The value of endocervical and endometrial lidocaine flushing before office hysteroscopy: A randomized controlled trial

Concerns about Data Integrity of 22 Randomized Controlled Trials in Women's Health

OBJECTIVE

During a review on postpartum hemorrhage, we identified randomized controlled trials (RCTs) of one author conducted at the same time and place for the same condition, with large differences in baseline characteristics. We assessed the data integrity of the RCTs of this author.

STUDY DESIGN

We undertook a focused analysis of the data integrity of all RCTs published by Dr. Ahmed M. Maged. We examined the studies for clinical logic and made pairwise comparisons of baseline characteristics and outcomes between trials. We used mathematical methods to assess whether the distribution of baseline characteristics was compatible with chance.

RESULTS

Between March 2015 and December 2019, Dr. Maged published 22 RCTs (n = 3,722). The median number of participants randomized per center per month was 32 (range = 1-89). Fifteen studies were either not or retrospectively registered, with one study registered 1 year after publication. One study was submitted for publication prior to the completion of the described study period. There were many unusual findings in the studies, including biologically implausible occurrences such as the absence of an association between gestational age and birthweight in seven studies and very different body mass index between three trials, which ran at the same time in the same hospital on the same topic as well as unlikely occurrences such as limited participant drop outs. One paper contained considerable text duplication and identical data to that in a paper published by a different author group from a different hospital, with both papers submitted at the same time. Mathematical analysis of the baseline characteristics of all 22 trials indicated that at least some of the reported baseline characteristics were unlikely to be the result of proper randomization.

CONCLUSION

Our analyses of the 22 RCTs of Dr. Maged suggest potential data integrity issues in at least some of them. We suggest that journals investigate according to the Committee on Publication Ethics guidelines. The procedures demonstrated in this paper may help to assess data integrity in future attempts to verify the authenticity of published RCTs.

KEY POINTS

· We identified a number of findings biologically implausible in RCTs by Maged.. · Monte Carlo simulation found pooled data of Maged RCTs were unlikely result of proper randomization.. · Textual overlap and almost identical data were found between a Maged paper and another paper.. · The methods we described may be useful for future efforts in validating scientific data integrity..

Assessment of Pain at Different Steps of Diagnostic Hysteroscopy Using Room Temperature Normal Saline versus Warmed Normal Saline Solution as Distension Medium: A Randomized Controlled Trial

Objectives

Compare pain intensity at entry into the cervical os, during uterine distension and 15 min after the procedure, in patients undergoing diagnostic hysteroscopy with room temperature normal saline versus that with saline warmed to 38-40°C, using visual analog scale (VAS) score. Furthermore, compare the time taken and failed procedures between them.

Materials and Methods

This was a randomized controlled, prospective study conducted at a Tertiary Care Center on 100 patients planned for diagnostic hysteroscopy with a 4 mm 30° hysteroscope using vaginoscopy technique. They were divided into two groups of 50 each, with control undergoing the procedure using normal saline at room temperature and the test with saline warmed to 38-40°C as distension medium. Primary outcomes were VAS at the point of entry into the internal os (T0), 1 min later (T1), and 15 min after the procedure (T15). Secondary outcomes were procedural acceptance, time taken, and failed procedures.

Results

The mean VAS in the control group at T0, T1, T15 was 3.31 (1.461;‒0.870-0.245), 2.46 (1.398;‒0.539-0.498), 0.75 (0.911;‒0.379-0.338), respectively, as compared to the test group of 3.62 (1.282;‒0.870-0.245), 2.48 (1.148;‒0.540-0.498), 0.77 (0.911;‒0.379-0.379), respectively. About 73.5% of controls and 68.8% in the test group were willing to undergo the procedure again. About 93.9% of controls would recommend it further as against 93.8% among the test controls. The time taken and number of failed procedures showed no statistical difference.

Conclusion

No significant difference was noted in terms of outcomes measured by warming the distension medium.

Analgesic Efficacy of Intrauterine Lidocaine Flushing in Hysterosalpingo-foam Sonography: A Double-blind Randomized Controlled Trial

STUDY OBJECTIVE

To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain.

DESIGN

A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure.

SETTING

University-affiliated medical center.

PATIENTS

A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively.

INTERVENTIONS

The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10).

MEASUREMENTS AND MAIN RESULTS

The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001).

CONCLUSION

Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure.

Addition of Lidocaine to the Distension Medium in Hysteroscopy Decreases Pain during the Procedure-A Randomized Double-blind, Placebo-controlled Trial

STUDY OBJECTIVE

To evaluate the effect of adding a local anesthetic to the distension medium in office diagnostic hysteroscopy using the vaginoscopic approach on pain during the procedure. Secondary aims included documenting side effects, patient satisfaction, and the time needed to complete the procedure.

DESIGN

Randomized double-blind placebo-controlled study.

SETTING

University-affiliated hospital; office hysteroscopy clinic.

PATIENTS

Total of 100 patients who underwent office hysteroscopies divided in half with 50 in the intervention group and 50 in the control group.

INTERVENTIONS

Ten mL of lidocaine 2% added to 1000 mL of saline solution that was used as the distension medium for hysteroscopy in the study group vs 1000 mL of saline alone in the control group.

MEASUREMENTS AND MAIN RESULTS

A significant difference was found in the increment of pain as measured by visual analog scale after the hysteroscopy between the 2 groups. Patients receiving lidocaine had an average rise of 1.9 in the visual analog scale score after the procedure compared with 2.9 in the control group (p = .033). There was also a nonsignificant trend for shorter duration of hysteroscopy in the intervention group compared with the control group (180.1 vs 222.1 seconds, p = .08). Patients' satisfaction was high in both groups (98% for the study group and 92% for the control group). Success rates were also similar between the 2 groups at approximately 95%. No side effects were recorded in either group.

CONCLUSION

The addition of local anesthetic to the distension medium in office hysteroscopy produces significant reduction in pain during the procedure without adding time to the procedure and without side effects.

Pain management during diagnostic office hysteroscopy in postmenopausal women: a randomized study

Objective: This study aimed to compare efficacy and safety of lidocaine versus tramadol versus placebo in reducing the pain of diagnostic outpatient hysteroscopy (OH) in postmenopausal women.Materials and methods: This randomized double-blinded study included 156 menopausal women who received intrauterine lidocaine infusion or oral tramadol (50 mg) or placebo before diagnostic OH (52 women/group). Primary outcome was pain severity during the procedure using a 10-cm visual analog scale. Secondary outcomes were pain scores 10 and 30 min post procedure, satisfaction level, and ease of cervical entry.Results: Lidocaine had lower pain scores compared to placebo during and 10 min after the procedure (p < 0.001). Tramadol had lower pain scores than placebo during the procedure (p = 0.04), 10 min after the procedure (p = 0.03), and 30 min after the procedure (p = 0.04). Both lidocaine and tramadol resulted in an easier procedure than placebo (p < 0.001 and p = 0.04, respectively). Lidocaine had an easier cervical entry compared to tramadol (p = 0.004). Satisfaction scores in the lidocaine and tramadol groups were significantly higher than in the placebo group (p < 0.001).Conclusions: Lidocaine and tramadol were effective in reducing postmenopausal women-reported pain during and after diagnostic OH. However, lidocaine was better than tramadol in facilitating hysteroscope passage through the cervical canal and the reduction in pain levels with lidocaine was clinically relevant.Trial registration number: NCT03701984.