An assessment of the quality of rotator cuff randomized controlled trials: utilizing the Jadad score and CONSORT criteria

The Effect of Colloids versus Crystalloids for Goal-Directed Fluid Therapy on Prognosis in Patients Undergoing Noncardiac Surgery: A Meta-Analysis of Randomized Controlled Trials

Background

Goal-directed fluid therapy (GDFT) contributes to improvements in intraoperative fluid infusion based on objective parameters and has been widely recommended in clinical practice. In addition, increasing evidence reveals that GDFT can improve the prognosis of surgical patients. However, considering the individual characteristics of colloids and crystalloids in clinical use, it is uncertain as to which type of fluids administered is associated with better outcomes in the condition of GDFT.

Objectives

To evaluate the effect of colloids versus crystalloids under GDFT on prognosis in patients undergoing noncardiac surgery. Data Sources. Randomized controlled trials (RCTs) from PubMed, EMBASE, Ovid MEDLINE, CNKI, Cochrane library, and reference lists of relevant articles.

Methods

Two investigators independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was a composite of postoperative complications. The secondary outcomes were (1) mortality at the follow-up duration; (2) postoperative complications of several organ systems, including cardiac, pulmonary, digestive, urinary, nervous system, and postoperative infection events; and (3) hospital and ICU length of stay. Heterogeneity was assessed by the I 2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data.

Results

Of 332 articles retrieved, 15 RCTs (involving 2,956 patients undergoing noncardiac surgery) were included in the final analysis. When the data were pooled, patients in the colloids and crystalloids group revealed no difference in postoperative composite complications (OR = 0.84, 95% CI = 0.51-1.38, P=0.49) under GDFT. Regarding the secondary outcomes, patients in the colloids group were associated with fewer digestive system complications (OR = 0.64, 95% CI = 0.41-0.98, P=0.04). However, no difference was found in mortality (OR = 1.37, 95% CI = 0.72-2.58, P=0.34), complications of the cardiac system (OR = 1.49, 95% CI = 0.66-3.37, P=0.34), pulmonary system (OR = 0.89, 95% CI = 0.62-1.28, P=0.53), urinary system (OR = 1.05, 95% CI = 0.61-1.80, P=0.87), nervous system (OR = 1.04, 95% CI = 0.55-1.98, P=0.90), postoperative infection events (OR = 0.89, 95% CI = 0.75-1.07, P=0.22), length of hospital stay (difference in mean = -0.71, 95% CI = -1.49-0.07, P=0.07), and ICU stay (difference in mean = -0.01, 95% CI = -0.20-0.18, P=0.95) between patients receiving GDFT with colloids or crystalloids.

Conclusion

There is no evidence of a benefit in using colloids over crystalloids under GDFT in patients undergoing noncardiac surgery, despite its use resulting in lower digestive system complications.

The Rising Quality of Randomized Controlled Trials in The Journal of Bone & Joint Surgery: An Updated Analysis from 2014 to 2022

Background

Previous reports found that 40% of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 and 47% of those published from 2001 to 2013 were of high quality. The purpose of this study was to assess the quality of RCTs published from 2014 to 2022 in JBJS and to compare these findings with those of prior analyses in order to identify trends over time and areas for continued improvement.

Methods

PubMed was searched for the term "randomized controlled trial" to identify studies published in JBJS from 2014 to 2022. Each included RCT was evaluated with use of the Detsky score and a risk-of-bias assessment modified from the Cochrane tool. These evaluations were then compared with previous evaluations of RCTs from the 1988 to 2000 and 2001 to 2013 periods with use of independent-sample t tests. A transformed Detsky score of >75% and a modified risk-of-bias score of ≥8 were defined as being indicative of high quality.

Results

A total of 218 RCTs were published in JBJS from 2014 to 2022. An a priori sample size was calculated in 183 studies (83.9%). A total of 152 (83.1%) of the 183 studies enrolled the calculated number of patients, of which 126 (82.9%) maintained an adequate number at the time of final follow-up. Most RCTs were conducted at a single center (146 of 218; 67%), evaluated a surgical intervention (162 of 218; 74%), and reported positive results (142 of 218; 65%). The mean transformed Detsky score was 85% ± 10% (95% confidence interval, 83.7% to 86.3%), with 82% of trials (179 of 218) scored as high quality. The mean transformed Detsky score from 2014 to 2022 was higher than that from 1988 to 2000 and that from 2001 to 2013 (85% versus 76% and 68%, respectively; p < 0.001). The mean modified risk-of-bias score was 7 ± 1, with 42% of trials (92 of 218) scored as high quality. RCTs published from 2014 to 2022 had a higher mean modified risk-of-bias score than those published from 2001 to 2013 (7 ± 1 versus 6 ± 1; p < 0.001). Compared with the 2001 to 2013 and 2014 to 2022 periods, the 1988 to 2000 period had a greater proportion of trials that reported positive results (51% and 65% versus 82%, respectively; p < 0.001) and that included data from multiple centers (31% and 33% versus 67%; p < 0.001).

Conclusions

The quality of RCTs published in JBJS from 2014 to 2022 has improved from that reported previously, as demonstrated by the increases in the modified risk-of-bias score and transformed Detsky score from prior periods. This may be the result of journal policies such as the requirements of CONSORT adherence and prospective trial registration. Investigators should focus on improving the clarity of reporting, limiting attrition bias, and making efforts to blind support staff in order to increase the quality of future RCTs.

Clinical Relevance

Improving the quality of RCTs is crucial given their potential to influence current clinical practice.

Meta-analysis on clinical outcomes of suprapapillary versus transpapillary stent insertion in malignant biliary obstruction

BACKGROUND/AIMS

Endoscopic biliary stenting is an essential treatment for malignant biliary obstruction (MBO). However, the optimal location for the placement of metal stents (MS) or plastic stents (PS) during the management of MBO, whether above (suprapapillary) or across (transpapillary) the sphincter of Oddi (SO), has not been thoroughly evaluated. This meta-analysis aims to compare the clinical outcomes associated with endoscopic retrograde cholangiopancreatography (ERCP)-guided biliary stents placed above and across the SO in patients with MBO.

METHODS

A comprehensive search of electronic databases was carried out to identify studies published from inception to April 2022. The clinical outcomes examined including stent patency, stent occlusion, and overall adverse events (AEs) such as cholangitis, post-ERCP pancreatitis (PEP), cholecystitis, stent migration, and bleeding. The selection of a random-effects model or fixed-effects model was based on the presence of heterogeneity.

RESULTS

A total of 12 articles involving 751 patients were analyzed. The findings showed that the suprapapillary approach had longer stent patency compared to the transpapillary approach (mean difference: 38.58; 95% confidence interval 16.02-61.14, P < 0.0001). Additionally, the suprapapillary approach was associated with a lower risk of stent occlusion and overall AEs (P = 0.04, P = 0.002, respectively), particularly in the incidence of PEP (P = 0.009). The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. The subgroup analyses indicated that suprapillary PS had a significant decrease in the incidence of stent occlusion and longer stent patency, while suprapillary MS had a significant decrease in the incidence of overall AEs and PEP than the transpapillary approach.

CONCLUSION

Compared with the transpapillary approach, the suprapapillary stent had superiority in longer stent patency, lower rates of stent occlusion and overall AEs, and notably, a lower incidence of PEP. The incidence of cholangitis, cholecystitis, stent migration, and bleeding were similar between the suprapapillary and transpapillary approaches. Further large-scale randomized controlled studies are needed to confirm our findings.

REGISTRATION NO

CRD42022336435.

Prospective registration of randomized clinical trials for total shoulder arthroplasty is low: a systematic review

BACKGROUND

Prospective trial registration has become an important means of improving the transparency and reproducibility of randomized controlled trials (RCTs) and is recommended by the Journal of Shoulder and Elbow Surgery (JSES) per the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Herein, we performed a cross-sectional evaluation of RCTs published in JSES from 2010 to present to determine the prevalence of trial registration and consistency of outcome reporting.

METHODS

The electronic database PubMed was searched to identify all RCTs on total shoulder arthroplasty (TSA) published in JSES from 2010 to 2022 using the search terms "randomized controlled trial" AND "shoulder" AND "arthroplasty OR replacement." RCTs were considered to be registered if they provided a registration number. For articles that were registered, authors also extracted the registry name, registration date, date of first enrollment, date of last enrollment, and if the primary outcomes reported in the registry were either (1) omitted, (2) newly introduced in the publication, (3) reported as a secondary outcome or vice versa, or (4) varied in timing of assessment compared to the publication. "Early" RCTs were considered those published from 2010 to 2016, whereas "later" RCTs were from 2017 to 2022.

RESULTS

Fifty-eight RCTs met inclusion criteria. There were 16 early RCTs and 42 later RCTs. Twenty-three of the 58 (39.7%) studies were registered, with 9 of 22 with an available registry (40.9%) of those being enrolled prior to patient enrollment. Nineteen of the registered studies (82.6%) provided the name of the registry and a registration number. The proportion of later RCTs that were registered was not significantly different from the early RCTs (45.2% vs. 25.0%, P = .232). Seven RCTs (31.8%) had at least 1 inconsistency compared with the registry. The most common discrepancy was the timing of the assessment (ie, follow-up period) reported in the publication vs. the registry.

DISCUSSION

Although JSES recommends prospective trial registration, less than half of shoulder arthroplasty RCTs are registered and more than 30% registered trials have at least 1 inconsistency with their registry record. More rigorous review of trial registration and accuracy is necessary to limit bias in published shoulder arthroplasty RCTs.

Comparisons of Different Bearing Surfaces in Cementless Total Hip Arthroplasty: A Systematic Review and Bayesian Network Analysis

BACKGROUND

We aimed to make comparisons of different bearing surfaces in patients after cementless total hip arthroplasty.

METHODS

The network meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. The primary outcomes were implant survival and Harris hip score (HHS). Secondary outcomes included linear wear rates and serum level of metal ions. Subgroup analyses were performed by: (1) classifying head sizes as small and large; (2) femoral heads as ceramic and metal; and (3) liners as metal, ceramic, polyethylene, highly cross-linked polyethylene (HXP), or vitamin E-infused highly cross-linked polyethylene (HXPE). A total of 64 eligible RCTs with different bearings were assessed. Overall inconsistency and heterogeneity were acceptable.

RESULTS

In the 10 years follow-up, metal-on-polythene and ceramic-on-polythene bearings with small heads showed higher risk for revisions compared with metal-on-HXP and ceramic-on-HXP bearings with small heads. Similarly, only metal or ceramic-on-polythene bearings with small heads showed inferiority in HHS compared with other bearings. Conventional polyethylene liners showed higher linear wear rates compared with HXP, HXPE, and ceramic liners at 5 and 10 years after surgery, while metal-on-metal and ceramic-on-metal bearings showed higher serum level of cobalt and chromium.

CONCLUSION

Bearings containing HXP, HXPE, and ceramic liners showed comparable survivorship and hip function at follow-up of 5 and 10 years. Hard-on-hard bearings containing metal had higher serum level of metal ions than others. Bearings containing conventional polyethylene had worse performance in terms of implant survival, hip function, and wear rates.

LEVEL OF EVIDENCE

Level I.

Quality of Reporting Using Good Reporting of A Mixed Methods Study Criteria in Chiropractic Mixed Methods Research: A Methodological Review

OBJECTIVE

The purpose of this review was to examine the reporting in chiropractic mixed methods research using Good Reporting of A Mixed Methods Study (GRAMMS) criteria.

METHODS

In this methodological review, we searched MEDLINE, Embase, CINAHL, and the Index to Chiropractic Literature from the inception of each database to December 31, 2020, for chiropractic studies reporting the use of both qualitative and quantitative methods or mixed qualitative methods. Pairs of reviewers independently screened titles, abstracts, and full-text studies, extracted data, and appraised reporting using the GRAMMS criteria and risk of bias with the Mixed Methods Appraisal Tool (MMAT). Generalized estimating equations were used to explore factors associated with reporting using GRAMMS criteria.

RESULTS

Of 1040 citations, 55 studies were eligible for review. Thirty-seven of these 55 articles employed either a multistage or convergent mixed methods design, and, on average, 3 of 6 GRAMMS items were reported among included studies. We found a strong positive correlation in scores between the GRAMMS and MMAT instruments (r = 0.78; 95% CI, 0.66-0.87). In our adjusted analysis, publications in journals indexed in Web of Science (adjusted odds ratio = 2.71; 95% CI, 1.48-4.95) were associated with higher reporting using GRAMMS criteria. Three of the 55 studies fully adhered to all 6 GRAMMS criteria, 4 studies adhered to 5 criteria, 10 studies adhered to 4 criteria, and the remaining 38 adhered to 3 criteria or fewer.

CONCLUSION

Our findings suggest that reporting in chiropractic mixed methods research using GRAMMS criteria was poor, particularly among studies with a higher risk of bias.

Perioperative Gabapentin May Reduce Opioid Requirement for Early Postoperative Pain in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

PURPOSE

To evaluate the efficacy of perioperative gabapentin or pregabalin treatment on postoperative pain and opioid requirement reduction in patients undergoing anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic review of randomized control trials was conducted evaluating the effect of gabapentin or pregabalin on postoperative pain and opioid requirement for patients undergoing ACLR. The primary outcomes assessed were postoperative pain scores and opioid requirements. Secondary outcomes were complications, side effects, dosage, and timing of intervention.

RESULTS

The initial search query identified 151 studies and 6 studies were included after full-text articles were reviewed. Three studies investigated the use of gabapentin and three studies investigated pregabalin. All three gabapentin studies reported significantly decreased or equivalent pain scores while also significantly reducing or removing total opioid consumption compared to control groups. Pregabalin demonstrated inconsistent efficacy for pain control and opioid consumption parameters across three studies. One study (pregabalin, n = 1) reported significantly increased incidence of dizziness with pregabalin compared to placebo.

CONCLUSION

There is moderate evidence demonstrating that preoperative gabapentin may be safe and effective in reducing postoperative pain and opioid consumption after ACLR. Gabapentin may be considered when employed as part of a multimodal analgesia regimen; however, the optimal protocol has yet to be determined. Currently, there is limited evidence demonstrating the efficacy of pregabalin on pain and opioid consumption in the setting of ACLR.

LEVEL OF EVIDENCE

Systematic Review of Level I Studies.

Post-ERCP pancreatitis occurs more frequently in self-expandable metallic stents than multiple plastic stents on benign biliary strictures: a meta-analysis

BACKGROUND

The occurrence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) after using covered self-expandable metallic stents (CSEMS) and multiple plastic stents (MPS) in the therapy of benign biliary strictures (BBS) remains ambiguous, this analysis aimed to evaluate the outcomes.

CONCLUSIONS

Compared with MPS, CSEMS caused a significantly higher incidence of PEP but fewer ERCP procedures, while the rate of stricture resolution, recurrence, and overall adverse events were comparable. Prevention methods of PEP should be further evaluated in BBS when undergoing CSEMS placement.

METHODS

A systematic search of electronic databases (PubMed, Web of Science and Cochrane Library) was conducted for randomised controlled trials (RCTs), and the included studies were published between 2008 and 2021. The primary outcome was PEP, while the secondary outcomes were stricture resolution, recurrence, overall adverse events, costs, and ERCP sessions. Pooled effect sizes were calculated with the random-effects model or fixed-effects model depending on the heterogeneity.

RESULTS

Six RCTs contained 444 patients (221 with CSEMS, 223 with MPS) finally included in the meta-analysis. The present analysis shows that compared to MPS, PEP is more likely to occur in CSEMS (OR [odds ratio] = 3.34, 95% confidence intervals [CI]:1.44-7.77, p = .005). CSEMS needs fewer ERCP sessions (Mean Deviation [MD]: -1.56; 95%CI:-2.66, -0.46], p = .006). The difference in stricture resolution and recurrence was not significant between the two stent types (OR = 0.87, 95%CI: 0.49-1.56, p = .64; and OR = 2.3, 95%CI: 0.68-7.76, p = .18). The incidence of overall adverse events was comparable between CSEMS and the MPS group (OR = 1.49, 95% CI: 0.97-2.29, p = .07).

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022314864. Key messagesCSEMS and MPS placement remain a mainstay for patients with BBS, and severe complications after stent placement have not been compared.The incidence of PEP was higher after deployment of CSEMS compared to MPS.Prevention methods of PEP should be evaluated in BBS when undergoing CSEMS placement.

Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Postoperative Analgesia in Abdominal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Regional anesthesia technique has been reported to exert excellent analgesic efficacy for various surgeries. Erector spinae plane block (ESPB) and transversus abdominis plane (TAP) block are good ways to relieve postoperative pain after abdominal surgery. However, the analgesic efficacy between them remains controversial. This meta-analysis evaluated the analgesic effect between these two blocks in abdominal surgery with statistical and clinical interpretation.

METHODS

PubMed, Web of Science, the Cochrane Library, ClinicalTrials.gov register, and Embase databases were systematically searched by two independent investigators from the inception to December 2021.

RESULTS

10 randomized controlled trials (RCTs) comprising 570 patients were included in the final meta-analysis. Meta-analysis revealed that ESPB decreased the opioid consumption and improved the pain scores during the first 24 postoperative hours compared with TAP groups statistically, while the magnitude of this difference did not reach the clinically significant threshold (10 mg of intravenous morphine consumption and 1.3 cm on the VAS scale). In addition, ESPB prolonged blockade duration and decreased the occurrence of postoperative nausea and vomiting (PONV). However, it did not improve the patients' satisfaction.

CONCLUSIONS

Although ESPB does not provide better clinical analgesia than the TAP block, it could be a comparable nerve block technique for abdominal wall analgesia.

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies

OBJECTIVE

To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.

METHOD

A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.

RESULTS

Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I² = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I² = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I² = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I² = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I² = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I² = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I² = 0%]. There have been no reports of complications from ESPB or other blocks.

CONCLUSION

Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.

Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis

INTRODUCTION

Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP).

AREAS COVERED

This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models.

EXPERT OPINION

1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.

The effect of erythropoietin on neonatal hypoxic-ischemic encephalopathy: An updated meta-analysis of randomized control trials

OBJECTIVE

Erythropoietin (EPO) seems to have a good application prospect both in experimental models and patients with hypoxic ischaemic encephalopathy (HIE). Data regarding the effect of EPO on death or neurodevelopmental impairment are conflicting.

METHODS

A search was conducted by two investigators involved in this research in PubMed, Embase, and Cochrane databases for studies in English, in Wanfang, VIP, and Cnki databases for Chinese studies (all last launched on 2022/08/31). Ultimately, we identified 11 original studies, including the EPO group (n = 636) and the control group (n = 626). Odds ratio (OR) and weighted mean difference were calculated using a random effects or fixed effects model, depending on the data type and heterogeneity of the included studies.

RESULTS

1. The comparison of effectiveness of EPO treatment on HIE: (1) With respect to death, data showed no significant difference between EPO and control groups (OR = 0.97, 95% CI, 0.66-1.43; P = 0.88); Considering the additional effect of mild hypothermia treatment (MHT), no significant difference was found between EPO + MHT/control + MHT groups either (OR = 1.09, 95% CI, 0.69-1.73; P = 0.72); With respect to the interference of different routes of medication administration, Meta-analysis further showed no difference between intravenous EPO/control groups (OR = 1.13, 95% CI, 0.70-1.82; P = 0.62). (2) With respect to cerebral palsy, the analysis showed no significant difference (OR = 0.76, 95% CI, 0.50-1.15; P = 0.20); Considering the effect of MHT and routes of medication administration, data further showed no difference between EPO group and control group (OR = 1.26, 95% CI, 0.73-2.19; P = 0.41). (3) Regarding epilepsy, no significant difference was found (OR = 0.49, 95% CI, 0.20-1.19; P = 0.12). MR abnormality was less common in EPO group (OR = 0.39, 95% CI, 0.19-0.79; P = 0.008). 2. The comparison of possible adverse events of EPO: EPO treatment would not increase the risk of thrombocytopenia, hypotension, and hepatic and kidney injury.

CONCLUSIONS

This meta-analysis showed that EPO treatment is not beneficial for reducing death and improving neurological impairment, though it would not increase the risk of adverse events.

Design of polyphenol-rich diets in clinical trials: A systematic review

Most randomized clinical trials of polyphenols focus on individual foods. Nevertheless, due to their presence in many foods and in order to reflect a real situation, clinical trials based on polyphenol-rich diets are particularly important. This systematic review explores the characteristics of the polyphenol-rich diets used in intervention studies. The bibliography search for English-language scientific papers was performed in the Elsevier Scopus Database and PUBMED in March 2020, and focused on intervention studies with whole polyphenol-rich diets, establishing several exclusion criteria. In studies fulfilling the requirements, information on the design of the polyphenol-rich diet and associated polyphenol intake was extracted and compared. A total of 5 studies were selected. Among them, substantial differences were found in the design of the polyphenol-rich diets, regarding specific instructions and concerning the foods provided. Similarly, although a median daily polyphenol intake of 2,564 mg/day (17,945 mg/week) was obtained from the studies, which corresponds to a nutritional dose, intake values varied widely both for total polyphenols (the difference between studies reached threefold), and for individual polyphenol intake (for hydroxycinnamic acids, a tenfold difference was found between percentile 25 and percentile 75 values). These differences made the comparison of results difficult and may affected the observed health effects. Thus, despite the relevance of studying polyphenol-rich diets as a whole, this systematic review found substantial differences between the studies performed, making direct comparisons difficult.

Effects of erector spinae plane block on postoperative pain in children undergoing surgery: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The erector spinae plane block is a novel regional anesthetic technique that is gaining popularity in pediatrics. However, the efficacy of erector spinae plane block in children is unclear. The aim of the systematic review and meta-analysis was to investigate effects of erector spinae plane block on postoperative pain relief in children.

METHODS

We searched MEDLINE, Cochrane Library, EMBASE, China National Knowledge Infrastructure, and Wan fang databases for randomized controlled trials that compared erector spinae plane block with no block or other types of block in pediatric patients undergoing surgeries. The primary outcomes were pain intensity at rest within 24 h postoperatively and the number of patients requiring rescue analgesics. Data were analyzed using the fixed- or random-effects model, depending on whether the heterogeneity tested by the I²  statistic was >30%. We assessed the quality of evidence for the outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation method.

RESULTS

Seven randomized controlled trials involving 379 patients were reviewed. Compared with no block, erector spinae plane block slightly reduced the pain scores at 0 h (standardized mean difference [SMD]: -1.07; 95% confidence interval [CI]: -1.60 to -0.54; I²  = 52%), 6 h (SMD: -0.82; 95% CI: -1.39 to -0.25; I²  = 79%) postoperatively at rest and significantly reduced the need for rescue analgesics (odds ratio 0.09; 95% CI: 0.04 to 0.21; I²  = 16%). One trial demonstrated the analgesic effect of erector spinae plane block was similar to a quadratus lumborum block, while another trial demonstrated the analgesic effect of ESPB was superior to an ilioinguinal nerve block.

CONCLUSIONS

This review provides low-quality evidence that erector spinae plane block exhibits superior analgesia compared to no block in children. Due to the limited data, evidence regarding the comparison with other regional blocks remains unclear. Future large-sized and well-designed randomized controlled trials are needed.

Quality of reporting in chiropractic mixed methods research: a methodological review protocol

Background

Mixed methods designs are increasingly used in health care research to enrich findings. However, little is known about the frequency of use of this methodology in chiropractic research, or the quality of reporting among chiropractic studies using mixed methods.

Objective

To quantify the use and quality of mixed methods in chiropractic research, and explore the association of study characteristics (e.g., authorship, expertise, journal impact factor, country and year of publication) with reporting quality.

Methods

We will conduct a systematic search of MEDLINE, EMBASE, CINAHL, and the Index to Chiropractic Literature to identify all chiropractic mixed methods studies published from inception of each database to December 31, 2020. Articles reporting the use of both qualitative and quantitative methods, or mixed qualitative methods, will be included. Pairs of reviewers will perform article screening, data extraction, risk of bias with the Mixed Methods Appraisal Tool (MMAT), and appraisal of reporting quality using the Good Reporting of A Mixed Methods Study (GRAMMS) guideline. We will explore the correlation between GRAMMS and MMAT scores, and construct generalized estimating equations to explore factors associated with reporting quality.

Discussion

This will be the first methodological review to examine the reporting quality of published mixed methods studies involving chiropractic research. The results of our review will inform opportunities to improve reporting in chiropractic mixed methods studies. Our results will be disseminated in a peer-reviewed publication and presented publicly at conferences and as part of a doctoral thesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00395-0.

Postoperative analgesic effects of paravertebral block versus erector spinae plane block for thoracic and breast surgery: A meta-analysis

Background

Paravertebral block (PVB) is the most recognized regional anesthesia technique after thoracic epidural anesthesia for postoperative analgesia in thoracic and breast surgery. Erector spinae plane block (ESPB) is a recently discovered blocking technique, and it has evidenced excellent postoperative analgesia for breast and thoracic surgery with fewer adverse reactions. However, there are controversies about the postoperative analgesic effects of the two analgesic techniques.

Objective

To assess the analgesic effects of PVB versus ESPB in postoperative thoracic and breast surgery.

Methods

We systematically searched PubMed, Cochrane Library, EMBASE, Web of Science, and ScienceDirect databases up to April 5, 2021. The primary outcome was postoperative pain scores. Secondary outcomes included: opioid consumption, additional analgesia, postoperative nausea and vomiting (PONV) 24 hours post-operation, and the time required for completing block procedure. This study was registered in PROSPERO, number CRD42021246160.

Results

After screening relevant, full-text articles, ten randomized controlled trials (RCTs) that met the inclusion criteria were retrieved for this meta-analysis. Six studies involved thoracic surgery patients, and four included breast surgery patients. Thoracic surgery studies included all of the outcomes involved in this meta-analysis while breast surgery did not report pain scores at movement and additional analgesia in 24 hours post-operation. For thoracic surgery, PVB resulted in significant reduction in the following pain scores: 0–1 hours (MD = -0.79, 95% CI: -1.54 to -0.03, P = 0.04), 4–6 hours (MD = -0.31, 95% CI: -0.57 to -0.05, P = 0.02), and 24 hours (MD = -0.42, 95% CI: -0.81 to -0.02, P = 0.04) at rest; significant reduction in pain scores at 4–6 hours (MD = -0.47, 95% CI: -0.93 to -0.01, P = 0.04), 8–12 hours (MD = -1.09, 95% CI: -2.13 to -0.04, P = 0.04), and 24 hours (MD = -0.31, 95% CI: -0.57 to -0.06, P = 0.01) at movement. Moreover, the opioid consumption at 24 hours post-operation (MD = -2.74, 95% CI: -5.41 to -0.07, P = 0.04) and the incidence of additional analgesia in 24 hours of the postoperative course (RR: 0.53, 95% CI: 0.29 to 0.97, P = 0.04) were significantly lower in the PVB group than in the ESPB group for thoracic surgery. However, no significant differences were found in pain scores at rest at various time points postoperatively, and opioid consumption at 24 hours post-operation for breast surgery. The time required for completing block procedure was longer in the PVB group than in the ESPB group for thoracic and breast surgery, and the incidence of PONV between the two groups showed no significant difference.

Conclusion

The postoperative analgesic effects of PVB versus ESPB are distinguished by the surgical site. For thoracic surgery, the postoperative analgesic effect of PVB is better than that of ESPB. For breast surgery, the postoperative analgesic effects of PVB and ESPB are similar.

The Analgesic Effects of Thoracic Paravertebral Block versus Thoracic Epidural Anesthesia After Thoracoscopic Surgery: A Meta-Analysis

Background

To date, there is no definitive evidence for the analgesic effects and side effects of thoracic epidural anesthesia (TEA) versus thoracic paravertebral block (TPVB) after thoracoscopic surgery. In this study, we conducted a meta-analysis of published randomized clinical trials (RCTs) to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery.

Methods

We systematically searched RCTs published by October 26, 2020, in PubMed, EMBASE, and Cochrane library and conducted a meta-analysis to analyze the analgesic effects of TEA versus TPVB after thoracoscopic surgery. The primary measure was postoperative pain score, and the secondary measures were postoperative 24-hour usage of opioids, hypotension, postoperative nausea, and vomiting.

Results

A total of 458 patients from five RCTs were included in this study. After thoracoscopic surgery, the numerical rating scale (NRS) score for resting pain was higher in the TPVB group than in the TEA group at 1–2 hours and 4–6 hours after surgery (MD = 0.44, 95% CI = 0.24 to 0.64, P < 0.0001, I2 = 0%; MD = 0.47, 95% CI = 0.23 to 0.70, P < 0.0001, I2 = 0%). The postoperative 24-hour usage of morphine was higher in the TPVB group than in the TEA group (SMD = 0.67; 95% CI = 0.03 to 1.31; P = 0.04; I2 = 84%). The incidence of hypotension was significantly lower in the TPVB group than in the TEA group (OR = 4.52; 95% CI = 2.03 to 10.10; P = 0.0002; I² = 0%). No significant between-group difference was observed in postoperative nausea and vomiting (PONV).

Conclusion

Compared with TPVB, TEA provides statistically significant but clinically unimportant short-term benefits following thoracoscopic surgery.

Levels of evidence backing the AAOS clinical practice guidelines

Purpose:

The American Academy of Orthopaedic Surgeons produces clinical practice guidelines for the treatment of orthopedic injuries. We examined the strength of the evidence underlying these recommendations in order to answer the following questions: (1) Have AAOS work groups improved guideline creation practices to locate evidence to generate strong recommendations? (2) Is there variability in the available evidence based on anatomic site or stage of care? (3) Has the level of evidence supporting improved over time?

Methods:

Twenty-two current guidelines of the Academy were examined which yielded 408 individual recommendations. These recommendations were assigned one of five strength of evidence ratings (strong, moderate, limited, inconclusive, consensus) by the guideline panel, based on the availability and quality of the supporting evidence. From these guidelines, we extracted all of the recommendations and their corresponding evidence ratings. We then classified the recommendations by stage of care, year, and anatomical site.

Results:

The distribution of the levels of evidence was as follows: 77 (18.9%) were based on consensus; 53 (13.0%) were inconclusive; 93 (22.8%) were based on limited evidence; 112 (27.5%) were based on moderate evidence; and 73 were based on (17.9%) strong evidence. Strong strength of evidence was found in 45.2% of the recommendations for preventive/screening/diagnostic care, 41.1% of nonsurgical treatment, 45.1% of surgical treatment, 51.1% of rehabilitation/postoperative treatment, and 45.5% of the recommendations that had mixed stages of care. Inconclusive strength of evidence was found to be prevalent from 2009–2013, but was eliminated starting in 2014.

Conclusions:

Only 73 (17.9%) recommendations generated by the Academy in its 22 clinical practice guidelines are based on a “strong” strength of evidence. More robust research is needed in orthopedics to bolster confidence in the recommendations in future guideline updates.

Meta-analysis of vancomycin versus linezolid in pneumonia with proven methicillin-resistant Staphylococcus aureus

OBJECTIVE

American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines suggest that linezolid (LZD) is preferred over vancomycin (VCM) for treating methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. We conducted a systematic review and comparative meta-analysis to compare VCM and LZD efficacy against proven MRSA pneumonia.

METHODS

We searched EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed up to November 2019. The outcomes of the meta-analysis were mortality, clinical cure, microbiological evaluation, and adverse events.

RESULTS

Seven randomized controlled trials (RCTs) with a total of 1239 patients and eight retrospective cohort or case-control studies (CSs) with a total 6125 patients were identified. Clinical cure and microbiological eradication rates were significantly increased in patients treated with LZD in RCTs (clinical cure: risk ratio (RR) = 0.81, 95% confidential interval (CI) = 0.71-0.92; microbiological eradication: RR = 0.71, 95% CI = 0.62-0.81) and CSs (clinical cure: odds ratio (OR) = 0.35, 95% CI = 0.18-0.69). However, mortality was comparable between patients treated with VCM and LZD in RCTs (RR = 1.08, 95% CI = 0.88-1.32) and CSs (OR = 1.20, 95% CI = 0.94-1.53). Likewise, there was no significant difference in adverse events between VCM and LZD in CSs (thrombocytopenia: OR = 0.95, 95% CI = 0.50-1.82; nephrotoxicity: OR = 1.72, 95% CI = 0.85-3.45).

CONCLUSIONS

According to our meta-analysis of RCTs and CSs conducted worldwide, we found robust evidence to corroborate the IDSA guidelines for the treatment of proven MRSA pneumonia.

Aspirin and heparin in the treatment of recurrent spontaneous abortion associated with antiphospholipid antibody syndrome: A systematic review and meta-analysis

The present study aimed to review relevant, randomized, controlled trials in order to determine the effects of aspirin and heparin treatment on recurrent spontaneous abortion (RSA) in women with antiphospholipid syndrome (APS). Previous relevant studies were identified using PubMed, Cochrane, Embase, CNKI, VANFUN and VIP by retrieving appropriate key words. Additionally, key relevant sources in the literature were reviewed and articles published before May 2019 were included. The 22 selected studies included 1,515 patients in the treatment group and 1,531 patients in the control group. These previous studies showed that heparin and aspirin significantly improved live birth rate when compared with treatments using intravenous immunoglobulin, aspirin alone or aspirin combined with prednisone. Moreover, heparin and aspirin greatly increased the birth weight compared with placebo and improved vaginal delivery relative to intravenous immunoglobulin. The gestational age at birth was significantly higher in the heparin and aspirin group compared with the placebo group and the incidence of intrauterine growth restriction was lower in the heparin and aspirin group compared with the placebo group. Furthermore, heparin and aspirin markedly reduced the incidence of miscarriage compared with the aspirin group and the placebo group, and the incidence of pre-eclampsia was lower in the heparin and aspirin group than the placebo group. Thus, heparin and aspirin could be further examined for the treatment of RSA in women with APS.

The effect of vitamin D supplementation on survival in patients with colorectal cancer: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Low circulating vitamin D levels are associated with poor colorectal cancer (CRC) survival. We assess whether vitamin D supplementation improves CRC survival outcomes.

METHODS

PubMed and Web of Science were searched. Randomised controlled trial (RCTs) of vitamin D supplementation reporting CRC mortality were included. RCTs with high risk of bias were excluded from analysis. Random-effects meta-analysis models calculated estimates of survival benefit with supplementation. The review is registered on PROSPERO, registration number: CRD42020173397.

RESULTS

Seven RCTs (n = 957 CRC cases) were identified: three trials included patients with CRC at outset, and four population trials reported survival in incident cases. Two RCTs were excluded from meta-analysis (high risk of bias; no hazard ratio (HR)). While trials varied in inclusion criteria, intervention dose and outcomes, meta-analysis found a 30% reduction in adverse CRC outcomes with supplementation (n = 815, HR = 0.70; 95% confidence interval (CI): 0.48-0.93). A beneficial effect was seen in trials of CRC patients (progression-free survival, HR = 0.65; 95% CI: 0.36-0.94), with suggestive effect in incident CRC cases from population trials (CRC-specific survival, HR = 0.76; 95% CI: 0.39-1.13). No heterogeneity or publication bias was noted.

CONCLUSIONS

Meta-analysis demonstrates a clinically meaningful benefit of vitamin D supplementation on CRC survival outcomes. Further well-designed, adequately powered RCTs are needed to fully evaluate benefit of supplementation in augmenting 'real-life' follow-up and adjuvant chemotherapy regimens, as well as determining optimal dosing.

Meta-analysis of fluoroquinolones versus macrolides for treatment of legionella pneumonia

BACKGROUND

Only a single meta-analysis has reported the clinical benefit of fluoroquinolones (FQs) for Legionella pneumonia; however, there is no robust data available to confirm this result, based on current guidelines.

METHODS

We performed a systematic review and meta-analysis comparing FQs with macrolides (MCs) on their efficacy and safety in Legionella pneumonia, using studies published until January 2020. The outcomes included mortality (overall; 30-day), clinical cure, time to apyrexia, length of hospital stay, and adverse events.

RESULTS

Five RCTs and twelve retrospective studies were identified. Clinical cure was comparable between the treatment groups (risk rate (RR) 1.07, 95% confidential interval (CI) 0.86-1.31). Mortality was significantly higher for MCs than for FQs (overall, odd rate (OR) 0.59, 95% CI 0.35-0.98; 30-day, OR 0.41, 95% CI 0.20-0.85). FQs significantly reduced the length of hospital stay, compared to MCs (mean difference -3.58, 95% CI -5.48-1.69). Other outcomes were not significantly different between the treatment groups (time to apyrexia; mean difference -1.83, 95% CI -5.15-1.5, adverse events; OR 0.61, 95% CI 0.33-1.15). In subgroup analyses, levofloxacin significantly reduced the length of hospital stay over two specific MCs (azithromycin and clarithromycin) (mean difference -3.03, 95% CI -5.33-0.72), whereas mortality was not significantly different between the treatment groups (overall, OR 0.49, 95% CI 0.19-1.24; 30-day, OR 0.38, 95% CI 0.13-1.13).

CONCLUSIONS

FQs exhibited superior effects in terms of mortality and length of hospital stay in Legionella pneumonia. These results support current guidelines recommending FQs for the treatment of Legionella pneumonia.

Systematic evaluation of therapeutic effects of stem cell transplantation trials for heart diseases in China

BACKGROUND

To systematically assess the quality of reports of clinical trials of stem cell for heart diseases published in Chinese.

METHODS

The quality of reports was assessed according to the CONSORT statement and the Jadad score. The association between the CONSORT scores and the reported therapeutic effects was evaluated.

RESULTS

A total of 36 randomized clinical trials were identified, and 1552 patients were included. The mean CONSORT score was 7.06 (SD = 2.99). The proportion of reports with a Jadad score of 3 was 8.33%. The improvement of left ventricular function, myocardial perfusion area, left ventricular diastolic diameter, and cardiac output decreased with the increase in the CONSORT score.

CONCLUSIONS

The percentages of high-quality reports published in Chinese on stem cell therapy for heart diseases are low. Although stem cell transplantation seems promising for heart diseases, high-quality studies are needed to verify the conclusions．.

Tianma Gouteng Decoction combined with Qiju Dihuang Pill for the treatment of essential hypertension: A protocol for systematic review and meta-analysis

BACKGROUND

Essential hypertension is one of the risk factors of cardiovascular and cerebrovascular diseases, which can cause target organ damage such as heart, brain and kidney, and has extremely high disability rate and death rate. With the development of economy and society, the prevalence rate of hypertension in China has increased rapidly from 9.8% in the 1980s to over 30% in the 21st century. According to the data published in "China Cardiovascular Disease Report 2018," China currently has 245 million hypertension patients. Comprehensive prevention and treatment of hypertension has become one of the major public health problems in China. The clinical practice and theoretical innovation of traditional Chinese medicine in the prevention and treatment of hypertension have been carried out for decades. Relevant literature points out that Tianma Gouteng Decoction combined with Qiju Dihuang Pill has ideal effect in the treatment of primary hypertension. However, most of the literatures are small sample studies, with uneven quality and clinical evidence, and lack of evidence-based medical evidence for clinical efficacy. Therefore, this study makes further meta-analysis of Tianma Gouteng Decoction combined with Qiju Dihuang Pill in the treatment of primary hypertension, with a view to providing evidence-based medical evidence for the treatment of primary hypertension.

METHODS

We will search 3 foreign electronic databases (Cochrane Library, Embase, PubMed) and 4 Chinese electronic databases (China National Knowledge Infrastructure, WangFang Database, Chinese Biomedical Literature Database, and Chinese Scientific Journal Database) to collect potential systematic reviews from their inceptions to February 2020. The language of publication is limited to Chinese or English. First, the quality of randomized controlled trials documents included in this study was evaluated by using the improved Jadad scoring scale. Then, the 2 researchers conducted the evaluation independently according to Cochrane bias risk tools. The evidence level of the results will be evaluated by using the recommended evaluation, development and evaluation grading of recommendations assessment, development, and evaluation method. Statistical analysis will be conducted using Revman 5.3.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSIONS

The conclusion of this study will provide evidence for the efficacy of Tianma Gouteng Decoction combined with Qiju Dihuang Pills in the treatment of primary hypertension due to the efficacy of western medicine alone in treating primary hypertension.

REGISTRATION NUMBER PROSPERO

INPLASY202050088.

Research Pearls: Checklists and Flowcharts to Improve Research Quality

To instill quality in published clinical research, reporting guidelines, consisting of checklists and flowcharts, were developed to protect against reporting poorly designed research, and researchers should be aware of the available instruments and their appropriate use. With the popularity of synthetic reviews, meta-analyses, and systematic reviews, there is a greater need to assess risk of bias and study quality. This review highlights the most frequently used guidelines and checklists, risk-of-bias scales, and quality rating scales that can assist researchers with improving their research and its eventual publication.

Polyphenols intervention is an effective strategy to ameliorate inflammatory bowel disease: a systematic review and meta-analysis

Whether polyphenols could ameliorate inflammatory bowel disease (IBD) is still conflicting. To explore the efficacy of polyphenols as an adjuvant therapy for IBD, we conducted this systematic review and meta-analysis. Literature search was performed using PubMed, Web of Science, Scopus and Cochrane databases. Finally, 12 randomized controlled trials (RCTs) were included. In contrast to control group, curcumin treatment significantly improved clinical remission in intention-to-treat (ITT) (OR = 3.36, 95% CI: 1.09-10.37) and per-protocol (PP) analysis (OR = 5.13, 95% CI: 1.84-14.27). Meanwhile, curcumin could significantly ameliorate endoscopic remission (OR = 5.69, 95% CI: 1.28-25.27) and clinical response (OR = 4.69, 95% CI: 1.03-21.47) in PP analysis. Heterogeneity was present across the studies. In conclusions, polyphenols might be an effective adjuvant treatment for ameliorating IBD. Considering the relatively few studies included in our present study, further clinical trials are required to verify the effects of polyphenols on IBD.

The efficacy and toxicity of induction chemotherapy plus concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma: A meta-analysis of randomized controlled trials

BACKGROUND

A systemic review and meta-analysis of randomized controlled trials (RCTs) was performed to compare the efficacy, toxicity and safety of concurrent chemoradiotherapy (CCRT) with or without induction chemotherapy (IC) for locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS

Research searching was performed in Web of Science, PubMed, The Cochrane Library, Embase, Chinese Biomedical Database, Chinese National Knowledge Infrastructure, Chongqing VIP Database for Chinese Technical Periodicals and Wanfang Database. RCTs including patients diagnosed with locoregionally advanced NPC without metastasis and randomly treated with IC plus CCRT and CCRT alone were included. Survival and outcome data were extracted and meta-analysis was performed using the Revman 5.3.0 software.

RESULTS

Ten RCTs (2280 patients) were selected and used for pooled meta-analysis. In comparison with CCRT, IC plus CCRT treatment significantly improved the overall survival (OS; HR = 0.70, 95%CI 0.56-0.87, P = .002), progression-free survival (PFS; HR = 0.75, 95%CI 0.65-0.87, P < .0001), distant metastasis failure-free survival (DMFS; HR = 0.71, 95%CI 0.58-0.85, P = .0003) and loco-regional failure-free survival (LFES; HR = 0.72, 95%CI 0.59-0.88, P = .002) of patients with locoregionally advanced NPC. Patients treated with IC and CCRT had higher incidence of grade 3-4 leucopenia and thrombocytopenia than patients treated with CCRT alone (P < .0001). No significant difference in other grade 3-4 adverse events and radiation toxicity was observed between the two groups. IC combined with CCRT improved the survival of patients with locoregionally advanced NPC.

CONCLUSIONS

Combined IC and CCRT therapy was an efficacy treatment regimen for locoregionally advanced NPC.

Evaluating the effectiveness of targeted therapies for thyroid carcinoma: an updated meta-analysis

Background

At present, most of the targeted therapies for thyroid carcinoma are in the clinical trial stage, and there is still no strong evidence to confirm their clinical effect. The aim of this meta-analysis was to evaluate the outcome of targeted therapies and provide quantitative evidence.

Method

Ovid, PubMed, EMBAS, ClinicalTrails.gov, and Cochrane Library electronic databases were searched until September 1, 2019. Randomized controlled studies (RCTs) studies that compared the treatment of thyroid carcinoma with the targeted therapies of utility and complications were analyzed.

Results

The study included 5 studies with a total of 1,615 patients, with 991 cases in the drug group and 624 cases in the placebo group. The meta-analysis indicated that compared with the placebo group, the progression-free survival (PFS) rate of the drug group was significantly improved. The PFS of the drug group was 10.8 to 30.5 months, compared with 4 to 19.3 months for the placebo group (6 months PFS: OR =3.23, 95% CI: 2.57 to 4.05, P<0.00001, 12 months PFS: OR =3.38, 95% CI: 2.58 to 4.42, P<0.00001, 18 months PFS: OR =2.48, 95% CI: 1.74 to 3.54, P<0.00001). Overall survival (OS) did not differ significantly in the study (6 months: OR =1.53, 95% CI: 1.00 to 2.35, P=0.05, 12 months: OR =1.26, 95% CI: 0.94 to 1.69, P=0.12, 18 months: OR =1.11, 95% CI: 0.87 to 1.42, P=0.39). The incidence of adverse reactions in the drug group was significantly higher than that in the placebo group (OR =4.76, 95% CI: 3.45 to 6.57, P<0.00001), and the subgroup of adverse reactions was still significantly higher than that in the placebo group.

Conclusions

This meta-analysis revealed that the targeted drugs can significantly prolong PFS in patients with thyroid carcinoma, but the targeted drugs did not prolong the OS. Although the incidence of adverse reactions was significantly higher than that of the placebo group, the patients were still tolerable in drug group.

Patterns in Outcomes Reporting of Operatively Managed Pediatric Patellofemoral Instability: A Systematic Review and Meta-analysis

BACKGROUND

Traumatic patellofemoral dislocation is a common injury in pediatric patients, and surgical treatment is often recommended. Increasingly, it has been recognized that clinical studies need to report age-appropriate treatment outcomes. However, the variability and appropriateness of outcomes reporting in the youth patellar instability literature are unknown.

PURPOSE

To analyze the patterns of outcomes reporting in studies published in high-impact orthopaedic journals after operative management of pediatric patellar instability.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Six high-impact orthopaedic journals were searched using PubMed and EMBASE to identify studies reporting outcomes of operative management of pediatric patellar instability. Studies containing adults were excluded. Clinical and radiographic outcomes were recorded from included articles. Descriptive statistics were calculated for overall instability recurrence rates, return-to-activity rates, and changes in Kujala and Tegner scores.

RESULTS

Of 545 identified articles, 8 studies met the inclusion criteria. These studies encompassed 213 patients and 230 knees (mean age, 13.2 years; range, 4.5-18.3 years). Seven of 8 studies reported patients' physeal status, but only 4 studies limited their outcomes reporting to patients with open physes. Two studies reported postoperative radiographic measures, and 5 studies reported preoperative radiographic findings. Six studies reported patient-reported outcome measures (PROMs). Seven unique PROMs were reported. All but one study reported complication rates and types of complications. The mean postoperative change in Tegner scores was -0.07 (range, -0.6 to 1.0). Among studies examining medial patellofemoral ligament reconstruction with adequate data, the mean return-to-activity rate was 86% (range, 81%-92%), the instability recurrence rate was 3% ± 20%, and the mean improvement in Kujala scores postoperatively was 22.1 (range, 19.9-26).

CONCLUSION

There is a need for more pediatric-specific outcomes studies regarding operatively managed traumatic patellofemoral instability. Of the outcomes reported, both radiographic outcomes and PROMs should be standardized. Among radiographic outcomes, there is a need for more studies that report tibial tubercle-trochlear groove distances and use Caton-Deschamps and/or Blackburne-Peel indices to assess patellar height. Among PROMs, there is a need for studies that use PROMs validated in pediatric populations, such as the International Knee Documentation Committee Pediatric Form or the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

The Effect of Level I Evidence on Surgical Decision Making in the United States Versus Canada

Background:

In this study, we examined the difference that randomized trials favoring either surgery or nonsurgical treatment had on the surgical indications of American versus Canadian surgeons.

Methods:

One randomized trial favoring surgical management of clavicle fractures and another one favoring nonsurgical management of Achilles tendon ruptures were used. American and Canadian orthopaedic surgeons were surveyed regarding their surgical indications for these injuries.

Results:

More than 2000 US and 200 Canadian responses were received. For clavicles, 57% of US respondents indicated that the trial changed their practice, with 64% operating on more fractures, compared with Canadians at 78% and 68%, respectively. For Achilles, 37% of US respondents indicated that the trial changed their practice, with 29% operating on fewer ruptures, compared with Canadians at 72% and 67%, respectively.

Conclusion:

American surgeons seem more willing to alter their practice to “evidence-based” indications for a trial that favors surgery rather than one that does not.

Does the medical literature remain inadequately described despite having reporting guidelines for 21 years? - A systematic review of reviews: an update

PURPOSE

Reporting guidelines (eg, Consolidated Standards of Reporting Trials [CONSORT] statement) are intended to improve reporting standards and enhance the transparency and reproducibility of research findings. Despite accessibility of such guidelines, researchers are not required to adhere to them. Our goal was to determine the current status of reporting quality in the medical literature and examine whether adherence of reporting guidelines has improved since the inception of reporting guidelines.

MATERIALS AND METHODS

Eight reporting guidelines, such as CONSORT, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), STrengthening the Reporting of OBservational studies in Epidemiology (STROBE), Quality of Reporting of Meta-analysis (QUOROM), STAndards for Reporting of Diagnostic accuracy (STARD), Animal Research: Reporting In Vivo Experiments (ARRIVE), Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and Meta-analysis of Observational Studies in Epidemiology (MOOSE) were examined. Our inclusion criteria included reviews published between January 1996 to September 2016 which investigated the adherence to reporting guidelines in the literature that addressed clinical trials, systematic reviews, observational studies, meta-analysis, diagnostic accuracy, economic evaluations, and preclinical animal studies that were in English. All reviews were found on Web of Science, Excerpta Medical Database (EMBASE), MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

RESULTS

Among the general searching of 26,819 studies by using the designed searching method, 124 studies were included post screening. We found that 87.9% of the included studies reported suboptimal adherence to reporting guidelines. Factors associated with poor adherence included non-pharmacological interventions, year of publication, and trials concluding with significant results. Improved adherence was associated with better study designs such as allocation concealment, random sequence, large sample sizes, adequately powered studies, multiple authorships, and being published in journals endorsing guidelines.

CONCLUSION

We conclude that the level of adherence to reporting guidelines remains suboptimal. Endorsement of reporting guidelines by journals is important and recommended.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Effect of covered self-expanding metal stents compared with multiple plastic stents on benign biliary stricture: A meta-analysis

BACKGROUND

Endoscopic placement of multiple plastic stents (MPS) has been the first-line treatment for benign biliary stricture (BBS). Covered self-expanding metal stents (cSEMS) have been used in treatment of BBS; however, the efficacy has not been verified. Therefore, we conducted this meta-analysis according to PRISMA guidelines.

METHODS

PubMed, Embase, and the Cochrane Library were electronically and manually searched for studies published between January 1, 1990 and April 12, 2017. Of 153 studies screened, 90 were excluded because of duplications. After scanning the title or abstract, only 24 studies were eligible for review and 6 were finally included. The investigators selected publications according to inclusion and exclusion criteria, processed the data, and assessed the quality of the selected studies. The primary endpoint outcome was stricture resolution, and the secondary endpoint outcomes included stricture recurrence rate, the number of endoscopic retrograde cholangiopancreatography (ERCP) sessions, and stent migration.

RESULTS

A total of 6 randomized controlled trials with 330 participants were included in the current meta-analysis. There was no significant difference in stricture resolution between the cSEMS and MPS groups (odds ratio [OR] = 1.05, 95% confidence interval [CI] = 0.53-2.07, I = 29%, P = .23, Z = 0.13, P = .90). Similarly, the stricture recurrence rates (OR = 1.39, 95% CI = 0.69-2.81, I = 38%, P = .17, Z = 0.91, P = .36) were comparable between cSEMS and MPS groups. Stent migration rates (OR = 1.71, 95% CI = 0.84-3.50, I = 4%, P = .241, Z = 1.47, P = .14) were similar between cSEMS and MPS groups. There were fewer ERCP sessions in the cSEMS group than in the MPS group.

CONCLUSIONS

This meta-analysis showed that cSEMS were comparable to MPS in achieving resolution of BBSs with fewer ERCP procedures.

Effect of various Danshen injections on patients with coronary heart disease after percutaneous coronary intervention: A protocol for a systematic review and network meta-analysis

BACKGROUND

Patients with coronary heart disease (CHD) who undergo percutaneous coronary intervention (PCI) have a certain risk of vascular complications, including coronary restenosis and thrombosis. Many recent randomized controlled trials have reported that Danshen injection (DSI) combined with conventional Western medicine can significantly reduce the occurrence of major cardiovascular adverse events in patients with CHD after PCI. However, there are many types of DSIs, and no study has yet compared each type. Therefore, we propose a study protocol for the systematic evaluation of the efficacy of various DSIs in the treatment of CHD after PCI.

METHODS

We will search the following electronic databases for randomized controlled trials evaluating the effect of DSI in patients with CHD after PCI: PubMed, Embase, Web of Science, Cochrane Library, Scopus, Ovid Evidence-Based Medicine Reviews, China National Knowledge Infrastructure, and Chinese Biomedicine Literature Database. Each database will be searched from inception to April 2018. The entire process will include study selection, data extraction, risk of bias assessment, pairwise meta-analyses, and network meta-analyses.

RESULTS

This proposed study will compare the efficacy of different DSIs in the treatment of patients with CHD after PCI. The outcomes will include major cardiovascular adverse events and left ventricular ejection fraction.

CONCLUSION

This proposed systematic review will evaluate the different advantages of various types of DSIs in the treatment of patients with CHD after PCI.

REGISTRATION

PROSPERO (registration number: CRD42018092705).

An Evaluation of Reporting Guidelines and Clinical Trial Registry Requirements Among Orthopaedic Surgery Journals

BACKGROUND

The responsibility for ensuring that studies are adequately reported is primarily that of those conducting the study; however, journal policies may influence how thoroughly authors choose to report their research. The use of reporting guidelines and prospective trial registration are promising avenues for ensuring that published studies adhere to the highest methodological standards. The purpose of this study is to evaluate orthopaedic surgery journal policies regarding reporting guidelines and trial registration, and to evaluate the effects that these policies have on adherence to reporting.

METHODS

We conducted a cross-sectional survey of journal policies and "Instructions for Authors" to determine the journals' policies and guidance regarding use of reporting guidelines and study registration. We also examined whether trials published in journals referencing CONSORT (Consolidated Standards of Reporting Trials) had higher rates of compliance with publishing a CONSORT flow diagram and whether journals with trial registration policies were more likely to contain registered trials than journals without these requirements.

RESULTS

Of the 21 orthopaedic surgery journals, 6 (29%) did not mention a single guideline, and clinical trial registration was required by 11 (52%) orthopaedic surgery journals and recommended by 2 (10%). Of the 21 general medical journals, 3 (14%) did not mention a single guideline, and trial registration was required by 13 (62%) general medical journals and recommended by 5 (24%) others. Furthermore, journals that referenced CONSORT were more likely to publish trials with a CONSORT flow diagram. Journals with trial registration policies were more likely to publish registered trials.

CONCLUSIONS

Reporting guidelines and trial registration are suboptimally required or recommended by orthopaedic surgery journals. These 2 mechanisms may improve methodology and quality, and should be considered for adoption by journal editors in orthopaedic surgery.

CLINICAL RELEVANCE

Because orthopaedic surgeons rely on high-quality research to direct patient care, measures must be taken to ensure that published research is of the highest quality. The use of reporting guidelines and prospective clinical trial registration may improve the quality of orthopaedic research, thereby improving patient care.

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Background:

Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.

Purpose:

To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.

Results:

Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.

Conclusion:

Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cN0 papillary thyroid carcinoma: An updated meta-analysis

BACKGROUND

The effectiveness of prophylactic central neck dissection (pCND) following total thyroidectomy (TT) in patients with clinical node-negative (cN0) papillary thyroid carcinoma (PTC) is still controversial. The aim of this meta-analysis is to evaluate the outcome of pCND and to provide quantitative evidence.

METHOD

A detailed literature search of PubMed, EMBASE, ClinicalTrails.gov and Cochrane Library electronic databases for articles published up to October 2016 was carried out. This meta-analysis was performed by the random method (Mantel-Haenszel) model. Locoregional recurrence (LRR) and surgical complications were analyzed.

RESULTS

Twenty-two studies comparing pCND + TT (combined) and TT alone in cN0 PTC patients were analyzed. A total of 6930 cases were enrolled, including 2381 cases in the combined group and 4009 cases in the TT-alone group. Compared with TT alone, patients in the combined group showed a significantly lower rate of overall LRR (OR = 0.66, 95% CI = 0.48-0.89) and central compartment recurrence (OR = 0.40, 95% CI = 0.22-0.73). There was no statistical difference in the rate of lateral compartment recurrence. However, the combined group showed a significantly higher rate of temporary and permanent hypoparathyroidism (OR = 2.28, 95% CI = 1.92-2.27/OR = 1.84, 95% CI = 1.15-2.95) and temporary recurrent laryngeal nerve injury (LNR) (OR = 1.53, 95% CI = 1.08-2.16). There was no statistical difference in the rate of permanent LNR, hematoma, hemorrhage or wound infection.

CONCLUSIONS

This meta-analysis revealed that pCND with TT was a significantly efficient way to reduce the risk of LRR. However, pCND + TT increased the incidence rate of temporary and permanent hypoparathyroidism and temporary LNR.

How are we measuring clinically important outcome for operative treatments in sports medicine?

OBJECTIVES

Minimal clinically important difference (MCID) and other measures of minimum clinical importance are increasingly recognized as important clinical considerations for evaluating the efficacy of an intervention. As our interpretation of clinical outcome evolves beyond statistical significance, psychometric properties such as MCID will be increasingly important to various stakeholders in the orthopaedic community. The purpose of this study was to: 1) describe the state of clinically important outcome reporting and 2) describe the methods used to derive these psychometric values for sports medicine patients undergoing operative treatments.

METHODS

A review of the MEDLINE database was performed. Studies primarily deriving and reporting clinically important outcome measures for operative interventions in sports medicine were included. Demographic, methodological and psychometric properties of included studies were extracted. Level of Evidence and the Newcastle Ottawa Scale (NOS) were used to assess study quality. Statistical analysis was primarily descriptive.

RESULTS

Fifteen studies met inclusion criteria; 10 of the 15 studies were Level II evidence and mean NOS score was 5.3/9. Minimal detectable change (MDC) was the most commonly derived measure of clinical importance, calculated in 53.3% of studies, followed by MCID, calculated in 40.0% of studies. A combination of distribution and anchor-based methods was the most commonly used method to determine clinical importance (N = 7, 46.7%) followed by distribution only (N = 5, 33.3%). Predictors of clinically important change were reported in four studies and were most commonly related to pre-operative functional score.

CONCLUSIONS

MDC and the MCID are the most commonly reported measures of clinically important outcome after operative treatment in sports medicine. A combination of both distribution and anchor-based methods is commonly used to derive these values. More attention should be paid to reporting outcomes that are clinically important and developing guidelines for reporting clinical meaningful outcome.

The quality of randomised controlled trials involving surgery from the hand to the elbow

Aims

Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics.

Materials and Methods

Based on five-year mean impact factors, we selected the six journals that routinely publish studies of upper extremity surgery. Using a journal-specific search query, 62 RCTs met our inclusion criteria. Then three blinded reviewers used the Jadad and revised Coleman Methodology Score (RCMS) to assess the quality of the manuscripts.

Results

Based on the Jadad scale, 28 studies were of high quality and 34 were of low quality. Methodological deficiencies in poorly scoring trials included the absence of rate of enrolment, no power analysis, no description of withdrawal or dropout, and a failure to use validated outcomes assessments with an independent investigator.

Conclusion

A large number of RCTs in hand, wrist, and elbow surgery were of suboptimal quality when judged against the RCMS and Jadad scales. Even with a high level of evidence, study design and execution of RCTs should be critically assessed. Methodological deficiencies may introduce bias and lead to statistically underpowered studies. Cite this article: Bone Joint J 2017;99-B:94–9.

Level of clinical evidence presented at the open and closed American Shoulder and Elbow Surgeons annual meeting over 10 years (2005-2014)

Background

The American Shoulder and Elbow Surgeons (ASES) annual scientific meetings are premier forums whereby orthopaedic surgeons are informed of the latest research advances in shoulder and elbow surgery. The purpose of the present study was to assess the Level of evidence (LOE) in the clinical papers presented at both the open and closed ASES annual scientific meetings from 2005 to 2014. Secondarily, the study evaluated whether there were any changes in the distribution of LOE over this period of time.

Methods

Two reviewers independently evaluated the abstracts of 532 paper presentations at either the open or closed ASES annual meetings. The independent reviewers first screened the abstracts for clinical evidence and excluded cadaveric, biomechanical, technique, and review studies. The included abstracts were then independently graded for methodological quality using LOE from Level I (highest quality) to IV (lowest quality) based on the classification system created by The American Academy of Orthopaedic Surgeons (AAOS).

Results

Overall, 421 presentations were included and graded for LOE. In general, 17% of the presentations were graded level I; 15% level II; 25% level III; and 43% assigned a LOE of IV. Chi-square analysis demonstrated a statistically significant improvement in the LOE of presentations at the open and closed ASES meetings combined (p = 0.028) between the years 2005 and 2014. In particular, the proportion of presentations graded as level IV significantly decreased over this period (p = <0.001).

Conclusions

While most presentations at the ASES annual scientific meetings were of lower LOEs the percentage of level I evidence is greater than that reported at other Orthopaedic meetings. There has been a significant improvement in the LOE of clinical research at open and closed ASES meetings from 2005 to 2014. Specifically, the proportion of level IV studies have dramatically decreased over time.

Comparison of clinical outcomes of patients with non-small-cell lung cancer harbouring epidermal growth factor receptor exon 19 or exon 21 mutations after tyrosine kinase inhibitors treatment: a meta-analysis

PURPOSE

Exon 19 deletion and exon 21 L858R mutation were the most common epidermal growth factor receptor (EGFR) mutations. We examined the clinical impact of these two mutations in patients with non-small-cell lung cancer (NSCLC) after EGFR tyrosine kinase inhibitor (TKI) treatment.

METHODS

The outcomes of interest were progression-free survival (PFS), overall survival (OS) and objective response rates (ORR), network meta-analysis and direct meta-analysis were conducted to calculate the efficacy of EGFR-TKIs between these two mutations. We also investigated the association between EGFR mutation types and clinical characteristics.

RESULTS

A total of 4835 patients from 26 trials were assessed. EGFR-TKIs, compared with chemotherapy, significantly prolonged PFS and OS in both exon 19 deletion and exon 21 L858R mutation based on 8 trials. Network meta-analysis revealed that treatment with EGFR-TKIs had greater benefit in exon 19 deletion than in exon 21 L858R mutation. Furthermore, direct meta-analysis from 12 studies showed the similar result; patients with exon 19 deletion had a significantly longer PFS compared with exon 21 L858R mutation (HR, 0.69; 95 % CI, 0.57–0.82; P < 0.001). There were also greater benefit on OS (HR, 0.61; 95 % CI, 0.43–0.86; P = 0.005) and higher ORR (OR, 2.14; 95 % CI, 1.63–2.81; P < 0.001). Additionally, we found that a significant association between the type of mutation and age (P < 0.001) or smoking status (P = 0.022), but no other significant differences were detected in sex, histologic subtype and performance status between these two mutations.

CONCLUSIONS

Patients with NSCLC and EGFR exon 19 deletion had a longer PFS, OS and higher response rates after EGFR-TKI therapy compared with exon 21 L858R mutation.

Comprehensiveness of Outcome Reporting in Studies of Articular Cartilage Defects of the Knee

PURPOSE

To assess the comprehensiveness of outcome reporting after treatment of focal articular cartilage defects in the knee.

METHODS

A systematic review of literature published over the past 5 years (October 2010 to October 2015) in 5 high-impact orthopaedic journals was completed to identify all recent clinical studies tracking outcomes after surgery for focal articular cartilage defects in the knee. A metric reporting score was calculated for each study, according to reporting of 6 cardinal domains: pain, satisfaction, osteoarthritis progression, subjective knee function, objective knee function, and patient-reported outcomes.

RESULTS

Of the 122 studies included for review, 117 (96%) tracked patient-reported outcomes during follow-up. Nearly two-thirds of studies (63%) monitored progression of osteoarthritis at follow-up. Fewer than half of studies (39%) specifically monitored pain outcomes in patients. One-third of studies (30%) tracked patient satisfaction. Only 21% of studies monitored subjective knee function using proxies such as return to play, and only 17% of studies reported on objective knee function during return visits to the clinic. The average metric reporting score of all studies was 2.6, and nearly half of studies (48%) reported on only 1 or 2 domains of interest.

CONCLUSIONS

There is substantial variability in outcome reporting after cartilage surgery in high-impact orthopaedic journals. Furthermore, most studies do not comprehensively track outcomes across domains. Both factors hinder comparison of results across studies. Future outcome metrics should focus on patient-centered factors to improve both accuracy of results reporting and standardization across studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Level of Clinical Evidence Presented at the Arthroscopy Association of North America Annual Meeting Over 10 Years (2006-2015)

PURPOSE

To evaluate any trends in the level of clinical evidence in the papers presented at the Arthroscopy Association of North America (AANA) annual scientific meetings from 2006 to 2015.

METHODS

The online abstracts of the paper presentations presented at the AANA meetings were independently evaluated by 2 reviewers (664 total presentations). The reviewers independently screened these results for clinical studies and graded their level of evidence from Level I (i.e., randomized trials) to IV (i.e., case series) based on the American Academy of Orthopaedic Surgeons classification system.

RESULTS

Five hundred thirteen presentations met the inclusion criteria and were evaluated. Overall, 16% of the presentations were Level I evidence, 15% were Level II, 26% were Level III, and 43% were Level IV. We observed a significant non-random improvement in the level of evidence of presentations at the AANA meetings (P ≤ .001) between 2006 and 2015. In particular, the percentage of papers with Level IV evidence presented significantly decreased (P ≤ .001) and the percentage of papers with Level III evidence increased (P = .004) over the study period.

CONCLUSIONS

Statistical trends show that the influence of evidence-based medicine in orthopaedics has had a positive impact on the quality of research presented at the AANA meetings.

LEVEL OF EVIDENCE

Level IV, review of abstracts of Level I to Level IV evidence.

Outcomes assessment in rotator cuff pathology: what are we measuring?

BACKGROUND

Assessments used to measure outcomes associated with rotator cuff pathology and after repair are varied. This lack of standardization leads to difficulty drawing comparisons across studies. We hypothesize that this variability in patient-reported outcome measures and objective metrics used in rotator cuff studies persists even in high-impact, peer reviewed journals.

METHODS

All studies assessing rotator cuff tear and repair outcomes in 6 orthopedic journals with a high impact factor from January 2010 to December 2014 were reviewed. Cadaveric and animal studies and those without outcomes were excluded. Outcome measures included range of motion (forward elevation, abduction, external rotation, and internal rotation), strength (in the same 4 planes), tendon integrity imaging, patient satisfaction, and functional assessment scores.

RESULTS

Of the 156 included studies, 63% documented range of motion measurements, with 18% reporting range of motion in all 4 planes. Only 38% of studies reported quantitative strength measurements. In 65% of studies, tendon integrity was documented with imaging (38% magnetic resonance imaging/magnetic resonance anrhrogram, 31% ultrasound, and 8% computed tomography arthrogram). Finally, functional score reporting varied significantly, with the 5 most frequently reported scores ranging from 16% to 61% in studies, and 15 of the least reported outcomes were each reported in ≤6% of studies.

CONCLUSIONS

Significant variability exists in outcomes reporting after rotator cuff tear and repair, making comparisons between clinical studies difficult. Creating a uniformly accepted, validated outcomes tool that assesses pain, function, patient satisfaction, and anatomic integrity would enable consistent outcomes assessment after operative and nonoperative management and allow comparisons across the literature.

What Are the Strength of Recommendations and Methodologic Reporting in Health Economic Studies in Orthopaedic Surgery?

BACKGROUND

Cost-effectiveness research is an increasingly used tool in evaluating treatments in orthopaedic surgery. Without high-quality primary-source data, the results of a cost-effectiveness study are either unreliable or heavily dependent on sensitivity analyses of the findings from the source studies. However, to our knowledge, the strength of recommendations provided by these studies in orthopaedics has not been studied.

QUESTIONS/PURPOSES

We asked: (1) What are the strengths of recommendations in recent orthopaedic cost-effectiveness studies? (2) What are the reasons authors cite for weak recommendations? (3) What are the methodologic reporting practices used by these studies?

METHODS

The titles of all articles published in six different orthopaedic journals from January 1, 2004, through April 1, 2014, were scanned for original health economics studies comparing two different types of treatment or intervention. The full texts of included studies were reviewed to determine the strength of recommendations determined subjectively by our study team, with studies providing equivocal conclusions stemming from a lack or uncertainty surrounding key primary data classified as weak and those with definitive conclusions not lacking in high-quality primary data classified as strong. The reasons underlying a weak designation were noted, and methodologic practices reported in each of the studies were examined using a validated instrument. A total of 79 articles met our prespecified inclusion criteria and were evaluated in depth.

RESULTS

Of the articles included, 50 (63%) provided strong recommendations, whereas 29 (37%) provided weak recommendations. Of the 29 studies, clinical outcomes data were cited in 26 references as being insufficient to provide definitive conclusions, whereas cost and utility data were cited in 13 and seven articles, respectively. Methodologic reporting practices varied greatly, with mixed adherence to framing, costs, and results reporting. The framing variables included clearly defined intervention, adequate description of a comparator, study perspective clearly stated, and reported discount rate for future costs and quality-adjusted life years. Reporting costs variables included economic data collected alongside a clinical trial or another primary source and clear statement of the year of monetary units. Finally, results reporting included whether a sensitivity analysis was performed.

CONCLUSIONS

Given that a considerable portion of orthopaedic cost-effectiveness studies provide weak recommendations and that methodologic reporting practices varied greatly among strong and weak studies, we believe that clinicians should exercise great caution when considering the conclusions of cost-effectiveness studies. Future research could assess the effect of such cost-effectiveness studies in clinical practice, and whether the strength of recommendations of a study's conclusions has any effect on practice patterns.

CLINICAL RELEVANCE

Given the increasing use of cost-effectiveness studies in orthopaedic surgery, understanding the quality of these studies and the reasons that limit the ability of studies to provide more definitive recommendations is critical. Highlighting the heterogeneity of methodologic reporting practices will aid clinicians in interpreting the conclusions of cost-effectiveness studies and improve future research efforts.

High Variability in Outcome Reporting Patterns in High-Impact ACL Literature

BACKGROUND

ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction.

METHODS

All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study.

RESULTS

Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively).

CONCLUSIONS

Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.