Nonpharmacological conservative treatments for chronic functional constipation: A systematic review and network meta-analysis

A Novel Herbal Composition Alleviates Functional Constipation, Reduces Gastrointestinal Transit Time, and Improves Bowel Function in Adults: A Double-Blind, Randomized Clinical Study

BACKGROUND AND OBJECTIVE

A recent proof-of-concept pilot clinical study has demonstrated that consumption of CL18100F4, a proprietary herbal blend of Withania somnifera root and Abelmoschus esculentus fruit extracts, significantly relieved the participants from functional constipation and improved their quality of life. The objective of the present randomized, double-blind, placebo-controlled study was to reevaluate the efficacy and tolerability of CL18100F4 in a larger number of subjects.

METHODS

Male and female subjects (n = 135; age: 25-60 years), selected through Rome-IV criteria for functional constipation, were randomized into placebo and 300 or 500 mg of CL18100F4 groups and supplemented daily over 60 consecutive days. The primary efficacy outcome measure was Patient Assessment of Constipation-Symptoms (PAC-SYM), evaluated at baseline and on days 7, 30, and 60 of supplementation. The secondary efficacy parameters included Patient Assessment of Constipation-Quality of Life (PAC-QOL), Gastrointestinal Symptom Rating Scale (GSRS) scores, Gastrointestinal Transit Time (GIT), and Complete Spontaneous Bowel Movement (CSBM). Serum levels of Interleukin (IL)-6, IL-10, cortisol, gastrin, serotonin, Diamine oxidase (DAO), and Zonulin were measured.

RESULTS

CL18100F4 supplementation significantly (p < 0.001) reduced the PAC-SYM, PAC-QOL, GSRS scores, and GIT and improved CSBM scores. CL18100F4 significantly improved (p < 0.001) sleep quality and decreased depression and anxiety symptoms in the participants. Notably, relief in constipation symptoms and improved gastrointestinal (GI) function were reported starting from day 7. Furthermore, CL18100F4 supplementation significantly (p < 0.001) increased the serum levels of IL-10, DAO, serotonin, gastrin, reduced IL-6, cortisol, and Zonulin. No major adverse events were observed. Participants' vital signs, hematology, clinical biochemistry, and urinalysis parameters were within the normal ranges.

CONCLUSION

The present investigation demonstrates that CL18100F4 is tolerable and efficacious in relieving functional constipation, alleviating GI dysfunction, and improving associated non-GI factors in male and female adults.

The efficacy and safety of vibrating capsules for functional constipation: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Chronic constipation is a challenging functional gastrointestinal disorder that remains a global burden. Pharmacologic therapy, including laxatives and dietary fibers, are suggested as lines of treatment. Recent trials introduced an orally ingested vibrating capsule (VC) as an eligible option for chronic constipation management.

METHODS

We conducted a literature search in English on electronic databases CENTRAL, PubMed, EMBASE, Scopus, and WOS until February 27th, 2023. RevMan was used to perform the meta-analysis. The results were reported as risk ratios (RRs), mean differences (MDs), and 95% confidence intervals (CIs). The study protocol was registered in PROSPERO with ID: (CRD42023409422).

RESULTS

Three RCTs with a total of 601 patients were included in our analysis. There was no difference between the VC and placebo in responder rate (RR: 1.37 with 95% CI [0.82, 2.28], p = .22), CSBM change from baseline (MD: 0.21 with 95% CI [-0.26, 0.69], p = .38), SBM change from baseline (MD: 0.14 with 95% CI [-0.22, 0.49], p = .46), and the incidence of any adverse event (RR: 1.45 with a 95% CI of [0.79, 2.63], p = .23). However, VC was associated with increased vibration sensation (RR: 17.23, 95% CI [3.29, 90.20], p = .0008).

CONCLUSIONS

VC was not effective to improve bowel movement in patients with functional constipation with no difference in response rate. However, evidence is still uncertain, with only three small RCTs that yielded heterogenous findings, mainly due to the different vibration protocols. Also, our findings suggest that VC is safe and well-tolerated, with no significant harmful effects observed. Therefore, more large-scale RCTs are needed to confirm the efficacy and safety of VC in patients with functional constipation, determining the most effective dose, frequency, and duration of treatment.

Comparative effectiveness of Chinese herbal injections treating for rotavirus enteritis in children: A systematic review and Bayesian network meta-analysis

Background

Rotavirus enteritis (RVE) accounts for 37% of all death in children (<5 years) with diarrhea. Chinese herbal injections (CHIs) have drawn more attention from practitioners because of the valid effects for RVE. However, the most beneficial one has not yet been determined.

Methods

Eight databases were searched from their inception up to September 3rd, 2022. The primary outcome was clinical effective rate and the secondary outcomes were time for disappearance of diarrhea, time of defervescence, time for disappearance of vomiting, and adverse drug reactions or adverse drug events. OpenBUGS 3.2.3 and STATA 14.0 software were employed to carry out the NMA.

Results

58 randomized controlled trials (RCTs) with 6436 child patients were included in this Bayesian NMA. Four CHIs were investigated including Yanhuning injection (YHN), Xiyanping injection (XYP), Reduning injection (RDN), and Zedoary Turmeric Oil injection (ZTO). The results showed that YHN [OR=6.16, 95% CI (4.39, 8.77)] had a superior effect in improving clinical effective rate compared to Ribavirin based on Western medicine (WM). According to SUCRA values, YHN (84.1%) ranked highest. As for the secondary outcomes, XYP was the better intervention in shortening the time for disappearance of diarrhea. Regarding time for defervescence, RDN had obvious advantages and also performed well in time for disappearance of vomiting.

Conclusion

CHIs combined with WM could be beneficial than Ribavirin in improving clinical effective rate, and YHN was the optimum treatment. From the comprehensive evaluations of both the clinical effective rate and other outcomes, YHN also indicated a favorable therapeutic effect in RVE.

Study registration

PROSPERO, CRD42022357149.

Comparative effectiveness of different acupuncture courses in functional constipation: A Bayesian network meta-analysis of clinical trials

AIM

The purpose of this study was to examine the comparative effectiveness of different acupuncture courses for functional constipation (FC).

BACKGROUND

There is a need to optimize the treatment course of acupuncture for FC to improve efficacy and save health resources.

METHODS

We performed a systematic electronic search of eight databases from inception to April 2021. Randomized controlled trials comparing acupuncture treatment with sham acupuncture were included. The main outcome indicators were complete spontaneous bowel movement (CSBM), spontaneous bowel movement, Bristol Stool Form Scale (BSFS), responder rate and safety evaluation (SE).

RESULTS

In this network meta-analysis, 19 studies with 1753 participants and 8 different acupuncture treatments were included. Using the consistency model via Monte Carlo simulation iterations, we found that the effect of acupuncture treatment at 3/4 weeks may be better in terms of CSBM and BSFS. The results of rank probability analysis showed that 6 weeks of treatment may be better for the responder rate, and 2 weeks of treatment may be better for SE. And, subgroup analysis found that, for patients with chronic severe functional constipation (CSFC), 8 weeks of acupuncture treatment may be the best for CSBM.

CONCLUSIONS

By indirect comparison, 3/4 weeks of acupuncture treatment may be the optimal course of treatment for FC in terms of improving bowel frequency and stool shape. And for CSFC, 8 weeks of acupuncture treatment may be the best. However, there is still a lack of direct comparison and publication bias that affects the accuracy of research results.

Modulation of the autonomic nervous system by one session of spinal low-level laser therapy in patients with chronic colonic motility dysfunction

Patients with a defecation disorder may not evoke a normal defecation reflex, or the reflex may be excessive, as a dysfunction of the spinal autonomic nervous system. Treatment with various forms of lumbar and sacral neuromodulation have shown symptom improvement, but potential changes in autonomic functioning are rarely studied. Here we evaluate the effects on autonomic function of a single session of low-level laser therapy (LLLT) on the lumbar and sacral spine in 41 patients with chronic gastrointestinal motor dysfunction. The LLLT protocol used red LED light at a wavelength of 660 nm for 10 min and infrared LED light at a wavelength of 840 nm for 10 min, followed by infrared laser light at a wavelength of 825 nm for 10 min. Effects on the autonomic nervous system were assessed by measuring heart rate variability (HRV) changes. Respiratory Sinus Arrhythmia (RSA) and Root Mean Square of Successive Differences (RMSSD) were used to quantify parasympathetic reactivity; the Baevsky’s Stress Index (SI) reflected sympathetic activity while the ratios SI/RSA and SI/RMSSD were used to show shifts in autonomic dominance. The results indicate that lumbar and sacral neuromodulation using light arrays reduced, whereas stimulation by the laser probes significantly increased parasympathetic activity. The light arrays increased whereas the laser probes significantly decreased sympathetic activity (SI). The entire protocol shifted the autonomic balance toward parasympathetic activity. The comparison of actual vs. sham neuromodulation proved that the change in HRV parameters was due to actual light stimulation and not due to the arrays and probe touching the skin. In conclusion, a single session of LLLT markedly affects autonomic nervous system activity reflected in changes in HRV which is only possible by generating activity in the spinal autonomic nerves. These results warrant a study into the effects of LLLT on restoring autonomic dysfunction in chronic refractory colonic motility disorders.

Comparative Efficacy of Chinese Patent Medicines for Clearing Heat and Dampness in the Treatment of NAFLD: A Network Meta-Analysis of Real-World Evidence

Background

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common chronic liver disease, as well as a worldwide medical problem with a substantial socioeconomic burden. In China, Chinese patent medicines (CPMs) have been widely utilized as promising and effective therapy options for NAFLD. Traditional Chinese medicine (TCM) is a particular kind of medical science reliant on real-world clinical practices and evidence. Therefore, using the real-world data extracted from pragmatic randomized controlled trials (PRCTs) have more reference value for the application of CPMs in NAFLD.

Method

Six databases were searched from their inception up to March 18, 2022. The methodological quality of the included study was evaluated by the Cochrane risk-of-bias tool. Then, The STATA 13.0 program was then used to do a network meta-analysis (NMA) of real-world studies. The surface under the cumulative ranking curve (SUCRA) probability values were applied to rank the examined treatments.

Results

Forty-three PRCTs (4997 cases in total) were identified. Da-Huang-Li-Dan capsule (DHLD), Dan-Ning tablet (DN), Dang-Fei-Li-Gan-Ning capsule (DFLGN), Qiang-Gan capsule (QG), and Hua-Zhi-Rou-Gan granule (HZRG) were among the five CPMs tested. As far as the clinical effective rate of the primary outcome index was concerned, the top three CPMs were DN + CDs: OR = 0.19, 95% CIs: 0.12, 0.31 (SUCRA: 81.8%); DFLGN + CDs: OR = 0.21, 95% CIs: 0.09, 0.46 (SUCRA: 74.9%), and DHLD + CDs: OR = 0.26, 95% CIs: 0.10, 0.67 (SUCRA: 61.1%). In terms of liver function index, DN + CDs ranked first in ALT index: MD = 15.81, 95% CIs: 10.05, 21.57 (SUCRA: 85.5%), DFLGN + CDs ranked first in AST index: MD = 14.94, 95% CIs: 4.77, 25.11 (SUCRA: 83.6%), HZRG + CDs ranked first in TC index: MD = 0.53, 95% CIs: 0.28, 1.03 (SUCRA: 87.1%) and TG index: MD = 1.8, 95% CIs: 1.41, 2.30 (SUCRA: 79.9%).

Conclusion

Using CPMs as a coadjuvant treatment might be positive efficacious intervention from which patients with NAFLD will derive benefits. When it came to the clinical effective rate and other outcomes, DN + CDs demonstrated a significant improvement in individuals with NAFLD.

Effect of Portulaca Oleracea L. extract on functional constipation: A randomized, double-blind, placebo-controlled trial

Background

: This study aimed to investigate the efficacy of P. oleracea in the management of patients with functional constipation.

Methods

: A total of 60 patients with functional constipation as defined by the Rome IV criteria were enrolled in this randomized, double-blind, placebo-controlled study; 70% ethanol extracts of the aerial parts of P. oleracea were used for the intervention. Patients were randomly assigned to the P. oleracea or placebo groups. Treatment response, quality of life, and changes in colonic transit time (CTT) were evaluated.

Results

: Complete spontaneous bowel movement (CSBM) improved significantly in the P. oleracea group compared with that in the placebo group over 8 weeks of treatment (P = 0.003). Overall Patient Assessment of Constipation Quality of Life (PAC-QOL) and Patient Assessment of Constipation Symptoms (PAC-SYM) score improvements were observed in the P. oleracea group (P < 0.05). Moreover, CTT decreased from 44.5 ± 22.0 h to 33.7 ± 22.7 h in the P. oleracea group after 7 weeks of treatment (P = 0.04). There were no significant differences in the Bristol Stool Form Scale (BSFS) or adverse events between the groups.

Conclusions

: Compared to placebo, the use of P. oleracea in patients with functional constipation significantly improved CSBM, severity of symptoms, and quality of life. Further large studies are required to assess the benefits of P. oleracea in the treatment of functional constipation.

Efficacy of acupuncture in subpopulations with functional constipation: A protocol for a systematic review and individual patient data meta-analysis

Background

Several systematic reviews have suggested that acupuncture is effective against functional constipation, but it is unknown whether variations in treatment effect across subgroups remain consistent. Our purpose of this study is to explore the heterogeneity of treatment effect of acupuncture on functional constipation across subgroups.

Methods

We will search eleven English and Chinese electronic databases and three clinical trial registries from inception to December 2021. Randomized controlled trials that evaluate acupuncture compared with sham acupuncture or no treatment for functional constipation will be eligible if they report at least one primary outcome. The primary outcomes will include the change in weekly complete spontaneous bowel movements or spontaneous bowel movements from baseline. Two authors will independently identify the relevant studies, assess the risk of bias using the Cochrane RoB 2 tool and contact the primary researchers of the eligible trials for individual patient data. Individual patient data obtained from the original trial author will be standardized and all trial data will be combined into a single database. Generalized linear mixed effects model will be used to determine possible subgroup effects by adding an interaction term for predefined subgroup and treatment.

Systematic review registration

International Prospective Register of Systematic Reviews (Number: CRD42020188366).

Comparative Efficacy of Tonic Chinese Herbal Injections for Treating Sepsis or Septic Shock: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background: Sepsis has high mortality and is responsible for significant healthcare costs. Chinese herbal injections (CHIs) have been widely used in China as a novel and promising treatment option for sepsis. Therefore, this study assessed and ranked the effectiveness of CHIs to provide more sights for the selection of sepsis treatment. Method: Eight databases were searched from their inception up to September 1, 2021. The methodological quality of included study was evaluated by the Revised Cochrane risk-of-bias tool for randomized trials. Then Bayesian network meta-analysis was performed by OpenBUGS 3.2.3 and STATA 14.0 software. The surface under the cumulative ranking curve (SUCRA) probability values were applied to rank the examined treatments. Publication bias was reflected by a funnel plot. Results: A total of 50 eligible randomized controlled trials involving 3,394 participants were identified for this analysis. Five CHIs including Shenfu injection, Shenmai injection, Shengmai injection, Shenqifuzheng injection, and Huangqi injection were included. The results of the NMA and sensitivity analysis showed that Shenqifuzheng (MD = -4.48, 95% CI = -5.59 to -3.24), Shenmai (MD = -3.38, 95% CI = -4.38 to -2.39), Shenfu (MD = -2.38, 95% CI = -3.03 to -1.70) and Shengmai (MD = -1.90, 95% CI = -3.47 to -0.31) combined with Western medicine (WM) had a superior effect in improving the APACHE II score. Based on SUCRA values, Shenqifuzheng injection (95.65%) ranked highest in the APACHE II score, followed by Shenmai (74%), Shenfu (47.1%), Shengmai (35.3%) and Huangqi injection (33.2%). Among the secondary outcomes, Shenmai injection was the most favorable intervention in reducing PCT and CRP levels, and Shenqifuzheng injection was the second favorable intervention in reducing CRP level. Shenfu injection combined with WM was more effective than the other treatments in decreasing the serum IL-6 and TNF-α levels and lowering the 28-days mortality. Regarding the improvement of immune function, Shenqifuzheng injections had obvious advantages. Conclusion: In conclusion, Shenqifuzheng injection was the optimum treatment regimen to improve APACHE II score, reduce CRP level, and regulate immune function. Shenfu injection was superior in reducing the expression of inflammatory factors and decreasing 28-days mortality. Nevertheless, more multicenter, diverse, and direct comparisons randomized controlled trials are needed to further confirm the results. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=254531, identifier CRD42021254531.

Comparative Efficacy of Chinese Herbal Injections for Treating Severe Pneumonia: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background: Severe pneumonia (SP) has a high mortality rate and is responsible for significant healthcare costs. Chinese herbal injections (CHIs) have been widely used in China as a novel and promising treatment option for SP. Therefore, this study assessed and ranked the effectiveness of CHIs to provide more sights for the selection of SP treatment. Method: Seven databases were searched from their inception up to April 1, 2021. The methodological quality of included study was evaluated by the Cochrane risk-of-bias tool. Then, a Bayesian network meta-analysis (NMA) was performed by OpenBUGS 3.2.3 and STATA 14.0 software. The surface under the cumulative ranking curve (SUCRA) probability values were applied to rank the examined treatments. A clustering analysis was utilized to compare the effect of CHIs between two different outcomes. Results: A total of 64 eligible randomized controlled trials (RCTs) involving 5,904 participants were identified for this analysis. Six CHIs including Xuebijing injection (XBJ), Tanreqing injection (TRQ), Reduning injection (RDN), Xiyanping injection (XYP), Shenfu injection (SF), and Shenmai injection (SM) were included. The results of the NMA showed that XBJ [odds ratio (OR) = 0.24, 95% credible interval (CI): 0.19, 0.30], TRQ (OR = 0.22, 95% CI: 0.12, 0.37), RDN (OR = 0.29, 95% CI: 0.04, 0.94), and SM (OR = 0.27, 95% CI: 0.08, 0.63) combined with conventional Western medicine (WM) improved the clinical effective rate more significantly than WM alone. Based on SUCRA values, TRQ + WM (SUCRA: 66.4%) ranked the highest in improving the clinical effective rate, second in four different outcomes, and third in only one. According to the cluster analysis, TRQ + WM exerted a positive effect on improving the efficacy of SP. As for safety, less than 30% (18 RCTs) of the included studies reported adverse drug reactions/adverse drug events (ADRs/ADEs), including 14 RCTs of XBJ, 3 RCTs of TRQ, and 1 RCT of RDN. Conclusion: In conclusion, the study found that the CHIs as co-adjuvant therapy could be beneficial for patients with SP. TRQ + WM showed an outstanding improvement in patients with SP considering both the clinical effective rate and other outcomes. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021244587].

Herbal Medicine for the Management of Laxative Activity

Constipation is one of the most common and prevalent chronic gastrointestinal conditions across the globe that is treated or managed through various methods. Laxatives are used for the treatment or management of chronic/acute constipation. But due to the adverse effects associated with these laxatives, herbal foods should be considered as alternative therapies for constipation. In this review, the laxative potential of plant-based medicines used for constipation were discussed. Constipation may be caused by various factors such as lifestyle, particular food habits, pregnancy and even due to some medication. Chronic constipation is responsible for different health issues. Pharmacological and non-pharmacological paradigms are applied for the treatment or management of constipation. In the pharmacological way of treatment, medicinal plants have a key role, because of their fibrous nature. Numerous plants such as Prunus persica (Rosaceae), Cyamopsis tetragonolobus (Leguminosae), Citrus sinensis (Rutaceae), Planta goovata (Plantaginaceae), Rheum emodi (Polygonaceae), Cassia auriculata (Caesalpinacea), Ricinus communis (Euphorbiaceae), Croton tiglium (Euphorbiaceae), Aloe barbadensis (Liliaceae), Mareya micrantha (Euphorbiaceae), Euphorbia thymifolia (Euphorbiaceae), Cascara sagrada (Rhamnaceae), Cassia angustifolia (Fabaceae) have laxative activity. Medicinal plants possess a significant laxative potential and support their folklore therefore, further, well-designed clinical-based studies are required to prove and improve the efficacy of herbal medicine for constipation. The present review showed that herbs laxative effect in various in-vivo/ in-vitro models.

Auricular Vagal Nerve Stimulation Improves Constipation by Enhancing Colon Motility via the Central-Vagal Efferent Pathway in Opioid-Induced Constipated Rats

OBJECTIVES

Constipation and opioid-induced constipation (OIC) are common with limited treatment options. We investigated whether a noninvasive method of auricular vagal nerve stimulation (aVNS) could be used for treating OIC and explored its potential mechanisms and neural pathways in a rodent model of OIC.

MATERIALS AND METHODS

Sprague-Dawley were chronically implanted with one pair of auricular electrodes for aVNS. Sixteen rats were treated with loperamide for a week while another 16 rats received bilateral vagotomy, then randomly treated with aVNS or sham-aVNS for a week. In addition, eight normal rats were implanted with a polyethylene catheter in the proximal colon for assessing whole colon transit.

RESULTS

1) The number of fecal pellets and water content in feces increased after aVNS, compared with sham-aVNS. 2) aVNS accelerated colon transit and whole gut transit, compared with sham-aVNS. 3) In colon tissues, aVNS increased the protein expression of choline acetyltransferase, glial cell line-derived neurotrophic factor and the c-kit expression in myenteric interstitial cells of Cajal but decreased the protein expression of neural nitric oxide synthase (p < 0.05 for all, vs. sham-VNS). 4) The prokinetic effects of aVNS were abolished by both subdiaphragmatic vagotomy and atropine. 5) aVNS increased the c-fos expression in both nucleus tractus solitarius and dorsal motor nucleus of vagus, and increased vagal efferent activity (p < 0.05, vs. sham-VNS).

CONCLUSIONS

aVNS improves OIC by enhancing colon motility and restoring enteric neural functions mediated via the central and vagal efferent pathway.

Effectiveness of acupuncture for the recovery of gastrointestinal function of patients with gastric cancer in the postoperative period: A protocol for systematic review and meta-analysis

BACKGROUND

Gastric cancer (GC) is the most common malignant tumors in the world and surgical resection remains the primary treatment for it. Postoperative patients often suffer from gastrointestinal dysfunction as the most common side effects of surgery for GC patients. Acupuncture has a regulatory effect on gastrointestinal function. We conducted this study to assess the effectiveness of acupuncture on the restoration of gastrointestinal function of postoperative patients with GC.

METHODS

Seven electronic databases will be searched from inception to November 2020 to identify any relevant study: Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), and Chinese Scientific Journal Database (VIP database). No restriction on time and language. The primary outcome measure will be the Time to First Flatus and secondary outcome measures include the time of first defecation and the quality of life (QOL) and the number of patients with abdominal distention. We will use EndNote V.9.1 to screen the eligible literature and the I2 statistic to assess heterogeneity in the included studies. The meta-analysis will be conducted using the Review Manager (RevMan) software (V.5.3).

RESULTS

Our study aims to systematically assess whether the pooled effects of currently available trials prove effects of acupuncture in improving gastrointestinal function of patients with GC in the postoperative period.

CONCLUSION

This study will conduct an evaluation about the efficacy of acupuncture for the recovery of gastrointestinal function of patients with GC in the postoperative period, making up for the lack of relevant clinical evidence.

INPLASY REGISTRATION NUMBER

INPLASY2020110066.

The Quality of Methodological and Reporting in Network Meta-Analysis of Acupuncture and Moxibustion: A Cross-Sectional Survey

Background

Acupuncture had long been a primary treatment in the healthcare system of China. In recent years, there were more and more network meta-analyses (NMAs) in the field of acupuncture and moxibustion, but the quality evaluation of NMAs was rare.

Objectives

The goal of this study was to evaluate the methodological and reporting quality of NMAs and summarize the effects of different treatments of acupuncture and moxibustion.

Methods

PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure Database (CNKI), WanFang Database (WF), Chinese Scientific Journal Database (VIP), and Chinese Biomedical Literature Database (CBM) were searched from inception to January 2020 without any language restriction. In addition, the unpublished studies and the references of initially included literature were also retrieved manually. We included all relevant NMAs treated with acupuncture and moxibustion; other therapies such as traditional Chinese medicine and Western medicine may also be included, but at least three types fall under the category of acupuncture in each NMA. Outcome indicators were not limited. We selected AMSTAR2 and PRISMA-NMA to evaluate the methodological and reporting quality of eligible studies, respectively.

Results

In total, 29 NMAs were included finally, including 12 Chinese references and 17 English references. All eligible studies were published from May 2013 to August 2019. The number of interventions was between 4 and 22. The number of clinical trials included ranged from 10 to 121, with a total of 1098 clinical trials. The NMAs were involved in up to 23 diseases, knee osteoarthritis and primary dysmenorrhea covered with 3 NMAs separately, others focusing on chronic functional constipation, lumbar disc herniation, chronic fatigue syndrome, and the like. The Jadad scale and RoB scale were used as the bias risk assessment tools. Among them, 7 articles adopted the Jadad scale, 22 articles adopted the RoB scale (1 article adopted both the Jadad scale and RoB scale), and only 1 article did not mention the risk assessment tool. The AMSTAR2 methodological evaluation showed that the highest score was 13.5 points and the lowest was 4, with an average of 8.64 and a median of 9.5. According to the quality criteria, only one of them was in high quality, twenty-four were in medium quality, and four were in low quality. The PRISMA-NMA reporting quality evaluation showed that the highest score was 29 points and the lowest was 13.5, with an average of 23.62 and a median of 24.5; severe flaws also existed in some items, especially in "Structured summary," "Protocol and registration," "Search," "Data collection process," "Data items," "Additional analyses," "Risk of bias across studies," and "Results of additional analyses."

Conclusion

The number of NMAs in the field of acupuncture and moxibustion was still in the initial stage. Overall, their methodology and reports were of moderate quality. However, severe flaws also existed in some items. Because the eligible NMAs were limited, the conclusion needed further research to confirm its authenticity and reliability.

Traditional Chinese medicine injections for heart failure: a protocol for systematic review and network meta-analysis of randomised controlled trials

INTRODUCTION

Heart failure (HF) has always been an important issue in global public health. The research and development of traditional Chinese medicine (TCM) provide more possibilities for improving the prognosis of HF patients. Because multiple TCM injections (TCMIs) are being widely applied in clinical work, it is important to choose the right TCMIs for HF patients. The purpose of this study is to assess and compare the effect of different TCMIs for HF using network meta-analysis (NMA) and further provide references for clinical decision-making.

METHODS AND ANALYSIS

The clinical randomised controlled trials (RCTs) and meta-analyses of TCMIs for treating HF will be searched in the relevant database, including PubMed, EMBASE, Cochrane Library (No. 2 of 2020), Chinese BioMedical Literature Database, China National Knowledge Infrastructure, Wan Fang Database and Chinese Scientific Journal Database from inception to 29 February 2020. The outcomes of interest include all-cause mortality, rehospitalisation rate, left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, brain natriuretic peptide (BNP), N-terminal pro-BNP, cardiac output, stroke volume, 6 min walking distance and adverse events. The risk of bias assessment of the included RCTs will be conducted according to the Cochrane Collaboration's tool for assessing the risk of bias. NMA will be performed in a Bayesian hierarchical framework using R V.3.6.1 with the gemtc package. Finally, we will rank the efficacy of these treatment programmes according to the surface under the cumulative ranking curve, and perform quality assessment and recommendation grading of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

This study will extract data from the published literature and will not involve private information from individuals or compromise their rights. Therefore, the study does not require ethical approval. The results will eventually be published in a peer-reviewed journal and disseminated at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020166900.

Short and long-term efficacy of massage for functional constipation: A protocol for systematic review and meta analysis

BACKGROUND

Functional constipation (FC) is one of the most common diseases throughout the world, which brings a bad influence on life quality as well as mental health. Massage has been widely used in the treatment of functional constipation in china. In several randomized controlled trials indicate that massage has a positive effect on FC. However, there remain exist controversy towards its effectiveness and safety. What's more, how about the short and long-term efficacy? We, therefore, design this systematic review to assess the short and long-term effects of massage for FC.

METHODS

The following electronic databases will be searched from their inception to May 2020, including PubMed, Cochrane Library, EMBASE, Web of Science, WHO International Clinical Trials Registry Platform, Chinese National Knowledge Infrastructure (CNKI), WanFang Database, Chinese Biomedical Literature Database (CBM), the Chongqing VIP Chinese Science, and Technology Periodical Database (VIP).

RESULTS

This systematic review will assess the short and long-term effects of massage in the treatment of FC.

CONCLUSION

This study will provide high-quality current evidence of short and long-term effects of massage for FC.

ETHICS AND DISSEMINATION

Ethical approval is not required, for this review will not involve individuals' information. The results will be published in a peer-reviewed publication or disseminated in relevant conferences.INPLASY Registration number: INPLASY202050001.

Treatment for acute flares of gout: A protocol for systematic review

INTRODUCTION

The current evidence confirms the effectiveness and safety of several drug interventions in the treatment of acute flares of gout, however, the most preferred drugs are still unclear. We, therefore, seek to conduct a network meta-analysis that can systematically compare non-steroidal anti-inflammatory drugs (NSAIDs), COXIBs, colchicine, hormones, or IL-1 receptor antagonists, etc. for acute gout based on the latest evidence.

METHODS AND ANALYSIS

Nine online databases are searched with inception to September 1, 2019; there will be no language restrictions on the included trials. Randomized controlled trials that include patients with acute flares of gout receiving drug therapy versus a control group will be included. The selection of studies, risk of bias assessment and data extraction will be conducted by 2 independent researchers. Bayesian network meta-analysis is applied using the Markov chain Monte Carlo method with Stata or R. The dichotomous data will be presented as risk ratios with 95% CIs and the continuous data will be presented as weighted mean differences or standardized mean differences with 95% CIs. Evidence quality will be evaluated using the GRADE system.

ETHICS AND DISSEMINATION

This network meta-analysis will not involve private information from personal or imperil their rights, so, ethical approval is not required. The results of this network meta-analysis may be published in a journal or publicized in concerned conferences.

TCM nonpharmacological interventions for chronic obstructive pulmonary disease (COPD): Protocol for a systematic review and network meta-analysis

BACKGROUND

Traditional Chinese medicine (TCM) nonpharmacological interventions are gaining an increasing popularity for chronic pulmonary obstructive disease (COPD) treatment and rehabilitation, yet their comparative effectiveness and safety remains unclear. Therefore, this study will aim to compare their effectiveness and safety for COPD by implementing a network-meta analysis.

METHODS

Electronic databases including MEDLINE via Ovid, and EMBASE via Ovid, the Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI) and Chinese BioMedical Literature Database (CBM) will be searched for related randomized controlled trials (RCTs) from inceptions to the search date without language restrictions. RCTs that compare TCM nonpharmacological interventions with placebo or conventional treatments will be included. The primary outcome will be lung function measures, dyspnea level and COPD-specified life quality and secondary ones will include functional exercise capacity, and general health-related life quality. Both classical meta-analysis and network meta-analysis will be implemented to investigate direct and indirect evidences on this topic. Continuous data will be expressed as standard mean differences (SMDs) and categorical data as risk ratios (RRs) with 95% confidence intervals. The evidence transitivity and consistency within network will be evaluated with Cochrane Q statistic and net-heat plot.

RESULTS

The study results will be disseminated through a peer-reviewed journal publication or conference presentation.

CONCLUSIONS

The review findings will provide a ranking evidence of current TCM nonpharmacological interventions and help to inform clinical practitioners, COPD patients, and policy-makers in the decision-making.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42019126554.