Randomisation to protect against selection bias in healthcare trials

Yoga intervention for colorectal cancer survivors: a qualitative study exploring participants' expectations and experiences

INTRODUCTION

Colorectal cancer (CRC) survivors often struggle with side effects following treatment such as reduced quality of life, fatigue and psychological distress and need therefore efficient comprehensive interventions. The aim of this qualitative study was to explore CRC survivors' expectations before the yoga intervention as well as their unique experiences beyond those reported with standard questionnaires.

METHODS

Interpretative phenomenological approach was used in this qualitative study. Semi-structured interviews were conducted before and after a 10-week yoga program (90 min once a week, Hatha Yoga) with CRC survivors enrolled in a randomized controlled trial. Thematic analysis was used to uncover themes present in participants' accounts.

RESULTS

Nine patients participated in the interviews, mean interview duration was 27.49 min (SD = 7.71) before and 38.41 min (SD = 15.93) after the intervention. Our analysis identified following themes: (1) representations and expectations from the yoga intervention; (2) course structure and implementation; (3) perceptions and effects of the intervention; (4) differences between the study yoga intervention and other physical activities. The superordinate theme regarding effects of intervention included aspects of intervention at multiple levels such as emotional, physical, behavioral and spiritual.

CONCLUSIONS

This qualitative study provides valuable insight regarding CRC survivors' expectations and experiences following a 10-week yoga intervention. While expectations varied from skepticism to specific symptom improvement, the majority of participants had a positive, open attitude towards yoga. Consistent with participants' experiences, yoga may represent a promising intervention for CRC survivors if the groups' specific concerns are taken into account.

Quality of Reporting Randomized Controlled Trials Published in Three of the Most Citable Periodontal Journals from 2018 to 2022

This study aimed to evaluate the reporting quality of randomized clinical trials (RCTs) in periodontology. Three leading periodontology journals, the Journal of Periodontology (JOP), the Journal of Clinical Periodontology (JOCP), and the Journal of Periodontal Research (JOPR), were selected for this investigation. The RCTs were identified by manually searching for human trial articles published in these three journals. Two authors independently conducted the literature search, and a pre-piloted extraction sheet was used to screen the potential RCTs. The CONSORT checklist guidelines were employed to calculate the score value. Intra-examiner reliability was assessed by scoring a random sample of 10% of the papers in a second round conducted by the first examiner three months after the initial data collection. A search of abstracts published over a five-year period yielded 176 articles that reported RCTs, accounting for 11.7% of all articles published in the three journals. The highest number of RCTs was published in 2020, and more than half of the included RCTs (51%) originated from Europe. Many of the analyzed RCTs inadequately reported almost half of the items on the CONSORT checklist. Furthermore, univariate analysis revealed significant associations between certain factors and the overall CONSORT score, such as publication in JOP (p = 0.048), publication year of 2019 (p = 0.041) and 2021 (p = 0.042), first author from North America (p = 0.016), and RCTs with more than six authors (p = 0.042). Clinical trial research in periodontics has made significant progress in the past five years. However, there is room for improvement in adhering to the CONSORT guidelines.

Anti-PD-1/PD-L1 for nasopharyngeal carcinoma: a comprehensive analysis of registered trials on ClinicalTrials.gov

Objective: Clinical trials play an important role in the development of healthcare. However, the current status of clinical trials on anti-PD-1/PD-L1 for nasopharyngeal carcinoma remains unclear. Therefore, this study aims to provide a comprehensive analysis of the registered trials related to anti-PD-1/PD-L1 for nasopharyngeal carcinoma on ClinicalTrials.gov. Methods: A search was conducted on the ClinicalTrials.gov database to identify all registered trials related to anti-PD-1/PD-L1 for nasopharyngeal carcinoma up to 26 February 2023. The characteristics of the trials were examined, and the studied drugs, disease conditions, as well as details of trials with available results were analyzed. Publication status was assessed by a PubMed search using the ClinicalTrials.gov NCT number. Results: A total of 112 interventional clinical trials registered between 2015 and 2023 were included. Of the trials, 90 were carried out in Asia, 72 were in phase 2, and 31 trials had either companies or universities as sponsors/collaborators. The sample sizes across the trials varied greatly, with a median of 71.5 participants per trial. The majority of trials were recruiting participants, with only 6 had posted results. PD-1 inhibitors were preferred over PD-L1, and Toripalimab emerged as the most extensively studied drug. About one-third (33.9%) of the studies looked into recurrent/metastatic nasopharyngeal cancer. Conclusion: This study provides an overview of all registered trials of anti-PD-1/PD-L1 for NPC. It is needed to improve the completeness, outcome selection, randomization and masking of trials and to be transparent and timely in reporting of results.

Effects of somatic acupoint stimulation on anxiety and depression in cancer patients: An updated systematic review of randomized controlled trials

OBJECTIVES

To explore the effectiveness of somatic acupoint stimulation (SAS) for cancer patients with anxiety and depression.

METHODS

Thirteen electronic databases were searched systematically until August 2022. Randomized controlled trials (RCTs) investigating SAS for anxiety and/or depression in cancer patients were retrieved. Methodological quality of the included studies was assessed by utilizing the Cochrane Back Review Group Risk of Bias Assessment Criteria. Evidence level was assessed by using the approach of Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Both meta-analysis and descriptive analysis were conducted for outcome assessment.

RESULTS

Twenty-eight records were finally included including 22 journal articles and six ongoing registered clinical trials. The overall methodological quality and level of evidence of the included studies were suboptimal, with no high-quality evidence identified. Moderate evidence showed that SAS could significantly decrease the anxiety of cancer patients (Acupuncture: [random effect model, SMD = -0.52, 95% CI = -0.79 to -0.24, p = 0.0002] and Acupressure: [random effect model, SMD = -0.89, 95% CI = -1.25 to -0.52, p < 0.00001]. While for depression, although the data analysis indicated that SAS can decrease depression significantly (Acupuncture: [random effect model, SMD = -1.26, 95% CI = -2.08 to -0.44, p = 0.003] and Acupressure: [random effect model, SMD = -1.42, 95% CI = -2.41 to -0.42, p = 0.005]), relevant evidence was rated as low. No statistically significant difference was identified between true and sham acupoints stimulation for both anxiety and depression.

CONCLUSIONS

This systematic review provides the latest research evidence to support SAS as a promising intervention for alleviating anxiety and depression in cancer patients. However, the research evidence should be interpreted prudently as methodological concerns were identified in some included studies, and some sub-group analyses were performed with a relatively small sample size. More rigorously designed large-scale RCTs with placebo-controlled comparisons are warranted to generate high-quality evidence.

REGISTRATION

The systematic review protocol has been registered with PROSPERO (CRD42019133070).

Deep learning-based tool affects reproducibility of pes planus radiographic assessment

Angle measurement methods for measuring pes planus may lose consistency by errors between observers. If the feature points for angle measurement can be provided in advance with the algorithm developed through the deep learning method, it is thought that the error between the observers can be reduced. A total of 300 weightbearing lateral radiographs were used for the development of the deep learning-based algorithm, and a total of 95 radiographs were collected for the clinical validation test set. Meary angle (MA) and calcaneal pitch (CP) were selected as measurement methods and measured twice by three less-experienced physicians with the algorithm-based tool and twice without. The intra- and inter-observer agreements of MA and CP measures were assessed via intra-class correlation coefficient. In addition, verification of the improvement of measurement performance by the algorithm was performed. Interobserver agreements for MA and CP measurements with algorithm were more improved than without algorithm. As for agreement with reference standard, combining the results of all readers, both MA and CP with algorithm were greater than those without algorithm. The deep learning algorithm tool is expected to improve the reproducibility of radiographic measurements for pes planus, especially by improving inter-observer agreement.

The Efficacy of Physical Activity for Children with Attention Deficit Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

This systematic review and meta-analysis assesses the efficacy of regular, moderate to vigorous physical activity (MVPA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents in randomized controlled trials (RCTs).

METHODS

RCTs including children and adolescents with clinically diagnosed ADHD, implementing regular MVPA, and assessing ADHD core-symptoms on a valid rating scale post-intervention (primary outcome) were included. Outcomes were pooled through random-effects meta-analysis. Prospero registration: CRD42019142166.

RESULTS

MVPA had a small effect on total ADHD core symptoms (n = 11; g = -0.33; 95% CI [-0.63; -0.02]; p = .037).

CONCLUSIONS

MVPA could serve as an alternative treatment for ADHD. New RCTs are necessary to increase the understanding of the effect regarding frequency, intensity, type of MVPA interventions, and differential effects on age groups.

Effect of Exercise Training on Quality of Life after Colorectal and Lung Cancer Surgery: A Meta-Analysis

Surgical treatment affects health-related quality of life (HRQoL) and increases fatigue symptoms in patients with lung cancer (LC) and colorectal cancer (CRC). We aimed to systematically review the effect of exercise training on HRQoL and fatigue after LC and CRC surgery. Randomized controlled trials published before 21 March 2021, were searched in PubMed, Scopus, Web of Science, SPORTDiscus and PEDro. Eligible trials compared the effect of exercise interventions initiated preoperatively or in the first 3 months after surgery versus usual care on postoperative HRQoL and fatigue. Standardized mean differences (SMD) were pooled using random-effects models. Twelve studies with a total of 777 patients were included. In LC patients (10 studies, n = 651), exercise training in general led to a moderate improvement in the physical domain of HRQoL (0.68: 95% CI: [0.47; 0.89]) and a small reduction in fatigue levels after surgery (SMD = 0.28: 95% CI: [0.02; 0.53]), while no effects were found in other HRQoL domains. In CRC (two studies, n = 126), exercise training showed no effects on HRQoL and fatigue after surgery. Exercise training is an effective intervention to improve physical function and fatigue after LC surgery. Further studies are necessary to clarify the effects of exercise on HRQoL and fatigue after CRC surgery.

Placebo response and effect in randomized clinical trials: meta-research with focus on contextual effects

BACKGROUND

Contextual effects (i.e., placebo response) refer to all health changes resulting from administering an apparently inactive treatment. In a randomized clinical trial (RCT), the overall treatment effect (i.e., the post-treatment effect in the intervention group) can be regarded as the true effect of the intervention plus the impact of contextual effects. This meta-research was conducted to examine the average proportion of the overall treatment effect attributable to contextual effects in RCTs across clinical conditions and treatments and explore whether it varies with trial contextual factors.

METHODS

Data was extracted from trials included in the main meta-analysis from the latest update of the Cochrane review on "Placebo interventions for all clinical conditions" (searched from 1966 to March 2008). Only RCTs reported in English having an experimental intervention group, a placebo comparator group, and a no-treatment control group were eligible.

RESULTS

In total, 186 trials (16,655 patients) were included. On average, 54% (0.54, 95%CI 0.46 to 0.64) of the overall treatment effect was attributable to contextual effects. The contextual effects were higher for trials with blinded outcome assessor and concealed allocation. The contextual effects appeared to increase proportional to the placebo effect, lower mean age, and proportion of females.

CONCLUSION

Approximately half of the overall treatment effect in RCTs seems attributable to contextual effects rather than to the specific effect of treatments. As the study did not include all important contextual factors (e.g., patient-provider interaction), the true proportion of contextual effects could differ from the study's results. However, contextual effects should be considered when assessing treatment effects in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42019130257 . Registered on April 19, 2019.

Transdiagnostic efficacy of a group exercise intervention for outpatients with heterogenous psychiatric disorders: a randomized controlled trial

BACKGROUND

Exercise efficaciously reduces disorder-specific symptoms of psychiatric disorders. The current study aimed to examine the efficacy of a group exercise intervention on global symptom severity and disorder-specific symptoms among a mixed outpatient sample.

METHODS

Groups of inactive outpatients, waiting for psychotherapy, with depressive disorders, anxiety disorders, insomnia, and attention-deficit/hyperactivity disorders were randomized to a manualized 12-week exercise intervention, combining moderate to vigorous aerobic exercise with techniques for sustainable exercise behaviour change (n = 38, female = 71.1% (n = 27), M_age = 36.66), or a passive control group (n = 36, female = 75.0% (n = 27), M_age = 34.33). Primary outcomes were global symptom severity and disorder-specific symptoms, measured with the Symptom Checklist-90-Revised and Pittsburgh Sleep Quality Index pre- and post-treatment. Secondary outcome was the self-reported amount of exercise (Physical Activity, Exercise, and Sport Questionnaire), measured pre-treatment, intermediate-, and post-treatment. Intention-to-treat analyses were conducted using linear mixed models. Linear regressions were conducted to examine the effect of the change of exercise behaviour on the change of symptoms.

RESULTS

The intervention significantly improved global symptom severity (d = 0.77, p = .007), depression (d = 0.68, p = .015), anxiety (d = 0.87, p = .002), sleep quality (d = 0.88, p = .001), and increased the amount of exercise (d = 0.82, p < .001), compared to the control group. Post-treatment differences between groups were significant for depression (d = 0.63, p = .031), sleep quality (d = 0.61, p = .035) and the amount of exercise (d = 1.45, p < .001). Across both groups, the reduction of global symptom severity was significantly predicted by an increase of exercise (b = .35, p = .012).

CONCLUSIONS

The exercise intervention showed transdiagnostic efficacy among a heterogeneous clinical sample in a realistic outpatient setting and led to sustained exercise behaviour change. Exercise may serve as an efficacious and feasible transdiagnostic treatment option improving the existing treatment gap within outpatient mental health care settings.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (ID: NCT03542396 , 25/04/2018).

Bias estimation in study design: a meta-epidemiological analysis of transcatheter versus surgical aortic valve replacement

BACKGROUND

Paucity of RCTs of non-drug technologies lead to widespread dependence on non-randomized studies. Relationship between nonrandomized study design attributes and biased estimates of treatment effects are poorly understood. Our purpose was to estimate the bias associated with specific nonrandomized study attributes among studies comparing transcatheter aortic valve implantation with surgical aortic valve replacement for the treatment of severe aortic stenosis.

RESULTS

We included 6 RCTs and 87 nonrandomized studies. Surgical risk scores were similar for comparison groups in RCTs, but were higher for patients having transcatheter aortic valve implantation in nonrandomized studies. Nonrandomized studies underestimated the benefit of transcatheter aortic valve implantation compared with RCTs. For example, nonrandomized studies without adjustment estimated a higher risk of postoperative mortality for transcatheter aortic valve implantation compared with surgical aortic valve replacement (OR 1.43 [95% CI 1.26 to 1.62]) than high quality RCTs (OR 0.78 [95% CI 0.54 to 1.11). Nonrandomized studies using propensity score matching (OR 1.13 [95% CI 0.85 to 1.52]) and regression modelling (OR 0.68 [95% CI 0.57 to 0.81]) to adjust results estimated treatment effects closer to high quality RCTs. Nonrandomized studies describing losses to follow-up estimated treatment effects that were significantly closer to high quality RCT than nonrandomized studies that did not.

CONCLUSION

Studies with different attributes produce different estimates of treatment effects. Study design attributes related to the completeness of follow-up may explain biased treatment estimates in nonrandomized studies, as in the case of aortic valve replacement where high-risk patients were preferentially selected for the newer (transcatheter) procedure.

The effects of chair intervention on lower back pain, discomfort and trunk muscle activation in office workers: a systematic review

Objectives. The chair is a standard piece of workstation equipment in an office. Previous studies showed that a suitable chair may reduce musculoskeletal symptoms. This review investigated the effect of chair intervention on lower back pain (LBP), discomfort and trunk muscle activation among office workers. Methods. Five electronic databases from 1980 to May 2020 were searched for relevant randomized and non-randomized controlled trials. The methodological quality of the included studies was assessed using the 13-item Cochrane risk of bias tool. Quality of evidence was assessed and rated according to Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines. Results. Two randomized controlled trials, 10 repeated-measures studies and two prospective cohort studies were included in this review. Nine studies were rated as high quality. The results indicated very low-quality to low-quality evidence for the conflicting effect of chair intervention on pain and discomfort reduction as well as trunk muscle activation among office workers. When stratified by chair type, the level of evidence for health benefits derived from any type of chair was still of very low to low quality. Conclusion. Unless supplementary high-quality studies provide different evidence, chair interventions are not recommended to reduce LBP or discomfort and activate trunk muscles.

Effect of aerobic exercise on functional capacity and quality of life in individuals with Parkinson's disease: A systematic review of randomized controlled trials

OBJECTIVES

To investigate the effect of aerobic exercise (AE) on functional capacity and quality of life in individuals with Parkinson's disease (PD) in the mild to moderate stages.

DATA SOURCES

Medline, Embase, Web of Science, The Cochrane Library, Lilacs and PEDro were searched from inception until January 2021 using the MeSH terms.

STUDY SELECTION

Studies conducted in individuals with PD involving AE compared to a control group were included.

DATA EXTRACTION

Characteristics of the studies were independently extracted by two reviewers. The PEDro scale was used to assess the methodological quality, and the level of evidence was analyzed and synthesized using the GRADE approach.

DATA SYNTHESIS

Of the ten studies, 411 individuals with PD were included. The level of synthesized evidence for cardiorespiratory function was low and without effect, and very low and without effect. For gait was very low and with effect for speed and stride length and without effect for cadence. For mobility was very low and with effect. For muscle strength was very low and with effect for the lower limbs as well as without effect for the upper limbs. For postural balance was very low and without effect. For quality of life was low and without effect.

CONCLUSION

Aerobic exercise was capable of promoting improvements in gait (walking speed and stride length), mobility, and lower limb muscle strength in individuals with PD in the mild to moderate stages. No significant improvement in quality of life was found due to the practice of AE.

Effect of Resistance Exercise on Body Structure and Function, Activity, and Participation in Individuals With Parkinson Disease: A Systematic Review

OBJECTIVE

To investigate the effects of resistance exercise (RE) on body structure and function, activity, and participation in individuals with Parkinson Disease (PD) in the mild to moderate stages.

DATA SOURCES

Medline, Embase, Web of Science, The Cochrane Library, Lilacs, and PEDro were searched from inception until June 2020 using the terms "Parkinson Disease," "Exercise," "Resistance Training," "Muscle Strength," "Cardiorespiratory Fitness," "Postural Balance," "Gait," and "Quality of Life."

STUDY SELECTION

We included studies conducted in individuals with PD involving RE compared with a control group. Two independent reviewers performed the selection process based on titles, abstracts, and full-text reading. In total, 270 individuals with PD were included from 10 selected studies.

DATA EXTRACTION

Two reviewers independently extracted characteristics related to participants, intervention and control types, and results. The PEDro scale was used to assess the methodological quality, and the level of evidence was analyzed and synthesized using the Grading of Recommendation, Assessment, Development, and Evaluations approach.

DATA SYNTHESIS

The level of evidence for body structure and function was low and without effect for lower limb muscle strength; very low and with effect for upper limb muscle strength, cardiorespiratory fitness, and postural balance; and very low and without effect for flexibility after RE training. For activity, the evidence was very low and with effect for gait and very low and without effect for mobility. For participation (ie, quality of life) the evidence was very low and without effect.

CONCLUSIONS

Although the level of evidence was low to very low, RE was shown to promote improvements in body structure and function (upper limb muscle strength, cardiovascular function, postural balance) and activity (gait). In contrast, RE did not significantly improve participation (quality of life). However, based on the present findings, the practice of RE can be recommended for individuals with PD in the mild to moderate stages.

Does a video clip enhance recruitment into a parenting trial? Learnings from a study within a trial

Background

Reaching recruitment targets in randomised controlled trials is a challenge. Media tools are increasingly used to engage participants, yet there is a paucity of research into the use of video to optimise recruitment. We therefore tested whether adding a participant information video clip to a standard participant information sheet improved recruitment into a parenting trial.

Methods

One hundred seven participants were randomised to receive either a participant information sheet (n = 51) or an informational video clip (n = 56) as part of an email contact following a screening phase. All participants went on to receive the information sheet as part of the existing consent procedure.

Results

The video condition did not increase the odds of recruitment into the trial, such that those in the video condition were significantly less likely to participate in the main trial (OR = 0.253, CI = 0.104–0.618, p = 0.003).

Conclusion

The introduction of a video clip into the recruitment stages of a parenting trial did not lead to an improvement in recruitment; however, the small sample size precludes definitive inferences. We offer reflections on challenges encountered in implementing the SWAT and suggestions for other researchers seeking to embed recruitment SWATs into similar trials.

Trial registration

Current controlled trials ISRCTN 58327365. Registered on 19 March 2015.

SWAT registration

SWAT 106; Effects of a video clip on recruitment into a randomised trial. Registered on 20 December 2016.

Quantifying treatment selection bias effect on survival in comparative effectiveness research: findings from low-risk prostate cancer patients

BACKGROUND

Comparative effectiveness research (CER) using national registries influences cancer clinical trial design, treatment guidelines, and patient management. However, the extent to which treatment selection bias (TSB) affects overall survival (OS) in cancer CER remains poorly defined. We sought to quantify the TSB effect on OS in the setting of low-risk prostate cancer, where 10-year prostate cancer-specific survival (PCSS) approaches 100% regardless of treatment modality.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients with low-risk prostate cancer (cT1-T2a, PSA < 10, and Gleason 6) who received radical prostatectomy (RP), brachytherapy (BT), or external beam radiotherapy (EBRT) from 2005 to 2015. The TSB effect was defined as the unadjusted 10-year OS difference between modalities that was not due to differences in PCSS. Propensity score matching was used to estimate the TSB effect on OS due to measured confounders (variables present in the database and associated with OS) and unmeasured confounders.

RESULTS

A total of 50,804 patients were included (8845 RP; 18,252 BT; 23,707 EBRT) with a median follow-up of 7.4 years. The 10-year PCSS for the entire cohort was 99%. The 10-year OS was 92.9% for RP, 83.6% for BT, and 76.9% for EBRT (p < 0.001). OS differences persisted after propensity score matching of RP vs. EBRT (7.4%), RP vs. BT (4.6%), and BT vs. EBRT (3.7%) (all p < 0.001). The TSB effect on 10-year OS was estimated to be 15.0% for RP vs. EBRT (8.6% measured, 6.4% unmeasured), 8.5% for RP vs. BT (4.8% measured, 3.7% unmeasured), and 6.5% for BT vs. EBRT (3.1% measured, 3.4% unmeasured).

CONCLUSIONS

Patients with low-risk prostate cancer selected for RP exhibited large OS differences despite similar PCSS compared to radiotherapy, suggesting OS differences are almost entirely driven by TSB. The quantities of these effects are important to consider when interpreting prostate cancer CER using national registries.

Assessing the Impact of Patient-Facing Mobile Health Technology on Patient Outcomes: Retrospective Observational Cohort Study

BACKGROUND

Despite the growth of and media hype about mobile health (mHealth), there is a paucity of literature supporting the effectiveness of widespread implementation of mHealth technologies.

OBJECTIVE

This study aimed to assess whether an innovative mHealth technology system with several overlapping purposes can impact (1) clinical outcomes (ie, readmission rates, revisit rates, and length of stay) and (2) patient-centered care outcomes (ie, patient engagement, patient experience, and patient satisfaction).

METHODS

We compared all patients (2059 patients) of participating orthopedic surgeons using mHealth technology with all patients of nonparticipating orthopedic surgeons (2554 patients). The analyses included Wilcoxon rank-sum tests, Kruskal-Wallis tests for continuous variables, and chi-square tests for categorical variables. Logistic regression models were performed on categorical outcomes and a gamma-distributed model for continuous variables. All models were adjusted for patient demographics and comorbidities.

RESULTS

The inpatient readmission rates for the nonparticipating group when compared with the participating group were higher and demonstrated higher odds ratios (ORs) for 30-day inpatient readmissions (nonparticipating group 106/2636, 4.02% and participating group 54/2048, 2.64%; OR 1.48, 95% CI 1.03 to 2.13; P=.04), 60-day inpatient readmissions (nonparticipating group 194/2636, 7.36% and participating group 85/2048, 4.15%; OR 1.79, 95% CI 1.32 to 2.39; P<.001), and 90-day inpatient readmissions (nonparticipating group 261/2636, 9.90% and participating group 115/2048, 5.62%; OR 1.81, 95% CI 1.40 to 2.34; P<.001). The length of stay for the nonparticipating cohort was longer at 1.90 days, whereas the length of stay for the participating cohort was 1.50 days (mean 1.87, SD 2 vs mean 1.50, SD 1.37; P<.001). Patients treated by participating surgeons received and read text messages using mHealth 83% of the time and read emails 84% of the time. Patients responded to 60% of the text messages and 53% of the email surveys. Patients were least responsive to digital monitoring questions when the hospital asked them to do something, and they were most engaged with emails that did not require action, including informational content. A total of 96% (558/580) of patients indicated high satisfaction with using mHealth technology to support their care. Only 0.40% (75/2059) patients opted-out of the mHealth technology program after enrollment.

CONCLUSIONS

A novel, multicomponent, pathway-driven, patient-facing mHealth technology can positively impact patient outcomes and patient-reported experiences. These technologies can empower patients to play a more active and meaningful role in improving their outcomes. There is a deep need, however, for a better understanding of the interactions between patients, technology, and health care providers. Future research is needed to (1) help identify, address, and improve technology usability and effectiveness; (2) understand patient and provider attributes that support adoption, uptake, and sustainability; and (3) understand the factors that contribute to barriers of technology adoption and how best to overcome them.

Psychosocial interventions on perinatal depression in China: A systematic review and meta-analysis

BACKGROUND

The prevalence of perinatal depression is 16.3% in China and has shown a rising trend in the last decade. However, few studies summarized psychosocial interventions for perinatal depression in this country. This study aimed at evaluating and characterizing psychosocial interventions for perinatal depression in Mainland China.

METHODS

Ten major English and Chinese language electronic bibliographic databases were searched for RCTs examining the effect of psychosocial interventions for perinatal depressed women in Mainland China. Studies meeting eligibility criteria and published before 25th February 2019 were included, while those focusing on a very specific sub-population or reporting non-psychosocial interventions were excluded. Data was extracted by a standard form. Meta-analysis was conducted to obtain a summary measure of the effectiveness of the interventions in reducing perinatal depressive symptoms. The theoretical underpinnings and implementation processes of the interventions were also characterised.

RESULTS

A total of 6857 articles were identified in the initial database searching, of which, 26 studies were eligible for data analysis, representing a sample size of 4673. Meta-analysis indicated that psychosocial interventions in China significantly reduced perinatal depressive symptoms (standard difference in means 0.81, 95% confidence intervals -1.03 to -0.58, P < 0.001). However, the overall evidence presented substantial heterogeneity (I² = 91.12%). Most interventions were implemented in hospitals in urban areas by non-specialist health care providers. Few studies reported details of implementation procedures or scale-up strategies.

LIMITATIONS

The evidence in this review is of moderate to low quality and therefore, should be interpreted with caution. Some of the trials were inadequately powered and tended to overestimate effect sizes.

CONCLUSIONS

Current psychosocial interventions in China are somewhat effective in reducing perinatal depressive symptoms. High quality RCTs on scale-up interventions are required, especially in rural areas.

Benchmarking Observational Analyses Against Randomized Trials: a Review of Studies Assessing Propensity Score Methods

BACKGROUND

Observational analysis methods can be refined by benchmarking against randomized trials. We reviewed studies systematically comparing observational analyses using propensity score methods against randomized trials to explore whether intervention or outcome characteristics predict agreement between designs.

METHODS

We searched PubMed (from January 1, 2000, to April 30, 2017), the AHRQ Scientific Resource Center Methods Library, reference lists, and bibliographies to identify systematic reviews that compared estimates from observational analyses using propensity scores against randomized trials across three or more clinical topics; reported extractable relative risk (RR) data; and were published in English. One reviewer extracted data from all eligible systematic reviews; a second reviewer verified the extracted data.

RESULTS

Six systematic reviews matching published observational studies to randomized trials, published between 2012 and 2016, met our inclusion criteria. The reviews reported on 127 comparisons overall, in cardiology (29 comparisons), surgery (49), critical care medicine and sepsis (46), nephrology (2), and oncology (1). Disagreements were large (relative RR < 0.7 or > 1.43) in 68 (54%) and statistically significant in 12 (9%) of the comparisons. The degree of agreement varied among reviews but was not strongly associated with intervention or outcome characteristics.

DISCUSSION

Disagreements between observational studies using propensity score methods and randomized trials can occur for many reasons and the available data cannot be used to discern the reasons behind specific disagreements. Better benchmarking of observational analyses using propensity scores (and other causal inference methods) is possible using observational studies that explicitly attempt to emulate target trials.

Topical 5% minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure: A randomized clinical trial

BACKGROUND

Chronic anal fissure (CAF) is a common painful anal condition. Medical treatment of CAF involves the use of agents that induce chemical sphincterotomy. The present trial aimed to compare the efficacy and safety of topical minoxidil and glyceryl trinitrate (GTN) preparations in treatment of CAF.

METHODS

Adult patients with CAF were randomly assigned to one of two equal groups; group I received topical 5% minoxidil gel and group II received topical 0.2% GTN cream. The main outcome measures were healing of anal fissure, duration to healing, relief of symptoms, and adverse effects.

RESULTS

62 patients (36 female and 26 male) were included to the study. Group I comprised 30 patients and group II comprised 32 patients. Healing of anal fissure was achieved in 23 (76.7%) patients in group I and 15 (46.9%) patients in group II (p = 0.03). The average duration to healing in group I was significantly shorter than group II (4.1 ± 1.9 vs 5.3 ± 2.7 weeks, p = 0.048). Adverse effects were recorded in 2 (6.6%) patients in group I and 13 (40.6%) patients in group II. The post-treatment pain score in the GTN group was significantly lower than the Minoxidil group.

CONCLUSION

Topical 5% minoxidil gel achieved greater and quicker healing of CAF and fewer adverse effects than topical 0.2% GTN cream. Post-treatment pain scores after GTN were significantly lower than minoxidil.

TRIAL REGISTRATION NUMBER

NCT03528772.

Using telehealth in motor neuron disease to increase access to specialist multidisciplinary care: a UK-based pilot and feasibility study

OBJECTIVES

Care of patients with motor neuron disease (MND) in a specialist, multidisciplinary clinic is associated with improved survival, but access is not universal. We wanted to pilot and establish the feasibility of a definitive trial of a novel telehealth system (Telehealth in Motor neuron disease, TiM) in patients with MND.

DESIGN

An 18-month, single-centre, mixed-methods, randomised, controlled pilot and feasibility study.

INTERVENTION

TiM telehealth plus usual care versus usual care.

SETTING

A specialist MND care centre in the UK.

PARTICIPANTS

Patients with MND and their primary informal carers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Recruitment, retention and data collection rates, clinical outcomes including participant quality of life and anxiety and depression.

RESULTS

Recruitment achieved the target of 40 patients and 37 carers. Participant characteristics reflected those attending the specialist clinic and included those with severe disability and those with limited experience of technology. Retention and data collection was good. Eighty per cent of patients and 82% of carer participants reported outcome measures were completed at 6 months. Using a longitudinal analysis with repeated measures of quality of life (QoL), a sample size of 131 per arm is recommended in a definitive trial. The methods and intervention were acceptable to participants who were highly motivated to participate to research. The low burden of participation and accessibility of the intervention meant barriers to participation were minimal. However, the study highlighted difficulties assessing the associated costs of the intervention, the challenge of recruitment in such a rare disease and the difficulties of producing rigorous evidence of impact in such a complex intervention.

CONCLUSION

A definitive trial of TiM is feasible but challenging. The complexity of the intervention and heterogeneity of the patient population means that a randomised controlled trial may not be the best way to evaluate the further development and implementation of the TiM.

TRIAL REGISTRATION NUMBER

ISRCTN26675465.

Nutrition Education and Dietary Behavior Change Games: A Scoping Review

Games provide an attractive venue for engaging participants and increasing nutrition-related knowledge and dietary behavior change, but no review has appeared devoted to this literature. A scoping review of nutrition education and dietary behavior change videogames or interactive games was conducted. A systematic search was made of PubMed, Agricola, and Google Scholar. Information was abstracted from 22 publications. To be included, the publication had to include a videogame or interactive experience involving games (a videogame alone, minigames inserted into a larger multimedia experience, or game as part of a human-delivered intervention); game's design objective was to influence dietary behavior, a psychosocial determinant of a dietary behavior, or nutrition knowledge (hereinafter referred to as diet-related); must have been reported in English and must have appeared in a professional publication, including some report of outcomes or results (thereby passing some peer review). This review was restricted to the diet-related information in the selected games. Diversity in targeted dietary knowledge and intake behaviors, targeted populations/audiences, game mechanics, behavioral theories, research designs, and findings was revealed. The diversity and quality of the research in general was poor, precluding a meta-analysis or systematic review. All but one of the studies reported some positive outcome from playing the game(s). One reported that a web-based education program resulted in more change than the game-based intervention. Studies of games may have been missed; a number of dietary/nutrition games are known for which no evaluation is known; and the data presented on the games and research were limited and inconsistent. Conclusions and Implications: A firmer research base is needed to establish the efficacy and effectiveness of nutrition education and dietary behavior change games.

The assessment of the quality of randomized controlled trials published in Indian medical journals

Aim:

In this retrospective cross-sectional study, we sought to evaluate if the published randomized controlled trials (RCTs) reported in the year 2017 among the Indian medical journals (IMJs) complied with the Consolidated Standards of Reporting Trials (CONSORT) guidelines and identify domains where reporting could be improved.

Methods:

A literature search was performed using PubMed and Google Scholar to identify all the IMJs that published RCTs in the year 2017. In the archives of the identified journals, the number of published RCTs was identified and the full text was obtained. We selected articles that stated RCT in abstract and title and that evaluated the safety and efficacy of all therapeutic and preventive interventions.

Results:

A total of seven IMJs comprising of the Indian Journal of Anesthesia, Indian Journal of Dermatology, Venereology and Leprology, Indian Journal of Pharmacology, Indian Journal of Ophthalmology, Journal of Obstetrics and Gynaecology, Journal of Pharmacology and Pharmacotherapeutics, and Indian Journal of Medical and Pediatric Oncology that published a total of 84 RCTs were included. The mean compliance score of all the RCTs was 13.7 ± 2.66 (57%). Most RCTs had serious reporting deficiencies in the methodology and result sections.

Discussion:

In spite of journals making it mandatory for prospective authors to comply with the CONSORT guidelines, it is intriguing that there continues to be significant lacunae in reporting RCTs adequately in most IMJs.

Conclusion:

There is an urgent need to impart training to the medical community of our country in clinical research methods and reporting of RCTs.

Acceptability of a German multicentre healthcare research study: a survey of research personnels' attitudes, experiences and work load

OBJECTIVES

The DACAPO study as a multicentre nationwide observational healthcare research study investigates the influence of quality of care on the quality of life in patients with acute respiratory distress syndrome. The aim of this study was to investigate the acceptability to the participating research personnels by assessing attitudes, experiences and workload associated with the conduct of the DACAPO study.

DESIGN, SETTING AND PARTICIPANTS

A prospective anonymous online survey was sent via email account to 169 participants in 65 study centres. The questionnaire included six different domains: (1) training for performing the study; (2) obtaining informed consent; (3) data collection; (4) data entry using the online documentation system; (5) opinion towards the study and (6) personal data. Descriptive data analysis was carried out.

RESULTS

A total of 78 participants took part (46%) in the survey, 75 questionnaires (44%) could be evaluated. 51% were senior medical specialists. 95% considered the time frame of the training as appropriate and the presentation was rated by 93% as good or very good. Time effort for obtaining consent, data collection and entry was considered by 41% as a burden. Support from the coordinating study centre was rated as good or very good by more than 90% of respondents. While the DACAPO study was seen as scientifically relevant by 81%, only 45% considered the study results valuable for improving patient care significantly.

CONCLUSION

Collecting feedback on the acceptability of a large multicentre healthcare research study provided important insights. Recruitment and data acquisition was mainly performed by physicians and often regarded as additional time burden in clinical practice. Reducing the amount of data collection and simplifying data entry could facilitate the conduct of healthcare research studies and could improve motivation of researchers in intensive care medicine.

TRIAL REGISTRATION NUMBER

NCT02637011; Pre-results.

Principles of designing a clinical trial: optimizing chances of trial success

PURPOSE OF REVIEW

Clinical trials are essential to advance health care and develop new therapies. In this review we discuss the underlying principles of clinical trial design with an emphasis on assessing design risks that lead to trial failure as well as negative trials. While of general interest, this is perhaps particularly timely for the neuromodulation community, given the paucity of well-designed trials in the field. We give some examples from the phantom limb pain (PLP) literature.

RECENT FINDINGS

It is critical to gather as much preliminary data as possible and to know how to interpret it in order to choose an appropriate trial design. Therefore, the investigator needs to effectively assess the likely trial design risk/benefit ratio with a view to maximizing the chance of a meaningful outcome, whether this outcome rejects or fails to reject the null hypothesis. This analysis is especially important in a complex and heterogeneous disorder such as PLP, which has had many negative trials.

SUMMARY

We discuss the factors pertaining to a strong trial design benefit/risk assessment, how late trial phases require greater support from preliminary data, how to design trials to minimize risks, maximize benefits, and optimize internal validity as well as the chances of a positive outcome. We highlight the need for investigators to incorporate best practice in trial design to increase the chances of success, to always anticipate unexpected challenges during the trial.

Use of online recruitment strategies in a randomized trial of cancer survivors

BACKGROUND/AIMS

Despite widespread Internet adoption, online advertising remains an underutilized tool to recruit participants into clinical trials. Whether online advertising is a cost-effective method to enroll participants compared to other traditional forms of recruitment is not known.

METHODS

Recruitment for the Survivorship Promotion In Reducing IGF-1 Trial, a community-based study of cancer survivors, was conducted from June 2015 through December 2016 via in-person community fairs, advertisements in periodicals, and direct postal mailings. In addition, "Right Column" banner ads were purchased from Facebook to direct participants to the Survivorship Promotion In Reducing IGF-1 Trial website. Response rates, costs of traditional and online advertisements, and demographic data were determined and compared across different online and traditional recruitment strategies. Micro-trials optimizing features of online advertisements were also explored.

RESULTS

Of the 406 respondents to our overall outreach efforts, 6% (24 of 406) were referred from online advertising. Facebook advertisements were shown over 3 million times (impressions) to 124,476 people, which resulted in 4401 clicks on our advertisement. Of these, 24 people ultimately contacted study staff, 6 underwent prescreening, and 4 enrolled in the study. The cost of online advertising per enrollee was $794 when targeting a general population versus $1426 when accounting for strategies that specifically targeted African Americans or men. By contrast, community fairs, direct mail, or periodicals cost $917, $799, or $436 per enrollee, respectively. Utilization of micro-trials to assess online ads identified subtleties (e.g. use of an advertisement title) that substantially impacted viewer interest in our trial.

CONCLUSION

Online advertisements effectively directed a relevant population to our website, which resulted in new enrollees in the Survivorship Promotion In Reducing IGF-1 Trial at a cost comparable to traditional methods. Costs were substantially greater with online recruitment when targeting under-represented populations, however. Additional research using online micro-trial tools is needed to evaluate means of more precise recruitment to improve yields in under-represented groups. Potential gains from faster recruitment speed remain to be determined.

Systematic review of public-targeted communication interventions to improve antibiotic use

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.

Vascular Impulse Technology versus elevation in the treatment of posttraumatic swelling of extremity fractures: study protocol for a randomized controlled trial

BACKGROUND

Fractures of the extremities are often complicated by a variable degree of swelling secondary to hemorrhage and soft tissue injury. Patients typically require up to 7 days of inpatient bed rest and elevation to reduce swelling to an acceptable level for operative treatment with internal fixation. Alternatively, an intermittent pneumatic compression device, such as the Vascular Impulse Technology (VIT) system, can be used at the injured extremity to reduce the posttraumatic swelling. The VIT system consists of a pneumatic compressor that intermittently rapidly inflates a bladder positioned under the arch of the hand or the foot, which results in compression of the venous hand or foot plexus. That intermittent compression induces an increased venous velocity and aims to reduce the soft tissue swelling of the affected extremity.

METHODS/DESIGN

The VIT study is a prospective, monocenter, randomized controlled trial to compare the VIT system with elevation in the treatment of posttraumatic swelling in the case of a fracture of the upper and lower extremity. This study will include 280 patients with fractures of the upper and the lower extremity with nine different injury types. For each of the nine injury types a separate randomization to the two intervention groups (VIT group or control group) will be performed. The primary outcome parameter is the time taken for the swelling to resolve sufficiently to permit surgery. A separate analysis for each of the nine injury types will be performed.

DISCUSSION

In the proposed study, the effectiveness of the VIT system in the treatment of posttraumatic swelling of upper and lower extremity fractures will be evaluated.

TRIAL REGISTRATION

German Clinical Trial Register, No. DRKS00010510 . Registered on 17 July 2016.

Effect of characteristics of women on attendance in blind and non-blind randomised trials: analysis of recruitment data from the EPHT Trial

OBJECTIVES

To analyse the effect of women's characteristics on their willingness to join a blind or a non-blind subtrial or to be excluded by physicians.

DESIGN

Primary prevention trial of postmenopausal hormone therapy (HT). A 2×2, randomised design with a non-blind HT arm or control arm and a blind HT arm or placebo arm.

SETTING

3 clinical centres in Estonia.

METHODS

Interest in joining the trial was asked in a questionnaire together with demographic and health status data. Interested and eligible women were invited to a health examination that also informed whether they belonged to a blind or to a non-blind subtrial; the arm was not revealed. Trial physicians made further exclusions when checking the women's eligibility. Thereafter, informed consent was asked as detailed in the flow chart. Comparisons were made between non-blind and blind subtrials. Analyses were carried out for each of the background variables.

OUTCOME MEASURES

The proportion of willingness, eligibility and attendance.

RESULTS

Women randomised to the non-blind subtrial were more willing to join (relative risk (RR) 1.17) and more likely to be found eligible by physicians (RR 1.10) than women in the blind subtrial, resulting in larger attendance (RR 1.29). Women with higher education were differentially more willing to join the non-blind trial (RR 1.29) than those with basic education (RR 1.08); the differential willingness of never-smokers (RR 1.20) was larger than that of current smokers (RR 1.07). The differential exclusion by physicians by education and smoking were small. Some subjective symptoms (eg, diarrhoea/constipation, stomach pain) had reverse differential effects on attendance in the non-blind subtrial in comparison to the blind subtrial. Menopausal symptoms did not affect the differential interest, eligibility or attendance.

CONCLUSIONS

Blinding in RCT reduces attendance, due to decisions of the women and the trial physicians. Differential attendance by blinding may affect the generalisability of the results from trials.

TRIAL REGISTRATION NUMBER

ISRCTN35338757.

Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail - which method is optimal?

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.

Acupoints Stimulation for Anxiety and Depression in Cancer Patients: A Quantitative Synthesis of Randomized Controlled Trials

This study aims at concluding the current evidence on the therapeutic effects of acupoints stimulation for cancer patients with anxiety and depression. Randomized controlled trials using acupoints stimulation for relieving anxiety and/or depression in cancer patients were searched, and 11 studies were finally included, of which eight trials compared acupoints stimulation with standard methods of treatment/care, and acupoints stimulation showed significantly better effects in improving depression than using standard methods of treatment/care. Four studies compared true acupoints stimulation with sham methods, and no significant differences can be found between groups for either depression or anxiety, although the pooled effects still favored true intervention. For the five studies that evaluated sleep quality, the results were conflicting, with three supporting the superiority of acupoints stimulation in improving sleep quality and two demonstrating no differences across groups. Acupoints stimulation seems to be an effective approach in relieving depression and anxiety in cancer patients, and placebo effects may partially contribute to the benefits. However, the evidence is not conclusive due to the limited number of included studies and the clinical heterogeneity identified among trials. More rigorous designed randomized, sham-controlled studies are necessary in future research.

Increased water intake to reduce headache: learning from a critical appraisal

CLINICAL BOTTOM LINE

Water intake is a cost effective, non-invasive and low-risk intervention to reduce or prevent headache pain.

RATIONALE

Chronic mild dehydration may trigger headache. Increased water intake could help. A small trial shows modest benefit; however, a larger methodologically sound randomized controlled trial is needed to confirm efficacy.

CRITICALLY APPRAISED PAPER

Spigt, M., Weerkamp, N., Troost, J., van Schayck, C. P., & Knottnerus, J. A. (2012). 'A randomized trial on the effects of regular water intake in patients with recurrent headaches.' Family practice, 29(4), 370-5. Doi: 10.1093/fampra/cmr112 CLINICAL SCENARIO: Patients from primary care registered as 'headache', 'tension headache' and/or 'migraine' for more than one year who suffer at least two episodes of moderately intense headache or more than four mildly intense episodes of headache per month with a daily fluid intake of less than 2.5 litres per day.

PICO (M)

Patient/Problem = Headache > 1 year with 2 moderately intense or 4 mildly intense episodes per month Intervention = 1.5 litres water per day + stress control and sleep hygiene Comparison/Control = stress control and sleep hygiene Outcome = Reduce or eliminate headache Methodology = Therapy RCT Table 1: Final Search Terms TRIP Data Base: hits = 517 used filter Extended Primary research 4 found 1 paper applicable 'Water intake '[MeSH Terms] AND 'Headache '[All Fields]' Best match to PICO, (2012) RCT SELECTION CRITERION AND OVERALL RESULTS: 102 headache patients in16 primary care clinics were randomized into control (n = 50) and intervention groups (n = 52) Inclusion criteria = two > episodes of moderately intense headache or five > mildly intense headaches per month and total fluid intake > 2.5 litres per day, Follow-up @ 3 months. 79% intervention and 66% of controls completed RCT. Drinking more water resulted in a statistically significant improvement of 4.5 (confidence interval: 1.3-7.8) points on Migraine-Specific Quality of Life (MSQOL). 47% in the intervention (water) group self-reported improvement (6 > on a 10-point scale) against 25% in controls. Drinking water did not reduce headache days.

COMMENTS

The transparency from the author of this critically appraised paper enables others to use this study as a teaching tool and to learn from the shortcomings in the trial. The study was underpowered and contains methodological shortcomings. Participants were partially un-blinded during the trial increasing the risk for bias. Only the subjective measures are statistically significant and attrition was significant. The intervention is low risk and of negligible cost. A methodologically sound RCT is recommended to evaluate if the intervention has beneficial effects.

Development of an algorithm to provide awareness in choosing study designs for inclusion in systematic reviews of healthcare interventions: a method study

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.

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic vs laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from study inception to October 9, 2014, using the intersection of the themes "robotic" and "hysterectomy." We included only randomized and quasi-randomized controlled trials of robotic vs laparoscopic hysterectomy in women for benign disease. Four trials met our inclusion criteria and were included in the analyses. We extracted data, and assessed the studies for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RRs) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 complications among 326 patients. Comparing robotic and laparoscopic hysterectomy, revealed no statistically significant differences in the rate of class 1 and 2 complications (RR, 0.66; 95% confidence interval [CI], 0.23-1.89) or in the rate of class 3 and 4 complications (RR, 0.99; 95% CI, 0.22-4.40). Analyses of secondary outcomes were limited owing to heterogeneity, but showed no significant benefit of the robotic technique over the laparoscopic technique in terms of length of hospital stay (weighted mean difference, -0.39 day; 95% CI, -0.92 to 0.14 day), total operating time (weighted mean difference, 9.0 minutes; 95% CI, -31.27 to 47.26 minutes), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were reported inconsistently and were not amenable to pooling. Current evidence demonstrates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

Methods of Intracanal Reinforcement in Primary Anterior Teeth-Assessing the Outcomes through a Systematic Literature Review

AIM

To assess how the various methods of intracanal reinforcement (short root canal posts) performed in their clinical and radiographic outcomes for restoring grossly broken down primary anterior teeth after pulpectomy for 1 year or longer follow-up period.

MATERIALS AND METHODS

Literature search of electronic databases (Sept 2013) and various journals (1980-Sept 2013) using medical subject headings and free text terms was conducted. For inclusion in quality assessment, prespecified inclusion criteria were applied. Quality assessment was performed by using 'The Cochrane collaboration's tool for assessing risk of bias'.

RESULTS

Seven relevant papers were selected for full text evaluation. After applying the inclusion criteria, only two trials could be considered for quality assessment. Both of these were classified as having high risk of bias.

CONCLUSION

The evidence to support any method of intracanal reinforcement for restoring grossly broken down anterior teeth is presently lacking. Further trials with well-defined methodology are needed. How to cite this article: Mittal N, Bhatia HP, Haider K. Methods of Intracanal Reinforcement in Primary Anterior Teeth- Assessing the Outcomes through a Systematic Literature Review. Int J Clin Pediatr Dent 2015;8(1):48-54.

Challenges in recruitment to a randomized controlled study of cardiovascular disease reduction in sleep apnea: an analysis of alternative strategies

STUDY OBJECTIVES

A challenge in conducting randomized controlled trials of sleep apnea is the timely recruitment of participants to active and control arms. This study assesses the costs and efficiencies of alternative recruitment methods.

DESIGN

Analysis of recruitment data from the Best Apnea Intervention in Research planning study.

SETTING

Sleep clinics and cardiology practices.

PARTICIPANTS

One hundred forty-eight individuals with an apnea-hypopnea index > 15 and cardiovascular (CV) risk factors randomized from a pool of more than 30,000 potentially eligible patients.

INTERVENTIONS

Comparisons: (1) modes of recruitment: face-to-face (F2F) recruitment versus mail-based recruitment (MBR); (2) recruitment source (sleep versus cardiology clinics).

MEASUREMENTS AND RESULTS

Recruitment yield was defined as the ratio of the number of subjects randomized to the number of screened records. Recruitment costs were estimated based on staff time. Of the 148 randomized subjects, 25 were recruited from sleep clinics using F2F recruitment and 123 were recruited from cardiology using a F2F (n = 35) or MBR (n = 88) strategy. F2F recruitment yields were 0.17% and 0.30% for sleep versus cardiology sources, respectively (P = 0.04). A comparison of F2F to MBR showed recruitment yields of 1.11% and 0.90% and costs per randomized subject of $2,139 and $647, respectively.

CONCLUSIONS

Large resources may be needed to meet the recruitment goals of sleep apnea intervention trials. Recruitment source and mode influence efficiencies. For a trial comparing active versus sham continuous positive airway pressure in patients with CV risk factors, recruiting from cardiology was more efficient than from sleep clinics. MBR was three times less costly than F2F recruitment.

Current evidence on auricular therapy for chemotherapy-induced nausea and vomiting in cancer patients: a systematic review of randomized controlled trials

Auricular therapy (AT) has been historically viewed as a convenient approach adjunct to pharmacological therapy for cancer patients with chemotherapy-induced nausea and vomiting (CINV). The aim of this study was to assess the evidence of the therapeutic effect of AT for CINV management in cancer patients. Relevant randomized controlled trials were retrieved from 12 electronic databases without language restrictions. Meanwhile, manual search was conducted for Chinese journals on complementary medicine published within the last five years, and the reference lists of included studies were also checked to identify any possible eligible studies. Twenty-one studies with 1713 participants were included. The effect rate of AT for managing acute CINV ranged from 44.44% to 93.33% in the intervention groups and 15% to 91.67% in the control groups. For delayed CINV, it was 62.96% to 100% and 25% to 100%, respectively. AT seems to be a promising approach in managing CINV. However, the level of evidence was low and the definite effect cannot be concluded as there were significant methodological flaws identified in the analyzed studies. The implications drawn from the 21 studies put some clues for future practice in this area including the need to conduct more rigorously designed randomized controlled trials.

Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment.

OBJECTIVES

To summarize treatment efficacy for patients presenting with NCCP.

METHODS

Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group).

RESULTS

Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions.

LIMITATIONS

Only a small number of studies were available.

CONCLUSIONS

Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.

The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review

OBJECTIVE

To evaluate the effectiveness of Pilates exercise in people with chronic low back pain (CLBP) through a systematic review of randomised controlled trials (RCTs).

DATA SOURCES

A search for RCTs was undertaken using Medical Search Terms and synonyms for "Pilates" and "low back pain" within the maximal date range of 10 databases. Databases included the Cumulative Index to Nursing and Allied Health Literature; Cochrane Library; Medline; Physiotherapy Evidence Database; ProQuest: Health and Medical Complete, Nursing and Allied Health Source, Dissertation and Theses; Scopus; Sport Discus; Web of Science.

STUDY SELECTION

Two independent reviewers were involved in the selection of evidence. To be included, relevant RCTs needed to be published in the English language. From 152 studies, 14 RCTs were included.

DATA EXTRACTION

Two independent reviewers appraised the methodological quality of RCTs using the McMaster Critical Review Form for Quantitative Studies. The author(s), year of publication, and details regarding participants, Pilates exercise, comparison treatments, and outcome measures, and findings, were then extracted.

DATA SYNTHESIS

The methodological quality of RCTs ranged from "poor" to "excellent". A meta-analysis of RCTs was not undertaken due to the heterogeneity of RCTs. Pilates exercise provided statistically significant improvements in pain and functional ability compared to usual care and physical activity between 4 and 15 weeks, but not at 24 weeks. There were no consistent statistically significant differences in improvements in pain and functional ability with Pilates exercise, massage therapy, or other forms of exercise at any time period.

CONCLUSIONS

Pilates exercise offers greater improvements in pain and functional ability compared to usual care and physical activity in the short term. Pilates exercise offers equivalent improvements to massage therapy and other forms of exercise. Future research should explore optimal Pilates exercise designs, and whether some people with CLBP may benefit from Pilates exercise more than others.

Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials

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.

Auditory-verbal therapy for promoting spoken language development in children with permanent hearing impairments

BACKGROUND

Congenital or early-acquired hearing impairment poses a major barrier to the development of spoken language and communication. Early detection and effective (re)habilitative interventions are essential for parents and families who wish their children to achieve age-appropriate spoken language. Auditory-verbal therapy (AVT) is a (re)habilitative approach aimed at children with hearing impairments. AVT comprises intensive early intervention therapy sessions with a focus on audition, technological management and involvement of the child's caregivers in therapy sessions; it is typically the only therapy approach used to specifically promote avoidance or exclusion of non-auditory facial communication. The primary goal of AVT is to achieve age-appropriate spoken language and for this to be used as the primary or sole method of communication. AVT programmes are expanding throughout the world; however, little evidence can be found on the effectiveness of the intervention.

OBJECTIVES

To assess the effectiveness of auditory-verbal therapy (AVT) in developing receptive and expressive spoken language in children who are hearing impaired.

SEARCH METHODS

CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, speechBITE and eight other databases were searched in March 2013. We also searched two trials registers and three theses repositories, checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

The review considered prospective randomised controlled trials (RCTs) and quasi-randomised studies of children (birth to 18 years) with a significant (≥ 40 dBHL) permanent (congenital or early-acquired) hearing impairment, undergoing a programme of auditory-verbal therapy, administered by a certified auditory-verbal therapist for a period of at least six months. Comparison groups considered for inclusion were waiting list and treatment as usual controls.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts identified from the searches and obtained full-text versions of all potentially relevant articles. Articles were independently assessed by two review authors for design and risk of bias. In addition to outcome data, a range of variables related to participant groups and outcomes were documented.

MAIN RESULTS

Of 2233 titles and abstracts searched, only 13 abstracts appeared to meet inclusion criteria. All 13 full-text articles were excluded following independent evaluation by two review authors (CGBJ and JW), as they did not meet the inclusion criteria related to the research design. Thus, no studies are included in this review.

AUTHORS' CONCLUSIONS

This review confirms the lack of well-controlled studies addressing the use of AVT as an intervention for promoting spoken language development in children with permanent hearing impairments. Whilst lack of evidence does not necessarily imply lack of effect, it is at present not possible for conclusions to be drawn as to the effectiveness of this intervention in treating children with permanent hearing impairments.

Percutaneous compression plate versus dynamic hip screw for treatment of intertrochanteric Hip fractures: a meta-analyse of five randomized controlled trials

BACKGROUND

Percutaneous compression plating (PCCP) has been advocated to reduce blood loss, relieve pain, and lead to faster rehabilitation for the treatment of intertrochanteric fractures. The purpose of this meta-analysis was to estimate the outcomes and complications of the PCCP versus dynamic hip screw (DHS) fixation for intertrochanteric fractures.

METHODS

All randomized controlled trials (RCT) that compared PCCP with DHS in treating adult patients with intertrochanteric fractures were included. Main outcomes were collected and analysed using the RevMan 5.1 version.

RESULTS

Five trials met the inclusion criteria. Compared with DHS, PCCP had similar operation time (95% CI: -26.01~4.05, P = 0.15), length of hospitalization (95% CI: -1.79~1.25, P = 0.73), mortality (95% CI: 0.37~1.02, P = 0.06), incidence of implant-related complications (95% CI: 0.29~1.82, P = 0.49), and reoperation rate (95% CI: 0.41~3.05, P = 0.83). But blood loss (95% CI: -173.84~-4.81, P = 0.04) and transfusion need (95% CI: -0.53~-0.07, P = 0.01) significantly favored the PCCP.

CONCLUSIONS

The PCCP was associated with reduced blood loss and less transfusion need, but similar to DHS in other respects. Owing to the limitations of this systematic review, more high-quality RCTs are still needed to assess the clinical efficiency of PCCP.

Using multiple types of studies in systematic reviews of health care interventions--a systematic review

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.

Factors influencing women's decision to participate or not in a surgical randomised controlled trial for surgical treatment of female stress urinary incontinence

The study aims to explore the potentially influential factors affecting women's decision to accept/decline participation in surgical randomised trial using a novel acceptance/refusal questionnaire (ARQ). All women who were eligible to participate in SIMS-RCT were asked to complete the relevant section (acceptance/refusal) of the ARQ. Women reported its degree of relevance for their decision on a six-point Likert scale (0 = highly irrelevant, 5 = highly relevant). 135 (98%) and 31 (70%) women completed the acceptance and refusal sections of the ARQ, respectively. The most influencing factor in women's acceptance was the anticipation of “potential personal benefit”; percentage of relevance (POR) was 91.9%, followed by interest in helping others by “supporting innovative medical research”; POR was 87.7%. Most influencing factor in refusal for participation was “do not have time for follow-up”; POR was 56.8%, followed by “do not like the concept of randomisation”; POR was 54.4%. In conclusion, this study identifies the most influential factors relevant to women decision-making whether or not to participate in RCTs assessing surgical interventions for female stress urinary incontinence (SUI). A number of factors leading to refusal of participation are potentially correctable leading to better recruitment rates in future RCTs.

Strategies for postmarketing surveillance of drugs and devices in patients with ESRD undergoing dialysis

The lack of evidence on the effectiveness and safety of interventions in chronic dialysis patients has been a subject of continuing criticism. New technologies are often introduced into the market without having specifically studied or even included patients with advanced kidney disease. Therefore, the need to generate valid effectiveness and safety data in this vulnerable subpopulation is of utmost importance. The US Food and Drug Administration has recently placed an increased focus on safety surveillance, and sponsors must now meet this additional postmarketing commitment. In patients with ESRD, the unique data collection environment in the United States allows for creative and efficient study designs to meet the needs of patients, providers, and sponsors. The purpose of this manuscript is to review the methodological and practical aspects of the different options for postmarketing study design in this field, with critical appraisal of their advantages and disadvantages.

Assessment of the reporting quality of randomized controlled trials on the treatment of diabetes mellitus with traditional chinese medicine: a systematic review

BACKGROUND

After the publication of the CONSORT 2010 statement, few studies have been conducted to assess the reporting quality of randomized clinical trials (RCTs) on treatment of diabetes mellitus with Traditional Chinese Medicine (TCM) published in Chinese journals.

OBJECTIVE

To investigate the current situation of the reporting quality of RCTs in leading medical journals in China with the CONSORT 2010 statement as criteria.

METHODS

The China National Knowledge Infrastructure (CNKI) electronic database was searched for RCTs on the treatment of diabetes mellitus with TCM published in the Journal of Traditional Chinese Medicine, Chinese Journal of Integrated Traditional & Western Medicine, and the China Journal of Chinese Materia Medica from January to December 2011. We excluded trials reported as "animal studies", "in vitro studies", "case studies", or "systematic reviews". The CONSORT checklist was applied by two independent raters to evaluate the reporting quality of all eligible trials after discussing and comprehending the items thoroughly. Each item in the checklist was graded as either "yes" or "no" depending on whether it had been reported by the authors.

RESULTS

We identified 27 RCTs. According to the 37 items in the CONSORT checklist, the average reporting percentage was 45.0%, in which the average reporting percentage for the "title and abstract", the "introduction", the "methods", the "results", the "discussion" and the "other information" was 33.3%, 88.9%, 36.4%, 54.4%, 71.6% and 14.8%, respectively. In the Journal of Traditional Chinese Medicine, Chinese Journal of Integrated Traditional & Western Medicine, and the China Journal of Chinese Materia Medica the average reporting percentage was 42.2%, 56.8%, and 46.0%, respectively.

CONCLUSIONS

The reporting quality of RCTs in these three journals was insufficient to allow readers to assess the validity of the trials. We recommend that editors require authors to use the CONSORT statement when reporting their trial results as a condition of publication.

SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials

High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.