Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses?

Pilot implementation of short message service for randomisation in a multisite pragmatic factorial clinical trial in Kenya

BACKGROUND

The traditional use of sealed envelopes for randomisation is susceptible to manipulation and the risk of damage to envelopes during shipping and storage. Additionally, the filling and sealing of envelopes are tedious, time-consuming, and error-prone. Other randomisation alternatives such as web-based methods are preferred. However, they are expensive and unsuitable in settings with poor internet infrastructure. Mobile phone-based randomisation using short message service (SMS) potentially offers a low-cost and reliable alternative.

METHODS

We developed an SMS-based method for random allocation of treatments. Plain text messaging or an Android app was used to formulate text messages using a fixed syntax consisting of the participant's unique identifier, trial site, stratum, and the trial name as input parameters. The system verified the input parameters and obtained an allocation from the database before returning a response to the sender. The text response contained the details of the treatment allocation. This was a Study Within A Trial (SWAT) conducted in two sites of a multi-site 3 × 2 factorial clinical trial in Kenya involving two interventions with up to nine possible allocations. SMS randomisation feasibility was assessed by comparing treatment allocations against the master randomisation list for each processed SMS, measuring SMS latency (in seconds), and gathering user feedback via a post-implementation survey.

RESULTS

A total of 218 participants were randomised between the 7th of February 2022 and the 11th of April 2022, out of which 179 were randomised to only one arm while 39 were randomised to both treatment arms. Allocation accuracy was 100%. Median latency was 22 s with the fastest message processed in 10 s and the slowest (non-network delayed) message processed in 2129 s. Four users completed a post-implementation survey.

CONCLUSIONS

The pilot study demonstrated that SMS randomisation is easy, user-friendly, fast, accurate, and a feasible alternative randomisation technique.

Efficacy and safety of different traditional Chinese medicine injections in the treatment of unstable angina pectoris: a systematic review and Bayesian network meta-analysis

Objectives

Several studies have explored the efficacy and safety of various traditional Chinese medicine (TCM) injections for unstable angina pectoris. However, comprehensive systematic evidence confirming the advantages of these injections is still lacking. This Bayesian network meta-analysis was carried out to evaluate and compare the efficacy of different TCM injections in treating unstable angina pectoris.

Methods

A systematic search was implemented across PubMed, Cochrane Library, Embase, and Web of Science, with the date of search cutoff being February 2024. The Cochrane risk of bias tool was utilized to evaluate the bias risk in the included studies.

Results

A total of 44 studies, encompassing 4,362 patients with unstable angina pectoris and 21 types of injections, were included. Compared with the standard treatment group, Danhong injection (SMD = -1.1, 95% CrI: -2.0, -0.15), Danshen Chuanxiongqin injection (SMD = -1.9, 95% CrI: -3.7, -0.12), Ginkgo Damole injection (SMD = -2.5, 95% CrI: -4.8, -0.29), Puerarin injection (SMD = -1.8, 95% CrI: -3.2, -0.37), and Shuxuetong injection (SMD = -7.8, 95% CrI: -13, -2.3) were found to significantly reduce the frequency of angina attacks. However, no significant improvement was observed in the duration of angina episodes with any of the included TCM injections compared with the standard treatment group. There was no significant difference in the incidence of adverse events from TCM injections.

Conclusion

Adjunctive treatment with TCM injections, in addition to conventional therapy, can remarkably reduce the frequency of angina attacks and demonstrates a favorable safety profile. However, it does not appear to significantly reduce the duration of angina episodes. Future studies should include more multicenter populations to validate our conclusions, as the population included in this study was predominantly Chinese.

Systematic Review Registration

identifier [CRD42024501984].

Sulfonylurea drugs for people with severe hemispheric ischemic stroke

BACKGROUND

Large hemispheric infarction (LHI), caused by occlusion of the internal carotid or middle cerebral artery, is the most malignant type of supratentorial ischemic stroke. Due to severe intracranial edema, mortality fluctuates between 53% and 78%, even after the most effective medical treatment. Decompressive craniectomy can reduce mortality by approximately 17% to 36%, but the neurological outcomes are not satisfactory, and there are contraindications to surgery. Therapeutic hypothermia shows promising effects in preclinical research, but it causes many complications, and clinical studies have not confirmed its efficacy. Glibenclamide is a type of sulfonylurea. Preclinical research shows that glibenclamide can reduce mortality and brain edema and improve neurological outcomes in animal models of ischemic stroke. Sulfonylureas may be a promising treatment for individuals with LHI.

OBJECTIVES

To evaluate the effects of sulfonylurea drugs in people with large hemispheric ischemic stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers. We also searched gray literature sources, checked the bibliographies of included studies and relevant systematic reviews, and used Cited Reference Search in Google Scholar. The latest search date was 23 March 2024.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared sulfonylureas with placebo, hypothermia, or usual care in people with severe hemispheric ischemic stroke.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were neurological and functional outcomes. Our secondary outcomes were death, quality of life, adverse events, and complications. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes two RCTs (N = 621): the GAMES-RP trial (glyburide advantage in malignant edema and stroke) and the CHARM trial (phase 3 study to evaluate the efficacy and safety of intravenous BIIB093 (glibenclamide) for severe cerebral edema following large hemispheric infarction). Both studies compared the effects of intravenous glyburide (0.13 mg bolus intravenous injection for the first 2 minutes, followed by an infusion of 0.16 mg/h for the first 6 hours and then 0.11 mg/h for the remaining 66 hours) to placebo. The GAMES-RP trial (N = 86) was conducted in 18 hospitals in the USA (mean age: intervention = 58 ± 11 years; control = 63 ± 9 years); the CHARM trial (N = 535) was conducted in 20 countries across North and South America and Eurasia (mean age: intervention = 60.5 ± 11.17 years; control = 61.6 ± 10.81 years). The overall risk of bias was high in both trials. Neither trial reported neurological outcomes. Compared with placebo, glyburide may result in little to no difference in functional outcomes, assessed with the modified Rankin Scale (range 0 to 4) at 90 days (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.89 to 1.32; P = 0.43; 2 studies, 508 participants; low-certainty evidence), or death (RR 0.78, 95% CI 0.36 to 1.69; P = 0.53; 2 studies, 595 participants; low-certainty evidence). Glyburide likely results in a large increased risk of hypoglycemia (RR 4.66, 95% CI 1.59 to 13.67; P = 0.005; 2 studies, 601 participants; moderate-certainty evidence) compared to placebo. However, it probably results in little to no difference between groups in cardiac events (RR 0.73, 95% CI 0.47 to 1.14; P = 0.17; 2 studies, 601 participants; moderate-certainty evidence), or pneumonia (RR 0.72, 95% CI 0.36 to 1.44; 1 study, 518 participants; moderate-certainty evidence), and may result in little to no difference between groups in neurological deterioration within three days (RR 0.88, 95% CI 0.61 to 1.27; 1 study, 77 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared to placebo, intravenous glyburide may have little to no effect on functional outcomes, assessed with the modified Rankin Scale, or mortality. It may also have little to no effect on neurological deterioration within three days, and probably has little to no effect on cardiac events or pneumonia. However, intravenous glyburide probably results in a large increased risk of hypoglycemia. This review includes only two RCTs at overall high risk of bias. We do not have sufficient evidence to determine the effects of sulfonylureas in people with ischemic stroke. More large studies, which include more sulfonylurea drugs with different routes of administration and dosages, and different age groups with ischemic stroke, would help to reduce the current uncertainties.

Quality Assessment of Randomized Controlled Trials Published In Journal of Maxillofacial and Oral Surgery (MAOS) From 2009-2021 Using RoB-2.0 Tool

Aim

Analyzing quality of Randomized Controlled trials (RCTs) published in the Journal of Maxillofacial and Oral Surgery (MAOS) since inception using Cochrane Risk of Bias tool version 2.0.

Methodology

Three authors independently screened and evaluated the RCTs according to Cochrane Risk of Bias tool version 2.0 based on the exclusion and inclusion criteria. All six domains of the RoB 2.0 tool were analyzed. The assessment of each judgment can be "Low" or "High" risk of bias, or can express "Some concerns."

Results

"Some concerns" were found in the randomization process (57%), and "low ROB" was evaluated in the second domain (57%), third domain (96%) and fourth domain (53%).In fifth domain, maximum of the articles had shown either some concerns in ROB (49%) or low ROB (45%).Analysis of the overall ROB in the included articles, maximum of the articles (50%) of the articles had shown high ROB followed by articles with some concerns in the ROB assessment (36%) and only 14% of the included article shad shown the low ROB in the RCT methodology.

Conclusion

The methodological and reporting quality in MAOS journal has a significant room for improvement.

The risks of adverse events with mirtazapine for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Mirtazapine is used to treat depression worldwide, and the effects of mirtazapine on depression rating scales are well-known. Our primary objective was to assess the risks of adverse events with mirtazapine for major depressive disorder.

METHODS

We searched relevant sources from inception to 7 March 2024 for randomised clinical trials comparing mirtazapine versus placebo in adults with major depressive disorder. The primary outcomes were suicides or suicide attempts, serious adverse events, and non-serious adverse events. Data were synthesised using meta-analysis and Trial Sequential Analysis.

RESULTS

We included 17 trials randomising 2,131 participants to mirtazapine versus placebo. All results were at high risk of bias, and the certainty of the evidence was very low. The included trials assessed outcomes at a maximum of 12 weeks after randomisation. Meta-analysis and Trial Sequential Analysis showed insufficient information to determine the effects of mirtazapine on the risks of suicides or suicide attempts and serious adverse events. Meta-analyses showed that mirtazapine increased the risks of somnolence, weight gain, dry mouth, dizziness, and increased appetite but decreased the risk of headaches.

CONCLUSIONS

There is a lack of evidence on the effects of mirtazapine on suicides and serious adverse events. Mirtazapine increases the risks of somnolence, weight gain, dry mouth, dizziness, and increased appetite. Mirtazapine might decrease the risk of headaches. The long-term effects of mirtazapine are unknown.

PROSPERO ID

CRD42022315395.

Relationship Between the Gut Microbiome, Tryptophan-Derived Metabolites, and Osteoarthritis-Related Pain: A Systematic Review with Meta-Analysis

INTRODUCTION

Osteoarthritis (OA) is the most prevalent form of arthritis and affects over 528 million people worldwide. Degenerative joint disease involves cartilage degradation, subchondral bone remodeling, and synovial inflammation, leading to chronic pain, stiffness, and impaired joint function. Initially regarded as a "wear and tear" condition associated with aging and mechanical stress, OA is now recognized as a multifaceted disease influenced by systemic factors such as metabolic syndrome, obesity, and chronic low-grade inflammation. Recent studies have focused on the gut-joint axis to investigate how the gut microbiome modulates inflammation and pain in OA.

MATERIALS AND METHODS

A systematic review was conducted following the PRISMA guidelines and was registered with PROSPERO (CRD42024556265). This review included studies involving adults with symptomatic OA and analyzed the relationship between the gut microbiome and OA-related pain. Randomized and non-randomized clinical trials, case reports, editorials, and pilot studies were excluded. Searches were performed in PubMed, Cochrane Library, and Web of Science without publication date restrictions, and filtered for "observational studies". The study selection and data extraction were performed by two independent researchers, and the risk of bias was assessed using appropriate tools.

RESULTS

Five observational studies were included in the systematic review, and three were included in the meta-analysis. Two studies reported an association between different tryptophan metabolites and pain levels in patients with OA. Two other studies demonstrated a correlation between lipopolysaccharide levels and pain in OA. A fifth study confirmed the relationship between Streptococcus relative abundance of Streptococcus spp. and knee pain. These results were not supported by a meta-analysis, which found no significant association between the presence of pain in OA and the presence of bacilli of the genus Streptococcus or plasma markers of the tryptophan pathway.

CONCLUSIONS

Current evidence indicates a potential link between gut microbiome dysbiosis and OA-related pain. However, methodological limitations preclude definitive conclusions. Further research using advanced techniques and larger cohorts is needed to validate and extend these findings and elucidate the underlying mechanisms. Targeted manipulation of the gut microbiome may be a valuable strategy for pain management in OA patients.

Effect of Physical Exercise on Telomere Length: Umbrella Review and Meta-Analysis

Background

Telomere length (TL) is a marker of cellular health and aging. Physical exercise has been associated with longer telomeres and, therefore, healthier aging. However, results supporting such effects vary across studies. Our aim was to synthesize existing evidence on the effect of different modalities and durations of physical exercise on TL.

Objective

The aim of this study was to explore the needs and expectations of individuals with physical disabilities and their interventionists for the use of a virtual reality physical activity platform in a community organization.

Methods

We performed an umbrella review and meta-analysis. Data sources included PubMed, Embase, Web of Science, Cochrane Library, and Scopus. We selected systematic reviews and meta-analyses of randomized and nonrandomized controlled clinical trials evaluating the effect of physical exercise on TL.

Results

Our literature search retrieved 12 eligible systematic reviews, 5 of which included meta-analyses. We identified 22 distinct primary studies to estimate the overall effect size of physical exercise on TL. The overall effect size was 0.28 (95% CI 0.118-0.439), with a heterogeneity test value Q of 43.08 (P=.003) and I² coefficient of 51%. The number of weeks of intervention explained part of this heterogeneity (Q_B=8.25; P=.004), with higher effect sizes found in studies with an intervention of less than 30 weeks. Exercise modality explained additional heterogeneity within this subgroup (Q_B=10.28, P=.02). The effect sizes were small for aerobic exercise and endurance training, and moderate for high-intensity interval training.

Conclusions

Our umbrella review and meta-analysis detected a small-moderate positive effect of physical exercise on TL, which seems to be influenced by the duration and type of physical exercise. High quality studies looking into the impact of standardized, evidence-based physical exercise programs on TL are still warranted.

Direct oral anticoagulants versus warfarin in adults with durable left ventricular assist devices: A systematic review and meta-analysis

INTRODUCTION

The management of anticoagulation in patients with durable left ventricular assist devices (LVADs) is challenging. Traditionally, warfarin has been used, but its limitations have prompted interest in direct oral anticoagulants (DOACs). This meta-analysis aims to evaluate the safety and efficacy of DOACs compared to warfarin in LVAD patients.

METHODS

We searched databases for studies comparing DOACs and warfarin in LVAD patients. Primary outcomes were thromboembolic events and major bleeding events. Secondary outcomes were the individual components of the thromboembolic events, minor bleeding events, and all-cause mortality. Random-effects model was used to calculate log risk-ratios (RR) with 95 % confidence intervals (CI).

RESULTS

Nine studies with a total of 316 LVAD patients (153 on DOACs, 163 on warfarin) were included. Thromboembolic events were similar between the groups (Log RR -0.42, 95 % CI:1.29 to 0.45, P = 0.34). Major bleeding events were significantly fewer in the DOAC group (Log RR -1.05, 95 % CI:1.73 to -0.36, P < 0.01). Minor bleeding events were also less common with DOACs (Log RR -0.77, 95 % CI:1.46 to -0.07, P = 0.03). No significant differences were observed in pump thrombosis, ischemic cerebrovascular accident events, or all-cause mortality.

CONCLUSION

DOACs appear to be a safe and effective alternative to warfarin for anticoagulation in LVAD patients, associated with fewer major and minor bleeding events. These findings support the consideration of DOACs in this patient population, though further research is needed to confirm these results and guide clinical practice.

Comprehensive Systematic Review of Poly-L-lactic Acid in Facial Clinical Application

OBJECTIVES

With the increasing global clinical application of regenerative injection materials, there is a growing recognition of the crucial role played by poly-L-lactic acid (PLLA). The aim of this study is to conduct a systematic review on the therapeutic efficacy and safety of PLLA in clinical applications for facial treatments.

METHODS

We conducted a search of the PubMed, EMBASE, Web of Science, and Wanfang databases, followed by screening of the retrieved articles based on predefined inclusion and exclusion criteria. We then performed an analysis on the final set of included articles that met our inclusion criteria. Within these included articles, quality assessment for randomized controlled trials (RCTs) was carried out using the Jadad scale, while non-randomized controlled trials (non-RCTs) were evaluated using the MINORS scale.

RESULTS

Our search of above database, using the relevant search terms, yielded a total of 1300 PLLA-related articles. After applying the inclusion and exclusion criteria, 1280 articles were excluded. Only 20 articles, 16 in English and 4 in Chinese, were included in our final analysis, among them 16 NRCTs and 4 RCTs. According to the different clinical evaluation standards, the treatment of PLLA has achieved good outcomes. Most PLLA injection-related adverse events are mild and self-limited, without any additional treatment requirement.

CONCLUSION

PLLA is a reasonably safe and effective facial injection material that can be applied in different facial injection areas and depth using various reconstitute and injection methods.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictors of early intracerebral hemorrhage in patients with cerebral sinus venous thrombosis: Systematic review and meta-analysis

OBJECTIVES

Patients with cerebral venous thrombosis (CVT) may present with early intracerebral hemorrhage (EICH). The objective of this study was to identify predictors for EICH in CVT patients via a systematic review and meta-analysis of observational studies. Additionally, we aimed to evaluate the clinical outcomes associated with the presence of EICH in these patients.

METHODS

Literature search on PubMed, EMBASE and Cochrane Library databases from inception up to 1 February 2024 was conducted. Five studies with predictors of EICH were included in qualitative synthesis and meta-analysis.

RESULTS

Pooled analysis demonstrated a statistically significant association between female gender and EICH (odd ratios (OR) = 1.51, 95 % confidence interval (CI) = 1.23-1.85, p < 0.01). The ICH patients had higher likelihood of seizures (OR = 3.07, 95 % CI = 1.69-5.58, p < 0.01), focal neurological deficits (OR = 4.07, 95 % CI = 2.57-6.44, p < 0.01), and decreased level of consciousness (OR = 3.89, 95 % CI = 2.53-5.87, p < 0.01). Superior Sagittal Sinus thrombosis was associated with higher likelihood of EICH (OR: 1.49, 95 % CI 1.05-2.13, P = 0.03). No statistically significant association was demonstrated between presence of EICH and pregnancy, presence of hematological diseases or thrombophilia, or other site of venous thrombosis (deep venous system, or multiple sinuses involvement). Furthermore, patients who exhibited early EICH were notably less likely to attain a favorable functional outcome (mRS 0-2) (OR: 0.28; 95 % CI 0.16-0.49; p < 0.001).

CONCLUSION

This meta-analysis demonstrates that among CVT patients, female patients with new onset seizures, focal neurological deficits and decreased level of consciousness are more likely to present with EICH.

Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children

BACKGROUND

About 80% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, half will relapse frequently, and are at risk of adverse effects from corticosteroids. While non-corticosteroid immunosuppressive medications prolong periods of remission, they have significant potential adverse effects. Currently, there is no consensus about the most appropriate second-line agent in children with frequently relapsing SSNS. In addition, these medications could be used with corticosteroids in the initial episode of SSNS to prolong the period of remission. This is the fifth update of a review first published in 2001 and updated in 2005, 2008, 2013 and 2020.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in SSNS in children with a relapsing course of SSNS and in children with their first episode of nephrotic syndrome.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to October 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they involved children with SSNS and compared non-corticosteroid immunosuppressive medications with placebo, corticosteroids or no treatment; different non-corticosteroid immunosuppressive medications, or different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias and extracted data from the included studies. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified 58 studies (122 reports) randomising 3720 children. Half were multicentre studies, and most studies were undertaken in South and East Asia (28 studies) and Europe (20 studies). The numbers of children randomised ranged from 14 to 211. Risk of bias assessment indicated that 32 and 33 studies were at low risk of bias for sequence generation and allocation concealment, respectively. Eleven studies were at low risk of performance bias and 13 were at low risk of detection bias. Forty-eight and 36 studies were at low risk of incomplete and selective reporting, respectively. Rituximab with or without prednisone compared with placebo with or without prednisone probably reduces the number of children experiencing relapse at six months (5 studies, 182 children: RR 0.22, 95% CI 0.11 to 0.43) and 12 months (3 studies, 108 children: RR 0.38, 95% CI 0.13 to 1.09) (moderate certainty), may increase the number with severe infusion reactions (4 studies, 162 children: RR 5.21, 95% CI 1.19 to 22.89; low certainty), but not severe infection or arthropathy (low certainty). Rituximab compared with tacrolimus probably reduces the risk of relapse at 12 months (4 studies, 238 children: RR 0.64, 95% CI 0.42 to 0.96) and may reduce the risk of relapse when compared with low dose mycophenolate mofetil (MMF) (1 study, 30 children: RR 0.17, 95% CI 0.04 to 0.62). Rituximab followed by MMF for 500 days reduces the risk of relapse compared with rituximab followed by placebo for 500 days (1 study, 78 children: RR 0.29, 95% CI 0.13 to 0.63; high certainty). Rituximab probably does not differ from ofatumumab in the riisk of relapse and 12 months (1 study, 140 children: RR 1.03, 95% CI 0.75 to 1.41; moderate certainty) or in adverse events. MMF and levamisole (1 study, 149 children: RR 0.90, 95% CI 0.70 to 1.16) may have similar effects on the number of children who relapse at 12 months (low certainty). Cyclosporin compared with MMF may reduce the risk of relapse at 12 months (3 studies, 114 children: RR 1.57, 95% CI 1.08 to 2.30) (low certainty). Levamisole compared with steroids or placebo may reduce the number of children with relapse during treatment (8 studies, 474 children: RR 0.52, 95% CI 0.33 to 0.82) (low certainty). Preliminary data from single studies indicate that levamisole and prednisone compared with prednisone alone may delay the onset of relapse after the initial episode of SSNS and that levamisole compared with increasing prednisone administration from alternate day to daily at the onset of infection may reduce the risk of relapse with infection (low certainty). Cyclosporin compared with prednisone may reduce the number of children who relapse (1 study, 104 children: RR 0.33, 95% CI 0.13 to 0.83) (low certainty). Alkylating agents compared with cyclosporin may make little or no difference to the risk of relapse during cyclosporin treatment (2 studies, 95 children: RR 0.91, 95% CI 0.55 to 1.48) (low certainty evidence) but may reduce the risk of relapse at 12 to 24 months (2 studies, 95 children: RR 0.51, 95% CI 0.35 to 0.74) (low certainty). Alkylating agents (cyclophosphamide and chlorambucil) compared with prednisone probably reduce the number of children who experience relapse at six to 12 months (6 studies, 202 children: RR 0.44, 95% CI 0.32 to 0.60) and at 12 to 24 months (4 studies, 59 children: RR 0.20, 95% CI 0.09 to 0.46) (moderate certainty).

AUTHORS' CONCLUSIONS

New studies incorporated in this review update indicate that rituximab compared with prednisone, tacrolimus, or MMF is a valuable additional agent for managing children with relapsing SSNS. Comparative studies of CNIs, MMF, and levamisole suggest that CNIs may be more effective than MMF and that levamisole may be similar in efficacy to MMF. Important new studies suggest that MMF prolongs remission following rituximab, that levamisole may prevent infection-related relapse more effectively than changing from alternate-day to daily prednisone and that levamisole and prednisone compared with prednisone alone may prolong the time to first relapse. There are currently 23 ongoing studies which should improve our understanding of how to treat children with frequently relapsing SSNS.

The efficacy and safety of ketorolac for postoperative pain management in lumbar spine surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Ketorolac is widely utilized for postoperative pain management, including back pain after lumbar spinal surgery. Several trials have assessed the efficacy of Ketorolac alone and in combination with other analgesics such as bupivacaine, morphine, epinephrine, paracetamol, and pregabalin. However, the effects and safety profile of ketorolac in these contexts remain controversial.

OBJECTIVE

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of Ketorolac administration, both as a monotherapy and in combination with other analgesics, for managing postoperative pain in adults undergoing lumbar spinal surgery.

METHODS

We searched PubMed, EMbase, Web of Science, EBSCO, CNKI, WanFang, VIP, and Cochrane library databases through July 2024 for randomized controlled trials (RCTs) assessing the analgesic efficacy of Ketorolac administration for postoperative pain of lumbar surgery. The meta-analysis was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statements. Data were extracted and analyzed using open-source meta-analysis software OpenMeta-Analyst, focusing on outcomes such as VAS pain scores, postoperative morphine requirements (PMR), length of hospital stay (LOS), and adverse effects, such as nausea, vomiting, pruritus, and constipation. The quality of evidence was assessed using the Jada scale.

RESULTS

Thirteen RCTs comprising a total of 938 patients were included. The methodological quality of the studies was high, with three studies scoring 5, six studies scoring 4, and four studies scoring 3 on the Jadad scale. Ketorolac significantly reduced pain compared to controls at 0-6 h, with a mean difference (MD) of - 1.42 (95% CI: - 2.03 to - 0.80; P < 0.0001), exceeding the Minimal Clinically Important Difference (MCID) of 1.2 to 2.0 points on the Visual Analog Scale (VAS), indicating clinically meaningful pain relief. During the 6-12-h period, the pain reduction was significant (MD =  - 0.58; 95% CI: - 0.80 to - 0.35; P < 0.0001), though below the MCID threshold. In the 12-24-h period, Ketorolac continued to show significant pain reduction (MD =  - 0.48; 95% CI: - 0.68 to - 0.28; P < 0.0001), but this reduction was also below the MCID. Heterogeneity was low in the 12-24-h period (I2 = 13%), indicating consistent results across studies. There was a significant reduction in PMR (SMD =  - 1.83; 95% CI =  - 3.42 to - 0.23; P < 0.0001), although with considerable heterogeneity among the studies (I2 = 93%, heterogeneity P < 0.01). Ketorolac administration also significantly reduced the LOS compared to controls (MD =  - 0.45 days; 95% CI =  - 0.74 to - 0.16; P = 0.0001), though this reduction, which is less than a full day (0.45 days), may have limited clinical significance. The findings suggest that Ketorolac effectively reduces pain and opioid use postoperatively, supporting its role in multimodal analgesia for lumbar spinal surgery. The significant reduction in PMR indicates a beneficial opioid-sparing effect, crucial in the context of reducing opioid-related complications. The observed reduction in LOS, while statistically significant, may not translate into substantial clinical benefit due to its limited magnitude. No significant increase in common adverse effects was noted, indicating Ketorolac's safety profile.

CONCLUSION

Ketorolac administration, either alone or in combination with other analgesics, effectively reduces postoperative pain and opioid consumption in adults following lumbar spinal surgery. And Ketorolac did not significantly increase the incidence of postoperative nausea and vomiting relative to other analgesics or placebos. While it also decreases LOS, the clinical relevance of this reduction is modest. However, the variability in study designs, dosages, and combination therapies contribute to significant heterogeneity in outcomes. Future research should focus on standardizing protocols and exploring optimal dosing strategies. Additionally, long-term safety and effectiveness studies are needed to better understand Ketorolac's role in postoperative pain management.

PERM1-An Emerging Transcriptional Regulator of Mitochondrial Biogenesis: A Systematic Review

BACKGROUND/OBJECTIVES

This systematic review aims to explore the role of PERM1 across different organisms, tissues, and cellular functions, with a particular focus on its involvement in regulating skeletal muscle mitochondrial biogenesis.

METHODS

This systematic review follows The PRISMA 2020 Statement. We used the Covidence systematic review software for abstract/title screening, full-text review, and data extraction. The review included studies that examined PERM1 expression or activity in skeletal muscle, heart, and adipose tissue and/or cells, from mice, rats, and humans, and involved exercise or disease models. Risk of bias was assessed using the Cochrane Collaboration tool, and the data were extracted and synthesized qualitatively, with bioinformatic analyses performed using the MetaMEx database.

RESULTS

Twenty-one studies were included in our data extraction process, where 10 studies involved humans, 21 involved mice, four involved rats, and 11 involved cells.

CONCLUSIONS

PERM1 in skeletal muscle increases with endurance exercise, affecting muscle function and oxidative metabolism, but its role in humans is not well understood. In cardiac tissue, PERM1 is vital for function and mitochondrial biogenesis purposes, but decreases with disease and pressure overload. Our review synthesizes the current understanding of PERM1's function, raises awareness of its role in mitochondrial regulation, and identifies key areas for future research in the field.

Non-invasive positive pressure ventilation for acute asthma in children

BACKGROUND

Asthma is one of the most common reasons for hospital admission among children, with significant economic burden and impact on quality of life. Non-invasive positive pressure ventilation (NPPV) is increasingly used in the care of children with acute asthma, although the evidence supporting it is weak, and clinical guidelines do not offer any recommendations on its routine use. However, NPPV might be an effective way to improve outcomes for some children with asthma. A previous review did not demonstrate a clear benefit, but was limited by few studies with small sample sizes. This is an update of the previous review.

OBJECTIVES

To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children (< 18 years) with acute asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, and Embase. We also conducted a search of ClinicalTrials.gov and the WHO ICTRP. We searched all databases from their inception to March 2023, with no restrictions on language of publication.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children hospitalised for acute asthma exacerbations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We included three RCTs randomising 60 children with acute asthma to NPPV and 60 children to control. All included trials assessed the effects of bilevel positive airway pressure (BiPAP) for acute asthma in a paediatric intensive care unit (PICU) setting. None of the trials used continuous positive airway pressure (CPAP). The controls received standard care. The median age of children ranged from three to six years, and asthma severity ranged from moderate to severe. Our primary outcome measures were all-cause mortality, serious adverse events, and asthma symptom score. Secondary outcomes were non-serious adverse events, health-related quality of life, arterial blood gases and pH, pneumonia, cost, and PICU length of stay. None of the trials reported any deaths or serious adverse events (except one trial that reported intubation rate). Two trials reported asthma symptom score, each demonstrating reductions in asthma symptoms in the BiPAP group. In one trial, the asthma symptom score was (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03; 19 children) lower in the BiPAP group. In the other trial, a cross-over trial, BiPAP was associated with a lower mean asthma symptom score (MD -3.7; 16 children; very low certainty evidence) before cross-over, but investigators did not report a standard deviation, and it could not be estimated from the first phase of the trial before cross-over. The reduction in both trials was above our predefined minimal important difference. Overall, NPPV with standard care may reduce asthma symptom score compared to standard care alone, but the evidence is very uncertain. The only reported serious adverse event was intubation rate in one trial. The trial had an intubation rate of 40% and showed that BiPAP may result in a large reduction in intubation rate (risk ratio 0.47, 95% CI 0.23 to 0.95; 78 children), but the evidence is very uncertain. Post hoc analysis showed that BiPAP may result in a slight decrease in length of PICU stay (MD -0.87 day, 95% CI -1.52 to -0.22; 100 children), but the evidence is very uncertain. Meta-analysis or Trial Sequential Analysis was not possible because of insufficient reporting and different scoring systems. All three trials had high risk of bias with serious imprecision of results, leading to very low certainty of evidence.

AUTHORS' CONCLUSIONS

The currently available evidence for NNPV is uncertain. NPPV may lead to an improvement in asthma symptom score, decreased intubation rate, and slightly shorter PICU stay; however, the evidence is of very low certainty. Larger RCTs with low risk of bias are warranted.

Stop Fooling Yourself! (Diagnosing and Treating Confirmation Bias)

Confirmation bias (CB) is a cognitive bias that allows us to fool ourselves by selectively filtering data and distorting analyses to support favored beliefs or hypotheses. In this article, I will briefly review some classic experiments from cognitive psychology that illustrate what a powerful, pernicious, and insidious force CB is. I will then discuss how to recognize CB in our own thinking and behavior and describe specific elements of good experimental design that can mitigate its effects. These elements-such as randomization and blinding-are conceptually straightforward but often difficult in practice and therefore not as widely implemented as they should be.

Effectiveness of telerehabilitation versus face-to-face pulmonary rehabilitation on physical function and quality of life in people with post COVID-19 condition: a systematic review and network meta-analysis

INTRODUCTION

Post COVID-19 condition (PCC) is characterized by the persistence of symptoms associated with COVID-19 infection for more than 12 weeks, with worsening quality of life and physical function deconditioning being among the most commonly reported persistent symptoms. Pulmonary rehabilitation has emerged as a safe and viable option for these patients. Administered either face-to-face (FTF) or telemedicine (TL), it has been shown to improve symptoms associated with PCC. However, little is known about which approach is best for this population. Therefore, we conducted a systematic review and network meta-analysis on the efficacy of FTF versus TL compared to usual care in improving physical function and quality of life (physical and mental) in patients with PCC.

EVIDENCE ACQUISITION

A systematic search of PubMed, Cochrane Library, and Web of Science was performed from 2020 to January 5th, 2024. Two independent reviewers performed study selection, data extraction, and risk of bias assessment; this selection included only randomized controlled trials. A network meta-analysis was performed to compare the effects of FTF and TL with usual care. Multivariate and univariate analysis were performed to evaluate the best intervention.

EVIDENCE SYNTHESIS

Data were extracted from 10 studies, five of which were treated with FTF and five of which were TL, involving 765 adults with PCC, ranging in age from 22 to 66 years. Interventions consisted of isolated or combined exercises (aerobic, resistance, breathing) and lasted between three and ten weeks in most of the included studies. Multivariate analysis found that FTF produced significant differences compared to TL or usual care with moderate quality of evidence. Univariate analysis found that significant differences were only found for physical function and mental domain of quality of life for TL vs. usual care, with moderate quality of evidence.

CONCLUSIONS

This study supports the use of FTF as a therapy to improve physical function and quality of life in patients with PCC. However, in the absence of differences between FTF and TL in the univariate model for any of the outcomes studied, the choice of the form of pulmonary rehabilitation administration should be individualized. Future studies should compare FTF with TL directly to clarify which is the best approach.

The prevalence of frailty among patients with metabolic syndrome: a systematic review and meta-analysis

BACKGROUND

Growing evidence shows that metabolic syndrome and frailty are significantly associated. Screening and assessing frailty in patients with metabolic syndrome is important to help improve their clinical outcomes and quality of life. Therefore, understanding the prevalence of frailty in patients with metabolic syndrome is the first critical step, however, the prevalence reported in the literature varies widely.

AIM

To pool the overall prevalence of frailty among patients with metabolic syndrome.

DESIGN

Systematic review and meta-analysis.

METHODS

The Cochrane Library, PubMed, Web of Science, Embase, APA PsycINFO, Scopus, CINAHL Complete, CNKI, Wan Fang, SinoMed, and VIP databases were searched from the inception to March 6, 2024. Statistical analysis was performed using STATA15 software. The prevalence was pooled using the random-effects model. The sources of heterogeneity were investigated by using meta-regression and subgroup analyses.

RESULTS

A total of 22 original studies published between 2007 and 2023 were included in this systematic review and meta-analysis, involving 19,921 metabolic syndrome patients. The prevalence of frailty and pre-frailty among patients with metabolic syndrome was 20% (95% CI: 16% to 25%, I2 = 99.44%) and 45% (95% CI: 36% to 53%, I2 = 99.20%). Subgroup analyses revealed differences in prevalence by frailty instruments, geographic regions, study settings, publication years, study quality, study design, and different components of metabolic syndrome.

CONCLUSIONS

This systematic review and meta-analysis showed the high prevalence of frailty and pre-frailty in patients with metabolic syndrome. In the future, more high-quality longitudinal studies and exploration of other potential demographic characteristics that may influence frailty are needed to understand more information on frailty in patients with metabolic syndrome.

Clinical trial design and treatment effects: a meta-analysis of randomised controlled and single-arm trials supporting 437 FDA approvals of cancer drugs and indications

OBJECTIVES

This study aims to analyse the association between clinical trial design and treatment effects for cancer drugs with US Food and Drug Administration (FDA) approval.

DESIGN

Cross-sectional study and meta-analysis.

SETTING

Data from Drugs@FDA, FDA labels, ClincialTrials.gov and the Global Burden of Disease study.

PARTICIPANTS

Pivotal trials for 170 drugs with FDA approval across 437 cancer indications between 2000 and 2022.

MAIN OUTCOME MEASURES

Treatment effects were measured in HRs for overall survival (OS) and progression-free survival (PFS), and in relative risk for tumour response. Random-effects meta-analyses and meta-regressions explored the association between treatment effect estimates and clinical trial design for randomised controlled trials (RCTs) and single-arm trials.

RESULTS

Across RCTs, greater effect estimates were observed in smaller trials for OS (ß=0.06, p<0.001), PFS (ß=0.15, p<0.001) and tumour response (ß=-3.61, p<0.001). Effect estimates were larger in shorter trials for OS (ß=0.08, p<0.001) and PFS (ß=0.09, p=0.002). OS (ß=0.04, p=0.006), PFS (ß=0.10, p<0.001) and tumour response (ß=-2.91, p=0.004) outcomes were greater in trials with fewer centres. HRs for PFS (0.54 vs 0.62, p=0.011) were lower in trials testing the new drug to an inactive (placebo/no treatment) rather than an active comparator. The analysed efficacy population (intention-to-treat, per-protocol, or as-treated) was not consistently associated with treatment effects. Results were consistent for single-arm trials and in multivariable analyses.

CONCLUSIONS

Pivotal trial design is significantly associated with measured treatment effects. Particularly small, short, single-centre trials testing a new drug compared with an inactive rather than an active comparator could overstate treatment outcomes. Future studies should verify results in unsuccessful trials, adjust for further confounders and examine other therapeutic areas. The FDA, manufacturers and trialists must strive to conduct robust clinical trials with a low risk of bias.

The effectiveness of cognitive behavioral therapy in women with gynecological cancer: A systematic review and meta-analysis of randomized controlled trials

Objective

This study aimed to perform a meta-analysis of randomized control trials to evaluate the effects of cognitive behavioral therapy on depression, anxiety, fatigue, distress, the fear of cancer recurrence, and the quality of life in gynecological cancer patients.

Methods

An extensive literature search of PubMed, Web of Science, Scopus, and CINAHL was performed, and a meta-analysis was conducted on ten studies that included 1027 patients. The quality of the data was evaluated using the Cochrane Risk of Bias tool. The effect size of the mean difference and standardized mean difference were computed using Revman 5.4.1.

Results

Gynecological cancer patients receiving cognitive behavioral therapy showed decreases in depression (P < 0.001), anxiety (P = 0.01), fatigue (P < 0.001), distress (P = 0.03), and the fear of cancer recurrence (P = 0.01) compared to those receiving no treatment, whereas no improvement in quality of life was seen in the cognitive behavioral therapy group (P = 0.05).

Conclusions

Cognitive behavioral therapy was shown to be a useful treatment for the symptoms experienced by women with gynecological cancer, with significant effect sizes. However, more research is required to validate the efficacy of cognitive behavioral therapy in patients with gynecological cancer, considering the limitations of this study's small sample size and statistical heterogeneity.

Systematic review registration

PROSPERO- CRD42024516039.

Nutrition users' guides: RCTs part 1 - structured guide for assessing risk of bias in randomised controlled trials that address therapy or prevention questions

The purpose of this article, part 1 of 2 on randomised controlled trials (RCTs), is to provide readers (eg, clinicians, patients, health service and policy decision-makers) of the nutrition literature structured guidance on interpreting RCTs. Evaluation of a given RCT involves several considerations, including the potential for risk of bias, the assessment of estimates of effect and their corresponding precision, and the applicability of the evidence to one's patient. Risk of bias refers to flaws in the design or conduct of a study that may lead to a deviation from measuring the underlying true effect of an intervention. Bias is assessed on a continuum from very low to very high (ie, definitely low to definitely high) risk of yielding estimates that do not represent true treatment-related effects and when appraising a study, judgement involves some degree of subjectivity. Specifically, when evaluating the risk of bias, one must first consider whether patient baseline characteristics (eg, age, smoking) are balanced between groups at randomisation, referred to as prognostic balance, and whether this balance is maintained throughout the study. While randomisation in sufficiently large trials may ensure prognostic balance between study arms at baseline; concealment of randomisation and blinding of participants, healthcare providers, data collectors, outcome adjudicators and data analysts to treatment allocation are needed to maintain prognostic balance between study arms after a trial begins. The status of each participant with respect to outcomes of interest must be known at the conclusion of a trial; when this is not the case, missing (lost) participant outcome data increases the likelihood that prognostic balance was not maintained at study completion. In addition, analysis of participants in the groups to which they were initially randomised (ie, intention-to-treat analysis) offers a reliable method to maintain prognostic balance. Finally, trials terminated early risk overestimating the treatment effect, especially when sample size is limited or stopping boundaries are not defined a priori.

Tamoxifen for adults with hepatocellular carcinoma

RATIONALE

Hepatocellular carcinoma is the most common type of liver cancer, accounting for 70% to 85% of individuals with primary liver cancer. Tamoxifen has been evaluated in randomised clinical trials in people with hepatocellular cancer. The reported results have been inconsistent.

OBJECTIVES

To evaluate the benefits and harms of tamoxifen or tamoxifen plus any other anticancer drugs compared with no intervention, placebo, any type of standard care, or alternative treatment in adults with hepatocellular carcinoma, irrespective of sex, administered dose, type of formulation, and duration of treatment.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, three other databases, and major trials registries, and handsearched reference lists up to 26 March 2024.

ELIGIBILITY CRITERIA

Parallel-group randomised clinical trials including adults (aged 18 years and above) diagnosed with advanced or unresectable hepatocellular carcinoma. Had we found cross-over trials, we would have included only the first trial phase. We did not consider data from quasi-randomised trials for analysis.

OUTCOMES

Our critical outcomes were all-cause mortality, serious adverse events, and health-related quality of life. Our important outcomes were disease progression, and adverse events considered non-serious.

RISK OF BIAS

We assessed risk of bias using the RoB 2 tool.

SYNTHESIS METHODS

We used standard Cochrane methods and Review Manager. We meta-analysed the outcome data at the longest follow-up. We presented the results of dichotomous outcomes as risk ratios (RR) and continuous data as mean difference (MD), with 95% confidence intervals (CI) using the random-effects model. We summarised the certainty of evidence using GRADE.

INCLUDED STUDIES

We included 10 trials that randomised 1715 participants with advanced, unresectable, or terminal stage hepatocellular carcinoma. Six were single-centre trials conducted in Hong Kong, Italy, and Spain, while three were conducted as multicentre trials in single countries (France, Italy, and Spain), and one trial was conducted in nine countries in the Asia-Pacific region (Australia, Hong Kong, Indonesia, Malaysia, Myanmar, New Zealand, Singapore, South Korea, and Thailand). The experimental intervention was tamoxifen in all trials. The control interventions were no intervention (three trials), placebo (six trials), and symptomatic treatment (one trial). Co-interventions were best supportive care (three trials) and standard care (one trial). The remaining six trials did not provide this information. The number of participants in the trials ranged from 22 to 496 (median 99), mean age was 63.7 (standard deviation 4.18) years, and mean proportion of men was 74.7% (standard deviation 42%). Follow-up was three months to five years.

SYNTHESIS OF RESULTS

Ten trials evaluated oral tamoxifen at five different dosages (ranging from 20 mg per day to 120 mg per day). All trials investigated one or more of our outcomes. We performed meta-analyses when at least two trials assessed similar types of tamoxifen versus similar control interventions. Eight trials evaluated all-cause mortality at varied follow-up points. Tamoxifen versus the control interventions (i.e. no treatment, placebo, and symptomatic treatment) results in little to no difference in mortality between one and five years (RR 0.99, 95% CI 0.92 to 1.06; 8 trials, 1364 participants; low-certainty evidence). In total, 488/682 (71.5%) participants died in the tamoxifen groups versus 487/682 (71.4%) in the control groups. The separate analysis results for one, between two and three, and five years were comparable to the analysis result for all follow-up periods taken together. The evidence is very uncertain about the effect of tamoxifen versus no treatment on serious adverse events at one-year follow-up (RR 0.44, 95% CI 0.19 to 1.06; 1 trial, 36 participants; very low-certainty evidence). A total of 5/20 (25.0%) participants in the tamoxifen group versus 9/16 (56.3%) participants in the control group experienced serious adverse events. One trial measured health-related quality of life at baseline and at nine months' follow-up, using the Spitzer Quality of Life Index. The evidence is very uncertain about the effect of tamoxifen versus no treatment on health-related quality of life (MD 0.03, 95% CI -0.45 to 0.51; 1 trial, 420 participants; very low-certainty evidence). A second trial found no appreciable difference in global health-related quality of life scores. No further data were provided. Tamoxifen versus control interventions (i.e. no treatment, placebo, or symptomatic treatment) results in little to no difference in disease progression between one and five years' follow-up (RR 1.02, 95% CI 0.91 to 1.14; 4 trials, 720 participants; low-certainty evidence). A total of 191/358 (53.3%) participants in the tamoxifen group versus 198/362 (54.7%) participants in the control group had progression of hepatocellular carcinoma. Tamoxifen versus control interventions (i.e. no treatment or placebo) may have little to no effect on adverse events considered non-serious during treatment, but the evidence is very uncertain (RR 1.17, 95% CI 0.45 to 3.06; 4 trials, 462 participants; very low-certainty evidence). A total of 10/265 (3.8%) participants in the tamoxifen group versus 6/197 (3.0%) participants in the control group had adverse events considered non-serious. We identified no trials with participants diagnosed with early stages of hepatocellular carcinoma. We identified no ongoing trials.

AUTHORS' CONCLUSIONS

Based on the low- and very low-certainty evidence, the effects of tamoxifen on all-cause mortality, disease progression, serious adverse events, health-related quality of life, and adverse events considered non-serious in adults with advanced, unresectable, or terminal stage hepatocellular carcinoma when compared with no intervention, placebo, or symptomatic treatment could not be established. Our findings are mostly based on trials at high risk of bias with insufficient power (fewer than 100 participants), and a lack of trial data on clinically important outcomes. Therefore, firm conclusions cannot be drawn. Trials comparing tamoxifen administered with any other anticancer drug versus standard care, usual care, or alternative treatment as control interventions were lacking. Evidence on the benefits and harms of tamoxifen in participants at the early stages of hepatocellular carcinoma was also lacking.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol available via DOI: 10.1002/14651858.CD014869.

Effectiveness of exercise on pain intensity and physical function in patients with knee and hip osteoarthritis: an umbrella and mapping review with meta-meta-analysis

PURPOSE

The aim of this review was to provide a qualitative and quantitative overview of the effects of exercise on pain, physical function, and quality of life for patients with knee and hip osteoarthritis.

MATERIALS AND METHODS

This study was an umbrella and mapping review with meta-meta-analysis. Meta-analyses of randomized controlled trials were included. The methodological quality and risk of bias were evaluated using the Modified Quality Assessment Scale for Systematic Reviews and the Risk of Bias in Systematic Reviews tool. The quality of evidence was evaluated using the Physical Activity Guidelines Advisory Committee Grading Criteria.

RESULTS

41 meta-analyses were included, 43.9% of the studies had adequate methodological quality, and 56.1% of the studies had a low risk of bias. Moderate evidence was found that exercise decreases pain intensity (33 meta-analyses; SMD = -0.49; 95% CI -0.56 to -0.42), improves function (19 meta-analyses; SMD = -0.50; 95% CI -0.58 to -0.41), strength (6 meta-analyses; SMD = -0.57; 95% CI -0.70 to -0.44) and quality of life (SMD = -0.36; 95% CI -0.46 to -0.27) for patients with hip and knee osteoarthritis.

CONCLUSION

Exercise is an effective intervention to decrease pain intensity and improve function in patients with hip and knee osteoarthritis.(PROSPERO, CRD42020221987).

Systematic reviews and meta-analyses in neurosurgery Part II: a guide to designing the protocol

Despite clearly established guidelines, recent audits have found the conduct and reporting of systematic reviews and meta-analyses (SRMAs) within neurosurgery to be relatively lackluster in methodological rigor and compliance. Protocols of SRMAs allow for planning and documentation of review methods, guard against arbitrary decision-making during the review process, and enable readers to assess for the presence of selective reporting. To aid transparency, authors should provide sufficient detail in their protocol so that the readers could reproduce the study themselves. Development of our guideline drew heavily from the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols (PRISMA-P) initiative. The objective of this article is not to enumerate every detail of this checklist, but to provide guidance to authors preparing their protocol, with examples, for a systematic review in neurosurgery. Particularly, we emphasize on the PICO framework - population (P), interventions (I), comparators (C), outcomes (O) - which is central to constructing a clinical question, defining the scope of the systematic review, defining and prioritizing the primary outcome, to specifying the eligibility criteria, designing the search strategy, and identifying potential sources of heterogeneity. We encourage our readers to make use of this guideline alongside the PRISMA-P 2015 statement, when drafting and appraising systematic review protocols.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Post-thyroidectomy bilateral cervical plexus block relieves pain: a systematic review

PURPOSE

To assess the effectiveness of bilateral superficial cervical plexus block (BSCPB) in treating post-thyroidectomy pain.

METHODS

MEDLINE, Embase, Google Scholar, LILACS, and the Cochrane Central Register of Controlled Trials, were extensively searched. The search period extended from 1968 until December 2022. Randomized controlled trials comparing BSCPB to placebo, no block in patients with thyroidectomy for benign or malignant thyroid disease were included. Outcomes were pain in the first 24 h after surgery. Analgesic rescue, period before the first rescue dosage, and 24-h opioid usage were secondary outcomes. The RoB 2 instrument was used to evaluate the risk of bias.

RESULTS

34 of 354 studies were eligible. There were 2,519 patients. BSCPB reduced the intensity of pain postoperatively [SMD: - 1.17 (95% CI: - 1.54 to - 0.81)] and in the first 24 h [- 0.62 (95%: 0.91 to 0.33)]. A considerable delay for the first opioid dose, rescue analgesics, and postoperative opioid usage was also found.

CONCLUSION

BSCPB's 24-h analgesic efficacy minimizes the requirement for rescue analgesia, postoperative opioid intake, and rescue analgesia start time. The choice of anesthetic and different application methods might affect its effectiveness.

Disagreements in risk of bias assessment for randomized controlled trials in hypertension-related Cochrane reviews

BACKGROUND

The inter-reviewer reliability of the risk of bias (RoB) assessment lacked agreement in previous studies. It is important to analyse these disagreements to improve the repeatability of RoB assessment. The objective of the study was to evaluate the frequency and reasons for disagreements in RoB assessments for randomised controlled trials (RCTs) that were included in multiple Cochrane reviews in the field of hypertension.

METHODS

A cross-sectional study was employed. We retrieved any RCTs that had been included in multiple Cochrane reviews in the field of hypertension from ARCHIE. The results of the RoB assessments were extracted, and the distributions of agreements and possible reasons for disagreement were analyzed.

RESULTS

Twenty-six Cochrane reviews were included in this study. A total of 78 RCTs appeared in more than one Cochrane review. The level of agreement ranged from domain to domain. "Blinding of outcome assessment" showed a reasonably high level of agreement (94.9%), while "incomplete outcome data", "selective outcome reporting" and "other sources of bias" showed moderate levels of agreement (74.6%, 79.2% and 75.6%, respectively). However, the domains of "allocation concealment", "random sequence generation" and "blinding of participants and personnel" showed low levels of agreement (24.4%, 23.5%, and 47.4%, respectively). In the domains of "allocation concealment" and "blinding of participants and personnel", the agreement group had higher proportion of publication year ≤ 1996 than the disagreement group (P = 0.008 and P < 0.001, respectively). In the "blinding of participants and personnel", the impact factor was higher in the agreement group (P < 0.001). By analyzing the support text, we found that the most likely reason for disagreement was extracting different information from the same RCT.

CONCLUSION

For Cochrane reviews in the field of hypertension using the 2011 version of the RoB tool, there was a large disagreement in the RoB assessment. It is suggested that the results of RoB assessments in systematic reviews that used the 2011 version of the RoB tool need to be interpreted with caution. More accurate information from RCTs needs to be collected when we synthesize clinical evidence.

The biological efficacy of Apelin against focal transient cerebral ischemia-reperfusion injury. A systematic review and meta-analysis of animal studies

BACKGROUND

Apelin has been extensively studied, and emerging experimental evidence suggests that Apelin may have effects on stroke by reducing infarct volume and neurological deficits, inhibiting the apoptosis process and reducing brain water content. However, the credibility of the evidence is uncertain. Thus, we aimed to perform a systematic review and meta-analysis to evaluate preclinical studies that used Apelin for the treatment of transient focal cerebral ischemia.

METHODS

Electronic bibliographic databases including PubMed, EMBASE, Scopus, and Google Scholar were searched for finding relevant studies from January 2000 to July 2023. The methodological quality and risk of bias scores for animal studies were calculated based on the CAMARADES and the SYRCLE's RoB tools, respectively. The effect sizes were assessed using Comprehensive Meta-Analysis (CMA) software.

RESULTS

A total of twelve eligible studies were used for the systematic review and meta-analysis. The median scores of study quality and risk of bias were 7.5 out of 10, and 5 out of 10, respectively. Apelin treatment effectively decreased infarct volume (primary outcome) [Hedges' g = 2.72, 95 % CI (1.93, 3.51), p < 0.001], neurological deficit [Hedges' g = 1.76, 95 % CI (0.96, 2.55), p < 0.001], cleaved caspase 3 [Hedges' g = 2.16, 95 % CI (0.87, 3.44), p = 0.001], and apoptotic cell number [Hedges' g = 4.07, 95 % CI (1.25,6.89), p = 0.005] compared with the control group. According to subgroup analysis, more notable neuroprotective effects were observed with intravenous administration than with intracerebroventricular (ICV) administration. Moreover, we determined that effect size of infarct volume was markedly related to the species. The combined measurement of two studies demonstrated that Apelin could reduce BCL2 and TNF-α levels as well as brain water content compared with the control group. However, pooled measurement of two studies showed that no relevancy was discovered between CHOP and altering infarct volume.

CONCLUSION

The present meta-analysis was conducted to assess preclinical studies related to Apelin treatment in rodent ischemic stroke. Apelin can exert promising neuroprotective effects by reducing infarct volume, neurological deficit, caspase 3, apoptotic cell number, TNF- α and brain water content and increasing BCL2. The current evidence supports the anti-apoptotic and anti-inflammatory properties of Apelin, but its effectiveness in decreasing CHOP level in animal models of ischemic stroke needs further elucidation. This study was registered within the International Prospective Register of Systematic Reviews (PROSPERO) as number CRD42023460926.

A methodological quality review of citations of randomized controlled trials of diabetes type2 in leading clinical practice guidelines and systematic reviews

Objective

Evaluate methodological quality of type 2 diabetes RCTs conducted in Iran and cited in clinical practice guidelines and systematic reviews and meta-analyses.

Methods

We conducted a descriptive methodological quality review, analyzing 286 Randomized Controlled Trials (RCTs) on diabetes mellitus published in Iran from July 2004 to 2021. We searched six databases systematically and evaluated eligible articles using the CONSORT 2010 checklist for abstracts. Two investigators assessed the data using a 17-item checklist derived from CONSORT. Additionally, we examined the citations of each RCT in 260 clinical practice guidelines, with a specific focus on the adequate reporting of outcomes.

Results

Out of 6667 articles, 286 analyzed. Poor reporting and failure to meet criteria observed. Only 3.8% cited in guidelines. Reporting rates: primary outcomes (41.9%), randomization (61.8%), trial recruitment (12.6%), blinding (50.8%). 27.9% cited in systematic reviews, 50.34% in systematic reviews and meta-analyses, 26.57% in meta-analyses. 67.8% of papers cited in systematic reviews. Adherence highest for participants, objective, randomization, intervention, outcome; lowest for recruitment, trial design, funding source, harms, and reporting primary outcomes.

Conclusions

Poor methodological reporting and adherence to CONSORT checklist in evaluated RCTs, especially in methodological sections. Improvements needed for reliable and applicable results in guidelines, reviews, and meta-analyses. Inadequate outcome reporting challenges researchers, clinicians, and policymakers, impacting evidence-based decision-making. Urgent improvements in RCT registration necessary.

Effects of primary or secondary prevention with vitamin A supplementation on clinically important outcomes: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

OBJECTIVES

This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically important outcomes, in people of any age.

METHODS

We searched different electronic databases and other resources for randomised clinical trials that had compared vitamin A supplements versus placebo or no intervention (last search 16 April 2024). We used Cochrane methodology. We used the random-effects model to calculate risk ratios (RRs), with 95% CIs. We analysed individually and cluster randomised trials separately. Our primary outcomes were mortality, adverse events and quality of life. We assessed risks of bias in the trials and used Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of the evidence.

RESULTS

We included 120 randomised trials (1 671 672 participants); 105 trials allocated individuals and 15 allocated clusters. 92 trials included children (78 individually; 14 cluster randomised) and 28 adults (27 individually; 1 cluster randomised). 14/105 individually randomised trials (13%) and none of the cluster randomised trials were at overall low risk of bias. Vitamin A did not reduce mortality in individually randomised trials (RR 0.99, 95% CI 0.93 to 1.05; I²=32%; p=0.19; 105 trials; moderate certainty), and this effect was not affected by the risk of bias. In individually randomised trials, vitamin A had no effect on mortality in children (RR 0.96, 95% CI 0.88 to 1.04; I²=24%; p=0.28; 78 trials, 178 094 participants) nor in adults (RR 1.04, 95% CI 0.97 to 1.13; I²=24%; p=0.27; 27 trials, 61 880 participants). Vitamin A reduced mortality in the cluster randomised trials (0.84, 95% CI 0.76 to 0.93; I²=66%; p=0.0008; 15 trials, 14 in children and 1 in adults; 364 343 participants; very low certainty). No trial reported serious adverse events or quality of life. Vitamin A slightly increased bulging fontanelle of neonates and infants. We are uncertain whether vitamin A influences blindness under the conditions examined.

CONCLUSIONS

Based on moderate certainty of evidence, vitamin A had no effect on mortality in the individually randomised trials. Very low certainty evidence obtained from cluster randomised trials suggested a beneficial effect of vitamin A on mortality. If preventive vitamin A programmes are to be continued, supporting evidence should come from randomised trials allocating individuals and assessing patient-meaningful outcomes.

PROSPERO REGISTRATION NUMBER

CRD42018104347.

Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients

BACKGROUND

The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis to prevent the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008 and 2013.

OBJECTIVES

To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause death in solid organ transplant recipients.

SEARCH METHODS

We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 5 February 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications or different regimens of the same antiviral medications for CMV prophylaxis in recipients of any solid organ transplant. Studies examining pre-emptive therapy for CMV infection are studied in a separate review and were excluded from this review.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

This 2024 update found four new studies, bringing the total number of included studies to 41 (5054 participants). The risk of bias was high or unclear across most studies, with a low risk of bias for sequence generation (12), allocation concealment (12), blinding (11) and selective outcome reporting (9) in fewer studies. There is high-certainty evidence that prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment is more effective in preventing CMV disease (19 studies: RR 0.42, 95% CI 0.34 to 0.52), all-cause death (17 studies: RR 0.63, 95% CI 0.43 to 0.92), and CMV infection (17 studies: RR 0.61, 95% CI 0.48 to 0.77). There is moderate-certainty evidence that prophylaxis probably reduces death from CMV disease (7 studies: RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduces the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but probably makes little to no difference to fungal infection, acute rejection or graft loss. No apparent differences in adverse events with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment were found. There is high certainty evidence that ganciclovir, when compared with aciclovir, is more effective in preventing CMV disease (7 studies: RR 0.37, 95% CI 0.23 to 0.60). There may be little to no difference in any outcome between valganciclovir and IV ganciclovir compared with oral ganciclovir (low certainty evidence). The efficacy and adverse effects of valganciclovir or ganciclovir were probably no different to valaciclovir in three studies (moderate certainty evidence). There is moderate certainty evidence that extended duration prophylaxis probably reduces the risk of CMV disease compared with three months of therapy (2 studies: RR 0.20, 95% CI 0.12 to 0.35), with probably little to no difference in rates of adverse events. Low certainty evidence suggests that 450 mg/day valganciclovir compared with 900 mg/day valganciclovir results in little to no difference in all-cause death, CMV infection, acute rejection, and graft loss (no information on adverse events). Maribavir may increase CMV infection compared with ganciclovir (1 study: RR 1.34, 95% CI: 1.10 to 1.65; moderate certainty evidence); however, little to no difference between the two treatments were found for CMV disease, all-cause death, acute rejection, and adverse events at six months (low certainty evidence).

AUTHORS' CONCLUSIONS

Prophylaxis with antiviral medications reduces CMV disease and CMV-associated death, compared with placebo or no treatment, in solid organ transplant recipients. These data support the continued routine use of antiviral prophylaxis in CMV-positive recipients and CMV-negative recipients of CMV-positive organ transplants.

Circulating leptin in patients with nonalcoholic fatty liver disease-related liver fibrosis: a systematic review and a meta-analysis

BACKGROUND AND AIM

Clinical data on the association between leptin levels and nonalcoholic fatty liver disease (NAFLD)-related liver fibrosis are conflicting. This meta-analysis aimed to compare circulating leptin between NAFLD patients with versus without liver fibrosis or non-NAFLD controls.

METHODS

A systematic search was conducted in PubMed, Scopus, and the Cochrane Library. Fifteen studies were included, reporting data from 964 individuals (422 NAFLD patients with fibrosis, 297 NAFLD patients without fibrosis, 245 no-NAFLD controls).

RESULTS

Leptin standardized mean difference (SMD) was higher in NAFLD patients with fibrosis (F1-F4) than in controls (SMD: 2.27; 95% confidence interval [CI]: 0.81-3.73); however, this association did not remain robust after the exclusion of studies with morbidly obese individuals. No difference was observed in leptin SMD between NAFLD patients with fibrosis and those without fibrosis (F0), and NAFLD patients without fibrosis versus controls. Heterogeneity was high (I2: 66-98%) among studies. Meta-regression analysis revealed a positive association of leptin SMD with homeostasis model assessment-insulin resistance, when comparing NAFLD patients with fibrosis versus NAFLD patients without fibrosis (beta: 0.53; 95% CI: 0.04-1.03), and a negative association of leptin SMD with age, when comparing NAFLD patients with fibrosis versus controls (beta: -0.29; 95% CI: -0.53 to -0.05).

CONCLUSION

Circulating leptin was higher in NAFLD patients with liver fibrosis than non-NAFLD controls, an association, however, attenuated after the exclusion of a study with morbidly obese individuals. Circulating leptin was not different between NAFLD patients with and without fibrosis, or NAFLD patients without fibrosis and controls.

Blood Pressure after Successful Endovascular Therapy: A Systematic Review and Meta-Analysis of Randomized Control Trials

OBJECTIVE

There are limited data evaluating the optimum blood pressure (BP) goal post mechanical thrombectomy (MT) and its effect on outcomes of patients with large vessel occlusions (LVO). The objective of this study was to compare the efficacy and safety of intensive versus conventional BP control after reperfusion with MT via a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched PubMed and Embase to obtain articles related to BP control post MT through September 2023. The primary outcome was functional independence (modified Rankin Scale [mRS] 0-2) at 3 months, while secondary outcomes included excellent outcome (mRS 0-1), symptomatic intracranial hemorrhage (sICH), and mortality.

RESULTS

Four RCTs with 1,566 patients (762 randomized into intensive BP control vs. 806 randomized into conventional BP control) were included. Analysis showed that there was a lower likelihood of functional independence (mRS 0-2: odds ratio [OR]: 0.68, 95% confidence interval [CI] 0.51-0.91, p = 0.009) in the more intensive treatment group compared with the conventional treatment group. There was no statistically significant difference in achieving excellent outcome (mRS0-1: OR: 0.82, 95% CI: 0.63-1.07; p = 0.15), risk of sICH or mortality.

INTERPRETATION

This systematic review and meta- analysis Indicates that in patients who achieved successful MT for acute ischemic stroke with LVO, intensive BP control was associated with a lower likelihood of functional independence at 3 months without significant difference in likelihood of achieving excellent outcome, sICH risk, or mortality. ANN NEUROL 2024;95:858-865.

Quality of reporting inflammatory bowel disease randomised controlled trials: a systematic review

OBJECTIVE

Our objective was to perform a systemic evaluation of the risk of bias in randomised controlled trial (RCT) reports published on inflammatory bowel disease (IBD).

DESIGN

We assessed the risk of bias using the Cochrane tool, as indicators of poor methodology or subsequently poor reporting. We systematically selected, with dual independent judgements, all studies published on IBD with no time limits and assessed the methodological quality of included studies again using independent dual ratings.

RESULTS

563 full texts were included after selection and review. No abstract publications were free of any source of bias. Full-text publications still fared badly, as only 103 full-text papers exhibited a low risk of bias in all reporting domains when excluding blinding. RCTs published in journals with higher impact factor (IF) were associated with an overall reduced rate of being at high risk. However, only 6% of full RCT publications in journals with an IF greater than 10, published in the past 5 years, were free of bias.The trend over time is towards improved reporting in all areas. Trials published by larger author teams, in full-text form and by industry and public sponsorship were positively correlated with a lower risk of bias. Only allocation concealment showed a statistically significant improvement with time (p=0.037).

CONCLUSION

These findings are consistent with those of other specialties in the literature. While this unclear risk of bias may represent poor reporting of methods instead of poor methodological quality, it leaves readers and future secondary researchers with significant questions regarding such key issues.

Slightly reduced early subsidence with similar outcomes and complications rate in collared stems - A systematic review of randomized clinical trials

Background

There is a growing trend towards using femoral stems with a medial calcar collar during total hip arthroplasty (THA).

Purpose

Systematically review the literature comparing a femoral collared stem and femoral collarless stem on subsidence, patient-reported outcomes (PROs), and revision rate.

Study design

Systematic Review, Level of Evidence 1.

Methods

A literature search of Pubmed and Medline was according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials that evaluated collared and collarless stems, subsidence and PROs for adult patients undergoing total hip arthroplasty (THA) were included. Additional data collection included patient demographics, stem-calcar contact, canal-fill ratio (CFR), stem orientation, surgical approach, Dorr Type, complications, and revisions.

Results

Five studies met inclusion criteria. 674 patients (704 hips) were included. Mean patient ages ranged 58.5-72.4 years old, and mean BMI ranged 26.6-29.8 kg/m2. Mean reported follow-up of the included clinical trials ranged 1-9.6 years. Two studies reported mean early subsidence at two weeks postoperatively, which was 0.36, 0.99 mm for collared stems and 0.52, 3.22 mm for collarless stems, proving to be statistically significant (P = 0.023), (P = 0.05). All studies demonstrated improved PROs at most recent follow-up. Revision rates ranged from 4 to 11.3 %, but these were not statistically significant.

Conclusions

Implantation of collared stems compared to collarless may reduce early post-operative subsidence, while no substantial effect on aseptic loosening, thigh pain, proximal femoral fracture, and revision is seen. When measuring patient-reported outcomes, the collared femoral stem was not superior to the collarless femoral stem as both resulted in similar improvement preoperatively to postoperative state.

Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review

INTRODUCTION

Different systematic reviews have been developed in the last decades about maternal risks of immediate pushing and delayed pushing, depending on the duration of the second stage of labour, but they do not provide conclusive evidence.

AIM

The main aim of this overview of systematic reviews was to assess the maternal outcomes using delayed pushing and immediate pushing in the second stage of labour in women receiving epidural analgesia.

METHODS

We searched systematically in PubMed (Medline), EMBASE, CINAHL, and Scopus (October 26th, 2023). Methodological quality was analysed using AMSTAR and ROBIS scales, and the strength of evidence was established according to the guidelines advisory committee grading criteria. The outcome measures were the duration of the second stage of labour, duration of active pushing, caesarean section, instrumental vaginal birth, spontaneous vaginal birth, fatigue score, perineal lacerations, postpartum haemorrhage, and rate of episiotomy. Seven systematic reviews with and without meta-analysis were included.

RESULTS

Results showed that delayed pushing increases the total time of the second stage of labour, although delayed pushing decreases the duration of active pushing with moderate quality of evidence. Mixed results were found with respect to the variables instrumental vaginal birth, spontaneous vaginal birth, and fatigue score although the results favour delayed pushing or show no statistically significant differences with respect to immediate pushing. No favourable results were ever found for immediate pushing with respect to delayed pushing, with a limited quality of evidence. Even so, delayed pushing seems to be associated with a significant increase in spontaneous vaginal birth rates. The results found no significant differences between the immediate pushing and delayed pushing groups in the caesarean section rates, perineal lacerations, postpartum haemorrhage, and episiotomy ratio, with a limited quality of evidence.

CONCLUSIONS

This study shows that delayed pushing during the second stage of labour produces at least the same maternal outcomes as immediate pushing, although we note that delayed pushing produces an increase of the duration of the second stage of labour, a shorter duration of the active pushing and a tendency to increase spontaneous vaginal birth and to reduce the instrumental vaginal birth rates and fatigue scores. This should be considered clinically. This review was registered in the International Prospective Register of Systematic Reviews PROSPERO (CRD42023397616).

Instrumental assessment of sleep bruxism: A systematic review and meta-analysis

This systematic review and meta-analysis (MA) aimed to evaluate the diagnostic validity of portable electromyography (EMG) diagnostic devices compared to the reference standard method polysomnography (PSG) in assessing sleep bruxism. This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and was registered with PROSPERO prior to the accomplishment of the main search. Ten clinical studies on humans, assessing the diagnostic accuracy of portable instrumental approaches with respect to PSG, were included in the review. Methodological shortcomings were identified by QUADAS-2 quality assessment. The certainty of the evidence analysis was established by different levels of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. A meta-analysis of diagnostic test accuracy was performed with multiple thresholds per study applying a two-stage random effects model, using the thresholds offered by the studies and based on the number of EMG bruxism events per hour presented by the participants. Five studies were included. The MA indicated that portable EMG diagnostic devices showed a very good diagnostic capacity, although a high variability is evident in the studies with some outliers. Very low quality of evidence due to high risk of bias and high heterogeneity among included studies suggests that portable devices have shown high sensitivity and specificity when diagnosing sleep bruxism (SB) compared to polysomnography. The tests performed in the MA found an estimated optimal cut-off point of 7 events/hour of SB with acceptably high sensitivity and specificity for the EMG portable devices.

Microwave coagulation for liver metastases

BACKGROUND

Liver metastases (i.e. secondary hepatic malignancies) are significantly more common than primary liver cancer. Long-term survival after radical surgical treatment is approximately 50%. For people in whom resection for cure is not feasible, other treatments must be considered. One treatment option is microwave coagulation utilising electromagnetic waves. It involves placing an electrode into a lesion under ultrasound or computed tomography guidance.

OBJECTIVES

To evaluate the beneficial and harmful effects of microwave coagulation versus no intervention, other ablation methods, or systemic treatments in people with liver metastases regardless of the location of the primary tumour.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest date of search was 14 April 2023.

SELECTION CRITERIA

Randomised clinical trials assessing beneficial or harmful effects of microwave coagulation and its comparators in people with liver metastases, irrespective of the location of the primary tumour. We included trials no matter the outcomes reported.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodological procedures. Our primary outcomes were: all-cause mortality at the last follow-up and time to mortality; health-related quality of life (HRQoL); and any adverse events or complications. Our secondary outcomes were: cancer mortality; disease-free survival; failure to clear liver metastases; recurrence of liver metastases; time to progression of liver metastases; and tumour response measures. We used risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) to present the results. Two review authors independently extracted data and assessed the risk of bias using the Cochrane RoB 1 tool. We used GRADE methodology to assess the certainty of the evidence.

MAIN RESULTS

Three randomised clinical trials fulfilled the inclusion criteria. The control interventions differed in the three trials; therefore, meta-analyses were not possible. The trials were at high risk of bias. The certainty of evidence of the assessed outcomes in the three comparisons was very low. Data on our prespecified outcomes were either missing or not reported. Microwave coagulation plus conventional transarterial chemoembolisation (TACE) versus conventional TACE alone One trial, conducted in China, randomised 50 participants (mean age 60 years, 76% males) with liver metastases from various primary sites. Authors reported that the follow-up period was at least one month. The trial reported adverse events or complications in the experimental group only and for tumour response measures. There were no dropouts in the trial. The trial did not report on any other outcomes. Microwave ablation versus conventional surgery One trial, conducted in Japan, randomised 40 participants (mean age 61 years, 53% males) with multiple liver metastases of colorectal cancer. Ten participants were excluded after randomisation (six from the experimental and four from the control group); thus, the trial analyses included 30 participants. Follow-up was three years. The reported number of deaths from all causes was 9/14 included participants in the microwave group versus 12/16 included participants in the conventional surgery group. The mean overall survival was 27 months in the microwave ablation and 25 months in the conventional surgery group. The three-year overall survival was 14% with microwave ablation and 23% with conventional surgery, resulting in an HR of 0.91 (95% CI 0.39 to 2.15). The reported frequency of adverse events or complications was comparable between the two groups, except for the required blood transfusion, which was more common in the conventional surgery group. There was no intervention-related mortality. Disease-free survival was 11.3 months in the microwave ablationgroup and 13.3 months in the conventional surgery group. The trial did not report on HRQoL. Microwave ablation versus radiofrequency ablation One trial, conducted in Germany, randomised 50 participants (mean age 62.8 years, 46% males) who were followed for 24 months. Two-year mortality showed an RR of 0.62 (95% CI 0.26 to 1.47). The trial reported that, by two years, 76.9% of participants in the microwave ablationgroup and 62.5% of participants in the radiofrequency ablation group survived (HR 0.63, 95% CI 0.23 to 1.73). The trial reported no deaths or major complications during the procedures in either group. There were two minor complications only in the radiofrequency ablation group (RR 0.19, 95% CI 0.01 to 3.67). The trial reported technical efficacy in 100% of procedures in both groups. Distant recurrence was reported for 10 participants in the microwave ablation group and nine participants in the radiofrequency ablation group (RR 1.03, 95% CI 0.50 to 2.08). No participant in the microwave ablation group demonstrated local progression at 12 months, while that occurred in two participants in the radiofrequency ablation group (RR 0.19, 95% CI 0.01 to 3.67). The trial did not report on HRQoL. One trial reported partial support by Medicor (MMS Medicor Medical Supplies GmbH, Kerpen, Germany) for statistical analysis. The remaining two trials did not provide information on funding. We identified four ongoing trials.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of microwave ablation in addition to conventional TACE compared with conventional TACE alone on adverse events or complications. We do not know if microwave ablation compared with conventional surgery may have little to no effect on all-cause mortality. We do not know the effect of microwave ablation compared with radiofrequency ablation on all-cause mortality and adverse events or complications either. Data on all-cause mortality and time to mortality, HRQoL, adverse events or complications, cancer mortality, disease-free survival, failure to clear liver metastases, recurrence of liver metastases, time to progression of liver metastases, and tumour response measures were either insufficient or were lacking. In light of the current inconclusive evidence and the substantial gaps in data, the pursuit of additional good-quality, large randomised clinical trials is not only justified but also essential to elucidate the efficacy and comparative benefits of microwave ablation in relation to various interventions for liver metastases. The current version of the review, in comparison to the previous one, incorporates two new trials in two additional microwave ablation comparisons: 1. in addition to conventional TACE versus conventional TACE alone and 2. versus radiofrequency ablation.

Intravenous iron therapy for patients with iron deficiency and heart failure: a systematic review and meta-analysis of randomized controlled trials

Introduction

Heart failure (HF) presents a significant health challenge, with intravenous (IV) iron therapy considered a potential treatment avenue.

Method

We assessed IV iron therapy's efficacy in HF patients with concurrent iron deficiency versus standard of care. Primary outcomes included the composite of HF hospitalizations or cardiovascular-related mortality, HF hospitalizations, and all-cause, HF, and cardiovascular mortality rates. Secondary measures encompassed improvements in New York Heart Association functional classification, quality of life, 6-minute walk test, left ventricular ejection fraction, and adverse events. We used a random-effects model to compute relative risk (RR) or mean difference (MD) with 95% confidence intervals (CIs).

Results

Based on an analysis of 14 randomized controlled trials involving 6614 patients, IV iron therapy significantly reduced composite outcome (RR: 0.84, 95% CI: 0.73, 0.96; P = 0.01) and HF hospitalizations (RR: 0.74, 95% CI: 0.61, 0.89; P = 0.002) compared to standard of care. Mortality rates showed no significant difference. IV iron therapy improved New York Heart Association functional classification, quality of life, and 6-minute walk test, with no major impact on left ventricular ejection fraction. Adverse events remained stable.

Conclusions

IV iron therapy holds promise for diminishing HF hospitalizations and enhancing quality of life and 6-minute walk test in HF patients. Yet, its effect on all-cause or cardiovascular mortalities appears limited.

Risk of bias in exercise science: A systematic review of 340 studies

Risk of bias can contribute to irreproducible science and mislead decision making. Analyses of smaller subsections of the exercise science literature suggest many exercise science studies have unclear or high risk of bias. The current review (osf.io/jznv8) assesses whether this unclear or high risk of bias is more widespread in the exercise science literature and whether this bias has decreased since the publication of the 1996 Consolidated Standards of Reporting Trials (CONSORT) guidelines. We report significant reductions in selection, performance, detection, and reporting biases in 2020 compared with 1995 in the 340 of 5,451 studies assessed using the Cochrane Risk of Bias tool. Despite these improvements, most 2020 studies still had unclear or high risks of bias. These results underscore the need for methodological vigilance, adherence to reporting standards, and education on experimental bias. Factors contributing to these improvements, such advancements in education and journal requirements, remain uncertain.

Influence of lack of blinding on the estimation of medication-related harms: a retrospective cohort study of randomized controlled trials

BACKGROUND

Empirical evidence suggests that lack of blinding may be associated with biased estimates of treatment benefit in randomized controlled trials, but the influence on medication-related harms is not well-recognized. We aimed to investigate the association between blinding and clinical trial estimates of medication-related harms.

METHODS

We searched PubMed from January 1, 2015, till January 1, 2020, for systematic reviews with meta-analyses of medication-related harms. Eligible meta-analyses must have contained trials both with and without blinding. Potential covariates that may confound effect estimates were addressed by restricting trials within the comparison or by hierarchical analysis of harmonized groups of meta-analyses (therefore harmonizing drug type, control, dosage, and registration status) across eligible meta-analyses. The weighted hierarchical linear regression was then used to estimate the differences in harm estimates (odds ratio, OR) between trials that lacked blinding and those that were blinded. The results were reported as the ratio of OR (ROR) with its 95% confidence interval (CI).

RESULTS

We identified 629 meta-analyses of harms with 10,069 trials. We estimated a weighted average ROR of 0.68 (95% CI: 0.53 to 0.88, P < 0.01) among 82 trials in 20 meta-analyses where blinding of participants was lacking. With regard to lack of blinding of healthcare providers or outcomes assessors, the RORs were 0.68 (95% CI: 0.53 to 0.87, P < 0.01 from 81 trials in 22 meta-analyses) and 1.00 (95% CI: 0.94 to 1.07, P = 0.94 from 858 trials among 155 meta-analyses) respectively. Sensitivity analyses indicate that these findings are applicable to both objective and subjective outcomes.

CONCLUSIONS

Lack of blinding of participants and health care providers in randomized controlled trials may underestimate medication-related harms. Adequate blinding in randomized trials, when feasible, may help safeguard against potential bias in estimating the effects of harms.

Hyperdense sign as a predictor for successful recanalization and clinical outcome in acute ischemic stroke: A systematic review and meta-analysis

OBJECTIVE

To assess the prognostic values of hyperdense sign on pretreatment non-contrast head CT scan for successful recanalization (mTICI ≥2b) and 90-day good functional outcome (mRs 0-2) in patients with acute ischemic stroke undergoing mechanical thrombectomy (MT).

METHODS

Literature search on PubMed, EMBASE, and Cochrane databases from inception up to 1 November 2023 was conducted. Twelve studies which reported hyperdense sign, recanalization and clinical outcomes were included in qualitative synthesis and meta-analysis.

RESULTS

Pooled analysis demonstrated a statistically significant association between successful recanalization and hyperdense sign-positive patients who underwent MT (odd ratios (OR) = 1.47, 95% confidence interval (CI) = 1.03-2.10, p = 0.04). No statistically significant association was demonstrated between presence of hyperdense sign and good functional outcome (OR = 1.04, 95% CI: 0.72-1.49, p = 0.85) or symptomatic intracranial hemorrhage sICH (OR: 1.80, 95% CI 0.72-4.47, p = 0.21).

CONCLUSIONS

This meta-analysis demonstrated that pre-intervention hyperdense sign on CT imaging might be useful in prediction of successful recanalization after MT.

Effectiveness of bevacizumab in the treatment of metastatic colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

To evaluate the benefit of bevacizumab under the comprehensive treatment strategy and its advantages over other drugs, so as to provide reference for the formulation of clinical plans.

METHODS

As of October 1, 2022, the randomized controlled clinical trials of bevacizumab in combination with metastatic colorectal cancer published in PubMed, Cochrane Library and Medline databases were searched. The odds ratio (OR) and its 95% confidence interval (CI) were used to evaluate the short-term disease control effect and long-term survival of the treatment strategy.

RESULTS

21 RCTs (6665 patients; 3356 patients in the experimental group and 3309 patients in the control group; average age, 55-75 years) were treated with bevacizumab as the experimental group for metastatic colorectal cancer. BEV has stronger anti-tumor activity than the single treatment scheme (OR = 1.30, 95% CI: 1.11-1.52). And Benefits of the BEV group were 0.73 (0.55, 0.96), 1.26 (0.71, 2.24), 1.63 (0.92, 2.87) and 0.07 (0.02, 0.25) compared with CET, VAN, CED and PAN respectively. The disease control of BEV combined therapy was better (OR = 1.36, 95% CI: 1.04-1.78). The same as compared with cediranib (OR = 1.94, 95% CI: 1.06-3.55). However, the long-term prognosis of BEV, including the overall survival (HRs = 0.98, 95% CI: 0.84-1.15) and progression-free survival (HRs = 1.05,95% CI: 0.97-1.13) were not prolonged. The survival benefits of cetuximab and panitumumab were not reflected.

CONCLUSION

The addition of BEV can enhance the anti-tumor ability and disease control, while cetuximab and panitumumab may have stronger ability. However, it did not effectively improve the survival of patients. A more reasonable and effective treatment plan needs more clinical experimental support.

Efficacy of Sildenafil on healthy humans in high‑altitude hypoxia at rest and during exercise: A meta‑analysis

The current meta-analysis aimed to fully evaluate the efficacy of Sildenafil in healthy humans at different altitudes, focusing on echocardiographic and hemodynamic parameters. Relevant studies were retrieved from the Cochrane, Embase and PubMed databases. Odds ratios (OR) were determined for dichotomous data and weighted mean differences with 95% confidence intervals (CIs) for continuous data. A total of 16 RCTs were included in the current meta-analysis. Short-term treatment with Sildenafil significantly elevated resting heart rate (P<0.01) at altitudes <4,000 meters. No significant differences in heart rate were observed between the Sildenafil and placebo groups at rest and during exercise at an altitude of >4,000 meters (P>0.05). Sildenafil improved resting cardiac output at an altitude of >5,000 meters (P<0.01) and exercising arterial oxygen saturation at <4,000 meters (P<0.01). Sildenafil reduced resting pulmonary artery systolic pressure (PASP) at altitudes >4,000 meters (P<0.01) and exercising PASP at altitudes >5,000 meters (P<0.01). Therefore, Sildenafil efficacy in healthy humans with high-altitude hypoxia is related to altitude and rest or exercise.

Beneficial and harmful effects of tricyclic antidepressants for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis

QUESTION

Tricyclic antidepressants are used to treat depression worldwide, but the adverse effects have not been systematically assessed. Our objective was to assess the beneficial and harmful effects of all tricyclic antidepressants for adults with major depressive disorder.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review with meta-analysis and trial sequential analysis. We searched CENTRAL, MEDLINE, Embase, LILACS and other sources from inception to January 2023 for randomised clinical trials comparing tricyclic antidepressants versus placebo or 'active placebo' for adults with major depressive disorder. The primary outcomes were depressive symptoms measured on the 17-item Hamilton Depression Rating Scale (HDRS-17), serious adverse events and quality of life. The minimal important difference was defined as three points on the HDRS-17.

FINDINGS

We included 103 trials randomising 10 590 participants. All results were at high risk of bias, and the certainty of the evidence was very low or low. All trials only assessed outcomes at the end of the treatment period at a maximum of 12 weeks after randomisation. Meta-analysis and trial sequential analysis showed evidence of a beneficial effect of tricyclic antidepressants compared with placebo (mean difference -3.77 HDRS-17 points; 95% CI -5.91 to -1.63; 17 trials). Meta-analysis showed evidence of a harmful effect of tricyclic antidepressants compared with placebo on serious adverse events (OR 2.78; 95% CI 2.18 to 3.55; 35 trials), but the required information size was not reached. Only 2 out of 103 trials reported on quality of life and t-tests showed no evidence of a difference.

CONCLUSIONS

The long-term effects of tricyclic antidepressants and the effects on quality of life are unknown. Short-term results suggest that tricyclic antidepressants may reduce depressive symptoms while also increasing the risks of serious adverse events, but these results were based on low and very low certainty evidence.

PROSPERO REGISTRATION NUMBER

CRD42021226161.

Harnack H, Huang L, Sikorski C, Mbuagbaw L, de Souza RJ. Assessment of reporting quality of randomized controlled trials investigating the effects of inulin-type fructans supplementation on cardiovascular disease risk factors: A systematic survey

BACKGROUND

Transparent and detailed reporting of randomized controlled trials (RCTs) is essential to judge its validity and generalizability. We assessed the reporting quality of RCTs examining the effects of inulin-type fructans supplementation on cardiovascular risk factors, before and after the publication of the Consolidated Standards of Reporting Trials (CONSORT) in 2010.

METHODS

We searched MEDLINE, EMBASE, Emcare, AMED, the Cochrane Library, and CINAHL from inception to May 15, 2022, including the reference lists of selected RCTs. We screened titles and abstracts and extracted the data independently and in duplicate. We included RCTs that investigated the effects of inulin-type fructans on cardiovascular disease risk factors (e.g., low-density lipoprotein cholesterol, triglycerides, fasting blood glucose) in adults (18 years or older). The primary outcomes of this study were: the overall reporting quality of RCTs (defined as the total number of items [0 to 36] present from the CONSORT checklist) published before and after CONSORT; and the study characteristics (e.g., sample size, significance of primary outcome) predictive of the CONSORT score. The secondary outcome was the reporting of each specific item of the CONSORT checklist during pre- and post-CONSORT periods. The mean difference in the total number of reported items in studies published before and after CONSORT were compared using a t-test and Poisson regression to explore the factors associated with overall reporting quality of RCTs. We used Fisher's exact test to compare the adherence to each of the 36 items during pre- and post-CONSORT periods.

RESULTS

We identified 1,767 citations from our systematic search, of which 55 were eligible. There was a significant increase in the reporting of CONSORT items (mean difference 8.5, 95% confidence interval [CI] 5.24 to 11.71) between studies published before and after publication of CONSORT. The sole variable that was predictive of better reporting quality of RCTs was whether the study was published before or after CONSORT (incidence rate ratio 1.67, 95% CI 1.40 to 2.02). Completeness of reporting of RCTs only improved in 15 out of 36 items (41.6%) after the publication of CONSORT.

CONCLUSION

The completeness of reporting in RCTs investigating inulin-type fructans supplementation on cardiovascular disease risk factors remains inadequate after the publication of CONSORT. Greater adherence to CONSORT by authors and enforcement of CONSORT by journals may improve the quality of reporting among RCTs.

Effects of robot-assisted gait training on cardiopulmonary function and lower extremity strength in individuals with spinal cord injury: A systematic review and meta-analysis

CONTEXT

Robot-assisted gait training (RAGT) has been increasingly adopted in many rehabilitation facilities for walking function and activity in individuals with spinal cord injury (SCI). However, the effectiveness of RAGT on lower extremity strength and cardiopulmonary function, especially static pulmonary function, have not been clearly outlined.

OBJECTIVE

Determine the effect of RAGT on cardiopulmonary function and lower extremity strength in SCI survivors.

METHODS

Eight databases were systematically searched for randomized controlled trials comparing RAGT with conventional physical therapy or other non-robotic therapies for survivors with SCI. Study selection required lower extremity strength decline after SCI at baseline. The overall effects of RAGT were calculated using a meta-analytic method. Begg's test was used to assess the risk of publication bias.

RESULTS

The pooled analysis demonstrated that RAGT may have a positive effect for individuals with SCI on lower extremity strength enhancing (n = 408; standardized mean difference [SMD]  =  0.81; 95% confidence interval [CI] = 0.14-1.48) and cardiopulmonary endurance(n = 104; standardized mean difference [SMD]  =  2.24; 95% confidence interval [CI] = 0.28-4.19). However, no significant effect was established on static pulmonary function. No publication bias was observed according to the Begg's test.

CONCLUSIONS

RAGT may be a useful technique for improving lower limb strength and cardiovascular endurance in SCI survivors. The usefulness of RAGT in enhancing static pulmonary function was not demonstrated by the study. However, these results should be interpreted with caution, given the low number of selected studies and subjects. Clinical studies with large sample sizes will be necessary in the future.

Compelling evidence from meta-epidemiological studies demonstrates overestimation of effects in randomized trials that fail to optimize randomization and blind patients and outcome assessors

OBJECTIVES

To investigate the impact of potential risk of bias elements on effect estimates in randomized trials.

STUDY DESIGN AND SETTING

We conducted a systematic survey of meta-epidemiological studies examining the influence of potential risk of bias elements on effect estimates in randomized trials. We included only meta-epidemiological studies that either preserved the clustering of trials within meta-analyses (compared effect estimates between trials with and without the potential risk of bias element within each meta-analysis, then combined across meta-analyses; between-trial comparisons), or preserved the clustering of substudies within trials (compared effect estimates between substudies with and without the element, then combined across trials; within-trial comparisons). Separately for studies based on between- and within-trial comparisons, we extracted ratios of odds ratios (RORs) from each study and combined them using a random-effects model. We made overall inferences and assessed certainty of evidence based on Grading of Recommendations, Assessment, development, and Evaluation and Instrument to assess the Credibility of Effect Modification Analyses.

RESULTS

Forty-one meta-epidemiological studies (34 of between-, 7 of within-trial comparisons) proved eligible. Inadequate random sequence generation (ROR 0.94, 95% confidence interval [CI] 0.90-0.97) and allocation concealment (ROR 0.92, 95% CI 0.88-0.97) probably lead to effect overestimation (moderate certainty). Lack of patients blinding probably overestimates effects for patient-reported outcomes (ROR 0.36, 95% CI 0.28-0.48; moderate certainty). Lack of blinding of outcome assessors results in effect overestimation for subjective outcomes (ROR 0.69, 95% CI 0.51-0.93; high certainty). The impact of patients or outcome assessors blinding on other outcomes, and the impact of blinding of health-care providers, data collectors, or data analysts, remain uncertain. Trials stopped early for benefit probably overestimate effects (moderate certainty). Trials with imbalanced cointerventions may overestimate effects, while trials with missing outcome data may underestimate effects (low certainty). Influence of baseline imbalance, compliance, selective reporting, and intention-to-treat analysis remain uncertain.

CONCLUSION

Failure to ensure random sequence generation or adequate allocation concealment probably results in modest overestimates of effects. Lack of patients blinding probably leads to substantial overestimates of effects for patient-reported outcomes. Lack of blinding of outcome assessors results in substantial effect overestimation for subjective outcomes. For other elements, though evidence for consistent systematic overestimate of effect remains limited, failure to implement these safeguards may still introduce important bias.

The Benefit of Exercise in Patients With Cancer Who Are Receiving Chemotherapy: A Systematic Review and Network Meta-Analysis

OBJECTIVE

This study aimed to determine which therapeutic exercise-based intervention is most effective in improving cardiorespiratory fitness (CRF) in patients with cancer receiving chemotherapy.

METHODS

The authors conducted a systematic review with network meta-analysis in MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, SPORTDiscus, and Web of Science. The authors employed the Physiotherapy Evidence Database and the Revised Cochrane Risk of Bias Tool for Randomized Trials to assess the methodological quality and risk of bias, respectively.

RESULTS

A total of 27 studies were included. Data were pooled using a random-effects model. Adding aerobic training (moderate to high intensity), with or without resistance training, to usual care versus usual care was statistically significant, with a small beneficial effect (aerobic training: standardized mean difference = 0.46; 95% CI= 0.17 to 0.75; aerobic and resistance training: standardized mean difference = 0.26; 95% CI = 0.00 to 0.52) for peak oxygen consumption at the postintervention assessment.

CONCLUSION

Therapeutic exercise-based interventions to improve short-term CRF in patients with cancer receiving chemotherapy should include moderate- to high-intensity aerobic exercise, with or without resistance training.

IMPACT

It is important to improve CRF in the oncological population due to its relationship with mortality. The results showed the benefit of exercise to improve cardiorespiratory fitness in the oncology population receiving chemotherapy treatment.

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

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

Effects of therapeutic exercise in primary dysmenorrhea: an umbrella and mapping review

PURPOSE

Primary dysmenorrhea (PD) is 1 of the most prevalent gynecologic conditions. The main aim of this umbrella review was to assess the effects of therapeutic exercise (TE) on PD.

METHODS

A systematic search was carried out in PubMed, Embase, SPORTDiscus, CINAHL, and PEDro (December 10, 2022). The outcome measures assessed were menstrual pain intensity, menstrual pain duration, and quality of life. Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the advisory committee grading criteria guidelines.

RESULTS

Nine systematic reviews were included. The results showed that TE, regardless of the exercise model and intensity, has a clinical effect in improving menstrual pain intensity in women with PD with moderate quality of evidence. In addition, the results showed that TE has a clinical effect in improving the duration of menstrual pain in women with PD with a limited quality of evidence. However, the results are controversial on the improvement of quality of life in women with PD with a limited quality of evidence.

CONCLUSIONS

TE seems an effective option to implement in women with PD to improve the intensity and duration of menstrual pain. We cannot draw robust results for quality of life due to the low number of primary studies. More research in this field can help us establish more robust conclusions, as well as to assess whether there is one exercise model or intensity of training that is more effective than others.PROSPERO number: This review was previously registered in PROSPERO (CRD42022371428).