Understanding randomised controlled trials

The performance of interrupted time series designs with a limited number of time points: Learning losses due to school closures during the COVID-19 pandemic

Interrupted time series (ITS) designs are increasingly used for estimating the effect of shocks in natural experiments. Currently, ITS designs are often used in scenarios with many time points and simple data structures. This research investigates the performance of ITS designs when the number of time points is limited and with complex data structures. Using a Monte Carlo simulation study, we empirically derive the performance-in terms of power, bias and precision- of the ITS design. Scenarios are considered with multiple interventions, a low number of time points and different effect sizes based on a motivating example of the learning loss due to COVID school closures. The results of the simulation study show the power of the step change depends mostly on the sample size, while the power of the slope change depends on the number of time points. In the basic scenario, with both a step and a slope change and an effect size of 30% of the pre-intervention slope, the required sample size for detecting a step change is 1,100 with a minimum of twelve time points. For detecting a slope change the required sample size decreases to 500 with eight time points. To decide if there is enough power researchers should inspect their data, hypothesize about effect sizes and consider an appropriate model before applying an ITS design to their research. This paper contributes to the field of methodology in two ways. Firstly, the motivation example showcases the difficulty of employing ITS designs in cases which do not adhere to a single intervention. Secondly, models are proposed for more difficult ITS designs and their performance is tested.

The Effect of Phacoemulsification on the Intraocular Pressure of Patients With Open Angle Glaucoma: A Systematic Review and Meta-Analysis

PRCIS

There is evidence that cataract surgery can reduce intraocular pressure in patients with primary open angle, normal tension, or exfoliative glaucoma. The complete effect of phacoemulsification is masked by topical intraocular pressure-lowering medications.

PURPOSE

To assess the impact of phacoemulsification and intraocular lens implantation on intraocular pressure (IOP) level in individuals with primary open angle glaucoma (POAG), exfoliative glaucoma (XFG), exfoliation syndrome (XFS), normal tension glaucoma (NTG), ocular hypertension (OH), or healthy controls 12 months after the surgery.

METHODS

In July 2023, a comprehensive literature review was conducted across six databases. The analysis focused on the phacoemulsification arms of randomized controlled trials (RCTs). The primary outcome of interest was the mean IOP change observed 12 months after phacoemulsification.

RESULTS

This meta-analysis included 9 arms from 9 RCTs, comprising a total of 502 participants. Overall, the average IOP was reduced by 3.77 mm Hg (95% CI: -5.55 to -1.99, I2 =67.9%) 12 months after surgery. The subgroup analysis, focused on whether a washout period was used before measuring IOP, revealed that studies with a washout period exhibited a more pronounced IOP reduction of 5.25 mm Hg (95% CI: -7.35 to -3.15, I2 =0%), while studies without a washout period exhibited a reduction of 3.13 mm Hg (95% CI: -5.46 to -0.81, I2 =75.8%). The sensitivity analysis for the latter group, excluding an outlier study, showed a reduction of 1.81 mm Hg (95% CI: -2.95 to -0.67, I2 =0%).

CONCLUSIONS

The findings of this systematic review and meta-analysis indicate that cataract surgery meaningfully lowers IOP in POAG, XFG/XFS, or OH 12 months after surgery. However, the use of topical medications masks the precise impact of phacoemulsification upon postoperative IOP. Further research using appropriate washout periods is warranted.

The Growing Role of Telerehabilitation and Teleassessment in the Management of Movement Disorders in Rare Neurological Diseases: A Scoping Review

Background: People with rare neurological diseases (RNDs) often experience symptoms related to movement disorders, requiring a multidisciplinary approach, including rehabilitation. Telemedicine applied to rehabilitation and symptom monitoring may be suitable to ensure treatment consistency and personalized intervention. The objective of this scoping review aimed to emphasize the potential role of telerehabilitation and teleassessment in managing movement disorders within RNDs. By providing a systematic overview of the available literature, we sought to highlight potential interventions, outcomes, and critical issues. Methods: A literature search was conducted on PubMed, Google Scholar, IEEE, and Scopus up to March 2024. Two inclusion criteria were followed: (1) papers focusing on telerehabilitation and teleassessment and (2) papers dealing with movement disorders in RNDs. Results: Eighteen papers fulfilled the inclusion criteria. The main interventions were home-based software and training programs, exergames, wearable sensors, smartphone applications, virtual reality and digital music players for telerehabilitation; wearable sensors, mobile applications, and patient home video for teleassessment. Key findings revealed positive outcomes in gait, balance, limb disability, and in remote monitoring. Limitations include small sample sizes, short intervention durations, and the lack of standardized protocols. Conclusion: This review highlighted the potential of telerehabilitation and teleassessment in addressing movement disorders within RNDs. Data indicate that these modalities may play a major role in supporting conventional programs. Addressing limitations through multicenter studies, longer-term follow-ups, and standardized protocols is essential. These measures are essential for improving remote rehabilitation and assessment, contributing to an improved quality of life for people with RNDs.

Effects of digital parenting interventions on self-efficacy, social support, and depressive symptoms in the transition to parenthood: A systematic review and meta-analysis

BACKGROUND

Parenting self-efficacy is essential for the transition to parenthood. As digital parenting educational interventions are rapidly being developed, their effects have not been examined by pooling available randomized controlled trials (RCTs).

OBJECTIVES

To comprehensively investigate the effects of digital educational interventions on parents' self-efficacy, social support, and depressive symptoms in the first year after childbirth and identify the significant associated factors.

METHODS

This study searched six electronic databases for relevant RCTs examining the efficacy of digital parenting interventions from inception to September 2022. The studied outcomes included changes in parent's self-efficacy, social support, and depressive symptoms observed after participating in a digital parenting program. The random-effects model was used to pool results. Subgroup and moderator analyses were performed.

RESULTS

In total, seven RCTs enrolling 1342 participants were included. The parents who received digital parenting interventions had higher parenting self-efficacy (standardized mean difference [SMD]: 1.06, 95 % confidence interval [CI]: 0.40-1.71, p =.002) and social support (SMD: 2.72, 95 % CI: 0.38-5.07, p =.02) and decreased depressive symptoms at 3 months postpartum (SMD: -0.39, 95 % CI: -0.73 to - 0.04, p =.03). Providing the interventions for ≥ 6 weeks (SMD: 1.62, 95 % CI: 1.18-2.06, p <.001), providing in-person orientation (SMD: 1.88, 95 % CI: 1.32-2.44, p <.001), including a guided curriculum (SMD: 2.00, 95 % CI: 1.78-2.22, p <.001), and conducting interventions in Organisation for Economic Co-operation and Development countries (SMD: 1.98, 95 % CI: 1.78-2.19, p <.001) were identified as significant moderators.

CONCLUSIONS

Digital parenting interventions significantly increase parenting self-efficacy and social support as well as alleviate depressive symptoms for parents during their first year after childbirth. Such interventions can be beneficial for parents who prefer online education. Future studies investigating the long-term effects of these interventions are warranted.

REGISTRATION

The protocol for this systematic review and meta-analysis is registered in PROSPERO (registration number: CRD42021243641).

A systematic review and meta-analysis of the effectiveness of co-designed, in-person, mental health interventions for reducing anxiety and depression symptoms

BACKGROUND

Co-design is recommended in mental health fields and has been associated with improved intervention efficacy. Despite its growing popularity, syntheses of evidence on the effectiveness of co-designed interventions are scarce, and little is known about their impact on anxiety and depression.

METHODS

The purpose of this systematic review and meta-analysis was to consolidate evidence on the effectiveness of in-person, co-designed mental health interventions for reducing anxiety and depression symptoms. An exhaustive search was conducted across six electronic databases (PubMed, PsycINFO, Embase, CINAHL, CENTRAL, and ProQuest) and grey literature. Criteria for inclusion comprised studies utilizing randomized or quasi-randomized methods, implementing non-digital/in-person, co-designed interventions for mental health enhancement, and assessing anxiety and/or depression. Intervention impacts were evaluated using random-effects meta-analyses.

RESULTS

The review identified 20 studies, with only three using the term 'co-design'. Other terminologies included 'co-developed' (n = 2), 'co-produced' (n = 2), and 'CBPR' (n = 11). Seventeen studies exhibited moderate risk of bias, while three demonstrated high risk. Meta-analyses demonstrated a moderate non-significant effect size of 0.5 (95 % CI: -0.8, 1.08; p = 0.08) on depression outcomes, and a small non-significant effect size of 0.12 (95 % CI: -0.1, 0.33; p = 0.23) on anxiety outcomes.

LIMITATIONS

The majority of studies lacked sufficient statistical power to detect between-group differences. Following GRADE criteria, confidence in estimates was low.

CONCLUSIONS

Notwithstanding widespread enthusiasm for co-design, the current evidence base is inadequate to confirm the impact of in-person, co-designed mental health interventions on anxiety and depression. More full-scale evaluation trials of higher quality are urgently needed, along with uniform terminology and measurement.

The revised JBI critical appraisal tool for the assessment of risk of bias for quasi-experimental studies

Systematic reviews of effectiveness offer a rigorous synthesis of the best evidence available regarding the effects of interventions or treatments. Randomized controlled trials are considered the optimal study design for evaluating the effectiveness of interventions and are the ideal study design for inclusion in a systematic review of effectiveness. In the absence of randomized controlled trials, quasi-experimental studies may be relied on to provide information on treatment or intervention effectiveness. However, such studies are subject to unique considerations regarding their internal validity and, consequently, the assessment of the risk of bias of these studies needs to consider these features of design and conduct. The JBI Effectiveness Methodology Group has recently commenced updating the suite of JBI critical appraisal tools for quantitative study designs to align with the latest advancements in risk of bias assessment. This paper presents the revised critical appraisal tool for risk of bias assessment of quasi-experimental studies; offers practical guidance for its use; provides examples for interpreting the results of risk of bias assessment; and discusses major changes from the previous version, along with the justifications for those changes.

Inadequate harms reporting among randomized controlled trials cited as supporting evidence in the AAOS management of hip fractures in older adults clinical practice guideline recommendations

BACKGROUND

Recommendations within clinical practice guidelines (CPGs) are heavily influenced by results from randomized controlled trials (RCTs). Therefore, it is imperative that all RCT outcomes are reported thoroughly to ensure CPGs are created using accurate information. Here, we evaluate the quality of harms reporting using the CONSORT Extension for Harms in RCTs underpinning recommendations in the American Academy of Orthopedic Surgeons (AAOS) Management of Hip Fractures in Older Adults CPG.

METHODS

Each RCT cited as evidence for recommendations in the AAOS Management of Hip Fractures in Older Adults CPG was evaluated using the CONSORT Extension for Harms to determine the quality of harms reporting. Descriptive statistics (frequencies, percentages, 95 % confidence intervals) were used to summarize adherence to CONSORT Harms items. A linear regression model was used to evaluate the CONSORT Harms influence on the quality of reporting over time.

RESULTS

Among the 156 RCTs identified, there were a total of 31,848 participants. Most RCTs were conducted at a single center (137; 87.8 %) and in a single-blind manner (130; 83.3 %). Fifty-four (34.6 %) RCTs did not provide funding statements. Trials adequately reported an average of 6.65 out of 18 CONSORT Extension for Harms items (37.0 %). One RCT adequately reported all items, while five reported zero items. Forty-seven RCTs (30.1 %) reported ≥ 50 % of items and 73 (46.8 %) reported ≤ 33.3 % of items. The linear regression model demonstrated no significant increase in mean adherence over time (adjusted R2 = -0.006; p = 0.563).

CONCLUSION

Our results highlight inadequate harms reporting among RCTs in the AAOS Management of Hip Fractures in Older Patients CPG. While the CONSORT Harms Extension was intended to enhance reporting, the linear regression model did not demonstrate significant improvements over time.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

The beneficial effects of transitional care for patients with stroke: A meta-analysis

INTRODUCTION

Transitional care interventions have emerged as a promising method of ensuring treatment continuity and health care coordination when patients are discharged from hospital to home. However, few studies have investigated the frequency and duration of interventions and the effects of interventions on physical function. Therefore, this study aimed to determine the efficacy of transitional care for patients with stroke.

METHODS

Six databases and the grey literature were searched to obtain relevant articles from October 1, 2022 to March 10, 2023. The primary outcomes studied were motor performance, walking speed, activities of daily living (ADLs) and caregiver burden following hospital-to-home transitional care. The quality of the studies was assessed with Cochrane risk of bias version 2. The quality and sensitivity of the evidence were assessed to ensure rigour of the findings. Meta-analyses were performed using stata 17.0.

RESULTS

A total of 2966 patients were identified from 23 studies. Transitional care improved post-stroke motor performance, walking speed and ADLs, and reduced caregiver burden.

CONCLUSION

The findings suggest that provision of transitional care model implementation in patients with stroke is important because it reduces disability in stroke patients and helps to decrease caregivers' burden.

IMPACT

The findings of the study emphasize the importance of transitional care programmes for stroke patients after they are discharged from the hospital and returned to their homes. To meet the needs of patients, all levels of health professionals including nurses should be aware of the discharge process and care plan.

Cost-Analysis of Telemedicine Interventions Compared with Traditional Care in the Management of Chronic Neurological Diseases: A Systematic Review

Background: Telemedicine has proven successful in relieving the burden of chronic neurological disorders from the national health care systems by ensuring a highly customized and effective management plan. Although many studies focus on assessing telemedicine effectiveness, little is known about the economic implications of telemedicine applications in chronic neurological diseases (CNDs). This issue could account for a lack of widespread implementation. Objective: Our study attempted to fill this gap by systematically reviewing scientific literature on the economic evaluation of telemedicine compared with traditional care in the management of CNDs. Methods: We performed a literature search on PubMed, Google Scholar, Scopus, Embase, and Medline. The inclusion criteria were as follows: (1) studies with a full cost-analysis; (2) randomized controlled trials; (3) studies comparing telemedicine interventions with traditional care; (4) articles focusing only on CNDs. Conversely, the exclusion criteria were as follows: (1) studies focusing on acute neurological conditions or other diseases and (2) study protocols, case report, duplicate articles, abstract only, books, letters to editors, and review articles. Results: Ten articles met the inclusion criteria. Three different approaches of telemedicine intervention could be identified: digital cognitive-behavioral therapy (CBT), motor telerehabilitation, and home monitoring and assessment devices. Conclusion: Cost-analysis showed an overall benefit in terms of both cost and effectiveness from the application of telemedicine instead of in-presence management in CNDs. Among the identified interventions, digital CBT proved to be the most cost-saving. However, promising results were also found in monitoring and assessment devices and in telerehabilitation. Definitely, however, more thorough, comprehensive, and high-quality economic evaluation studies are needed.

Reporting of social determinants of health in randomized controlled trials conducted in the pediatric intensive care unit

Introduction

The influence of social determinants of health (SDOH) on access to care and outcomes for critically ill children remains an understudied area with a paucity of high-quality data. Recent publications have highlighted the importance of incorporating SDOH considerations into research but the frequency with which this occurs in pediatric intensive care unit (PICU) research is unclear. Our objective was to determine the frequency and categories of SDOH variables reported and how these variables were defined in published PICU randomized controlled trials (RCTs).

Methods

We searched Medline, Embase, Lilacs, and Central from inception to Dec 2022. Inclusion criteria were randomized controlled trials of any intervention on children or their families in a PICU. Data related to study demographics and nine WHO SDOH categories were extracted, and descriptive statistics and qualitative data generated.

Results

586 unique RCTs were included. Studies had a median sample size of 60 patients (IQR 40-106) with 73.0% of studies including ≤100 patients and 41.1% including ≤50 patients. A total of 181 (181/586, 30.9%) studies reported ≥1 SDOH variable of which 163 (163/586, 27.8%) reported them by randomization group. The most frequently reported categories were food insecurity (100/586, 17.1%) and social inclusion and non-discrimination (73/586, 12.5%). Twenty-five of 57 studies (43.9%) investigating feeding or nutrition and 11 of 82 (13.4%) assessing mechanical ventilation reported baseline nutritional assessments. Forty-one studies investigated interventions in children with asthma or bronchiolitis of which six reported on smoking in the home (6/41, 14.6%).

Discussion

Reporting of relevant SDOH variables occurs infrequently in PICU RCTs. In addition, when available, categorizations and definitions of SDOH vary considerably between studies. Standardization of SDOH variable collection along with consistent minimal reporting requirements for PICU RCT publications is needed.

Rethinking the pros and cons of randomized controlled trials and observational studies in the era of big data and advanced methods: a panel discussion

Randomized controlled trials (RCTs) have traditionally been considered the gold standard for medical evidence. However, in light of emerging methodologies in data science, many experts question the role of RCTs. Within this context, experts in the USA and Canada came together to debate whether the primacy of RCTs as the gold standard for medical evidence, still holds in light of recent methodological advances in data science and in the era of big data. The purpose of this manuscript, aims to raise awareness of the pros and cons of RCTs and observational studies in order to help guide clinicians, researchers, students, and decision-makers in making informed decisions on the quality of medical evidence to support their work. In particular, new and underappreciated advantages and disadvantages of both designs are contrasted. Innovations taking place in both of these research methodologies, which can blur the lines between the two, are also discussed. Finally, practical guidance for clinicians and future directions in assessing the quality of evidence is offered.

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.

Assessing the uptake of the type 1 diabetes core outcome set in randomized controlled trials: A Cross-Sectional study

AIMS

This study analyzed uptake of the core outcome set (COS) for type 1 diabetes (T1D) and trends in its use before and after its development in December 2017.

METHODS

On June 26, 2023, ClinicalTrials.gov was systematically searched for T1D randomized controlled trials. The Core Outcome Measures in Effectiveness Trials (COMET) database provided a COS of eight key outcomes for analysis. Included trials were analyzed for COS uptake before and after its release in December 2017 in a masked, duplicate fashion by independent reviewers. We also calculated the proportion of trials that measured the complete COS and assessed the most frequently reported COS outcomes.

RESULTS

Of 3,792 originally screened articles, 144 RCTs were included in the final sample. Following COS publication, its use steadily decreased. Within the COS, HbA1c and severe hypoglycemia were most frequently implemented as endpoints; other recommended outcomes were rarely used in the published trials.

CONCLUSION

Despite the 2017 T1D COS publication, use has decreased over time. This inconsistency negatively influences evidence-based practices and care. Educating researchers on COS and promoting uptake is crucial. Wider COS adoption in T1D trials could enhance clinical research overall. Further study of barriers and facilitators influencing uptake is essential to support consistent use and reporting.

Types, functions and mechanisms of robot-assisted intervention for fall prevention: A systematic scoping review

BACKGROUND

Any individual may experience accidental falls, particularly older adults. Although robots can prevent falls, knowledge of their fall-preventive use is limited.

OBJECTIVE

To explore the types, functions, and mechanisms of robot-assisted intervention for fall prevention.

METHODS

A systematic scoping review of global literature published from inception to January 2022 was conducted according to Arksey and O'Malley's five-step framework. Nine electronic databases, namely, PubMed, Embase, CINAHL, IEEE Xplore, the Cochrane Library, Scopus, Web of Science, PsycINFO, and ProQuest, were searched.

RESULTS

Seventy-one articles were found with developmental (n = 63), pilot (n = 4), survey (n = 3), and proof-of-concept (n = 1) designs across 14 countries. Six types of robot-assisted intervention were found, namely cane robots, walkers, wearables, prosthetics, exoskeletons, rollators, and other miscellaneous. Five main functions were observed including (i) detection of user fall, (ii) estimation of user state, (iii) estimation of user motion, (iv) estimation of user intentional direction, and (v) detection of user balance loss. Two categories of mechanisms of robots were found. The first category was executing initiation of incipient fall prevention such as modeling, measurement of user-robot distance, estimation of center of gravity, estimation and detection of user state, estimation of user intentional direction, and measurement of angle. The second category was achieving actualization of incipient fall prevention such as adjust optimal posture, automated braking, physical support, provision of assistive force, reposition, and control of bending angle.

CONCLUSIONS

Existing literature regarding robot-assisted intervention for fall prevention is in its infancy. Therefore, future research is required to assess its feasibility and effectiveness.

Acupuncture in management of acute dental pain - A systematic review and meta-analysis

Acute dental pain is a common issue leading to dental consultation. Besides causal therapy, patients are treated with acupuncture, but efficacy in acute dental pain is still not clarified. We aimed to evaluate results of recent research to estimate the efficacy of acupuncture compared to pain-relieving approaches in treatment of acute dental pain. A systematic review of controlled trials being published between database inception and 2020 were conducted to evaluate the efficacy of acupuncture (alone or as complementary therapy) compared to local anesthesia or conventional analgesic medications in acute dental pain (intraoperatively and postoperatively) and to clarify whether acupuncture reduces the use of postoperative analgesic medications. Of 1672 publications, 23 publications met the inclusion criteria. From these, 11 randomized controlled trials (n = 668) reported on the efficacy of acupuncture on postoperative acute dental pain. Patients, who received acupuncture, showed lower pain scores postoperatively compared to sham acupuncture (Relative Risk -0.77, 95% Confidence interval -1.52 to -0.03). Overall, the results suggest a potential role of acupuncture in improving acute dental pain intraoperatively and postoperatively as well as improving the efficacy of local anesthesia, but the results are limited due to methodological shortcomings emphasizing the necessity for future high-quality research.

The role of quantitative bias analysis for nonrandomized comparisons in health technology assessment: recommendations from an expert workshop

The use of treatment effects derived from nonrandomized studies (NRS) in health technology assessment (HTA) is growing. NRS carry an inherently greater risk of bias than randomized controlled trials (RCTs). Although bias can be mitigated to some extent through appropriate approaches to study design and analysis, concerns around data availability and quality and the absence of randomization mean residual biases typically render the interpretation of NRS challenging. Quantitative bias analysis (QBA) methods are a range of methods that use additional, typically external, data to understand the potential impact that unmeasured confounding and other biases including selection bias and time biases can have on the results (i.e., treatment effects) from an NRS. QBA has the potential to support HTA bodies in using NRS to support decision-making by quantifying the magnitude, direction, and uncertainty of biases. However, there are a number of key aspects of the use of QBA in HTA which have received limited discussion. This paper presents recommendations for the use of QBA in HTA developed using a multi-stakeholder workshop of experts in HTA with a focus on QBA for unmeasured confounding.

Development of clinical trials for non-small cell lung cancer drugs in China from 2005 to 2023

Objective

Over the past few decades, the development of anti-cancer drugs in China has made outstanding achievements based on the support of national policies. To assess the progress of non-small cell lung cancer (NSCLC) drugs, we conducted a statistical analysis of clinical trials of drugs targeting NSCLC in China from 2005 to 2023.

Methods

We downloaded, screened and analysed the data from three official websites, the Centre for Drug Evaluation of China National Medical Products Administration website (NMPA), ClinicalTrials.gov and the Chinese Clinical Trial Registry (ChiCTR).

Results

From January 1, 2005 to April 15, 2023, a total of 1,357 drug clinical trials that met the standards were included, and the number of registered drug clinical trials has been increasing year by year, reaching the maximum of 199 in 2021. Among them, the maximum of 462 items (34.05%) in phase II clinical trials, followed by 333 (24.54%) in phase III clinical trials, and 139 (10.24%) in phase IV clinical trials. In all drug clinical trials, industry sponsored trials (ISTs) have 722 items (53.21%), which are higher than investigator-initiated trials (IITs). The clinical trials of chemical drugs have a maximum of 723 items (53.28%), while biopharmaceuticals have grown rapidly in the past 10 years, with a total of 374 (27.56%), and 48.19% of the drug clinical trials of combined medication. In addition, the geographical distribution of the leading units and participating units of Chinese drug clinical trials are uneven, and economic regions such as Beijing, Shanghai, Jiangsu are obviously ahead of other regions.

Conclusion

From 2005 to 2023, the clinical trials of registered drugs for the treatment of NSCLC increased rapidly. Among them, due to the development of immunotherapy, the clinical trials of biopharmaceuticals and drugs for combined medication are growing most rapidly, while the exploration of the original drugs is a little far from enough. Our research provides a direction for the future drug clinical trials of NSCLC, laying foundation for further extending the survival rate of patients with NSCLC.

Evaluating the Efficacy of a Narrative Language Intervention for Bilingual Students

PURPOSE

This study examines the narrative language and reading outcomes of monolingual and bilingual students who received instruction with the Supporting Knowledge in Language and Literacy (SKILL) program, a narrative language intervention.

METHOD

The main effects of the SKILL program were evaluated in a randomized controlled trial in which students (N = 355) who were at risk for English language and literacy difficulties were randomized to the SKILL intervention or a business-as-usual instruction. This article reports secondary analyses examining the efficacy of SKILL for bilingual (n = 148) and monolingual (n = 207) students who completed measures of oral and written narrative language and reading comprehension in English.

RESULTS

Moderation results showed that the effects of SKILL did not differ for monolinguals and bilinguals across most narrative language measures and did not vary for monolinguals or bilinguals based on their pre-intervention language performance.

CONCLUSION

These findings that suggest a language-based approach to improving narrative production and comprehension yielded similar results for monolinguals and bilinguals and that neither monolinguals nor bilinguals in this study needed to meet a certain threshold of English language proficiency to benefit from the intervention.

National priority setting partnership using a Delphi consensus process to develop neonatal research questions suitable for practice-changing randomised trials in the UK

BACKGROUND

The provision of neonatal care is variable and commonly lacks adequate evidence base; strategic development of methodologically robust clinical trials is needed to improve outcomes and maximise research resources. Historically, neonatal research topics have been selected by researchers; prioritisation processes involving wider stakeholder groups have generally identified research themes rather than specific questions amenable to interventional trials.

OBJECTIVE

To involve stakeholders including parents, healthcare professionals and researchers to identify and prioritise research questions suitable for answering in neonatal interventional trials in the UK.

DESIGN

Research questions were submitted by stakeholders in population, intervention, comparison, outcome format through an online platform. Questions were reviewed by a representative steering group; duplicates and previously answered questions were removed. Eligible questions were entered into a three-round online Delphi survey for prioritisation by all stakeholder groups.

PARTICIPANTS

One hundred and eight respondents submitted research questions for consideration; 144 participants completed round one of the Delphi survey, 106 completed all three rounds.

RESULTS

Two hundred and sixty-five research questions were submitted and after steering group review, 186 entered into the Delphi survey. The top five ranked research questions related to breast milk fortification, intact cord resuscitation, timing of surgical intervention in necrotising enterocolitis, therapeutic hypothermia for mild hypoxic ischaemic encephalopathy and non-invasive respiratory support.

CONCLUSIONS

We have identified and prioritised research questions suitable for practice-changing interventional trials in neonatal medicine in the UK at the present time. Trials targeting these uncertainties have potential to reduce research waste and improve neonatal care.

Uveitis Registries - A Digital Tool for Patient Care, Education, Research, and Collaboration

PURPOSE

Clinical registries are increasingly important in research and clinical advancement. This review explores and compares current uveitis registries and recommends future directions on how uveitis registries can complement one another for synergistic effect and benefit.

METHODS

From a systematic search, 861 citations were screened for longitudinal, non-interventional, and multicenter uveitis-specific registries. Additional registries were identified via consultations with uveitis experts. Characteristics of all registries were analyzed and compared.

RESULTS

Four registries were identified: Treatment Exit Options for Non-infectious Uveitis, AutoInflammatory Disease Alliance International Registry, Ocular Autoimmune Systemic Inflammatory Infectious Study, and Fight Uveitis Blindness!. Despite certain differences, these registries have the overarching goal of collecting large quantities of real-world, high-quality patient data to improve the understanding of uveitis.

CONCLUSION

The four uveitis registries share similar goals and collect clinical data from overlapping geographical regions. There is vast potential for collaboration, including data sharing to further augment datasets for analysis.

'Being disabled' as an exclusion criterion for clinical trials: a scoping review

BACKGROUND

People with disabilities (PWDs) are often excluded from biomedical research, but comprehensive data regarding their participation in clinical trials are not available. The objective of this study was to assess the rates of exclusion of PWDs from recent medical scientific research.

METHODS

The protocol of the study was designed according to PRISMA-ScR (PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for Scoping Reviews) guidelines. All completed interventional clinical trials registered on ClinicalTrials.gov between 2010 and 2020 regarding the 10 leading causes of global disability-adjusted life-years according to the Global Burden of Disease Study were analysed. An exclusion criterion from the study was considered explicit if it could be associated with one of the following seven categories: disability, physical impairment, cognitive impairment, behavioural or psychiatric disorders, language and communication impairment, sensory impairment. Comorbidities not more clearly defined and researcher discretion regarding exclusion of study participants were considered to be 'implicit exclusion criteria'. We assessed the appropriateness of explicit exclusion criteria in relation to the primary objectives of the trials and labelled them as 'absolute', 'relative' or 'questionable'.

RESULTS

The total number of trials analysed was 2710; 170 were paediatric trials (6.3%), 2374 were adult trials (87.6%) and 166 were trials including subjects of all ages (6.1%). Explicit exclusion criteria were found in 958 trials (35.3%). The disability category most frequently excluded was behavioural or psychiatric disorders, present in 588 trials (61.4%). In only 3% and 1% of the trials, the exclusion criteria were considered either 'absolute' or 'questionable', while in 96% the exclusion criteria were judged as 'relative'. Implicit exclusion criteria were present in 1205 trials (44.5%).

CONCLUSIONS

This study highlights the high rate of exclusion of PWDs from biomedical research and the widespread use of ill-defined exclusion criteria in clinical trials. It underscores the importance of more inclusive study designs so that PWDs can become active participants in research.

Medication Reviews and Clinical Outcomes in Persons with Dementia: A Scoping Review

Persons diagnosed with dementia are often faced with challenges related to polypharmacy and inappropriate medication use and could benefit from regular medication reviews. However, the benefit of such reviews has not been examined in this population. Therefore, the current scoping review was designed to identify the gaps in the current knowledge regarding the impact of medication reviews on the clinical outcomes in older adults with dementia. Relevant studies were identified by searching three databases (Ovid MEDLINE, Ovid EMBASE, and Scopus) from inception to January 2022 with a combination of keywords and medical subject headings. After the removal of duplicates and ineligible articles, 22 publications of the initial 8346 were included in this review. A total of 57 outcomes were identified, including those pertaining to the evaluation of medication use (n = 17), drug-related interventions (n = 11), drug-related problems (n = 10), dementia-related behavioral symptoms (n = 8), cost-effectiveness (n = 2), drug-related hospital admissions (n = 1), as well as outcomes classified as other (n = 7). Gaps identified through this scoping review included the paucity of studies measuring the impact of medication reviews on the medication management capacity and medication adherence, quality of life, and mortality.

The effect of health behavior interventions to manage Type 2 diabetes on the quality of life in low-and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Behavioral interventions targeted at managing Type 2 diabetes mellitus (T2DM) may have a positive effect on quality of life (QOL). Limited reviews have synthesized this effect in low- and middle-income countries (LMICs). This review and meta-analysis synthesised available evidence on the effect of behavioral interventions to manage T2DM on the QOL of people with T2DM in LMICs.

METHODS

Electronic databases PUBMED/MEDLINE, SCOPUS, CINAHL, Embase, Web of Science and PsycINFO were searched from May to June 2022. Studies published between January 2000 and May 2022, conducted in LMICs using randomized controlled trial design, using a health behavior intervention for T2DM management, and reporting QOL outcomes were included. Difference in QOL change scores between the intervention and control group was calculated as the standardized mean difference (SMD) of QOL scores observed between the intervention and control groups. Random-effects model was used for meta-analysis.

RESULTS

Of 6122 studies identified initially, 45 studies met the inclusion criteria (n = 8336). Of them, 31 involved diabetes self-management education and 14 included dietary and/or physical activity intervention. There was moderate quality evidence from the meta-analysis of mean QOL (n = 25) that health behavior intervention improved the QOL of people with T2DM (SMD = 1.62, 95%CI = 0.65-2.60 I2 = 0.96, p = 0.001). However, no significant improvements were found for studies (n = 7) separately assessing the physical component summary (SMD = 0.76, 95%CI = -0.03-1.56 I2 = 0.94, p = 0.060) and mental component summary (SMD = 0.43, 95%CI = -0.30-1.16 I2 = 0.94, p = 0.249) scores. High heterogeneity and imprecise results across studies resulted in low to moderate quality of evidence.

CONCLUSION

The findings suggest that health behavior interventions to manage T2DM may substantially improve the QOL of individuals with T2DM over short term. However, due to low to moderate quality of evidence, further research is required to corroborate our findings. Results of this review may guide future research and have policy implications for T2DM management in LMICs.

Leveraging the Expertise of the CTSA Program to Increase the Impact and Efficiency of Clinical Trials

Importance

Multicenter clinical trials play a critical role in the translational processes that enable new treatments to reach all people and improve public health. However, conducting multicenter randomized clinical trials (mRCT) presents challenges. The Trial Innovation Network (TIN), established in 2016 to partner with the Clinical and Translational Science Award (CTSA) Consortium of academic medical institutions in the implementation of mRCTs, consists of 3 Trial Innovation Centers (TICs) and 1 Recruitment Innovation Center (RIC). This unique partnership has aimed to address critical roadblocks that impede the design and conduct of mRCTs, in expectation of accelerating the translation of novel interventions to clinical practice. The TIN's challenges and achievements are described in this article, along with examples of innovative resources and processes that may serve as useful models for other clinical trial networks providing operational and recruitment support.

Observations

The TIN has successfully integrated more than 60 CTSA institution program hubs into a functional network for mRCT implementation and optimization. A unique support system for investigators has been created that includes the development and deployment of novel tools, operational and recruitment services, consultation models, and rapid communication pathways designed to reduce delays in trial start-up, enhance recruitment, improve engagement of diverse research participants and communities, and streamline processes that improve the quality, efficiency, and conduct of mRCTs. These resources and processes span the clinical trial spectrum and enable the TICs and RIC to serve as coordinating centers, data centers, and recruitment specialists to assist trials across the National Institutes of Health and other agencies. The TIN's impact has been demonstrated through its response to both historical operational challenges and emerging public health emergencies, including the national opioid public health crisis and the COVID-19 pandemic.

Conclusions and Relevance

The TIN has worked to reduce barriers to implementing mRCTs and to improve mRCT processes and operations by providing needed clinical trial infrastructure and resources to CTSA investigators. These resources have been instrumental in more quickly and efficiently translating research discoveries into beneficial patient treatments.

What is the quality of reporting in randomized controlled trials in spinal conditions

Purpose

Substandard quality across published randomized controlled trials (RCTs) is a major concern. Imperfect reporting has the potential to distort the evidence landscape and waste valuable health-care resources. In this study, we aim to assess the current quality of reporting in the field of spine using a modified version of the Consolidated Standards of Reporting Trials (CONSORT) checklist.

Materials and Methods

A list of published RCTs in the field of spine disease from January 1, 2013, to December 31, 2020, was built. Two reviewers scored the published RCTs against a modified CONSORT checklist. The mean adjusted CONSORT scores for each study, reporting category, and checklist item were calculated.

Results

The mean and median scores across all of the RCTs were 0.72 and 0.74 out of 1.00, respectively. The spectrum of scores was wide, ranging from 0.45 to 0.94. The reporting categories with the lowest score included randomization, blinding, and abstract. The items which were most under-reported included allocation sequence generation, type of randomization used, full trial protocol details, and abstract methodology. The inter-rater reliability between our reviewers was substantial (κ = 0.7, κ = 0.71).

Conclusion

Our findings correlate with only a moderate level of compliance to the CONSORT criteria on the quality of reporting for RCTs in spinal conditions. This is in line with previous reports on compliance, both within and outside the field of spinal conditions. Further continued and sustained efforts are still required to enhance the quality and consistency of RCT reporting, ultimately reducing health-care resource wastage and improving patient safety.

Engaging diverse midlife and older adults in a multilevel participatory physical activity intervention: evaluating impacts using Ripple Effects Mapping

Multilevel interventions are increasingly recommended to increase physical activity (PA) but can present evaluation challenges. Participatory qualitative evaluation methods can complement standard quantitative methods by identifying participant-centered outcomes and potential mechanisms of individual and community-level change. We assessed the feasibility and utility of Ripple Effects Mapping (REM), a novel qualitative method, within the context of a multi-level cluster randomized trial, Steps for Change. Housing sites with ethnically diverse, low-income aging adults were randomized to a PA behavioral intervention alone or in combination with a citizen science-based intervention (Our Voice) for promoting PA-supportive neighborhoods. Four REM sessions were conducted after 12 months of intervention and involved six housing sites (n = 35 participants) stratified by intervention arm. Interviews (n = 5) were also conducted with housing site staff. Sessions leaders engaged participants in visually mapping intended and unintended outcomes of intervention participation and participant-driven solutions to reported challenges. Maps were analyzed using Excel and Xmind 8 Pro and data were classified according to the socio-ecological model. Eight themes were identified for outcomes, challenges, and solutions. Most themes (6/8) were similar across intervention arms, including increasing PA and PA tracking, improving health outcomes, and increasing social connectedness. Groups (n = 2) engaged in Our Voice additionally identified increased community knowledge and activities directly impacting local environmental change (e.g., pedestrian infrastructure changes). Housing staff interviews revealed additional information to enhance future intervention recruitment, sustainability, and implementation. Such qualitative methodologies can aid in evaluating multi-level, multi-component interventions and inform future intervention optimization, implementation, and dissemination.

A systematic review of the safety and efficacy on cognitive function of herbal and nutritional medicines in older adults with and without subjective cognitive impairment

BACKGROUND

Subjective cognitive impairment (SCI) substantially increases dementia risk and is often conceptualised as the preclinical asymptomatic phase of the cognitive decline continuum. Due to the lack of pharmacological interventions available to treat SCI and reduce dementia risk, and the popularity of herbal and nutritional medicines, the primary aim of this review was to investigate the efficacy on cognitive function and safety of herbal and nutritional medicines (relative to a control) for older adults with and without SCI. The secondary aims were to describe the study characteristics and assess the methodological quality of included studies.

METHOD

Five databases (Cochrane, MEDLINE, CINAHL, PsycInfo, and EMBASE) were searched from database inception with weekly alerts established until review finalisation on 18 September 2022. Articles were eligible if they included the following: study population of older adults with and without SCI, herbal and nutritional medicines as an intervention, evaluated cognitive outcomes and were randomised control trials.

RESULTS

Data were extracted from 21/7666 eligible full-text articles, and the risk of methodological bias was assessed (with SCI = 9/21; without SCI = 12/21). Most studies (20/21) employed parallel, randomised, placebo-controlled designs and were 12 weeks in length. Herbal supplements were widely used (17/21), namely a form of Ginkgo biloba (8/21) or Bacopa monnieri (6/21). Measures of cognition varied across studies, with 14/21 reporting improvements in at least one domain of cognitive functioning over time, in the intervention group (compared to control). A total of 14/21 studies were deemed as having an overall high methodological risk of bias, 6/21 had some concerns, and only one study (using an SCI population) was assessed as having a low risk of methodological bias.

CONCLUSIONS

Overall, this review found that there is a low quality of evidence regarding the efficacy of cognitive function and safety of herbal and nutritional medicines for older adults with and without SCI, due to a high risk of bias across studies. Additionally, further work needs to be done in classifying and understanding SCI and selecting appropriate trial primary outcomes before future studies can more accurately determine the efficacy of interventions for this population.

How to Conduct a Randomized Controlled Trial

Randomized controlled trials (RCTs) are considered to produce the highest level of evidence in the original studies that informs the practice of evidence-based medicine (EBM). By manipulating an independent variable to study its impact on the outcome, RCTs establish causal relationships and provide valuable insights into clinical treatment. To improve patient outcomes and optimize the use of clinical resources, the practice of EBM plays a crucial role in designing and conducting RCTs to evaluate the effectiveness of clinical interventions. This review aims to explore the essential steps involved in conducting a rigorous and reliable RCT, ensuring the generation of high-quality evidence.

A meta-analysis investigating the outcomes and correlation between heart rate variability biofeedback training on depressive symptoms and heart rate variability outcomes versus standard treatment in comorbid adult populations

BACKGROUND AND AIM

Heart rate variability biofeedback (HRVB) has previously been used to ameliorate depressive symptoms but its uses for tackling depressive symptoms in an array of comorbid adult patients is less established. This meta-analysis aims to evaluate whether HRVB is a useful tool to reduce depressive symptoms and improve HRV relative to standard treatment in adult comorbid populations, while also attempting to establish the association between the two outcomes.

METHODS

An extensive literature review was conducted using several databases including PubMed, Cinahl, Medline, Web of science and clinical.gov/UK register. A total of 149 studies were identified with 9 studies, totalling 428 participants were analysed using a random effects model.

RESULTS

Depressive outcomes yielded a mean effect size g=0.478 (CI 95% 0.212, 0.743) with HRV outcomes, yielding a mean effect size of g=0.223 (95% CI 0.036 to 0.411). Total heterogeneity was non-significant for depressive outcomes (Q= 13.77, p=0.088 I^=42.86%) and HRV (Q= 1.598, p=0.991, I^=0.000%) which indicates that little variance existed for the included studies.

CONCLUSIONS

In summary, the outcomes demonstrate that HRVB can improve both clinically relevant depressive symptoms and physiological HRV outcomes in various comorbid conditions in adult populations, while the correlation between the two was moderately negative, but non-significant.

Personalised lifestyle recommendations for type 2 diabetes: Design and simulation of a recommender system on UK Biobank Data

Mobile health applications, which employ wireless technology for healthcare, can aid behaviour change and subsequently improve health outcomes. Mobile health applications have been developed to increase physical activity, but are rarely grounded on behavioural theory and employ simple techniques for personalisation, which has been proven effective in promoting behaviour change. In this work, we propose a theoretically driven and personalised behavioural intervention delivered through an adaptive knowledge-based system. The behavioural system design is guided by the Behavioural Change Wheel and the Capability-Opportunity-Motivation behavioural model. The system exploits the ever-increasing availability of health data from wearable devices, point-of-care tests and consumer genetic tests to issue highly personalised physical activity and sedentary behaviour recommendations. To provide the personalised recommendations, the system firstly classifies the user into one of four diabetes clusters based on their cardiometabolic profile. Secondly, it recommends activity levels based on their genotype and past activity history, and finally, it presents the user with their current risk of developing cardiovascular disease. In addition, leptin, a hormone involved in metabolism, is included as a feedback biosignal to personalise the recommendations further. As a case study, we designed and demonstrated the system on people with type 2 diabetes, since it is a chronic condition often managed through lifestyle changes, such as physical activity increase and sedentary behaviour reduction. We trained and simulated the system using data from diabetic participants of the UK Biobank, a large-scale clinical database, and demonstrate that the system could help increase activity over time. These results warrant a real-life implementation of the system, which we aim to evaluate through human intervention.

Assessing the reporting quality of adult neuro-oncology protocols, abstracts, and trials: Adherence to the SPIRIT and CONSORT statements

Background

Comprehensive and transparent reporting of clinical trial activity is important. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 and Consolidated Standards of Reporting Trials (CONSORT) 2010 statements define the items to be reported in clinical trial protocols and randomized controlled trials, respectively. The aim of this methodological review was to assess the reporting quality of adult neuro-oncology trial protocols and trial result articles.

Methods

Adult primary and secondary brain tumor phase 3 trial protocols and result articles published after the introduction of the SPIRIT 2013 statement, were identified through searches of 4 electronic bibliographic databases. Following extraction of baseline demographic data, the reporting quality of independently included trial protocols and result articles was assessed against the SPIRIT and CONSORT statements respectively. The CONSORT-A checklist, an extension of the CONSORT 2010 statement, was used to specifically assess the abstract accompanying the trial results article. Percentage adherence (standard deviation [SD]) was calculated for each article.

Results

Seven trial protocols, and 36 trial result articles were included. Mean adherence of trial protocols to the SPIRIT statement was 79.4% (SD: 0.11). Mean adherence of trial abstracts to CONSORT-A was 75.3% (SD: 0.12) and trial result articles to CONSORT was 74.5% (SD: 0.10).

Conclusion

The reporting quality of adult neuro-oncology trial protocols and trial result articles requires improvement to ensure comprehensive and transparent communication of planned neuro-oncology clinical trials and results within the literature. Raising awareness by clinical triallists and implementing mandatory evidence of proof of adherence by journals should improve reporting quality.

Nurse-led interventions in systemic autoimmune rheumatic diseases: a systematic review

BACKGROUND

Nurses play an important role in the management of patients with systemic autoimmune rheumatic diseases. Little is known about the effectiveness of nurse-led interventions on patient-reported outcomes in this population. The aim of this systematic review was to examine the evidence of nurse-led interventions in systemic autoimmune rheumatic diseases.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive literature search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Embase for studies published from database inception to September 2022. Studies were included if they were published in a peer-reviewed journal in English and evaluated the effectiveness of a nurse-led intervention using a randomized controlled trial design in adults with a systemic autoimmune rheumatic disease. Screening, full-text review, and quality appraisal were conducted by two independent reviewers.

RESULTS

A total of 162 articles were identified for possible inclusion, of which five studies were included. Four of five studies (80%) were conducted in systemic lupus erythematosus. There was significant variability in the types of nurse-led interventions; the majority included educational sessions and follow up counseling by a nurse (n = 4). The most common patient-reported outcomes were health-related quality of life (n = 3), fatigue (n = 3), mental health (including anxiety and depression) (n = 2), and self-efficacy (n = 2). The duration of the interventions varied from 12 weeks to 6 months. All studies included a nurse with specialized training and education and showed significant improvements in their primary outcomes. The majority of the studies (60%) were considered high methodological quality.

CONCLUSION

This systematic review provides emerging evidence for the use of nurse-led interventions in systemic autoimmune rheumatic diseases. Our findings emphasize the important role of nurses in providing nonpharmacological strategies to help patients better manage their disease and improve health outcomes.

A System for Rapidly Yet Rigorously Evaluating the Quality of Randomized Controlled Trials

ABSTRACT

This tutorial describes a system for rapidly yet rigorously assessing the quality of randomized controlled trials (RCTs). The system has 7 criteria, represented by the acronym "BIS FOES." The BIS FOES system directs readers to assess RCTs based on the following 7 criteria: the RCT's use (or not) of effective (1) Blinding; the RCT's use (or not) of (2) Intent-to-Treat Analysis; the RCT's (3) Size and other information reflecting the effectiveness of randomization; the amount of sample lost during (4) Follow-up; the (5) Outcomes examined by the RCT (specifically, the outcome measures used by the RCT), the (6) Effects reported (ie, the statistical and clinical significance of the RCT's primary, secondary, and safety findings), and any (7) Special Considerations (ie, additional strengths, limitations, or notable features of the RCT). The first 6 criteria are of basic importance to the assessment of every RCT, whereas the Special Considerations criteria allows the system to be expanded to include virtually any other important aspect of the RCT. This tutorial explains the importance of these criteria and how to assess them. This tutorial also describes how many BIS FOES criteria can be initially assessed from the RCT Abstract while also directing readers to specific locations in the RCT article where additional important information can be found. We hope that the BIS FOES system will help healthcare trainees, but also potentially clinicians, researchers, and the general public, rapidly and thoroughly assess RCTs.

Social Return on Investment of Social Prescribing via a Diabetes Technician for Preventing Type 2 Diabetes Progression

In Wales, the prevalence of Type 2 Diabetes Mellitus (T2DM) has increased from 7.3% in 2016 to 8% in 2020, creating a major concern for the National Health Service (NHS). Social prescribing (SP) has been found to decrease T2DM prevalence and improve wellbeing. The MY LIFE programme, a scheme evaluated between June 2021 and February 2022 in the Conwy West Primary Care Cluster, aimed to prevent T2DM by referring prediabetic patients with a BMI of ≥30 to a diabetes technician (DT), who then signposted patients to community-based SP programmes, such as the National Exercise Referral Scheme (NERS), KindEating, and Slimming World. Although some patients engaged with SP, others chose to connect only with the DT. A Social Return on Investment (SROI) analysis was conducted to evaluate those patients who engaged with the DT plus SP, and those who connected solely with the DT. Relevant participant outcomes included 'mental wellbeing' and 'good overall health', which were measured at baseline (n = 54) and at the eight-week follow-up (n = 24). The estimated social value for every GBP 1 invested for participants who engaged with the 'DT only' ranged from GBP 4.67 to 4.70. The social value for participants who engaged with the 'DT plus SP programme' ranged from GBP 4.23 to 5.07. The results indicated that most of the social value generated was associated with connecting with the DT.

Safety and effectiveness of vaccines against COVID-19 in children aged 5-11 years: a systematic review and meta-analysis

BACKGROUND

To date, more than 761 million confirmed SARS-CoV-2 infections have been recorded globally, and more than half of all children are estimated to be seropositive. Despite high SARS-CoV-2 infection incidences, the rate of severe COVID-19 in children is low. We aimed to assess the safety and efficacy or effectiveness of COVID-19 vaccines approved in the EU for children aged 5-11 years.

METHODS

In this systematic review and meta-analysis, we included studies of any design identified through searching the COVID-19 L·OVE (living overview of evidence) platform up to Jan 23, 2023. We included studies with participants aged 5-11 years, with any COVID-19 vaccine approved by the European Medicines Agency-ie, mRNA vaccines BNT162b2 (Pfizer-BioNTech), BNT162b2 Bivalent (against original strain and omicron [BA.4 or BA.5]), mRNA-1273 (Moderna), or mRNA-1273.214 (against original strain and omicron BA.1). Efficacy and effectiveness outcomes were SARS-CoV-2 infection (PCR-confirmed or antigen-test confirmed), symptomatic COVID-19, hospital admission due to COVID-19, COVID-19-related mortality, multisystem inflammatory syndrome in children (MIS-C), and long-term effects of COVID-19 (long COVID or post-COVID-19 condition as defined by study investigators or per WHO definition). Safety outcomes of interest were serious adverse events, adverse events of special interest (eg, myocarditis), solicited local and systemic events, and unsolicited adverse events. We assessed risk of bias and rated the certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluation approach. This study was prospectively registered with PROSPERO, CRD42022306822.

FINDINGS

Of 5272 screened records, we included 51 (1·0%) studies (n=17 [33%] in quantitative synthesis). Vaccine effectiveness after two doses against omicron infections was 41·6% (95% CI 28·1-52·6; eight non-randomised studies of interventions [NRSIs]; CoE low), 36·2% (21·5-48·2; six NRSIs; CoE low) against symptomatic COVID-19, 75·3% (68·0-81·0; six NRSIs; CoE moderate) against COVID-19-related hospitalisations, and 78% (48-90, one NRSI; CoE very low) against MIS-C. Vaccine effectiveness against COVID-19-related mortality was not estimable. Crude event rates for deaths in unvaccinated children were less than one case per 100 000 children, and no events were reported for vaccinated children (four NRSIs; CoE low). No study on vaccine effectiveness against long-term effects was identified. Vaccine effectiveness after three doses was 55% (50-60; one NRSI; CoE moderate) against omicron infections, and 61% (55-67; one NRSI; CoE moderate) against symptomatic COVID-19. No study reported vaccine efficacy or effectiveness against hospitalisation following a third dose. Safety data suggested no increased risk of serious adverse events (risk ratio [RR] 0·83 [95% CI 0·21-3·33]; two randomised controlled trials; CoE low), with approximately 0·23-1·2 events per 100 000 administered vaccines reported in real-life observations. Evidence on the risk of myocarditis was uncertain (RR 4·6 [0·1-156·1]; one NRSI; CoE low), with 0·13-1·04 observed events per 100 000 administered vaccines. The risk of solicited local reactions was 2·07 (1·80-2·39; two RCTs; CoE moderate) after one dose and 2·06 (1·70-2·49; two RCTs; CoE moderate) after two doses. The risk of solicited systemic reactions was 1·09 (1·04-1·16; two RCTs; CoE moderate) after one dose and 1·49 (1·34-1·65; two RCTs; CoE moderate) after two doses. The risk of unsolicited adverse events after two doses (RR 1·21 [1·07-1·38]; CoE moderate) was higher among mRNA-vaccinated compared with unvaccinated children.

INTERPRETATION

In children aged 5-11 years, mRNA vaccines are moderately effective against infections with the omicron variant, but probably protect well against COVID-19 hospitalisations. Vaccines were reactogenic but probably safe. Findings of this systematic review can serve as a basis for public health policy and individual decision making on COVID-19 vaccination in children aged 5-11 years.

FUNDING

German Federal Joint Committee.

Accelerated Repetitive Transcranial Magnetic Stimulation to Treat Major Depression: The Past, Present, and Future

Repetitive transcranial magnetic stimulation (rTMS) is an effective and evidence-based therapy for treatment-resistant major depressive disorder. A conventional course of rTMS applies 20-30 daily sessions over 4-6 weeks. The schedule of rTMS delivery can be accelerated by applying multiple stimulation sessions per day, which reduces the duration of a treatment course with a predefined number of sessions. Accelerated rTMS reduces time demands, improves clinical efficiency, and potentially induces faster onset of antidepressant effects. However, considerable heterogeneity exists across study designs. Stimulation protocols vary in parameters such as the stimulation target, frequency, intensity, number of pulses applied per session or over a course of treatment, and duration of intersession intervals. In this article, clinician-researchers and neuroscientists who have extensive research experience in accelerated rTMS synthesize a consensus based on two decades of investigation and development, from early studies ("Past") to contemporaneous theta burst stimulation, a time-efficient form of rTMS gaining acceptance in clinical settings ("Present"). We propose descriptive nomenclature for accelerated rTMS, recommend avenues to optimize therapeutic and efficiency potential, and suggest using neuroimaging and electrophysiological biomarkers to individualize treatment protocols ("Future"). Overall, empirical studies show that accelerated rTMS protocols are well tolerated and not associated with serious adverse effects. Importantly, the antidepressant efficacy of accelerated rTMS appears comparable to conventional, once daily rTMS protocols. Whether accelerated rTMS induces antidepressant effects more quickly remains uncertain. On present evidence, treatment protocols incorporating high pulse dose and multiple treatments per day show promise and improved efficacy.

Recommendations for progression criteria during external randomised pilot trial design, conduct, analysis and reporting

BACKGROUND

External randomised pilot trials aim to assess whether a future definitive Randomised Controlled Trial (RCT) is feasible. Prespecified progression criteria help guide the interpretation of pilot trial findings to decide whether, and how, a definitive RCT should be conducted. This commentary presents a set of proposed recommendations for progression criteria to guide researchers when (i) designing, (ii) conducting, (iii) analysing and (iv) reporting external randomised pilot trials.

METHODS

Recommendations were developed following a mixed methods approach. This involved (i) a methodological review of pilot trial publications, (ii) a cross-sectional study of pilot trial research funding applications, (iii) qualitative interviews with pilot trial researchers and (iv) a survey of corresponding authors of identified pilot trial publications. Initial recommendations were refined following two consultation stakeholder workshops held in July 2022. Recommendations for progression criteria for external randomised pilot trials: i.

DESIGN

consider progression criteria from the earliest opportunity; map progression criteria to feasibility objectives; consider quantitative and qualitative interpretations of feasibility; provide justification; develop guidelines rather than rules; seek input from relevant stakeholders. ii. Conduct: regularly monitor pilot trial data against progression criteria. iii.

ANALYSIS

avoid considering each progression criterion in isolation; engage in discussion with relevant stakeholders; consider context and other factors external to the pilot trial; consider feasibility (can we?) and progression (will we?). iv. Reporting: we propose a reporting checklist in relation to progression criteria and recommend reporting in a table format for clarity.

CONCLUSION

These recommendations provide a helpful resource for researchers to consider progression criteria at different stages of external randomised pilot trials. We have produced a simple infographic tool to summarise these recommendations for researchers to refer to. Further research is needed to evaluate whether these proposed recommendations should inform future development, or update, of established guidelines for the design, conduct, analysis and reporting of external randomised pilot trials.

Effects of exercise training programmes on fasting gastrointestinal appetite hormones in adults with overweight and obesity: A systematic review and meta-analysis

A systematic review and meta-analysis was performed to determine the effect of exercise training on fasting gastrointestinal appetite hormones in adults living with overweight and obesity. For eligibility, only randomised controlled trials (duration ≥ four weeks) examining the effect of exercise training interventions were considered. This review was registered in the International Prospective Register of Systematic Reviews (CRD42020218976). The searches were performed on five databases: MEDLINE, EMBASE, Cochrane Library, Web of Science, and Scopus. The initial search identified 13204 records. Nine studies, which include sixteen exercise interventions, met the criteria for inclusion. Meta-analysis was calculated as the standardised mean difference (Cohen's d). Exercise training had no effect on fasting concentrations of total ghrelin (d: 1.06, 95% CI -0.38 to 2.50, P = 0.15), acylated ghrelin (d: 0.08, 95% CI: -0.31 to 0.47, P = 0.68) and peptide YY (PYY) (d = -0.16, 95% CI: -0.62 to 0.31, P = 0.51) compared to the control group. Analysis of body mass index (BMI) (d: -0.31, 95% CI: -0.50 to -0.12, P < 0.01) and body mass (d: -0.22, 95% CI: -0.42 to -0.03, P = 0.03) found a significant reduction after exercise compared to controls. Overall, exercise interventions did not modify fasting concentrations of total ghrelin, acylated ghrelin, and PYY in individuals with overweight or obesity, although they reduced body mass and BMI. Thus, any upregulation of appetite and energy intake in individuals with overweight and obesity participating in exercise programmes is unlikely to be related to fasting concentrations of gastrointestinal appetite hormones.

Psychosocial-behavioural interventions for school-aged children with intellectual disabilities: A systematic review of randomised control trials

BACKGROUND

Evidence-based interventions are essential for school-aged children with intellectual disabilities to facilitate development and promote future independence.

METHODS

Using a PRISMA approach, systematic screening of five databases was undertaken. Original randomised controlled studies with psychosocial-behavioural interventions were included where participants were school aged (5-18 yrs) with documented intellectual disability. Study methodology was assessed using the Cochrane RoB 2 tool.

RESULTS

Two thousand three hundred and three records were screened with 27 studies included. Studies mainly included primary school participants with mild intellectual disabilities. Most interventions focused on intellectual skills (e.g., memory, attention, literacy and mathematics) followed by adaptive skills (e.g., daily living, communication, social and education/vocation) and some focused on a combination of these.

CONCLUSION

This review highlights the gap in evidence-base for social, communication and education/vocation interventions with school-aged children with moderate and severe intellectual disability. Future RCTs that bridge this knowledge gap across ages and ability are required for best practice.

Examination of early treatment effects and related biases during the conduct of two UK-wide pragmatic orthopaedic surgical trials: ProFHER and UK FROST

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this. Included RCTs were ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation), a two-arm study of surgery versus non-surgical treatment for proximal humerus fractures, and UK FROST (United Kingdom Frozen Shoulder Trial), a three-arm study of two surgical and one non-surgical treatment for frozen shoulder. To determine whether early treatment effects were present, the primary outcome of Oxford Shoulder Score (OSS) was compared on forest plots for: the chief investigator's (CI) site to the remaining sites, the first five sites opened to the other sites, and patients grouped in quintiles by randomization date. Potential for bias was assessed by comparing mean age and proportion of patients with indicators of poor outcome between included and excluded/non-consenting participants. No bias in treatment effect was observed overall for the CI site, or the first five sites, compared with the remaining sites in either trial. An early treatment effect on the OSS was observed for the first quintile of participants recruited to ProFHER only (clinically relevant difference of seven points). Selection bias for age was observed in the ProFHER trial only, with slightly younger patients being recruited into the study. Both trials showed some selection bias for markers of poor prognosis, although these did not appear to change over time. No bias in treatment effects overall were found at the CI or early sites set-up. An early treatment effect was found in one of the two trials, which was likely a chance effect as this did not continue during the study. Selection bias was observed in both RCTs, however this was minimal and did not impact on outcome.

The effect of preoperative statins on postoperative mortality, renal, and neurological complications in patients undergoing cardiac surgeries: a retrospective cohort study

BACKGROUND

Cardiac surgery is performed worldwide to treat severe cases of cardiovascular diseases. Statins have shown controversial effects on complications after cardiac surgeries. We aimed to investigate the effect of preoperative statin therapy on the frequency of postoperative mortality, renal, and neurological complications.

METHODS

In a retrospective cohort study, the database of patients operated on in two hospitals in southern Iran during 2008-2019 was used to compare preoperative statin use with no use on the composite outcome of mortality, renal, and neurological complications as well as on each component of the composite, separately. Effects of low dose (<40 mg simvastatin equivalence) vs. high dose (≥40 mg) statins were also evaluated. Confounders that could affect the outcomes were considered in the logistic regression model, and multiple imputation techniques were used to categorize patients with unknown statin dose use as either high or low-dose users.

RESULTS

Of total 7329 patients, 17.6% of statin users and 17% of non-statin users developed the composite outcome (P=0.51). Statin use had no statistically significant association with the composite outcome (aRR 1.01 [95% CI: 0.88-1.16]). There was no significant association with mortality [aRR: 0.75 (95% CI: 0.34-1.69)], neurological [aRR: 1.25 (95% CI: 0.77-2.12)], or renal complications [aRR: 1.03 (95% CI 0.90-1.19)] after surgery. Neither low nor high doses had any statistically significant effect on the composite or any of its components.

CONCLUSIONS

In this large study, preoperative statin use, either high dose or low dose, did not affect short-term postoperative mortality, neurological, or renal complications.

Characteristics of Depression Clinical Trials Registered on ClinicalTrials.gov

Background

Mental disorders are among the leading causes of the global health-related burden, and depression is one of the most disabling mental disorders. The emergence of the COVID-19 pandemic has created an environment where many determinants of mental health are exacerbated. Many studies have been registered and conducted over the past 16 years, but how to choose the proper design for depression clinical trials remains the main concern. This study aimed to characterize the current status of global depression clinical trials registered on ClinicalTrials.gov.

Methods

We examined all the trials registered on ClinicalTrials.gov from 2007 to 2021.

Results

Overall, 7623 depression clinical trials were identified for analysis. Of those trials, 6402 (83.98%) were intervention trials and 1212 (15.90%) were observational trials. The majority of intervention types were behavioral (35.2%) and drug (28.55%), with very few procedures, dietary supplements, and diagnostic test studies. In addition, 55.53% of trials enrolled <100 participants. The proportions of trials registered in North America were higher than on other continents. Furthermore, the trials that involved only females (12.6%) were more than only males (0.87%) from 2019 to 2021.

Conclusion

Depression clinical trials registered on ClinicalTrials.gov were dominated by small sample size trials, and there is a lack of trials related to COVID-19. The choice of study design is crucial, and properly designed trials can help improve study efficiency and reduce the likelihood of study failure. Given the increased number of RCT trials, the trial quality is gradually improving over the years. In addition, depression trials concentrating on children and older adults need more scientific attention. Further studies related to COVID-19 are needed, given the great damage that causes to people's physical and mental health.

Psychologically informed oral health interventions in pregnancy and type 2 diabetes: A scoping review

Introduction

Oral health is a critical aspect of gestational diabetes management. Gestational diabetes is high blood glucose levels during pregnancy and is managed like type 2 diabetes with diet and physical activity interventions. This scoping review sets out to discuss why oral health support should also become part of gestational diabetes management.

Objectives

The primary objective was to synthesise the existing psychologically informed oral health interventions for pregnant women and individuals with type 2 diabetes, and the extent to which these interventions map on to the COM-B Model. No literature exists on oral health interventions in gestational diabetes, why studies with type 2 diabetes populations were selected instead. The secondary objective was to identify the precise outcomes targeted in the interventions.

Methodology

The Joanna Briggs Institute's Methodology for Scoping Reviews was used to conduct this review. The populations of interest were pregnant women and individuals with type 2 diabetes, and eligible concepts were psychologically informed oral health interventions. Quasi-experimental and experimental designs were considered. The Ovid Interface including Embase, Medline, Global Health, APA PsychInfo, Health Management Information, Maternity, Infant Care Database, the Cochrane Library, and CINAHL was used as information sources. The study selection followed the PRISMA guidelines. The first search was conducted on the week commencing the 25th of July 2022, with a follow-up search conducted on the 10th of October 2022.

Results

28 records were included for synthesis. The most frequently assessed psychological outcome was oral health knowledge and the most frequently assessed oral clinical outcome was Plaque Index. All studies used an educational intervention approach, while psychological capability in the COM-B Model was targeted in all interventions by increasing oral health knowledge among the participants. The Health Belief Model was the most frequently used theory in the interventions.

Conclusion

The results demonstrate that oral health is a recognised aspect of pregnancy and type 2 diabetes. The findings from this review and a qualitative interview study which is under development will inform the first oral health intervention for women with gestational diabetes in the United Kingdom.

Surrogate endpoints in trials: a call for better reporting

Using a surrogate endpoint as a substitute for a patient-relevant final outcome enables randomised controlled trials (RCTs) to be conducted more efficiently. However, the use of surrogates remains controversial and there is currently no guideline for the reporting of RCTs using surrogate endpoints; therefore, we seek to develop SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) extensions to improve the reporting of these trials. We would like to invite interested individuals (trial methodologists, journal editors, healthcare industry, regulators and payers, and patient/public representative groups), particularly those with experience in the use of surrogate endpoints in trials.