, depressive and mixed episodes of bipolar disorder;b) in preventing or attenuating episodes of bipolar disorder in patients with rapid cycling disorder; and; c) in improving patients' general health and social functioning, as measured by global clinical impression, employment and marital stability.2. To review the acceptability to patients of long-term valproate treatment, as measured by numbers of dropouts and reasons for dropping out, by compliance and by reference to patients' expressed views regarding treatment.3. To investigate the adverse effects of valproate treatment (including general prevalence of side effects) and overall mortality rates. SEARCH METHODS Search of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) (to January 2013), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE, (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). No language restrictions were applied. Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing valproate and experts in this field were contacted for supplemental data. SELECTION CRITERIA Randomised controlled trials allocating participants with bipolar disorder to long-term treatment with valproate or any other mood stabiliser, or antipsychotic drugs, or placebo. Maintenance treatment was defined as treatment instituted specifically or mainly to prevent further episodes of illness. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. A double-entry procedure was employed by two review authors. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy, acceptability and tolerability. For dichotomous data, risk ratios were calculated with 95% confidence intervals (CIs). For statistically significant results, we calculated the number needed to treat for an additional beneficial outcome (NNTB) and the number needed to treat for an additional harmful outcome (NNTH). For continuous data, mean differences (MDs) or standardised mean differences (SMDs) were calculated along with 95% CIs. MDs were used when the same scale was used to measure an outcome; SMDs were employed when different scales were used to measure the same outcome. The primary analysis used a fixed-effect model. Binary outcomes were calculated on a strict intention-to-treat (ITT) basis; dropouts were included in this analysis. When data were missing and the method of "last observation carried forward" (LOCF) had been used to do an ITT analysis, then the LOCF data were used. MAIN RESULTS Six randomised controlled trials (overall 876 participants) lasting 6 to 24 months were included. Two studies (overall 312 participants) compared valproate with placebo, four studies (overall 618 participants) valproate with lithium, one study (overall 23 participants) valproate with olanzapine and one study (overall 220 participants) valproate with the combination of valproate plus lithium. In terms of study quality, most studies reported the methods used to generate random sequence; however, only one study reported enough details on allocation concealment. Four of six included studies described their design as "double blind", but only two trials reported full details about blinding. Valproate was more effective than placebo in preventing study withdrawal due to any mood episode (RR 0.68, 95% CI 0.49 to 0.93; NNTB 8), but no difference in efficacy was found between valproate and lithium (RR 1.02, 95% CI 0.87 to 1.20). Valproate was associated with fewer participants dropping out of treatment for any cause when compared with placebo or lithium (RR 0.82, 95% CI 0.71 to 0.95 and RR 0.87, 95% CI 0.77 to 0.98, respectively). However, combination therapy with lithium plus valproate was more likely to prevent relapse than was monotherapy with valproate (RR 0.78, 95% CI 0.63 to 0.96). Significant differences in adverse event frequencies were found, and lithium was associated with more frequent diarrhoea, polyuria, increased thirst and enuresis, whereas valproate was associated with increased sedation and infection. AUTHORS' CONCLUSIONS Limited evidence supports the efficacy of valproate in the long-term treatment of bipolar disorder. Clinicians and patients should consider acceptability and tolerability profile when choosing between lithium and valproate-their combination or other agents-as long-term treatment for bipolar disorder.
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Affiliation(s)
- Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | - Keith Reid
- Northumberland Tyne and Wear NHS Foundation TrustBamburgh ClinicJubilee RoadNewcastleUKNE3 3XT
| | - Allan H Young
- Imperial College LondonDivision of Brain Sciences, Centre for Mental HealthLondonUKW6 8RP
| | - Karine Macritchie
- University of EdinburghDivision of PsychiatryRoyal Edinburgh HospitalEdinburghUKEH10 5HF
| | - John Geddes
- University of Oxford/Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
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Park JW, Lee BH, Lee H. Moxibustion in the management of irritable bowel syndrome: systematic review and meta-analysis. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 13:247. [PMID: 24088418 PMCID: PMC3851749 DOI: 10.1186/1472-6882-13-247] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 09/26/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Many patients suffer from IBS that can be difficult to treat, thus complementary therapies which may be effective and have a lower likelihood of adverse effects are being sought.This systematic review and meta-analysis aimed at critically evaluating the current evidence on moxibustion for improving global symptoms of IBS. METHODS We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials, AMED, CINAHL, and CNKI databases for randomised controlled trials (RCTs) of moxibustion comparing with sham moxibustion, pharmacological medications, and other active treatments in patients with IBS. Trials should report global symptom improvement as an outcome measure. Risk of bias for each RCT was assessed according to criteria by the Cochrane Collaboration, and the dichotomous data were pooled according to the control intervention to obtain a risk ratio (RR) of global symptom improvement after moxibustion, with 95% confidence intervals (CI). RESULTS A total of 20 RCTs were eligible for inclusion (n = 1625). The risk of bias was generally high. Compared with pharmacological medications, moxibustion significantly alleviated overall IBS symptoms but there was a moderate inconsistency among studies (7 RCTs, RR 1.33, 95% CI [1.15, 1.55], I² = 46%). Moxibustion combined with acupuncture was more effective than pharmacological therapy but a moderate inconsistency among studies was found (4 RCTs, RR 1.24, 95% CI [1.09, 1.41], I² = 36%). When moxibustion was added to pharmacological medications or herbal medicine, no additive benefit of moxibustion was shown compared with pharmacological medications or herbal medicine alone. One small sham-controlled trial found no difference between moxibustion and sham control in symptom severity (mean difference 0.35, 95% CI [-0.77, 1.47]). Moxibustion appears to be associated with few adverse events but the evidence is limited due to poor reporting. CONCLUSIONS This systematic review and meta-analysis suggests that moxibustion may provide benefit to IBS patients although the risk of bias in the included studies is relatively high. Future studies are necessary to confirm whether this finding is reproducible in carefully-designed and conducted trials and to firmly establish the place of moxibustion in current practice.
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Affiliation(s)
- Jae-Woo Park
- Gastroenterology Division, Department of Internal Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Korea
| | - Byung-Hee Lee
- Department of Medical Science of Meridian, Graduate School, Kyung Hee University, Seoul, Korea
| | - Hyangsook Lee
- Department of Medical Science of Meridian, Graduate School, Kyung Hee University, Seoul, Korea
- Acupuncture & Meridian Science Research Centre, College of Korean Medicine, Kyung Hee University, Seoul, Korea
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Silva IS, Fregonezi GAF, Dias FAL, Ribeiro CTD, Guerra RO, Ferreira GMH. Inspiratory muscle training for asthma. Cochrane Database Syst Rev 2013; 2013:CD003792. [PMID: 24014205 PMCID: PMC7163283 DOI: 10.1002/14651858.cd003792.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND In some people with asthma, expiratory airflow limitation, premature closure of small airways, activity of inspiratory muscles at the end of expiration and reduced pulmonary compliance may lead to lung hyperinflation. With the increase in lung volume, chest wall geometry is modified, shortening the inspiratory muscles and leaving them at a sub-optimal position in their length-tension relationship. Thus, the capacity of these muscles to generate tension is reduced. An increase in cross-sectional area of the inspiratory muscles caused by hypertrophy could offset the functional weakening induced by hyperinflation. Previous studies have shown that inspiratory muscle training promotes diaphragm hypertrophy in healthy people and patients with chronic heart failure, and increases the proportion of type I fibres and the size of type II fibres of the external intercostal muscles in patients with chronic obstructive pulmonary disease. However, its effects on clinical outcomes in patients with asthma are unclear. OBJECTIVES To evaluate the efficacy of inspiratory muscle training with either an external resistive device or threshold loading in people with asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and reference lists of included studies. The latest search was performed in November 2012. SELECTION CRITERIA We included randomised controlled trials that involved the use of an external inspiratory muscle training device versus a control (sham or no inspiratory training device) in people with stable asthma. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included five studies involving 113 adults. Participants in four studies had mild to moderate asthma and the fifth study included participants independent of their asthma severity. There were substantial differences between the studies, including the training protocol, duration of training sessions (10 to 30 minutes) and duration of the intervention (3 to 25 weeks). Three clinical trials were produced by the same research group. Risk of bias in the included studies was difficult to ascertain accurately due to poor reporting of methods.The included studies showed a statistically significant increase in inspiratory muscle strength, measured by maximal inspiratory pressure (PImax) (mean difference (MD) 13.34 cmH2O, 95% CI 4.70 to 21.98, 4 studies, 84 participants, low quality evidence). Our other primary outcome, exacerbations requiring a course of oral or inhaled corticosteroids or emergency department visits, was not reported. For the secondary outcomes, results from one trial showed no statistically significant difference between the inspiratory muscle training group and the control group for maximal expiratory pressure, peak expiratory flow rate, forced expiratory volume in one second, forced vital capacity, sensation of dyspnoea and use of beta2-agonist. There were no studies describing inspiratory muscle endurance, hospital admissions or days off work or school. AUTHORS' CONCLUSIONS There is no conclusive evidence in this review to support or refute inspiratory muscle training for asthma. The evidence was limited by the small number of trials with few participants together with the risk of bias. More well conducted randomised controlled trials are needed. Future trials should investigate the following outcomes: lung function, exacerbation rate, asthma symptoms, hospital admissions, use of medications and days off work or school. Inspiratory muscle training should also be assessed in people with more severe asthma and conducted in children with asthma.
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Affiliation(s)
- Ivanizia S Silva
- Federal University of Rio Grande do NortePhD Program in Physical Therapy, Federal University of Rio Grande do NorteAvenida Senador Salgado Filho 3000, Lagoa NovaNatalRio Grande do NorteBrazil59072‐970
| | - Guilherme AF Fregonezi
- Federal University of Rio Grande do NorteDepartment of Physical TherapyAvenida Senador Salgado Filho, 3000, Lagoa NovaNatalRio Grande do NorteBrazil59078‐470
| | - Fernando AL Dias
- Federal University of ParanáDepartment of PhysiologyCentro Politécnico, Jardim das AméricasCaixa Postal 19031CuritibaParanáBrazil81531‐980
| | - Cibele TD Ribeiro
- Federal University of Rio Grande do NorteGraduate Program in PhysiotherapyAvenida Senador Salgado Filho, 3000Bairro Lagoa NovaNatalRio Grande do NorteBrazil59078‐970
| | - Ricardo O Guerra
- Federal University of Rio Grande do NortePhD Program in Physical TherapyRua Senador Salgado, Filho 3000Lagoa NovaNatalRio Grande do NorteBrazil59072‐970
| | - Gardenia MH Ferreira
- Federal University of Rio Grande do NortePhD Program in Physical Therapy, Federal University of Rio Grande do NorteAvenida Senador Salgado Filho 3000, Lagoa NovaNatalRio Grande do NorteBrazil59072‐970
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