Assessment of methodological quality and outcome measures of acute stroke randomized controlled trials in China in recent 15 years

Evaluation of quality and quantity of randomized controlled trials in hepatobiliary surgery: A scoping/mapping review

AIM

To evaluate the quantity and quality of randomized controlled trials (RCTs) in hepatobiliary surgery and for identifying gaps in current evidences.

METHODS

A systematic search was conducted in MEDLINE (via PubMed), Web of Science, and Cochrane Controlled Register of Trials (CENTRAL) for RCTs of hepatobiliary surgery published from inception until the end of 2023. The quality of each study was assessed using the Cochrane risk-of-bias (RoB) tool. The associations between risk of bias and the region and publication date were also assessed. Evidence mapping was performed to identify research gaps in the field.

RESULTS

The study included 1187 records. The number and proportion of published randomized controlled trials (RCTs) in hepatobiliary surgery increased over time, from 13 RCTs (.0005% of publications) in 1970-1979 to 201 RCTs (.003% of publications) in 2020-2023. There was a significant increase in the number of studies with a low risk of bias in RoB domains (p < .01). The proportion of RCTs with low risk of bias improved significantly after the introduction of CONSORT guidelines (p < .001). The evidence mapping revealed a significant research focus on major and minor hepatectomy and cholecystectomy. However, gaps were identified in liver cyst surgery and hepatobiliary vascular surgery. Additionally, there are gaps in the field of perioperative management and nutrition intervention.

CONCLUSION

The quantity and quality of RCTs in hepatobiliary surgery have increased over time, but there is still room for improvement. We have identified gaps in current research that can be addressed in future studies.

DL-3-n-butylphthalide for acute ischemic stroke: An updated systematic review and meta-analysis of randomized controlled trials

Background: DL -3-n-butylphthalide (NBP) is widely used as a neuroprotective drug in stroke patients in China. A systematic review in 2010 suggested NBP to be safe and effective at promoting neurological recovery, but could not conclude whether it decreased risk of long-term death or disability. Since numerous randomized controlled trials (RCTs) have been conducted on NBP since 2010, we performed an updated systematic review and meta-analysis of safety and efficacy data.

Method: We searched electronic databases and reference lists to identify RCTs that compared patients who received NBP or not (including placebo). Methodological quality of RCTs was assessed using the Revised Cochrane Risk of Bias Tool 2.0, and data were meta-analyzed using Review Manager 5.4 software.

Results: Fifty-seven RCTs involving 8,747 participants were included. Twenty trials examined NBP as a capsule, 29 as an injection, and 8 as sequential injection-capsule therapy. Meta-analyses showed that NBP treatment was associated with a reduction in composite outcome of death and dependency (risk ratio 0.59, 95% CI 0.42 to 0.83; 260 participants; 2 studies), death (risk ratio 0.32, 95% CI 0.13 to 0.75; 2,287 participants; 10 studies), modified Rankin Scale score (mean difference -0.80, 95% CI -0.88 to -0.72; 568 participants; 4 studies), and an increase in Barthel Index, which assesses the ability to engage in basic activities of daily living (mean difference 11.08, 95% CI 9.10 to 13.05; 2,968 participants; 22 studies). Meta-analyses found that NBP significantly reduced neurological deficit based on National Institute of Health Stroke Scale (mean difference -3.39, 95% CI -3.76 to -3.03; 7.283 participants; 46 studies) and Chinese Stroke Scale (mean difference -4.16, 95% CI -7.60 to -0.73; 543 participants; 4 studies). Of the adverse events reported in 31 trials, elevated transaminase (incidence, 1.39-17.53%), rash (0-1.96%) and gastrointestinal discomfort (1.09-6.15%) were most frequent and no serious adverse events were reported.

Conclusion: This update review confirms that NBP can help acute ischemic stroke patients regain the ability to perform activities of daily living, reduce their neurological deficit and short-term death rates. However, the available evidence on whether NBP reduces risk of long-term death or dependence after ischemic stroke remains insufficient.

Does the traditional Chinese medicine theory of five circuits and six qi improve treatment effectiveness? A systematic review of randomized controlled trials

Objective

To evaluate whether the traditional Chinese medicine (TCM) theory of five circuits and six qi (FCSQ) is beneficial in terms of improving clinical effectiveness.

Methods

Randomized controlled trials (RCTs) evaluating the clinical value of FCSQ theory were reviewed. Multiple databases (China Network Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang Data, SinoMed, Cochrane Library, PubMed, and Embase) were systematically searched from inception to June 12, 2018. Two authors independently extracted the data and performed a methodological quality assessment of the RCTs. RevMan 5.3 software was used for the data analysis. The effect sizes for the primary outcome measures were expressed as relative risks or mean differences with 95% confidence intervals.

Results

A total of 13 RCTs were selected, involving 12 types of diseases and 4695 patients. The methodological quality of the RCTs was generally low. Five studies compared the effectiveness of TCM treatments guided by FCSQ theory with conventional TCM therapies, and the remaining eight studies compared the effectiveness of TCM treatments guided by FCSQ theory with biomedical treatments. All of the RCTs reported that the effectiveness of the treatment intervention was better than that of the intervention in the control group.

Conclusion

Because of many methodological problems in existing clinical studies, it remains impossible to definitively conclude that FCSQ theory can improve clinical effectiveness. It is difficult to unify the clinical application of FCSQ theory. The feasibility and repeatability of FCSQ as an intervention should be given more attention in future clinical research. Future work should also follow international norms for clinical research implementation and reporting to provide high-quality evidence for evaluating the clinical value of FCSQ theory.

Characteristics of Randomized Trials Focusing on Stroke due to Intracerebral Hemorrhage: Systematic Review

BACKGROUND AND PURPOSE

The absence of treatments for intracerebral hemorrhage with significant consistent benefit in randomized controlled trials (RCTs) could be because of lack of treatment efficacy or the design of RCTs.

METHODS

We searched the Cochrane Stroke Group Trials Register in December 2015 for completed and published RCTs reporting clinical outcome in adults with intracerebral hemorrhage. We collected data on publication year and language, study characteristics, and effect size. We regarded RCTs to be at lower risk of bias if they performed ≥2 of describing randomization, using blinding, or specifying the primary outcome. We registered this systematic review (PROSPERO, international prospective register of systematic reviews CRD42016051103).

RESULTS

We found 136 eligible RCTs: 57% were phase II, 76% were single center, 98% studied acute treatments, 49% involved drug interventions, 24% were placebo-controlled, the primary outcome was death or disability in 30%, and median sample size was 77 (interquartile range, 47-160). Forty-six percent explained randomization, 24% blinded treatment allocation, and 24% specified the primary outcome such that 38 (28%) were at lower risk of bias. RCTs at lower risk of bias were more likely to use multicenter recruitment (adjusted odds ratio, 6.95; 95% confidence interval, 2.2-21.5) and be published in English (adjusted odds ratio, 12.9, 95% confidence interval, 2.7-62.5). RCTs with larger sample sizes were independently more likely to be phase III/IV (P<0.01) and use multicenter recruitment (P<0.01). RCTs at lower risk of bias had smaller pooled treatment effects on death/disability (P=0.02).

CONCLUSIONS

Intracerebral hemorrhage RCTs have often been at high risk of bias, and these RCTs have been characterized by small sample sizes and larger effect sizes.

Optimising outcome assessment to improve quality and efficiency of stroke trials

Substantial progress has been made in treatment of stroke and much of this has been driven by large scale, multi-centre, randomised controlled trials. Although stroke is a frequent cause of mortality, stroke-related disability and functional decline is of equal or greater concern to patients and carers. Thus, to prove efficacy of an intervention for stroke, we need robust methods of describing recovery. Various functional assessment scales are available, the tool recommended as trial end point by many specialist societies and regulatory authorities is the modified Rankin Scale (mRS). We will use the mRS as exemplar to discuss contemporary research around functional assessment for stroke trials, including recent work around structured assessments, assessor training and end point adjudication panels. We will present an overview and critique of these studies and give examples where strategies to improve mRS assessment are impacting on the quality of stroke clinical trials.