Addressing continuous data for participants excluded from trial analysis: a guide for systematic reviewers

Oral vitamin D supplementation for adults with obesity undergoing bariatric surgery

BACKGROUND

Vitamin D deficiency following bariatric surgery is common and is expected to be associated with a deleterious impact on the skeleton. However, the benefits of vitamin D supplementation and the optimal dose in this population is currently unknown. The available guidelines on the topic are derived from experts' opinions, and are not evidence based.

OBJECTIVES

To compare the effects of different doses of vitamin D supplementation (low dose (less than 600 international units (IU)/day), moderate dose (600 IU/day to 3500 IU/day), high dose (greater than 3500 IU/day)) to each other or to placebo in adults living with obesity undergoing bariatric surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, two trial registries, and the reference lists of systematic reviews, articles, and health technology assessment reports without language restrictions. The last search of all databases was 27 June 2023, except Embase, which we searched on 14 August 2015.

SELECTION CRITERIA

We included randomised controlled trials or controlled clinical trials on vitamin D supplementation comparing different doses or comparing vitamin D to placebo in people undergoing bariatric surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were fractures and adverse events. Secondary outcomes were vitamin D status, all-cause mortality, bone mineral change, secondary hyperparathyroidism, health-related quality of life, and muscle strength. We used GRADE to assess the certainty of the evidence for each outcome in each comparison.

MAIN RESULTS

We identified five trials with 314 participants. We included three trials in the quantitative analysis. Moderate-dose vitamin D compared to placebo One trial compared moderate-dose vitamin D (3200 IU/day) to placebo. Moderate-dose vitamin D, compared to placebo, may improve vitamin D status and may result in little to no difference in the achieved parathyroid hormone level (achieved 25-hydroxyvitamin D level: mean difference (MD) 13.60 ng/mL, 95% confidence interval (CI) 7.94 to 19.26; achieved parathyroid hormone level: -6.60 pg/mL, 95% CI -17.12 to 3.92; 1 study, 79 participants; low-certainty evidence). The trial reported no adverse events in the moderate-dose vitamin D arm, but did not provide any information on adverse events in the placebo arm. There were no data on fractures, all-cause mortality, bone density change, health-related quality of life, and muscle strength. High-dose vitamin D compared to moderate-dose vitamin D Two trials in Roux-en-Y gastric bypass compared moderate-dose (equivalent dose 800 IU/day to 2000 IU/day) to high-dose (equivalent dose 5000 IU/day to 7943 IU/day) vitamin D. The evidence of high-dose vitamin D on adverse events is very uncertain (risk ratio (RR) 5.18, 95% CI 0.23 to 116.56; 2 studies, 81 participants; very low-certainty evidence). High-dose vitamin D may increase 25-hydroxyvitamin D levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 15.55 ng/mL, 95% CI 3.50 to 27.61; I2 = 62%; 2 studies, 73 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on parathyroid hormone levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 2.15 pg/mL, 95% CI -21.31 to 17.01; I2 = 0%; 2 studies, 72 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on mortality and bone mineral density at the lumbar spine, hip, and forearm, but the evidence is very uncertain. There were no data on fractures, health-related quality of life, or muscle strength.

AUTHORS' CONCLUSIONS

No trials reported on fractures and the evidence available on adverse events is scarce. Moderate-dose vitamin D may improve vitamin D status and may result in little to no improvement in parathyroid hormone levels compared with placebo. High-dose vitamin D supplementation (greater than 3500 IU/day) may increase 25-hydroxyvitamin D levels, and may have little to no effect on parathyroid hormone levels, compared to a moderate dose, but the evidence for both is very uncertain. The currently available limited evidence may not have a significant impact on practice. Further studies are needed to explore the impact of vitamin D supplementation on fractures, adverse events, and musculoskeletal parameters in people undergoing bariatric surgery.

Immunotherapy for advanced and recurrent malignant pleural mesothelioma

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of immune checkpoint inhibitors (single-agent or combination therapy) in people with advanced malignant pleural mesothelioma in a first-line or salvage setting.

Effectiveness of Mobile App Interventions to Improve Periodontal Health: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Periodontal health plays a key role as a shared reference point for evaluating periodontal diseases and identifying significant treatment outcomes. Providing adequate instruction and enhancing the motivation of patients to maintain proper oral hygiene are crucial factors for successful periodontal treatment, with self-performed regular oral hygiene identified as a critical factor in improving the outcomes of treatment for periodontal diseases. Recently, mobile health (mHealth) solutions, especially mobile apps, have emerged as valuable tools for self-management in chronic diseases such as periodontal disease, providing essential health education and monitoring capabilities. However, the use of mHealth apps for periodontal health is complex owing to various interacting components such as patient behavior, socioeconomic status, and adherence to oral hygiene practices. Existing literature has indicated positive effects of mHealth on oral health behaviors, knowledge, attitude, practice, plaque index score, and gingivitis reduction. However, there has been no systematic review of mobile apps specifically targeting patients with periodontal disease. Understanding the design and impact of mHealth apps is crucial for creating high-quality apps.

OBJECTIVE

The aim of this systematic review and meta-analysis is to evaluate the effectiveness of existing mobile apps in promoting periodontal health.

METHODS

A comprehensive search strategy will be performed in multiple electronic databases (PubMed, EBSCOhost, CINAHL Plus, Dentistry & Oral Sciences, ScienceDirect, Scopus, and Cochrane Central Register of Controlled Trials) with the following keywords in the title/abstract: "mobile application," "mobile health," "mHealth," "telemedicine," "periodontal health," "periodontitis," and "text message." Only randomized controlled trials will be included that assessed the following outcomes to measure periodontal health improvement: gingival index, bleeding index, periodontal pocket depth, and clinical attachment loss. Covidence will be used for data collection, and a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flowchart will be used to describe the selection process of the included, identified, and excluded studies. The Confidence in Network Meta-Analysis approach will be used for meta-analysis of the extracted data from the included studies.

RESULTS

This review will not require ethical approval since no primary data will be included. As of July 2024, a total of 83 articles retrieved from various databases have been imported to Covidence with 13 articles deemed eligible for inclusion in the review. The review is currently ongoing and is expected to be complete by the end of 2024 with the results published in early 2025.

CONCLUSIONS

This systematic review and meta-analysis will contribute to developing mobile apps with enhanced criteria to improve periodontal clinical outcomes. The review emphasizes the importance of mHealth and preventing periodontal disease, which can set the stage for informed global health care strategies.

TRIAL REGISTRATION

PROSPERO CRD42022340827; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=340827.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50479.

Higher versus lower protein intake in formula-fed term infants

BACKGROUND

Many infants are fed infant formulas to promote growth. Some formulas have a high protein content (≥ 2.5 g per 100 kcal) to accelerate weight gain during the first year of life. The risk-benefit balance of these formulas is unclear.

OBJECTIVES

To evaluate the benefits and harms of higher protein intake versus lower protein intake in healthy, formula-fed term infants.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, OpenGrey, clinical trial registries, and conference proceedings in October 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of healthy formula-fed infants (those fed only formula and those given formula as a complementary food). We included infants of any sex or ethnicity who were fed infant formula for at least three consecutive months at any time from birth. We excluded quasi-randomized trials, observational studies, and infants with congenital malformations or serious underlying diseases. We defined high protein content as 2.5 g or more per 100 kcal, and low protein content as less than 1.8 g per 100 kcal (for exclusive formula feeding) or less than 1.7 g per 100 kcal (for complementary formula feeding).

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed the risk of bias and extracted data from trials, and a fifth review author resolved discrepancies. We performed random-effects meta-analyses, calculating risk ratios (RRs) or Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) with 95% CIs for continuous outcomes. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We included 11 RCTs (1185 infants) conducted in high-income countries. Seven trials (1629 infants) compared high-protein formula against standard-protein formula, and four trials (256 infants) compared standard-protein formula against low-protein formula. The longest follow-up was 11 years. High-protein formula versus standard-protein formula We found very low-certainty evidence that feeding healthy term infants high-protein formula compared to standard-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.05 SDs, 95% CI -0.09 to 0.19; P = 0.51, I2 = 61%; 7 studies, 1629 participants), stunting (MD in height-for-age z-score 0.15 SDs, 95% CI -0.05 to 0.35; P = 0.14, I2 = 73%; 7 studies, 1629 participants), and wasting (MD in weight-for-height z-score -0.12 SDs, 95% CI -0.31 to 0.07; P = 0.20, I2 = 94%; 7 studies, 1629 participants) in the first year of life. We found very low-certainty evidence that feeding healthy infants high-protein formula compared to standard-protein formula has little or no effect on the occurrence of overweight (RR 1.26, 95% CI 0.63 to 2.51; P = 0.51; 1 study, 1090 participants) or obesity (RR 1.96, 95% CI 0.59 to 6.48; P = 0.27; 1 study, 1090 participants) at five years of follow-up. No studies reported all-cause mortality. Feeding healthy infants high-protein formula compared to standard-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (RR 0.93, 95% CI 0.76 to 1.13; P = 0.44, I2 = 0%; 4 studies, 445 participants; low-certainty evidence) in the first year of life. Standard-protein formula versus low-protein formula We found very low-certainty evidence that feeding healthy infants standard-protein formula compared to low-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.0, 95% CI -0.43 to 0.43; P = 0.99, I2 = 81%; 4 studies, 256 participants), stunting (MD in height-for-age z-score -0.01, 95% CI -0.36 to 0.35; P = 0.96, I2 = 73%; 4 studies, 256 participants), and wasting (MD in weight-for-height z-score 0.13, 95% CI -0.29 to 0.56; P = 0.54, I2 = 95%; 4 studies, 256 participants) in the first year of life. No studies reported overweight, obesity, or all-cause mortality. Feeding healthy infants standard-protein formula compared to low-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (Peto OR 1.55, 95% CI 0.70 to 3.40; P = 0.28, I2 = 0%; 2 studies, 206 participants; low-certainty evidence) in the first four months of life.

AUTHORS' CONCLUSIONS

We are unsure if feeding healthy infants high-protein formula compared to standard-protein formula has an effect on undernutrition, overweight, or obesity. There may be little or no difference in the risk of adverse effects between infants fed with high-protein formula versus those fed with standard-protein formula. We are unsure if feeding healthy infants standard-protein formula compared to low-protein formula has any effect on undernutrition. There may be little or no difference in the risk of adverse effects between infants fed with standard-protein formula versus those fed with low-protein formula. The findings of six ongoing studies and two studies awaiting classification studies may change the conclusions of this review.

Efficacy and safety of acupuncture for post-COVID-19 depression: a protocol for systematic review and meta-analysis

INTRODUCTION

Post-COVID-19 depression (PCD) is a possible sequela of COVID-19. Some doctors have used acupuncture to treat PCD, but no systematic review or meta-analysis has yet evaluated its efficacy and safety for the treatment of PCD. The aim of this systematic review is to assess the efficacy and safety of acupuncture therapy for PCD.

METHODS AND ANALYSIS

Two reviewers will independently search the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (PubMed), Excerpt Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Chinese Scientific Journal Database (VIP) and Wan-Fang Database from inception to 24 January 2023. Study selection, data extraction and assessment of study quality will be independently performed by two reviewers. If a meta-analysis is appropriate, Review Manager V.5.3 will be used for data synthesis; otherwise, a descriptive analysis will be conducted. Data will be synthesised using a fixed-effects or random-effects model, according to the results of a heterogeneity test. The results will be presented as risk ratios with 95% CIs for dichotomous data, and weighted mean differences or standardised mean differences with 95% CIs for continuous data.

ETHICS AND DISSEMINATION

The entire process used for this systematic review does not use private information, so ethical approval is not required. The results of this meta-analysis will be disseminated through publication in a peer-reviewed journal and/or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022379312.

Ultrasound-guided arterial cannulation in the paediatric population

BACKGROUND

In arterial line cannulation in children and adolescents, traditional methods of locating the artery include palpation and Doppler auditory assistance. It is unclear whether ultrasound guidance is superior to these methods. This is an update of a review originally published in 2016.

OBJECTIVES

To evaluate the benefits and harms of ultrasound guidance compared with traditional techniques (palpation, Doppler auditory assistance) for assisting arterial line placement at all potential sites in children and adolescents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science from inception to 30 October 2022. We also searched four trials registers for ongoing trials, and we checked the reference lists of included studies and relevant reviews for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing ultrasound guidance versus other techniques (palpation or Doppler auditory assistance) to guide arterial line cannulation in children and adolescents (aged under 18 years). We planned to include quasi-RCTs and cluster-RCTs. For RCTs with both adult and paediatric populations, we planned to include only the paediatric population data.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of included trials and extracted data. We used standard Cochrane meta-analytical procedures, and we applied the GRADE method to assess the certainty of evidence.

MAIN RESULTS

We included nine RCTs reporting 748 arterial cannulations in children and adolescents (under 18 years of age) undergoing different surgical procedures. Eight RCTs compared ultrasound with palpation, and one compared ultrasound with Doppler auditory assistance. Five studies reported the incidence of haematomas. Seven involved radial artery cannulation and two involved femoral artery cannulation. The people performing arterial cannulation were physicians with different levels of experience. The risk of bias varied across studies, with some studies lacking details of allocation concealment. It was not possible to blind practitioners in any case; this adds a performance bias that is inherent to the type of intervention studied in our review. Compared to traditional methods, ultrasound guidance probably causes a large increase in first-attempt success rates (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.64 to 2.46; 8 RCTs, 708 participants; moderate-certainty evidence) and probably causes a large reduction in the risk of complications such as haematoma formation (RR 0.26, 95% CI 0.14 to 0.47; 5 RCTs, 420 participants; moderate-certainty evidence). No studies reported data about ischaemic damage. Ultrasound guidance probably improves success rates within two attempts (RR 1.78, 95% CI 1.25 to 2.51; 2 RCTs, 134 participants; moderate-certainty evidence) and overall rate of successful cannulation (RR 1.32, 95% CI 1.10 to 1.59; 6 RCTs, 374 participants; moderate-certainty evidence). In addition, ultrasound guidance probably reduces the number of attempts to successful cannulation (mean difference (MD) -0.99 attempts, 95% CI -1.15 to -0.83; 5 RCTs, 368 participants; moderate-certainty evidence) and duration of the cannulation procedure (MD -98.77 seconds, 95% CI -150.02 to -47.52, 5 RCTs, 402 participants; moderate-certainty evidence). More studies are needed to confirm whether the improvement in first-attempt success rates is more pronounced in neonates and younger children compared to older children and adolescents.

AUTHORS' CONCLUSIONS

We identified moderate-certainty evidence that ultrasound guidance for arterial cannulation compared with palpation or Doppler auditory assistance improves first-attempt success rate, second-attempt success rate and overall success rate. We also found moderate-certainty evidence that ultrasound guidance reduces the incidence of complications, the number of attempts to successful cannulation and the duration of the cannulation procedure.

Effects of inulin-type fructans supplementation on cardiovascular disease risk factors: a protocol for a systematic review and meta-analysis of controlled trials

INTRODUCTION

This review aims to assess the effects of dietary supplementation with inulin-type fructans (ITF) compared with no supplementation on cardiovascular disease risk factors in adults and assess the quality of trial reporting using the Consolidated Standards of Reporting Trials (CONSORT) and CONSORT for abstract (CONSORT-A) checklists.

METHODS AND ANALYSIS

We will search randomised controlled trials (RCTs) in MEDLINE, EMBASE, CINAHL, Emcare, AMED and the Cochrane Database of Systematic Reviews from inception to 31 March 2022, without any language restrictions. The RCTs need to administer ITF in adults for at least 2 weeks and assess effects on at least one cardiovascular risk factor. We will exclude RCTs that (1) assessed the postprandial effects of ITF; (2) included pregnant or lactating participants; (3) enrolled participants undergoing treatment that might affect the response to ITF. We will assess the study risk of bias (RoB) using V.2 of the Cochrane RoB tool for RCTs (RoB 2) and the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We will pool data using a random-effects model. We will use the χ² test to compare compliance of CONSORT and CONSORT-A checklists and Poisson regression to identify factors associated with better reporting.

ETHICS AND DISSEMINATION

Ethics approval is not required for secondary analysis of already published data. We will publish the reviews in a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42019136745.

Exercise dose-response relationship with heart rate variability in individuals with overweight and obesity: protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Obesity is a chronic relapsing disease process and serious public health concern that can lead to chronic diseases, medical complications and a higher risk of disability. Another significant feature of obesity is dysfunction in cardiac autonomic function, which leads to changes in parasympathetic and sympathetic regulation, which can be measured using heart rate variability (HRV). The objective of this review is to estimate the extent to which exercise doses impacts on HRV among individuals living with overweight and obesity class I and II.

METHODS AND ANALYSIS

A systematic literature search will be performed using PubMed/Medline, Scopus, EMBASE, ProQuest, CINAHL, Web of Science and the Cochrane Library for articles dating from 1965 to December 2021. Inclusion criteria include studies designed as parallel-arm randomised trials, enrolling adolescent and adult individuals with overweight (body mass index, BMI≥25 to ≤29.9) and obesity (class I BMI: 30-34.9 and class II BMI: 35-39.9) undergoing aerobic or resistance training or concurrent exercise training. For data synthesis, sensitivity analysis, subgroup analysis and risk of bias assessment, Stata V.13.0 software will be used.

ETHICS AND DISSEMINATION

Formal ethical approval is not required. This systematic review will be submitted to a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019104154.

Fire needle for recurrent aphthous stomatitis: A protocol for systematic review and network meta-analysis

BACKGROUND

Recurrent aphthous stomatitis (RAS), are common inflammatory lesions of the oral mucous, usually round or ovoid, circumscribed by erythematous haloes with a yellow-grey floor and mostly painful. The purpose of this study was to evaluate the efficacy and safety of fire needle in the treatment of RAS.

METHODS

PubMed, EMBASE, the Cochrane Library, Chinese National Knowledge Infrastructure, Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database were searched by 2 reviewers from the inception until December 2021. The original study that randomized control trials of fire needle for RAS will be selected and is not limited by country or language. In addition, researches in progress, the reference lists and the citation lists of identified publications will be retrieved similarly. Study selection, data extraction, and assessment of the quality will be performed independently by 2 reviewers who have been trained prior to data extraction. A meta-analysis will be conducted if the quantity and quality of the original studies included are satisfactory; otherwise, a descriptive analysis will be conducted. Review Manager V5.4 software will be using for data synthesis and assessment of the risk of bias according to Cochrane Handbook.

RESULTS

This study will provide a comprehensive review of current evidence for the treatment of fire needle on RAS.

CONCLUSION

The conclusion of this study will provide a judging basis that whether the treatment of RAS with fire needle is effective.

INPLASY REGISTRATION NUMBER

INPLASY2021120118.

Efficacy of excision versus ablation for improving endometriosis related pain: A systematic review and meta-analysis

Background:

Surgical treatment of superficial peritoneal endometriosis includes excision or ablation. Controversy exists about which method is better for providing pain relief. We performed a meta-analysis of randomized control trials (RCTs) comparing the efficacy of excision versus ablation for improving the most frequently encountered endometriosis pain symptoms: dysmenorrhea, dyspareunia, non-cyclic pelvic pain, and dyschezia.

Methods:

A search from inception to May 2020 was conducted in PubMed, MEDLINE, Clinicaltrials.gov, Cochrane Central Register of Controlled Trials, and Web of Science. RCTs comparing excision versus ablation for peritoneal endometriosis were included if they assessed dysmenorrhea, dyspareunia, dyschezia, and pelvic pain/non-menstrual pain. Exclusion criteria included extra-peritoneal endometriosis or endometriomas, and non-English publications. Publications were assessed for risk of bias and quality of evidence using Cochrane risk of bias tool (RoB 2) and GradePro.

Results:

Of the 2025 records identified initially, four met inclusion criteria. The sample sizes of the included studies ranged from 24 to 133 participants. The excision and ablation groups included 204 participants each. There was no difference after excision or ablation for dysmenorrhea when comparing the mean change in pain scores from baseline to 12 months after surgery (−0.31, 95% CI −1.66, 1.04, p = 0.65), dyspareunia (−0.24, 95% CI −1.78, 1.30, p = 0.76), dyschezia (−0.72, 95% CI −1.94, 0.50, p = 0.25), or non-cyclic pain (−0.78, 95% CI −2.47, 0.91, p = 0.37).

Conclusions:

We found low to moderate quality evidence suggesting that neither excision nor ablation is superior in reduction of endometriosis-related pain up to 12 months after surgery.

Effectiveness and safety of auricular therapy for post-stroke depression: A protocol for systematic review and meta-analysis

BACKGROUND

Post-stroke depression is a common and serious complication after stroke. Its main clinical manifestations are depression or instability, loss of interest, loss of appetite, sleep disorders, pessimism, and unworthiness, and even suicidal tendencies. Auricular therapy (AT), as part of traditional Chinese acupuncture, has achieved good results in the treatment of depression, but different clinical studies have shown mixed results. Therefore, the aim of this systematic review is to assess the effectiveness and safety of AT for post-stroke depression.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials; Medline (via PubMed); Excerpt Medica Database; China National Knowledge Infrastructure; Chinese Biomedical Literature Database; Chinese Scientific Journal Database; and Wan-Fang Database from the inception to January 1, 2022. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. If it is appropriate for a meta-analysis, Review Manager Version 5.3 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio with 95% confidence intervals for dichotomous data and weight mean difference or standard mean difference 95% confidence intervals for continuous data.

RESULT

This study will provide a comprehensive review of the available evidence for the treatment of AT with post-stroke depression.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether AT is an effective and safe intervention for patients with post-stroke depression.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021289870.

Anticoagulation for the initial treatment of venous thromboembolism in people with cancer

BACKGROUND

Compared with people without cancer, people with cancer who receive anticoagulant treatment for venous thromboembolism (VTE) are more likely to develop recurrent VTE.

OBJECTIVES

To compare the efficacy and safety of three types of parenteral anticoagulants (i.e. fixed-dose low molecular weight heparin (LMWH), adjusted-dose unfractionated heparin (UFH), and fondaparinux) for the initial treatment of VTE in people with cancer.

SEARCH METHODS

We performed a comprehensive search in the following major databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid) and Embase (via Ovid). We also handsearched conference proceedings, checked references of included studies, and searched for ongoing studies. This update of the systematic review is based on the findings of a literature search conducted on 14 August 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the benefits and harms of LMWH, UFH, and fondaparinux in people with cancer and objectively confirmed VTE.

DATA COLLECTION AND ANALYSIS

Using a standardised form, we extracted data - in duplicate - on study design, participants, interventions, outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, symptomatic VTE, major bleeding, minor bleeding, postphlebitic syndrome, quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

Of 11,484 identified citations, 3073 were unique citations and 15 RCTs fulfilled the eligibility criteria, none of which were identified in the latest search. These trials enrolled 1615 participants with cancer and VTE: 13 compared LMWH with UFH; one compared fondaparinux with UFH and LMWH; and one compared dalteparin with tinzaparin, two different types of low molecular weight heparin. The meta-analyses showed that LMWH may reduce mortality at three months compared to UFH (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.40 to 1.10; risk difference (RD) 57 fewer per 1000, 95% CI 101 fewer to 17 more; low certainty evidence) and may reduce VTE recurrence slightly (RR 0.69, 95% CI 0.27 to 1.76; RD 30 fewer per 1000, 95% CI 70 fewer to 73 more; low certainty evidence). There were no data available for bleeding outcomes, postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing fondaparinux with heparin (UFH or LMWH) found that fondaparinux may increase mortality at three months (RR 1.25, 95% CI 0.86 to 1.81; RD 43 more per 1000, 95% CI 24 fewer to 139 more; low certainty evidence), may result in little to no difference in recurrent VTE (RR 0.93, 95% CI 0.56 to 1.54; RD 8 fewer per 1000, 95% CI 52 fewer to 63 more; low certainty evidence), may result in little to no difference in major bleeding (RR 0.82, 95% CI 0.40 to 1.66; RD 12 fewer per 1000, 95% CI 40 fewer to 44 more; low certainty evidence), and probably increases minor bleeding (RR 1.53, 95% CI 0.88 to 2.66; RD 42 more per 1000, 95% CI 10 fewer to 132 more; moderate certainty evidence). There were no data available for postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing dalteparin with tinzaparin found that dalteparin may reduce mortality slightly (RR 0.86, 95% CI 0.43 to 1.73; RD 33 fewer per 1000, 95% CI 135 fewer to 173 more; low certainty evidence), may reduce recurrent VTE (RR 0.44, 95% CI 0.09 to 2.16; RD 47 fewer per 1000, 95% CI 77 fewer to 98 more; low certainty evidence), may increase major bleeding slightly (RR 2.19, 95% CI 0.20 to 23.42; RD 20 more per 1000, 95% CI 14 fewer to 380 more; low certainty evidence), and may reduce minor bleeding slightly (RR 0.82, 95% CI 0.30 to 2.21; RD 24 fewer per 1000, 95% CI 95 fewer to 164 more; low certainty evidence). There were no data available for postphlebitic syndrome, quality of life, or thrombocytopenia.

AUTHORS' CONCLUSIONS

Low molecular weight heparin (LMWH) is probably superior to UFH in the initial treatment of VTE in people with cancer. Additional trials focusing on patient-important outcomes will further inform the questions addressed in this review. The decision for a person with cancer to start LMWH therapy should balance the benefits and harms and consider the person's values and preferences.

Impact of missing outcome data in meta-analyses of lifestyle interventions during pregnancy to reduce postpartum weight retention: An overview of systematic reviews with meta-analyses and additional sensitivity analyses

High risk of bias associated with missing outcome data (MOD) in meta-analyses (MAs) of the effects of lifestyle interventions during pregnancy on postpartum weight retention (PPWR) casts doubt on whether such interventions can be relied upon as truly effective. This systematic overview of three MAs (19 RCTs), each with high MOD rates in the subset of RCTs included, examined how MOD were addressed in the estimation of summary intervention effects. All MAs reported beneficial and statistically significant intervention effects estimated based on complete case analyses, deemed valid if MOD was missing at random (MAR). Therefore, we conducted sensitivity analyses using pattern mixture models and informative missingness parameters (describing how the outcome in the missing participants may be related to the outcome in the completers), to ascertain the robustness of the estimates to reasonable deviations from the MAR assumption. In plausible scenarios where the response in intervention group participants with versus without MOD was worse (by just 0.5 kg), effect estimates were attenuated in all MAs and no longer statistically significant in two MAs. Statistical significance was retained when all 19 RCTs identified across MAs were examined together in a broader meta-analysis: -0.63 kg (95%CI -0.17, -0.08), but the clinical relevancy of effects of this magnitude remains unclear.

Comparative efficacy and safety of monoclonal antibodies and aspirin desensitization for chronic rhinosinusitis with nasal polyposis: A systematic review and network meta-analysis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory condition of the upper airways. Optimal management is unclear.

OBJECTIVE

We compared the effects of mAbs and aspirin desensitization (ASA-D) for treatment of CRSwNP.

METHODS

We searched the Medline, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, US Food and Drug Administration, and the European Medicines Agency databases from inception to August 4, 2021, for randomized controlled trials comparing the effects of mAbs and ASA-D for CRSwNP. We conducted network meta-analysis of sinusitis symptoms, heath-related quality of life, rescue oral corticosteroids and surgery, endoscopic and radiologic scores, and adverse events. We used the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach to assess certainty of evidence. PROSPERO CRD42020177334.

RESULTS

Twenty-nine randomized controlled trials evaluating 8 treatments (n = 3461) were included in the network meta-analysis. Compared to placebo, moderate to high certainty evidence showed that health-related quality of life (SNOT-22) improved with dupilumab (mean difference [MD] -19.91 [95% confidence interval (CI) -22.50, -17.32]), omalizumab (MD -16.09 [95% CI -19.88, -12.30]), mepolizumab (MD -12.89 [95% CI -16.58, -9.19], ASA-D (MD -10.61 [95% CI -14.51, -6.71]), and benralizumab (MD -7.68 [95% CI -12.09, -3.27]). The risk of rescue nasal polyp surgery likely decreased with dupilumab (risk difference [RD] -16.35% [95% CI -18.13, -13.48]), omalizumab (RD -7.40% [95% CI -11.04, -2.43]), mepolizumab (RD -12.33% [95% CI -15.56, -7.22]), and ASA-D (RD -16.00% [95% CI -19.79, 0.21]; all moderate certainty). Comparisons among agents show with moderate to high certainty that dupilumab ranks among the most beneficial for 7 of 7 outcomes, omalizumab for 2 of 7, mepolizumab for 1 of 7, and ASA-D for 1 of 7.

CONCLUSIONS

Multiple biologics and ASA-D credibly improve patient-important outcomes, with clinically important differences in effects among agents; dupilumab uniquely ranks among the most beneficial for all outcomes studied.

Reporting and Handling of Missing Participant Data in Systematic Reviews of Kidney Transplant Studies

BACKGROUND

Participant withdrawal from clinical trials occurs for various reasons, predominantly adverse effects or intervention inefficacy. Because these missing participant data can have implications for the validity, reproducibility, and generalizability of study results, when conducting a systematic review, it is important to collect and appropriately analyze missing data information to assess its effects on the robustness of the study results.

METHODS

In this methodologic survey of missing participant data reporting and handling in systematic reviews, we included meta-analyses that provided pooled estimates of at least 1 dichotomous intervention outcome of a randomized controlled trial performed in adult kidney transplant subjects.

RESULTS

Eighty-three systematic reviews (17 Cochrane and 66 non-Cochrane reviews) met the inclusion criteria. The most common intervention was drugs (80%), with the majority involving immunosuppressant drugs 55% (n = 46), followed by surgery in 14% (n = 12). The median follow-up duration was 12 months (maximum, 240 mo). Intention-to-treat or modified intention-to-treat analysis was reported in 24% (n = 20) of the reviews (76% of Cochrane and 10% of non-Cochrane). Overall, the majority of systematic reviews did not quantify (90% [n = 60] non-Cochrane and 29% [n = 5] Cochrane) or include the reasons for missing participant data (88% [n = 58] non-Cochrane and 24% [n = 4] Cochrane). Eleven percent (n = 9) handled missing participant data, 5% (n = 4) justified the analytical method(s) used to handle it, and 2% (n = 2) performed a sensitivity analysis for it.

CONCLUSIONS

Systematic reviews of kidney transplantation provide inadequate information on missing participant data and usually do not handle or discuss the associated risk of bias with it.

Effectiveness and safety of traditional Chinese medicine in the treatment of senile hypotension: A protocol for systematic review and meta-analysis

BACKGROUND

Senile hypotension refers to those whose blood pressure (BP) is lower than 90/60 mm Hg. The consequences can not only cause insufficient cardio-cerebral perfusion, but severe cases may also cause angina pectoris and stroke. At present, Western medicine has no ideal therapeutic drugs for senile hypotension. The aim of this systematic review is to assess the effectiveness and safety of traditional Chinese medicine (TCM) therapy for senile hypotension.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials; PubMed; EMBASE; China National Knowledge Infrastructure; Chinese Biomedical Literature Database; Chinese Scientific Journal Database (VIP database); and Wan-Fang Database from the inception, without restriction of publication status and languages. Additional searching including researches in progress, the reference lists and the citation lists of identified publications. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. If it is appropriate for a meta-analysis, RevMan 5.4 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data and weight mean difference (WMD) or standard mean difference 95% CIs for continuous data.

RESULTS

This study will provide a comprehensive review of the available evidence for the treatment of TCM with senile hypotension.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether TCM is an effective and safe intervention for patients with senile hypotension.

ETHICS AND DISSEMINATION

This systematic review will be disseminated in a peer-reviewed journal or presented at relevant conferences. It is not necessary for a formal ethical approval because the data are not individualized.

TRIAL REGISTRATION NUMBER

INPLASY2020110091.

Little needle-scalpel for piriformis syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Piriformis syndrome (PS) is a condition in which the sciatic nerve is compressed when passing through the inferior mouth of the piriformis muscle, mainly caused by pain in one hip and leg. In severe cases, patients may experience severe buttock and lower limb pain, discomfort, difficulty walking, and claudication. It is estimated that the annual incidence of low back pain and sciatica is about 40 million cases, and the annual incidence of piriformis syndrome is about 2.4 million cases. The aim of this systematic review is to assess the effectiveness and safety of Little needle-scalpel therapy for Piriformis syndrome.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; China National Knowledge Infrastructure (CNKI); Chinese Biomedical Literature Database (CBM); Chinese Scientific Journal Database (VIP database); and Wan-Fang Database from the inception, without restriction of publication status and languages. Additional searching including researches in progress, the reference lists, and the citation lists of identified publications. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. If it is appropriate for a meta-analysis, RevMan 5.4 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data and weight mean difference (WMD) or standard mean difference (SMD) 95% CIs for continuous data.

RESULTS

This study will provide a comprehensive review of the available evidence for the treatment of Little needle-scalpel with piriformis syndrome.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether Little needle-scalpel is an effective and safe intervention for patients with piriformis syndrome.

ETHICS AND DISSEMINATION

This systematic review will be disseminated in a peer-reviewed journal or presented at relevant conferences. It is not necessary for a formal ethical approval because the data are not individualized.

TRIAL REGISTRATION NUMBER

INPLASY2020110092.

Chloroquine or hydroxychloroquine for prevention and treatment of COVID-19

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial mortality. Some specialists proposed chloroquine (CQ) and hydroxychloroquine (HCQ) for treating or preventing the disease. The efficacy and safety of these drugs have been assessed in randomized controlled trials.

OBJECTIVES

To evaluate the effects of chloroquine (CQ) or hydroxychloroquine (HCQ) for 1) treating people with COVID-19 on death and time to clearance of the virus; 2) preventing infection in people at risk of SARS-CoV-2 exposure; 3) preventing infection in people exposed to SARS-CoV-2.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Current Controlled Trials (www.controlled-trials.com), and the COVID-19-specific resources www.covid-nma.com and covid-19.cochrane.org, for studies of any publication status and in any language. We performed all searches up to 15 September 2020. We contacted researchers to identify unpublished and ongoing studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) testing chloroquine or hydroxychloroquine in people with COVID-19, people at risk of COVID-19 exposure, and people exposed to COVID-19. Adverse events (any, serious, and QT-interval prolongation on electrocardiogram) were also extracted.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of search results, extracted data from the included studies, and assessed risk of bias using the Cochrane 'Risk of bias' tool. We contacted study authors for clarification and additional data for some studies. We used risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CIs). We performed meta-analysis using a random-effects model for outcomes where pooling of effect estimates was appropriate.

MAIN RESULTS

1. Treatment of COVID-19 disease We included 12 trials involving 8569 participants, all of whom were adults. Studies were from China (4); Brazil, Egypt, Iran, Spain, Taiwan, the UK, and North America (each 1 study); and a global study in 30 countries (1 study). Nine were in hospitalized patients, and three from ambulatory care. Disease severity, prevalence of comorbidities, and use of co-interventions varied substantially between trials. We found potential risks of bias across all domains for several trials. Nine trials compared HCQ with standard care (7779 participants), and one compared HCQ with placebo (491 participants); dosing schedules varied. HCQ makes little or no difference to death due to any cause (RR 1.09, 95% CI 0.99 to 1.19; 8208 participants; 9 trials; high-certainty evidence). A sensitivity analysis using modified intention-to-treat results from three trials did not influence the pooled effect estimate.  HCQ may make little or no difference to the proportion of people having negative PCR for SARS-CoV-2 on respiratory samples at day 14 from enrolment (RR 1.00, 95% CI 0.91 to 1.10; 213 participants; 3 trials; low-certainty evidence). HCQ probably results in little to no difference in progression to mechanical ventilation (RR 1.11, 95% CI 0.91 to 1.37; 4521 participants; 3 trials; moderate-certainty evidence). HCQ probably results in an almost three-fold increased risk of adverse events (RR 2.90, 95% CI 1.49 to 5.64; 1394 participants; 6 trials; moderate-certainty evidence), but may make little or no difference to the risk of serious adverse events (RR 0.82, 95% CI 0.37 to 1.79; 1004 participants; 6 trials; low-certainty evidence). We are very uncertain about the effect of HCQ on time to clinical improvement or risk of prolongation of QT-interval on electrocardiogram (very low-certainty evidence). One trial (22 participants) randomized patients to CQ versus lopinavir/ritonavir, a drug with unknown efficacy against SARS-CoV-2, and did not report any difference for clinical recovery or adverse events. One trial compared HCQ combined with azithromycin against standard care (444 participants). This trial did not detect a difference in death, requirement for mechanical ventilation, length of hospital admission, or serious adverse events. A higher risk of adverse events was reported in the HCQ-and-azithromycin arm; this included QT-interval prolongation, when measured. One trial compared HCQ with febuxostat, another drug with unknown efficacy against SARS-CoV-2 (60 participants). There was no difference detected in risk of hospitalization or change in computed tomography (CT) scan appearance of the lungs; no deaths were reported. 2. Preventing COVID-19 disease in people at risk of exposure to SARS-CoV-2 Ongoing trials are yet to report results for this objective. 3. Preventing COVID-19 disease in people who have been exposed to SARS-CoV-2 One trial (821 participants) compared HCQ with placebo as a prophylactic agent in the USA (around 90% of participants) and Canada. Asymptomatic adults (66% healthcare workers; mean age 40 years; 73% without comorbidity) with a history of exposure to people with confirmed COVID-19 were recruited. We are very uncertain about the effect of HCQ on the primary outcomes, for which few events were reported: 20/821 (2.4%) developed confirmed COVID-19 at 14 days from enrolment, and 2/821 (0.2%) were hospitalized due to COVID-19 (very low-certainty evidence). HCQ probably increases the risk of adverse events compared with placebo (RR 2.39, 95% CI 1.83 to 3.11; 700 participants; 1 trial; moderate-certainty evidence). HCQ may result in little or no difference in serious adverse events (no RR: no participants experienced serious adverse events; low-certainty evidence). One cluster-randomized trial (2525 participants) compared HCQ with standard care for the prevention of COVID-19 in people with a history of exposure to SARS-CoV-2 in Spain. Most participants were working or residing in nursing homes; mean age was 49 years. There was no difference in the risk of symptomatic confirmed COVID-19 or production of antibodies to SARS-CoV-2 between the two study arms.

AUTHORS' CONCLUSIONS

HCQ for people infected with COVID-19 has little or no effect on the risk of death and probably no effect on progression to mechanical ventilation. Adverse events are tripled compared to placebo, but very few serious adverse events were found. No further trials of hydroxychloroquine or chloroquine for treatment should be carried out. These results make it less likely that the drug is effective in protecting people from infection, although this is not excluded entirely. It is probably sensible to complete trials examining prevention of infection, and ensure these are carried out to a high standard to provide unambiguous results.

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis

OBJECTIVES

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points.

METHODS

We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations.

ETHICS AND DISSEMINATION

Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals.

PROSPERO REGISTRATION

CRD42020187852.

Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data

OBJECTIVE

To determine the efficacy and safety of low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) for people with type 2 diabetes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Searches of CENTRAL, Medline, Embase, CINAHL, CAB, and grey literature sources from inception to 25 August 2020.

STUDY SELECTION

Randomized clinical trials evaluating LCDs (<130 g/day or <26% of a 2000 kcal/day diet) and VLCDs (<10% calories from carbohydrates) for at least 12 weeks in adults with type 2 diabetes were eligible.

DATA EXTRACTION

Primary outcomes were remission of diabetes (HbA1c <6.5% or fasting glucose <7.0 mmol/L, with or without the use of diabetes medication), weight loss, HbA1c, fasting glucose, and adverse events. Secondary outcomes included health related quality of life and biochemical laboratory data. All articles and outcomes were independently screened, extracted, and assessed for risk of bias and GRADE certainty of evidence at six and 12 month follow-up. Risk estimates and 95% confidence intervals were calculated using random effects meta-analysis. Outcomes were assessed according to a priori determined minimal important differences to determine clinical importance, and heterogeneity was investigated on the basis of risk of bias and seven a priori subgroups. Any subgroup effects with a statistically significant test of interaction were subjected to a five point credibility checklist.

RESULTS

Searches identified 14 759 citations yielding 23 trials (1357 participants), and 40.6% of outcomes were judged to be at low risk of bias. At six months, compared with control diets, LCDs achieved higher rates of diabetes remission (defined as HbA1c <6.5%) (76/133 (57%) v 41/131 (31%); risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264, I2=58%). Conversely, smaller, non-significant effect sizes occurred when a remission definition of HbA1c <6.5% without medication was used. Subgroup assessments determined as meeting credibility criteria indicated that remission with LCDs markedly decreased in studies that included patients using insulin. At 12 months, data on remission were sparse, ranging from a small effect to a trivial increased risk of diabetes. Large clinically important improvements were seen in weight loss, triglycerides, and insulin sensitivity at six months, which diminished at 12 months. On the basis of subgroup assessments deemed credible, VLCDs were less effective than less restrictive LCDs for weight loss at six months. However, this effect was explained by diet adherence. That is, among highly adherent patients on VLCDs, a clinically important reduction in weight was seen compared with studies with less adherent patients on VLCDs. Participants experienced no significant difference in quality of life at six months but did experience clinically important, but not statistically significant, worsening of quality of life and low density lipoprotein cholesterol at 12 months. Otherwise, no significant or clinically important between group differences were found in terms of adverse events or blood lipids at six and 12 months.

CONCLUSIONS

On the basis of moderate to low certainty evidence, patients adhering to an LCD for six months may experience remission of diabetes without adverse consequences. Limitations include continued debate around what constitutes remission of diabetes, as well as the efficacy, safety, and dietary satisfaction of longer term LCDs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020161795.

Continuous(ly) missing outcome data in network meta-analysis: A one-stage pattern-mixture model approach

Appropriate handling of aggregate missing outcome data is necessary to minimise bias in the conclusions of systematic reviews. The two-stage pattern-mixture model has been already proposed to address aggregate missing continuous outcome data. While this approach is more proper compared with the exclusion of missing continuous outcome data and simple imputation methods, it does not offer flexible modelling of missing continuous outcome data to investigate their implications on the conclusions thoroughly. Therefore, we propose a one-stage pattern-mixture model approach under the Bayesian framework to address missing continuous outcome data in a network of interventions and gain knowledge about the missingness process in different trials and interventions. We extend the hierarchical network meta-analysis model for one aggregate continuous outcome to incorporate a missingness parameter that measures the departure from the missing at random assumption. We consider various effect size estimates for continuous data, and two informative missingness parameters, the informative missingness difference of means and the informative missingness ratio of means. We incorporate our prior belief about the missingness parameters while allowing for several possibilities of prior structures to account for the fact that the missingness process may differ in the network. The method is exemplified in two networks from published reviews comprising a different amount of missing continuous outcome data.

Effect of diverting stoma for rectovaginal fistula: A protocol of systematic review and meta-analysis

BACKGROUND

Rectovaginal fistula (RVF) is a pathologic channel between the anterior wall of the rectum and the posterior wall of the vagina, is rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, rectal surgery or caused by chronic inflammatory bowel disease. Once the disease will seriously affect the patient's quality of life, and generally not self-healing, most require surgical intervention. At present, diverting stoma is mainly used in patients with severe RVF or complicated RVF or patients with Crohn disease. Due to the lack of large sample, linical studies, its clinical effectiveness is still controversial. The purpose of this systematic review is to evaluate the efficacy of diverting stoma in the treatment of diverting stoma.

METHODS

EMBASE, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), and Chinese VIP Information will be searched systematically by 2 reviewers from the inception until October 2020. The original study that randomized controlled trials (RCTs), clinical controlled trials (CCTs), nonrandomized control trials (NCTs), and retrospective trials (RTs) of diverting stoma for RVF will be selected. In addition, similar searches will be conducted for the reference lists, researches in progress, and the citation lists of identified publications. Study selection, data extraction, and assessment of the quality will be performed independently by 2 reviewers who have been trained prior to data extraction. A meta-analysis will be conduct if the quantity and quality of the original studies included are satisfactory; otherwise, a descriptive analysis will be conducted. Review Manager 5.4 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) will be using for data synthesis and assessment the risk of bias according by Cochrane Handbook.

RESULT

This study will provide a comprehensive review of current evidence for the treatment of diverting stoma on RVF.

CONCLUSION

The conclusion of this study will provide a judging basis that whether the treatment of RVF with diverting stoma is effective.

INPLASY REGISTRATION NUMBER

INPLASY2020090070.

The effectiveness of moxibustion for treating of low back pain: A protocol for systematic review and meta-analysis

BACKGROUND

Low back pain is a common clinical chronic disease with symptoms of back soreness, numbness, and pain. The incidence of low back pain is high, and gradually increases with age. It is mainly middle-aged and has a high recurrence rate. It is considered to be one of the common diseases with the highest disability rate. The aim of this systematic review is to assess the effectiveness and safety of moxibustion therapy for low back pain.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL);PubMed; EMBASE; China National Knowledge Infrastructure (CNKI); Chinese Biomedical Literature Database (CBM); Chinese Scientific Journal Database (VIP database); and Wan-Fang Database from the inception, without restriction of publication status and languages. Additional searching including researches in progress, the reference lists and the citation lists of identified publications. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. If it is appropriate for a meta-analysis, RevMan 5.4 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data and weight mean difference (WMD) or standard mean difference (SMD) 95% CIs for continuous data.

RESULTS

This study will provide a comprehensive review of the available evidence for the treatment of moxibustion with low back pain.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether moxibustion is an effective and safe intervention for patients with low back pain.

TRIAL REGISTRATION NUMBER

INPLASY202080027.

Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults

BACKGROUND

Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach.

OBJECTIVES

To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism.

SEARCH METHODS

We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied.

SELECTION CRITERIA

We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%.

AUTHORS' CONCLUSIONS

The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.

Effect of fire needle for ganglion cysts: A protocol of systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Ganglion cysts (GCs) are tumor-like lesions that often occur in the soft tissues, which are mostly caused by the degeneration of mucin produced by the joint capsule and tendon sheath on the carpal dorsal joints of extremities. GCs may appear asymptomatic as benign tumors, but some patients also seek treatment because of the pain caused by these fluid-filled cysts. As a kind of complementary and alternative therapy, there have been some studies published in China which have proved that the fire needle has a better therapeutic effect on ganglion cyst. The purpose of this systematic review is to evaluate the efficacy of fire needle in the treatment of GCs.

METHODS

PubMed, EMBASE, the Cochrane Library, Chinese National Knowledge Infrastructure, Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database were searched by 2 reviewers from the inception until August 2020. The original study that randomised control trials of fire needle for GCs will be selected and is not limited by country or language. In addition, researches in progress, the reference lists and the citation lists of identified publications will be retrieved similarly. Study selection, data extraction, and assessment of the quality will be performed independently by 2 reviewers who have been trained prior to data extraction. A meta-analysis will be conduct if the quantity and quality of the original studies included are satisfactory; otherwise, a descriptive analysis will be conducted. Review Manager V5.4: (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) software will be using for data synthesis and assessment the risk of bias according by Cochrane Handbook.

RESULT

This study will provide a comprehensive review of current evidence for the treatment of fire needle on GCs.

CONCLUSION

The conclusion of this study will provide a judging basis that whether the treatment of GCs with fire needle is effective.

INPLASY REGISTRATION NUMBER

INPLASY202080032.

Surgical and Non-Surgical Interventions in Complete Rotator Cuff Tears

BACKGROUND

This systematic review compares the efficacy and safety of surgical and non-surgical interventions for full- thickness rotator cuff tears.

METHODS

A systematic literature search was conducted in five databases. Randomized (RCTs) and non-randomized controlled trials of interventions (non-RCTs) for the surgical or non-surgical treatment of patients with traumatic or atraumatic full-thickness rotator cuff tears were included. The review protocol was published in the PROSPERO registry (CRD42018100343).

RESULTS

Ten studies (three RCTs with 332 participants; seven non-RCTs with 650 participants) met the inclusion criteria. One year after treatment, shoulder function, measured with the 100-point Constant score, had improved by 6.7 points (95% confidence interval [2.3; 11.0]) and pain, measured with the 10-cm visual analog scale, by 1.1 cm (0.5; 1.7] in the full-thickness rotator cuff tears treated surgically compared with non-surgical treatment. In one study the difference in favor of surgery persisted after 10 years' follow-up. For other outcomes, such as range of motion, muscle strength, quality of life, and adverse events, the data were sparse and the group differences were similar. The findings of the non-RCTs were comparable with those of the RCTs.

CONCLUSION

With regard to functional improvement and pain reduction, surgical treatment of full-thickness rotator cuff tears was superior to non-surgical treatment in the short and the long term. Whether the differences between the groups are relevant for individual cases is uncertain, as the measured results were distributed below and above the threshold of clinical relevance. The conclusions may not be applicable to rotator cuff tears over 3 cm in size or to young persons.

Potential impact of missing outcome data on treatment effects in systematic reviews: imputation study

OBJECTIVE

To assess the risk of bias associated with missing outcome data in systematic reviews.

DESIGN

Imputation study.

SETTING

Systematic reviews.

POPULATION

100 systematic reviews that included a group level meta-analysis with a statistically significant effect on a patient important dichotomous efficacy outcome.

MAIN OUTCOME MEASURES

Median percentage change in the relative effect estimate when applying each of the following assumption (four commonly discussed but implausible assumptions (best case scenario, none had the event, all had the event, and worst case scenario) and four plausible assumptions for missing data based on the informative missingness odds ratio (IMOR) approach (IMOR 1.5 (least stringent), IMOR 2, IMOR 3, IMOR 5 (most stringent)); percentage of meta-analyses that crossed the threshold of the null effect for each method; and percentage of meta-analyses that qualitatively changed direction of effect for each method. Sensitivity analyses based on the eight different methods of handling missing data were conducted.

RESULTS

100 systematic reviews with 653 randomised controlled trials were included. When applying the implausible but commonly discussed assumptions, the median change in the relative effect estimate varied from 0% to 30.4%. The percentage of meta-analyses crossing the threshold of the null effect varied from 1% (best case scenario) to 60% (worst case scenario), and 26% changed direction with the worst case scenario. When applying the plausible assumptions, the median percentage change in relative effect estimate varied from 1.4% to 7.0%. The percentage of meta-analyses crossing the threshold of the null effect varied from 6% (IMOR 1.5) to 22% (IMOR 5) of meta-analyses, and 2% changed direction with the most stringent (IMOR 5).

CONCLUSION

Even when applying plausible assumptions to the outcomes of participants with definite missing data, the average change in pooled relative effect estimate is substantive, and almost a quarter (22%) of meta-analyses crossed the threshold of the null effect. Systematic review authors should present the potential impact of missing outcome data on their effect estimates and use this to inform their overall GRADE (grading of recommendations assessment, development, and evaluation) ratings of risk of bias and their interpretation of the results.

Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials

Objective:

Synthesize evidence regarding effectiveness of progressive and resisted or non-progressive and non-resisted exercise compared with placebo or no treatment, in rotator cuff related pain.

Data sources:

English articles, searched in Cochrane CENTRAL, MEDLINE, EMBASE and CINAHL databases up until May 19, 2020.

Methods:

Randomized controlled trials in people with rotator cuff related pain comparing either progressive and resisted exercise or non-progressive and non-resisted exercise, with placebo or no treatment were included. Data extracted independently by two authors. Risk of bias appraised with the Cochrane Collaboration tool.

Results:

Seven trials (468 participants) were included, four trials (271 participants) included progressive and resisted exercise and three trials (197 participants) included non-progressive or non-resisted exercise. There was uncertain clinical benefit for composite pain and function (15 point difference, 95% CI 9 to 21, 100-point scale) and pain outcomes at >6 weeks to 6 months with progressive and resisted exercise compared to placebo or no treatment (comparison 1). For non-progressive or non-resisted exercise there was no significant benefit for composite pain and function (4 point difference, 95% CI −2 to 9, 100-point scale) and pain outcomes at >6 weeks to 6 months compared to placebo or no treatment (comparison 2). Adverse events were seldom reported and mild.

Conclusions:

There is uncertain clinical benefit for all outcomes with progressive and resisted exercise and no significant benefit with non-progressive and non-resisted exercise, versus no treatment or placebo at >6 weeks to 6 months. Findings are low certainty and should be interpreted with caution.

Meta-Analyses Proved Inconsistent in How Missing Data Were Handled Across Their Included Primary Trials: A Methodological Survey

Background

How systematic review authors address missing data among eligible primary studies remains uncertain.

Objective

To assess whether systematic review authors are consistent in the way they handle missing data, both across trials included in the same meta-analysis, and with their reported methods.

Methods

We first identified 100 eligible systematic reviews that included a statistically significant meta-analysis of a patient-important dichotomous efficacy outcome. Then, we successfully retrieved 638 of the 653 trials included in these systematic reviews’ meta-analyses. From each trial report, we extracted statistical data used in the analysis of the outcome of interest to compare with the data used in the meta-analysis. First, we used these comparisons to classify the “analytical method actually used” for handling missing data by the systematic review authors for each included trial. Second, we assessed whether systematic reviews explicitly reported their analytical method of handling missing data. Third, we calculated the proportion of systematic reviews that were consistent in their “analytical method actually used” across trials included in the same meta-analysis. Fourth, among systematic reviews that were consistent in the “analytical method actually used” across trials and explicitly reported on a method for handling missing data, we assessed whether the “analytical method actually used” and the reported methods were consistent.

Results

We were unable to determine the “analytical method reviews actually used” for handling missing outcome data among 397 trials. Among the remaining 241, systematic review authors most commonly conducted “complete case analysis” (n=128, 53%) or assumed “none of the participants with missing data had the event of interest” (n=58, 24%). Only eight of 100 systematic reviews were consistent in their approach to handling missing data across included trials, but none of these reported methods for handling missing data. Among seven reviews that did explicitly report their analytical method of handling missing data, only one was consistent in their approach across included trials (using complete case analysis), and their approach was inconsistent with their reported methods (assumed all participants with missing data had the event).

Conclusion

The majority of systematic review authors were inconsistent in their approach towards reporting and handling missing outcome data across eligible primary trials, and most did not explicitly report their methods to handle missing data. Systematic review authors should clearly identify missing outcome data among their eligible trials, specify an approach for handling missing data in their analyses, and apply their approach consistently across all primary trials.

GRADE-Leitlinien: 17. Beurteilung des Bias-Risikos durch fehlende Endpunkt-Daten im Evidenzkörper

OBJECTIVE

To provide GRADE guidance for assessing risk of bias across an entire body of evidence consequent on missing data for systematic reviews of both binary and continuous outcomes.

STUDY DESIGN AND SETTING

Systematic survey of published methodological research, iterative discussions, testing in systematic reviews, and feedback from the GRADE Working Group.

RESULTS

Approaches begin with a primary meta-analysis using a complete case analysis followed by sensitivity meta-analyses imputing, in each study, data for those with missing data, and then pooling across studies. For binary outcomes, we suggest use of "plausible worst case" in which review authors assume that those with missing data in treatment arms have proportionally higher event rates than those followed successfully. For continuous outcomes, imputed mean values come from other studies within the systematic review and the standard deviation (SD) from the median SDs of the control arms of all studies.

CONCLUSIONS

If the results of the primary meta-analysis are robust to the most extreme assumptions viewed as plausible, one does not rate down certainty in the evidence for risk of bias due to missing participant outcome data. If the results fail to prove robust to plausible assumptions, one would rate down certainty in the evidence for risk of bias.

Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis

INTRODUCTION

Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery.

METHODS AND ANALYSIS

Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system.

ETHICS AND DISSEMINATION

Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.

Dealing with missing outcome data in meta-analysis

Missing data result in less precise and possibly biased effect estimates in single studies. Bias arising from studies with incomplete outcome data is naturally propagated in a meta-analysis. Conventional analysis using only individuals with available data is adequate when the meta-analyst can be confident that the data are missing at random (MAR) in every study-that is, that the probability of missing data does not depend on unobserved variables, conditional on observed variables. Usually, such confidence is unjustified as participants may drop out due to lack of improvement or adverse effects. The MAR assumption cannot be tested, and a sensitivity analysis to assess how robust results are to reasonable deviations from the MAR assumption is important. Two methods may be used based on plausible alternative assumptions about the missing data. Firstly, the distribution of reasons for missing data may be used to impute the missing values. Secondly, the analyst may specify the magnitude and uncertainty of possible departures from the missing at random assumption, and these may be used to correct bias and reweight the studies. This is achieved by employing a pattern mixture model and describing how the outcome in the missing participants is related to the outcome in the completers. Ideally, this relationship is informed using expert opinion. The methods are illustrated in two examples with binary and continuous outcomes. We provide recommendations on what trial investigators and systematic reviewers should do to minimize the problem of missing outcome data in meta-analysis.

Biofeedback for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a prevalent condition that currently lacks highly effective therapies for its management. Biofeedback has been proposed as a therapy that may help individuals learn to exert conscious control over sympatho-vagal balance as an indirect method of symptom management.

OBJECTIVES

Our primary objective was to assess the efficacy and safety of biofeedback-based interventions for IBS in adults and children.

SEARCH METHODS

We searched the Cochrane Inflammatory Bowel Disease (IBD) Group Specialized Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Allied and Complementary Medicine Database (AMED) from inception to 24 July 2019. We also searched reference lists from published trials, trial registries, device manufacturers, conference proceedings, theses, and dissertations.

SELECTION CRITERIA

We judged randomized controlled trials to be eligible for inclusion if they met the Association for Applied Psychophysiology and Biofeedback definition of biofeedback, and if they compared a biofeedback intervention to an active, sham, or no-treatment control for the management of IBS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened trials for inclusion, extracted data, and assessed risk of bias. Primary outcomes were IBS global or clinical improvement scores and overall quality of life measures. Secondary outcome measures were adverse events, assessments of stool frequency and consistency, changes in abdominal pain, depression, and anxiety. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and 95% CI. We used GRADE criteria to assess the overall certainty of the evidence.

MAIN RESULTS

We identified eight randomized trials with a total of 300 adult participants for our analysis. We did not identify any trials in children. Four trials assessed thermal biofeedback. One trial assessed rectosigmoidal biofeedback. Two trials assessed heart rate variability biofeedback. Two trials assessed electrocutaneous biofeedback. Comparators were: no treatment (symptom monitoring group; three studies), attention control (pseudomeditation; two studies), relaxation control (one study), counseling (two studies), hypnotherapy (one study), standard therapy (one study), and sham biofeedback (one study). We judged all trials to have a high or unclear risk of bias. Global/Clinical improvement The clinical benefit of biofeedback plus standard therapy compared to standard therapy alone was uncertain (RR 4.20, 95% CI 1.40 to 12.58; 1 study, 20 participants; very low-certainty evidence). The same study also compared biofeedback plus standard therapy to sham biofeedback plus standard therapy. The clinical benefit in the biofeedback group was uncertain (RR 2.33, 95% CI 1.13 to 4.80; 1 study, 20 participants; very low-certainty evidence). The clinical benefit of heart rate biofeedback compared to hypnotherapy was uncertain when measured with the IBS severity scoring system (IBS-SSS) (MD -58.80, 95% CI -109.11 to -8.49; 1 study, 61 participants; low-certainty evidence). Compared to counseling, the effect of heart rate biofeedback was unclear when measured with a composite symptom reduction score (MD 7.03, 95% CI -51.07 to 65.13; 1 study, 29 participants; low-certainty evidence) and when evaluated for clinical response (50% improvement) (RR 1.09, 95% CI 0.48 to 2.45; 1 study, 29 participants; low-certainty evidence). The clinical benefit of thermal biofeedback used in a multi-component psychological intervention (MCPI) compared to no treatment was uncertain when measured with a composite clinical symptom reduction score (MD 30.34, 95% CI 8.47 to 52.21; 3 studies, 101 participants; very low-certainty evidence), and when evaluated as clinical response (50% improvement) (RR 2.12, 95% CI 1.24 to 3.62; 3 studies, 101 participants; very low-certainty evidence). Compared to attention control, the effects of thermal biofeedback within an MCPI were unclear when measured with a composite clinical symptom reduction score (MD 4.02, 95% CI -21.41 to 29.45; 2 studies, 80 participants; very low-certainty evidence) and when evaluated as clinical response (50% improvement) (RR 1.10, 95% CI 0.72 to 1.69, 2 studies, 80 participants; very low-certainty evidence). Quality of life A single trial used overall quality of life as an outcome measure, and reported that both the biofeedback and cognitive therapy groups improved after treatment. The trial did not note any between-group differences, and did not report any outcome data. Adverse events Only one of the eight trials explicitly reported adverse events. This study reported no adverse events in either the biofeedback or cognitive therapy groups (RD 0.00, 95% CI -0.12 to 0.12; 29 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently not enough evidence to assess whether biofeedback interventions are effective for controlling symptoms of IBS. Given the positive results reported in small trials to date, biofeedback deserves further study in people with IBS. Future research should include active control groups that use high provider-participant interaction, in an attempt to balance non-specific effects of interventions between groups, and report both commonly used outcome measures (e.g. IBS-SSS) and historical outcome measures (e.g. the composite primary symptom reduction (CPSR) score) to allow for meta-analysis with previous studies. Future studies should be explicit in their reporting of adverse events.

Moxibustion for treating patients with hyperlipidemia: A systematic review and meta-analysis protocol

BACKGROUND

Hyperlipidemia has been a root cause of atherosclerosis, which leads to a high risk to serious cardio-cerebrovascular disease. Many trials have reported that moxibustion therapy is effective in lowering blood lipid levels when treating hyperlipidemia. The aim of this systematic review is to assess the effectiveness and safety of moxibustion therapy for hyperlipidemia.

METHODS

Two reviewers will electronically search the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; China National Knowledge Infrastructure (CNKI); Chinese Biomedical Literature Database (CBM); Chinese Scientific Journal Database (VIP database); and Wan-Fang Database from the inception, without restriction of publication status and languages. Additional searching including researches in progress, the reference lists and the citation lists of identified publications. Study selection, data extraction, and assessment of study quality will be performed independently by 2 reviewers. Changes of blood lipid levels from baseline to the end of the treatment, including low-density lipoprotein cholesterol (LDL-C) level, total cholesterol (TC) level, triglycerides (TG) level and high-density lipoprotein cholesterol (HDL-C) level will be assessed as the primary outcomes. Quality of life, long-term effect and safety will be evaluated as secondary outcomes. If it is appropriate for a meta-analysis, RevMan 5.3 statistical software will be used; otherwise, a descriptive analysis will be conducted. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. The results will be presented as risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data and weight mean difference (WMD) or standard mean difference (SMD) 95% CIs for continuous data.

RESULTS

This study will provide a comprehensive review of the available evidence for the treatment of moxibustion with hyperlipidemia.

CONCLUSIONS

The conclusions of our study will provide an evidence to judge whether moxibustion is an effective and safe intervention for patients with hyperlipidemia.

ETHICS AND DISSEMINATION

This systematic review will be disseminated in a peer-reviewed journal or presented at relevant conferences. It is not necessary for a formal ethical approval because the data are not individualized.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42019130545.

Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review

INTRODUCTION

There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components.

METHODS AND ANALYSIS

We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not.

ETHICS AND DISSEMINATION

Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results.

PROSPERO REGISTRATION NUMBER

CRD42018102441.

A guidance was developed to identify participants with missing outcome data in randomized controlled trials

BACKGROUND AND OBJECTIVES

In order for authors of systematic reviews to address missing data in randomized controlled trials (RCTs), they need to first identify the number of trial participants with missing data. The objective of this study was to provide guidance for authors of systematic reviews on how to identify participants with missing outcome data in reports of RCTs.

METHODS

Guidance statements were informed by a review of studies addressing the topic of missing data and an iterative process of feedback and refinement, through meetings involving experts in health research methodology and authors of systematic reviews.

RESULTS

The proposed guidance includes (1) definitions of key terms, (2) 19 categories of participants described in RCT reports and who might have missing data, and (3) a flowchart on how to judge the outcome data missingness for each category. The judgment of missingness relies on how trial authors report on the categories and handle them in their analyses. Practically, for their primary analysis, systematic review authors should choose how to identify participants with missing outcome data (i.e., use either "definitely missing data" or "total possible missing data"), then select a method for handling missing data in meta-analysis. Sensitivity analyses should be undertaken to explore consistency with competing options for classifying patients as having missing data.

CONCLUSION

Adopting the proposed guidance will help promote transparency and consistency regarding how missing data are managed in systematic reviews.

An empirical comparison of Bayesian modelling strategies for missing binary outcome data in network meta-analysis

Background

A number of strategies have been proposed to handle missing binary outcome data (MOD) in systematic reviews. However, none of these have been evaluated empirically in a series of published systematic reviews.

Methods

Using published systematic reviews with network meta-analysis (NMA) from a wide range of health-related fields, we evaluated comparatively the most frequently described Bayesian modelling strategies for MOD in terms of log odds ratio (log OR), between-trial variance, inconsistency factor (i.e. difference between direct and indirect estimates for a comparison), surface under the cumulative ranking (SUCRA) and rankings. We extended the Bayesian random-effects NMA model to incorporate the informative missingness odds ratio (IMOR) parameter, and applied the node-splitting approach to investigate inconsistency locally. We considered both pattern-mixture and selection models, different structures for prior distribution of log IMOR, and different scenarios for MOD. To illustrate level of agreement between different strategies and scenarios, we used Bland-Altman plots.

Results

Addressing MOD using extreme scenarios and ignoring the uncertainty about the scenarios led to systematically different and more precise log ORs compared to modelling MOD under the missing at random (MAR) assumption. Hierarchical structure of log IMORs led to lower between-trial variance, especially in the case of substantial MOD. Assuming common-within-network or trial-specific log IMORs yielded similar posterior results for all NMA estimates, whereas intervention-specific structure systematically inflated uncertainty around log ORs and SUCRAs. Pattern-mixture model agreed with selection model, particularly under the trial-specific structure; however, selection model systematically reduced precision around log IMORs. Overall, different strategies and scenarios mostly had good agreement in the case of low MOD.

Conclusions

Addressing MOD using extreme scenarios and/or ignoring the uncertainty about the scenarios may negatively affect NMA estimates. Modelling MOD via the IMOR parameter can ensure bias-adjusted estimates and offer valuable insights into missingness mechanisms. The researcher should seek an expert opinion in order to decide on the structure of log IMOR that best aligns to the condition and interventions studied and to define a proper prior distribution for log IMOR. Our findings also apply to pairwise meta-analyses.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0731-y) contains supplementary material, which is available to authorized users.

Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis

OBJECTIVE

To determine the benefits and harms of subacromial decompression surgery in adult patients with subacromial pain syndrome lasting for more than 3 months.

DESIGN

Systematic review with meta-analysis.

MAIN OUTCOME MEASURES

Pain, physical function and health-related quality of life.

DATA SOURCES

Systematic searches for benefits and harms were conducted to 23 July 2018 in MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Database of Abstracts of Reviews of Effects, and Health Technology Assessment.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing subacromial decompression surgery for subacromial pain syndrome with any other treatment(s). For harms, we included prospective cohort studies.

REVIEW METHODS

Two reviewers independently determined eligibility, extracted the data and assessed the risk of bias of eligible studies. Thirty patients seeking primary or outpatient care for subacromial pain syndrome and a parallel guideline committee (BMJ Rapid Recommendations) provided input regarding systematic review design and interpretation.

RESULTS

There was high certainty evidence of no additional benefit of subacromial decompression surgery over placebo surgery in reducing pain at 1 year following surgery (mean difference [MD] -0.26, 95% CI -0.84 to 0.33, minimally important difference [MID] 1.5) or improving physical function at 1-2 years (MD 2.8, 95% CI -1.4 to 6.9, MID 8.3). There was moderate certainty evidence for no additional benefit of subacromial decompression surgery on health-related quality of life at 1 year (MD -0.03 points, 95% CI -0.11 to 0.06, MID 0.07). There was moderate certainty evidence for six serious harms per 1000 (95% CI 5 to 7) patients undergoing subacromial decompression.

CONCLUSION

Subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy, and probably carries a small risk of serious harms.

SYSTEMATIC REVIEWREGISTRATION NUMBER

CRD42018086862.