Repeated-measure analyses: Which one? A survey of statistical models and recommendations for reporting

Using CT images to assist the segmentation of MR images via generalization: Segmentation of the renal parenchyma of renal carcinoma patients

BACKGROUND

Developing deep learning models for segmenting medical images in multiple modalities with less data and annotation is an attractive and challenging task, which was previously discussed as being accomplished by complex external frameworks for bridging the gap between different modalities. Exploring the generalization ability of networks in medical images in different modalities could provide more simple and accessible methods, yet comprehensive testing could still be needed.

PURPOSE

To explore the feasibility and robustness of using computed tomography (CT) images to assist the segmentation of magnetic resonance (MR) images via the generalization, in the segmentation of renal parenchyma of renal cell carcinoma (RCC) patients.

METHODS

Nephrographic CT images and fat-suppressed T2-weighted (fs-T2 W) images were retrospectively collected. The pure CT dataset included 116 CT images. Additionally, 240 MR images were randomly divided into subsets A and B. From subset A, three training datasets were constructed, each containing 40, 80, and 120 images, respectively. Similarly, three datasets were constructed from subset B. Subsequently, datasets with mixed modality were created by combining these pure MR datasets with the 116 CT images. The 3D-UNET models for segmenting the renal parenchyma in two steps were trained using these 13 datasets: segmenting kidneys and then the renal parenchyma. These models were evaluated in internal MR (n = 120), CT (n = 65) validation datasets, and an external validation dataset of CT (n = 79), using the mean of the dice similarity coefficient (DSC). To demonstrate the robustness of generalization ability over different proportions of modalities, we compared the models trained with mixed modality in three different proportions and pure MR, using repeated measures analysis of variance (RM-ANOVA). We developed a renal parenchyma volume quantification tool by the trained models. The mean differences and Pearson correlation coefficients between the model segmentation volume and the ground truth segmentation volume were calculated for its evaluation.

RESULTS

The mean DSCs of models trained with 116 data in CT in the validation of MR were 0.826, 0.842, and 0.953, respectively, for the predictions of kidney segmentation model on whole image, renal parenchymal segmentation model on kidneys with RCC and without RCC. For all models trained with mixed modality, the means of DSC were above 0.9, in all validations of CT and MR. According to the results of the comparison between models trained with mixed modality and pure MR, the means of DSC of the former were significantly greater or equal to the latter, at all three different proportions of modalities. The differences of volumes were all significantly lower than one-third of the volumetric quantification error of a previous method, and the Pearson correlation coefficients of volumes were all above 0.96 on kidneys with and without RCC of three validations.

CONCLUSION

CT images could be used to assist the segmentation of MR images via the generalization, with or without the supervision of MR data. This ability showed acceptable robustness. A tool for accurately measuring renal parenchymal volume on CT and MR images was established.

The effects of a 5-year physical activity on prescription (PAP) intervention in patients with metabolic risk factors

BACKGROUND

Increased physical activity (PA) has positive effects on health and longevity. In Swedish healthcare, the physical activity on prescription (PAP) method reportedly increases patients' PA levels for up to 12 months, but long-term follow ups are lacking. As it remains difficult to maintain lifestyle changes, our aim was to evaluate adherence and clinical effects at a 5-year follow-up of PAP treatment in primary healthcare.

METHODS

This longitudinal, prospective cohort study included 444 patients, (56% female), aged 27-85 years, with at least one metabolic risk factor. Participants were offered PAP by nurses or physiotherapists. The PAP intervention included an individualised dialogue, a PA recommendation by written prescription, and individually adjusted follow-up over 5 years, according to the Swedish PAP model. Patient PA level, metabolic risk factors, and health related quality of life (HRQoL) were measured at baseline and at the 6-month, 1.5-year, 2.5-year, 3.5-year, and 5-year follow-ups. Estimated latent growth curves were used to examine levels and rates of change in the outcomes.

RESULTS

The study dropout rate was 52%, with 215 of 444 patients completing the 5-year follow-up. At follow-up, the mean PA level had increased by 730 MET-minutes per week or 3 hours of moderate-intensity PA/week when compared to baseline. During the 5-year intervention, we observed significant positive changes (p ≤ 0.05) in 9 of 11 metabolic risk factors and HRQoL parameters: body mass index, waist circumference, systolic and diastolic blood pressure, fasting plasma glucose, triglycerides, cholesterol, high-density lipoprotein, and mental component summary.

CONCLUSION

This first evaluation of a 5-year PAP intervention in primary care demonstrated positive long-term (5 years) effects regarding PA level, metabolic health, and HRQoL. The recorded long-term adherence was ~50%, which is in line with medical treatment. Despite limitations, PAP can have long-term effects in an ordinary primary care setting.

Coaching-Based Teleoccupational Guidance for Home-Based Stroke Survivors and Their Family Caregivers: Study Protocol for a Superior Randomized Controlled Trial

Background

Home-based rehabilitation has been shown to be useful for stroke survivors to participate in daily life activities and return to their families. However, many home-based stroke survivors face challenges in the lack of professional guidance, rational training plans, and insufficient motivation, which will affect their rehabilitation outcomes to varying degrees. Though occupational therapy and coaching are widely recommended for stroke rehabilitation, studies that combine these two interventions via telerehabilitation in home-based rehabilitation are limited. Hence, this study will explore whether coaching-based teleoccupational guidance (CTG) will help stroke survivors and caregivers obtain satisfactory outcomes.

Methods

This single-blind (assessor), two-arm parallel superior randomised controlled trial will be conducted in the Hebei General Hospital, Shijiazhuang, China. Ninety-two participant dyads in home-based rehabilitation will be recruited and randomised to either CTG (intervention group) or a standard telerehabilitation group (control group). Participant dyads in the intervention group will follow a 6-step circle procedure and receive 12 teleoccupational coaching sessions over 3 months via WeChat. Data will be collected at baseline, after the intervention (3 months), and follow-up (6 months). The Reintegration to Normal Living Index will be the primary outcome to assess the participation of stroke survivors. Secondary outcomes will not only involve an observation of changes in activities of daily living, intrinsic motivation, motor function, and quality of life of stroke survivors but also will focus on the caregivers' perceived benefit and care burden. Discussion. This trial will assess the effects of CTG compared with standard telerehabilitation. We believe that the results of this study will add to the understanding of occupational therapy for stroke survivors in home-based rehabilitation and provide a reference for developing health policy and facilitating other chronic management. Trial Registration Number. The Chinese Clinical Trial Registry ChiCTR2200061107.

Analyses of repeatedly measured continuous outcomes in randomized controlled trials needed substantial improvements

OBJECTIVES

Systematic understanding is lacking regarding how current trials handle repeated measure data and the extent to which appropriate statistical methods are used for such data set. This study investigated the current practice of analyzing the repeated measure data among randomized controlled trials (RCTs).

STUDY DESIGN AND SETTING

We searched the Core Clinical Journals indexed in PubMed for RCTs published in 2019 and included a continuous primary outcome with repeated measures. We randomly sampled RCTs from the eligible trials. Team of methods trained investigators screened studies for eligibility and collected data using the pilot-tested, standardized questionnaires. We thoroughly documented statistical analyses of the continuous primary outcome with repeated measures and particularly recorded how statistically advanced methods were used to handle these repeated measures.

RESULTS

In total, 200 trials were included. Of these trials, the mean number of repeated measures for the continuous primary outcome was 5.46 (SD = 3.4); 58 (29.0%) trials did not specify the time point of primary outcome in the method; 113 (56.5%) trials did not use statistically advanced methods for handling repeated measure data in the primary analyses. Among187 trials included the baseline values, 88 (47.1%) trials did not adjust for outcome value at baseline. Among 87 trials using statistically advanced methods, 49 (56.3%) did not specify correlation structure for model.

CONCLUSIONS

The statistical analyses of repeatedly measured continuous outcomes in RCTs need substantial improvements. Careful planning of the primary outcome and the use of statistically advanced methods for analyzing data are warranted.

A Proper Increasing in the Testosterone Level May Be Associated With Better Pregnancy Outcomes for Patients With Tubal or Male Infertility During in vitro Fertilization/Intracytoplasmic Sperm Injection

We aimed to investigate the relationship between testosterone (T) levels and pregnancy outcomes in patients with tubal or male infertility at different times during in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles. Patients with tubal or male infertility and normal androgen levels undergoing IVF/ICSI were consecutively recruited. We performed a longitudinal analysis of T levels at three time points (i.e., T0: baseline, T1: trigger day, and T2: day after the trigger day) in three groups with different pregnancy outcomes (i.e., group 1: no pregnancy; group 2: clinical pregnancy but no live birth; and group 3: live birth) as repeated measurement data using linear mixed-effects models. We also plotted fitted curves depicting the relationship between T levels and a number of oocytes retrieved at different time points and identified the inflection points of the curves. In total, 3,012 patients were recruited. Groups 1 and 3 had improvements in T levels at the three time points. After refitting, the slope in group 3 was significantly higher than that in group 1 (P = 0.000). Curves that reflected the association between T levels and numbers of retrieved oocytes presented an upward trend before a certain inflection point, after which the curves had no obvious changes or fell with increasing T levels. The inflection points for T0, T1, and T2 were calculated as 0.45, 0.94, and 1.09, respectively. A faster upward trend in T levels might be associated with better pregnancy outcomes. Within a range lower than a T level inflection point, more oocytes and embryos could be obtained with increasing T levels.

Detection of renal hypoxia configuration in patients with lupus nephritis: a primary study using blood oxygen level-dependent MR imaging

BACKGROUND

Renal microstructure and function are closely associated with oxygenation homeostasis. Analyzing renal blood oxygen level‒dependent (BOLD) magnetic resonance imaging (MRI) examination results will provide information on the biological status of the kidneys. The current study was performed to explore the hypoxia mode of the entire renal parenchyma in patients with lupus nephritis (LN).

METHODS

A total of 23 adult patients with LN and 18 healthy volunteers were recruited. R²* values were acquired using BOLD MRI analysis. The narrow rectangular region of interest was used to explore the hypoxia configuration in entire depths of renal parenchyma. Acquired sequential R²* data were fitted using four categories of mathematic functions. The tendency of R²* data in both patients with LN and healthy volunteers was also compared using repeated-measures analysis of variance.

RESULTS

R²* data from the superficial cortex to deep medulla displayed two patterns called a sharp uptrend style and a flat uptrend style. After sequential R²* data were fitted individually with the use of four mathematic formulas, the multiple-compartment Gaussian function showed the highest goodness of fit. Compared with two categories of R²* value styles, the R²* tendency of entire parenchyma in patients with LN was different from that in healthy volunteers.

CONCLUSIONS

Deep renal medullary oxygenation was not always overtly lower than oxygenation in the superficial renal cortical zone. The manifestation of renal parenchyma oxygenation could be described using a Gaussian function model. Deoxygenation tolerance was damaged in patients with LN.

Benzoic acid derivatives as luminescent sublimation dyes in cyanoacrylate fuming of latent fingerprints

Development of latent prints employing cyanoacrylate ester (CA) can be a multistep process including CA fuming and subsequent fluorescent staining to produce fingerprints of sufficient contrast for comparison work. To enable a single-step CA fuming-staining process, a selection of fluorophores have been developed as sublimation dyes in CA fuming. A greater array of such luminescent sublimation dyes would allow users greater flexibility in selecting a particular dye-CA combination to best suit their processing needs. Toward this end, six benzoic acid derivatives were evaluated for use as luminescent sublimation dyes under elementary CA fuming conditions using a single non-porous surface type and an inexpensive handheld UV lamp for excitation. Two benzoic acid derivatives, 2-hydroxybenzoic acid (salicylic acid) and 2-aminobenzoic acid (anthranilic acid), were identified as new potential luminescent sublimation dyes with stained fingerprints excited at 254 nm. The fluorescence intensity and stability of prints produced via the sublimation of CA with 2-hydroxybenzoic acid and 2-aminobenzoic acid were evaluated over approximately six weeks using image and statistical analysis.

Long-term physical activity on prescription intervention for patients with insufficient physical activity level-a randomized controlled trial

BACKGROUND

Physical activity (PA) can be used to prevent and treat diseases. In Sweden, licensed healthcare professionals use PA on prescription (PAP) to support patients to increase their PA level. The aim of this randomized controlled trial was to evaluate a 2-year intervention of two different strategies of PAP treatment for patients with insufficient PA level, after a previous 6-month period of ordinary PAP treatment in a primary health care setting.

METHODS

We included 190 patients, 27-77 years, physically inactive with metabolic risk factors where the patients were not responding to a previous 6-month PAP treatment with increased PA. The patients were randomized to either enhanced support from a physiotherapist (PT group) or continued ordinary PAP treatment at the health care centre (HCC group). The PAP treatment included an individualized dialogue; an individually dosed PA recommendation, including a written prescription; and a structured follow-up. In addition to PAP, the PT group received aerobic fitness tests and more frequent scheduled follow-ups. The patient PA level, metabolic health, and health-related quality of life (HRQOL) were measured at baseline and at 1- and 2-year follow-ups.

RESULTS

At the 2-year follow-up, 62.9% of the PT group and 50.8% of the HCC group had increased their PA level and 31.4% vs. 38.5% achieved ≥ 150 min of moderate-intensity PA/week (difference between groups n.s.). Over 2 years, both groups displayed increased high-density lipoproteins (HDL) (p = 0.004 vs. baseline), increased mental health status (MCS) (p = 0.036), and reduced body mass index (BMI) (p = 0.001), with no difference between groups.

CONCLUSION

During long-term PAP interventions, the PA level, metabolic health, and HRQOL increased in patients at metabolic risk without significant differences between groups. The results indicate to be independent of any changes in pharmacological treatment. We demonstrated that the PAP treatment was feasible in ordinary primary care. Both the patients and the healthcare system benefitted from the improvement in metabolic risk factors. Future studies should elucidate effective long-term PAP-treatment strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03012516 . Registered on 30 December 2016-retrospectively registered.

Detection of water-molecular-motion configuration in patients with lupus nephritis: a primary study using diffusion-weighted imaging

BACKGROUND

Lupus nephritis (LN) is one of most common types of secondary glomerulonephritis, which is characterized by longitudinal pathological changes. Microstructural lesions of LN will impact the motion of water molecules, which can be detected by diffusion-weighted imaging (DWI). There are few reported measurements of water diffusion in patients with LN, and the nature of water diffusion across the entire depth of the renal parenchyma remains largely unknown.

METHODS

Twenty adult patients with LN and 11 healthy volunteers underwent DWI inspection. Renal biopsy samples were characterized based on the revised ISN/RPS 2003 classification. The apparent-diffusion coefficient (ADC) was calculated via fitting into a mono-exponential model. To compare the ADC level across the entire renal parenchyma between the two groups, repeated-measures analysis of variance (RM-ANOVA) was performed. ADC data derived from DWI pictures were transformed into tridimensional maps by MATLAB software.

RESULTS

Compared with data from healthy volunteers, lower average ADC values with major undulatory magnitudes were found in patients with LN, especially in the cortical zone. Tridimensional maps of patients with LN displayed geographic terrain-like canyons and/or valleys that were different from the corresponding terrain-like flatlands and/or plateaus in healthy volunteers. A heterogeneity of ADC values was found in bilateral kidneys. Left kidneys predominated higher ADC values in patients with LN. The ADC values across the entire renal parenchyma exhibited statistically significant differences among the three identified pathological subclasses (P < 0.001).

CONCLUSIONS

Analysis of the motion of water molecules across the entire renal parenchyma may be helpful for better understanding the pathological conditions of LN, for which microstructural and functional heterogeneity may be detected and visualized via DWI.

A Novel Synthetic Interfering Peptide Tat-3L4F Attenuates Olanzapine-Induced Weight Gain Through Disrupting Crosstalk Between Serotonin Receptor 2C and Protein Phosphatase and Tensin Homolog in Rats

BACKGROUND

Accompanied with profound efficacy, atypical antipsychotics (AAPs) contribute to metabolic adverse effects with few effective strategies to attenuate. Serotonin 5-HT2C receptor (HTR2C) plays a critical role in hyperphagia and weight gain induced by AAPs, and expression of phosphatase tensin homolog (PTEN) in the hypothalamus also affects feeding behavior and weight change. Moreover, PTEN has a physical crosstalk between PTEN and a region in the third intracellular loop (3L4F) of the HTR2C. Tat-3L4F has the property to disrupt crosstalk between PTEN and HTR2C. This is the first study to our knowledge to investigate the effect of Tat-3L4F on olanzapine-induced metabolic abnormalities and PTEN/ phosphatidylinositol 3-kinase/protein kinase B expression in the hypothalamus in rats.

METHODS

The effects of Tat-3L4F were investigated through measuring body weight, food intake, and blood glucose. In addition, PTEN/phosphatidylinositol 3-kinase/protein kinase B level in the hypothalamus was detected by immunofluorescence assay and western blot. Metabolites in the liver tissue were detected by liquid chromatography-mass spectrometry and analyzed by multivariate analyses and pairwise comparison.

RESULTS

Our results showed that hyperphagia and weight gain were evident in the olanzapine alone-fed rats but was attenuated after Tat-3L4F treatment. In addition, oral glucose tolerance test indicated blood glucose at 120 minutes was higher in the olanzapine alone-treated group than in groups treated with vehicle and olanzapine + Tat-3L4F (10 μmol kg-1 per day). Furthermore, compared with olanzapine alone treatment, treatment with Tat-3L4F (10 μmol kg-1 per day) significantly inhibited PTEN expression in the hypothalamus. The olanzapine alone-treated group had the highest bile acid level, followed by the olanzapine with Tat-3L4F (1 μmol kg-1) group, olanzapine with Tat-3L4F (10 μmol kg-1) group, and vehicle group.

CONCLUSIONS

Our present results reveal that Tat-3L4F is a potential pharmacological strategy for suppressing hyperphagia and weight gain induced by olanzapine, which acts through disrupting crosstalk between HTR2C and PTEN as a result of PTEN downregulation in the hypothalamus.

Does an effective shoulder injury prevention program affect risk factors in handball? A randomized controlled study

BACKGROUND

Shoulder problems are common in handball, but injury risk reduction is possible by implementing a prevention program. However, player compliance to the program remains a challenge, with feedback from players that the program is too time consuming.

AIM

To develop a more efficient program, we aimed to assess the effect of the Oslo Sports Trauma Research Center shoulder injury prevention program on external rotation (ER) strength and internal rotation (IR) range of motion (ROM), considered to represent key risk factors for injury.

METHODS

Four youth handball teams (three females, one males, 57 players, mean age 17.1 years) were randomized to an intervention or control group. The intervention program was conducted three times per week as a part of handball warm-up for 18 weeks, supervised by physical therapists. The main outcome variables were the between-group differences in ER strength and IR ROM change from baseline to postintervention. Isometric ER strength was measured with a handheld dynamometer and IR ROM with a digital goniometer.

RESULTS

Mean dominant shoulder isometric ER strength increased both in the intervention (10%) and the control group (6%) during the intervention, but there was no significant group by time interaction (group difference: 0.06 N/kg (95% CI: -0.04 to 0.17). IR ROM did not change in either group during the intervention.

CONCLUSION

The Oslo Sports Trauma Research Center shoulder injury prevention program did not affect the risk factors ER strength and IR ROM. The preventive effect of the program must therefore be due to other factors.

Prognostic value of perioperative NT-proBNP after corrective surgery for pediatric congenital heart defects

Background

It is critically important to assess the prognostic value of NT-proBNP in the form of repeated measures among children undergoing surgery for congenital heart defects (CHD). The aim of the present study is to assess the value of repeated perioperative NT-proBNP in evaluating the time dependent and temporal trajectory in prognostics diagnosis during the perioperative period in a large series of children with CHD.

Methods

Repeated measures of NT-proBNP from 329 consecutive children with CHD were obtained before and 1, 12, and 36 h after surgery, respectively. For fully utilizing longitudinal characteristics, we employed parallel cross-sectional logistic regression, a two stage mixed effect model and trajectories over time analysis to mine the predictive value of perioperative NT-proBNP on the binary outcome of prolonged intensive care unit (ICU) stay.

Results

The two stage mixed effects model confirmed that both the mean NT-proBNP level (aOR = 1.46, P = 0.001) and the time trends had prognostic value on the prediction of prolonged ICU stay. In the fully adjusted logistic regression analyses based on gaussian distributions, “rapidly rising NT-proBNP” put the subjects at 5.4-times higher risk of prolonged ICU stay compared with “slowly rising” group (aOR = 5.40, P = 0.003).

Conclusions

Comprehensive assessment of the time dependent and temporal trajectory in perioperative NT-proBNP, indicated by repeated measurements, can provide more accurate identification of children with higher risk of prolonged ICU stay after CHD surgery.

Psychological Flexibility and Mindfulness as Predictors of Individual Outcomes in Hospital Health Workers

Research in organizational psychology emphasizes the idea that wellbeing and productivity outcomes are influenced both by individual differences (traits, values) and work environment characteristics (relationships, climate). Evidence on the effectiveness of psychological interventions for stress is currently unclear. To date, research on psychological flexibility in workplaces has not been systematically conducted in Italy. We investigated its relevance in the context of the Italian health care system. In this study, the relationship between sources of stress at work and its outcomes in terms of psychological and physical health are explored. Furthermore, the moderating effect of psychological flexibility and mindfulness on psychological and physical health are investigated. Four hundred and eleven health workers from a Sicilian hospital, with different job positions were recruited, of which 42.7% were males (N = 169) and 57.3% were females (N = 227). Their ages ranged between 25 and 72 years (M = 49.16; SD = 8.65). Participants answered a questionnaire that assessed psychological flexibility, mindfulness, sources of stress at work and health benefits. In a bivariate analysis, managerial factors (MF), relationships, and intrinsic factors are partially negatively related to psychological and physical health; whereas, multivariate analyses show that psychological flexibility does not moderate the relationship between psychological and physical health. Instead, mindfulness is strongly and consistently correlated to psychological and physical health. Employees who show psychological flexibility, are more likely to show greater openness to the acceptance of setbacks in the working environment and to carry on their valued living and working path. This seems to correlate positively on individual wellbeing. Data show that a flexible and mindful attitude toward difficult psychological events aids responsiveness to changes and the ability to work more effectively.

Statistical primer: performing repeated-measures analysis

Longitudinal data arise when repeated measurements are taken on the same individuals over time. Inference about between-group differences of within-subject change is usually of interest. This statistical primer for cardiothoracic and vascular surgeons aims to provide a short and practical introduction of biostatistical methods on how to analyse repeated-measures data. Several methodological approaches for analysing repeated measures will be introduced, ranging from simple approaches to advanced regression modelling. Design considerations of studies involving repeated measures are discussed, and the methods are illustrated with a data set measuring coronary sinus potassium in dogs after occlusion. Cardiothoracic and vascular surgeons should be aware of the myriad approaches available to them for analysing repeated-measures data, including the relative merits and disadvantages of each. It is important to present effective graphical displays of the data and to avoid arbitrary cross-sectional statistical comparisons.

The relationship between naturalistic sleep variation and error monitoring in young adults: An event-related potential (ERP) study

Sleep deprivation studies have highlighted the importance of adequate sleep for optimal daytime functioning. However, there is limited research exploring whether variations in natural sleep patterns produce similar difficulties to those seen in sleep deprivation studies. The aim of the current study was to explore whether naturalistic reductions in sleep duration and/or sleep quality were associated with behavioural and electrophysiological measures of cognitive control. Sixty undergraduate students were asked to wear an actigraph for 7 consecutive nights before completing a hybrid Flanker-Go/NoGo task whilst continuous EEG data were recorded. Participants were assigned to high or low sleep quality and short or long sleep duration groups using the National Sleep Foundation guidelines. Results indicated that individuals who, on average, slept <7 h each night showed inefficiencies in error-monitoring, as reflected by a reduction in amplitude of the error-related negativity (ERN) in comparison to those with longer sleep duration. These findings suggest that natural variations in sleep quantity are associated with atypical error detection.

Evaluating the statistical methodology of randomized trials on dentin hypersensitivity management

The present study aimed to evaluate the characteristics and quality of statistical methodology used in clinical studies on dentin hypersensitivity management. An electronic search was performed for data published from 2009 to 2014 by using PubMed, Ovid/MEDLINE, and Cochrane Library databases. The primary search terms were used in combination. Eligibility criteria included randomized clinical trials that evaluated the efficacy of desensitizing agents in terms of reducing dentin hypersensitivity. A total of 40 studies were considered eligible for assessment of quality statistical methodology. The four main concerns identified were i) use of nonparametric tests in the presence of large samples, coupled with lack of information about normality and equality of variances of the response; ii) lack of P-value adjustment for multiple comparisons; iii) failure to account for interactions between treatment and follow-up time; and iv) no information about the number of teeth examined per patient and the consequent lack of cluster-specific approach in data analysis. Owing to these concerns, statistical methodology was judged as inappropriate in 77.1% of the 35 studies that used parametric methods. Additional studies with appropriate statistical analysis are required to obtain appropriate assessment of the efficacy of desensitizing agents.