Reporting guidance considerations from a statistical perspective: overview of tools to enhance the rigour of reporting of randomised trials and systematic reviews

Evolution of Research Reporting Standards: Adapting to the Influence of Artificial Intelligence, Statistics Software, and Writing Tools

Reporting standards are essential to health research as they improve accuracy and transparency. Over time, significant changes have occurred to the requirements for reporting research to ensure comprehensive and transparent reporting across a range of study domains and foster methodological rigor. The establishment of the Declaration of Helsinki, Consolidated Standards of Reporting Trials (CONSORT), Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) are just a few of the historic initiatives that have increased research transparency. Through enhanced discoverability, statistical analysis facilitation, article quality enhancement, and language barrier reduction, artificial intelligence (AI)-in particular, large language models like ChatGPT-has transformed academic writing. However, problems with errors that could occur and the need for transparency while utilizing AI tools still exist. Modifying reporting rules to include AI-driven writing tools such as ChatGPT is ethically and practically challenging. In academic writing, precautions for truth, privacy, and responsibility are necessary due to concerns about biases, openness, data limits, and potential legal ramifications. The CONSORT-AI and Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)-AI Steering Group expands the CONSORT guidelines for AI clinical trials-new checklists like METRICS and CLEAR help to promote transparency in AI studies. Responsible usage of technology in research and writing software adoption requires interdisciplinary collaboration and ethical assessment. This study explores the impact of AI technologies, specifically ChatGPT, on past reporting standards and the need for revised guidelines for open, reproducible, and robust scientific publications.

Five aspects of research waste in biomedicine: A scoping review

BACKGROUND

The number of published journal articles has grown exponentially during the last 30 years, which may have led to some wasteful research. However, the terminology associated with research waste remains unclear. To address this, we aimed to identify, define, and categorize the aspects of research waste in published biomedical reports.

METHODS

In this scoping review, we systematically searched for biomedical literature reports from 1993 to 2023 in two databases, focusing on those addressing and defining research waste. Through data charting, we analyzed and categorized the aspects of research waste.

RESULTS

Based on 4285 initial records in the searches, a total of 832 reports were included in the analysis. The included reports were primarily narrative reviews (26%) and original reports (21%). We categorized research waste into five aspects: methodological, invisible, negligible, underreported, and structural (MINUS) research waste. More than half of the reports (56%) covered methodological research waste concerning flaws in study design, study conduct, or analysis. Invisible research waste covered nonpublication, discontinuation, and lack of data-sharing. Negligible research waste primarily concerned unnecessary repetition, for example, stemming from the absence of preceding a trial with a systematic review of the literature. Underreported research waste mainly included poor reporting, resulting in a lack of transparency. Structural research waste comprised inadequate management, collaboration, prioritization, implementation, and dissemination.

CONCLUSION

MINUS encapsulates the five main aspects of research waste. Recognizing these aspects of research waste is important for addressing and preventing further research waste and thereby ensuring efficient resource allocation and scientific integrity.

Health-related quality of life after total knee arthroplasty and unicompartmental knee arthroplasty for unicompartmental osteoarthritis: A systematic review and meta-analysis

BACKGROUND

While previous research has demonstrated potential advantages of unicompartmental knee arthroplasty (UKA) over total knee arthroplasty (TKA), particularly in terms of clinical outcomes such as function and pain relief, the specific impact on health-related quality of life (HRQOL) remains unclear. This systematic review and meta-analysis aim to address this gap by comparing HRQOL outcomes between UKA and TKA, providing valuable insights for clinical decision-making.

METHODS

We conducted a literature search in the PubMed, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Web of Science databases up to July 15, 2023. Eligible studies assessed HRQOL using EQ-5D, SF-36, or SF-12 and were assessed for methodological quality using the Newcastle-Ottawa Scale (NOS).

RESULTS

Seven eligible studies were included, comprising a total of 64,585 patients with 35,809 undergoing TKA and 28,776 undergoing UKA. Patient age ranged from 52.0 to 67.7 years with an average BMI ranging from 27.2 to 31.0 kg/m2. Follow-up periods ranged from 6 months to 10 years. Five studies (63,829 patients) that evaluated HRQOL using EQ-5D showed significantly better outcomes for UKA compared to TKA (MD -0.04, 95% CI -0.05 to -0.02). Two studies (756 patients) that evaluated HRQOL using SF-36 showed no significant difference between TKA and UKA. Five studies (63,286 patients) that evaluated functional outcomes using Oxford Knee Score (OKS) showed significantly better functional scores for UKA compared to TKA (MD -1.29, 95% CI -1.86 to -0.72). Four studies (24,570 patients) that reported patient satisfaction showed no statistically significant difference between TKA and UKA (MD 0.97, 95% CI 0.90 to 1.05). Further subgroup analysis did not affect the conclusions.

CONCLUSIONS

Our meta-analysis suggests that UKA is associated with better HRQOL and knee function, as well as similar patient satisfaction, compared to TKA for patients with unicompartmental osteoarthritis.

The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids have been shown anti-inflammatory and antiemetic effects, but can also elevate blood glucose levels and increase the risk of wound infection. Thus, it is essential to investigate the efficacy and safety of glucocorticoid usage in TKA.

METHOD

A comprehensive systematic search of PubMed, Medline, EMBASE, Cochrane databases, to identify relevant randomized controlled trials (RCTs) of glucocorticoid application in TKA. The primary outcomes assessed were the postoperative pain assessment. Secondary outcomes included the range of motion in knee joint, levels of inflammatory cytokines, adverse complications, and the length of hospital stay.

RESULTS

Thirty-six randomized controlled trials were included in the final analysis. The glucocorticoid group exhibited significant reduction in the resting VAS scores on postoperative days 1, 2 (POD1, 2)and postoperative 3 months (POM3), as well as decreased morphine consumption on POD1 and increased range of motion (ROM) in knee joint on POD1, 3. Additionally, the glucocorticoid group exhibited decreased levels of postoperative inflammatory cytokines and the incidence of PONV along with a shorter length of hospital stay. The blood glucose concentration was significantly increased in the glucocorticoid group on POD1 compared with the control group. While the blood glucose on POD2 and occurrence of postoperative adverse complications were similar between two groups including wound infection and venous thrombosis. The periarticular injection analgesia (PIA) group demonstrated lower VAS scores on POD2 comparing to the systemic administration (SA) group according to two studies. However, there was no significant difference of the resting VAS on POD1 and POD2 between PIA and SA group across all studies.

CONCLUSION

Perioperative glucocorticoids treatment in TKA significantly reduced short-term pain score and opioid-use which was probably not patient relevant. The application of glucocorticoids in TKA implied a beneficial trend in analgesic, anti-inflammatory, and antiemetic effects, as well as improved range of motion and shortened hospital stay. While it will not increase the risk of continued high glucose, postoperative wound infection and venous thrombosis.

Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis

Purpose

Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients.

Methods

Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality).

Results

There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03).

Conclusions

Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients.

Level of evidence

III.

Intraarticular viscosupplementation following arthroscopic anterior cruciate ligament reconstruction: A systematic review

BACKGROUND

Pain, swelling and joint stiffness are the major problems following arthroscopic ACL reconstruction (ACLR) surgery that restrict early return to sports and athletic activities. The patients often receive prolonged analgesic medications to control the inflammatory response and resume the pre-injury activities. This systematic review aims to evaluate the safety and efficacy of intraarticular (IA) hyaluronic acid (HA) injection following ACLR.

MATERIAL AND METHODS

A literature search of electronic databases and a manual search of studies reporting clinical effectiveness of IA HA following ACLR was performed on 1^st November 2020. The quality of the methodology and risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool and Newcastle-Ottawa scale for randomized-controlled trial and prospective cohort studies, respectively.

RESULTS

Of 324 studies retrieved, four studies (3 RCTs and one prospective cohort study) were found to be suitable for inclusion in this review. These studies had a low to moderate risk of bias. There were 182 patients in the HA group and 121 patients in the control group. The demographic characteristics of the patients were similar in all studies. The pooled analysis of studies evaluating pain at different follow up periods (2-week, 4-6 weeks, 8-12 weeks) after ACLR revealed no significant difference between the HA and control groups (p > 0.05). The knee swelling was significantly less in the HA group at two weeks (MD -7.85, 95% CI: [-15.03, -0.68], p = 0.03, I2 = 0%), but no such difference was noted after 4-6 weeks and 8-12 weeks. The functional outcome score was not significantly different between the groups (SMD 0.00, 95% CI: 0.38 to 0.38, p = 0.99, I² = 0%).

CONCLUSIONS

Although the individual study demonstrated a short-term positive response regarding pain control and swelling reduction, the pooled analysis did not find any clinical benefit of IA HA injection following ACLR surgery.

LEVEL OF EVIDENCE

II.

Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis

Background

For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas.

Methods

A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison.

Results

DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate.

Conclusion

For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41016-022-00277-1.

Do preoperative intra-articular injections of corticosteroids or hyaluronic acid increase the risk of infection after total knee arthroplasty? A meta-analysis

Aims

There is conflicting evidence on the safety of intra-articular injections of hyaluronic acid (HA) or corticosteroids (CSs) before total knee arthroplasty (TKA). We performed a meta-analysis of the relationship between intra-articular injections and subsequent infection rates after TKA.

Methods

We searched PubMed, EMBASE, and the Cochrane Library for cohort studies that assessed the effect of preoperative injection of drugs into the joint cavity on the infection rate after TKA. The outcomes analyzed included the total infection rate, as well as those for different preoperative injection time periods and different drugs.

Results

Eight studies, including 73,880 in the injection group and 126,187 in the control group, met the inclusion criteria. The injection group had a significantly higher postoperative infection rate than the control group (risk ratio (RR) 1.16; 95% confidence interval (CI) 1.07 to 1.27; p < 0.001; I² = 32%). For patients who received injections up to three months preoperatively, the postoperative infection risk was significantly higher than that in the control group (RR 1.26; 95% CI 1.18 to 1.35; p＜0.001; I² = 0%). There was no significant difference in the infection rates between the four-to-six-month injection and control groups (RR 1.12; 95% CI 0.93 to 1.35; p = 0.240; I² = 75%) or between the seven-to-12-month injection and control groups (RR 1.02; 95% CI 0.94 to 1.12; p = 0.600; I² = 0%).

Conclusion

Current evidence suggests that intra-articular injections of CSs or HA before TKA increase the risk of postoperative infection. Injections administered more than three months before TKA do not significantly increase the risk of infection.

Cite this article: Bone Joint Res 2022;11(3):171–179.

Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis

INTRODUCTION

Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture.

MATERIALS AND METHODS

Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening.

RESULTS

There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55-75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD - 16.84, 95% CI - 25.34, - 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD - 9.86, 95% CI - 44.97, 25.26, p = 0.58).

CONCLUSION

Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.

Joint awareness after unicompartmental knee arthroplasty and total knee arthroplasty: a systematic review and meta-analysis of cohort studies

PURPOSE

The purpose of this systematic review and meta-analysis is to evaluate the joint awareness after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). It was hypothesized that patients with UKA could better forget about their artificial joint in comparison to TKA.

METHODS

A search of major literature databases and bibliographic details revealed 105 studies evaluating forgotten joint score in UKA and TKA. Seven studies found eligible for this review were assessed for risk of bias and quality of evidence using the Newcastle-Ottawa Scale. The forgotten joint score (FJS-12) was assessed at 6 months, 1 year, and 2 years.

RESULTS

The mean FJS-12 at 2 years was 82.35 in the UKA group and 74.05 in the TKA group. Forest plot analysis of five studies (n = 930 patients) revealed a mean difference of 7.65 (95% CI: 3.72, 11.57, p = 0.0001; I² = 89% with p < 0.0001) in FJS-12 at 2 years. Further sensitivity analysis lowered I² heterogeneity to 31% after exclusion of the study by Blevin et al. (MD 5.88, 95%CI: 3.10, 8.66, p < 0.0001). A similar trend of differences in FJS-12 between the groups was observed at 6 months (MD 32.49, 95% CI: 17.55, 47.43, p < 0.0001) and at 1 year (MD 25.62, 95% CI: 4.26, 46.98, p = 0.02).

CONCLUSIONS

UKA patients can better forget about their artificial joint compared to TKA patients.

LEVEL OF EVIDENCE

III.

Psychotherapies for depression: a network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types

The effects of psychotherapies for depression have been examined in several hundreds of randomized trials, but no recent network meta-analysis (NMA) has integrated the results of these studies. We conducted an NMA of trials comparing cognitive behavioural, interpersonal, psychodynamic, problem-solving, behavioural activation, life-review and "third wave" therapies and non-directive supportive counseling with each other and with care-as-usual, waiting list and pill placebo control conditions. Response (50% reduction in symptoms) was the primary outcome, but we also assessed remission, standardized mean difference, and acceptability (all-cause dropout rate). Random-effects pairwise and network meta-analyses were conducted on 331 randomized trials with 34,285 patients. All therapies were more efficacious than care-as-usual and waiting list control conditions, and all therapies - except non-directive supportive counseling and psychodynamic therapy - were more efficacious than pill placebo. Standardized mean differences compared with care-as-usual ranged from -0.81 for life-review therapy to -0.32 for non-directive supportive counseling. Individual psychotherapies did not differ significantly from each other, with the only exception of non-directive supportive counseling, which was less efficacious than all other therapies. The results were similar when only studies with low risk of bias were included. Most therapies still had significant effects at 12-month follow-up compared to care-as-usual, and problem-solving therapy was found to have a somewhat higher long-term efficacy than some other therapies. No consistent differences in acceptability were found. Our conclusion is that the most important types of psychotherapy are efficacious and acceptable in the acute treatment of adult depression, with few significant differences between them. Patient preference and availability of each treatment type may play a larger role in the choice between types of psychotherapy, although it is possible that a more detailed characterization of patients with a diagnosis of depression may lead to a more precise matching between individual patients and individual psychotherapies.

Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis

PURPOSE

Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem.

METHODS

A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3.

RESULTS

After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13-7.47, p < 0.00001) and 15.12 (95% CI: 6.12-37.37, p < 0.00001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49-17.30, p < 0.009) and they remain admitted for a longer time in hospital (MD = 3.6, 95% CI: 1.74-5.45, p = 0.0001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 - patients.

CONCLUSIONS

There are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.

Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis

PURPOSE

Most patients with depression are treated by general practitioners, and most of those patients prefer psychotherapy over pharmacotherapy. No network meta-analyses have examined the effects of psychotherapy compared with pharmacotherapy, combined treatment, care as usual, and other control conditions among patients in primary care.

METHODS

We conducted systematic searches of bibliographic databases to identify randomized trials comparing psychotherapy with pharmacotherapy, combined treatment, care as usual, waitlist, and pill placebo. The main outcome was treatment response (50% improvement of depressive symptoms from baseline to end point).

RESULTS

A total of 58 studies with 9,301 patients were included. Both psychotherapy and pharmacotherapy were significantly more effective than care as usual (relative risk [RR] for response = 1.60; 95% CI, 1.40-1.83 and RR = 1.65; 95% CI, 1.35-2.03, respectively) and waitlist (RR = 2.35; 95% CI, 1.57-3.51 and RR = 2.43; 95% CI, 1.57-3.74, respectively) control groups. We found no significant differences between psychotherapy and pharmacotherapy (RR = 1.03; 95% CI, 0.88-1.22). The effects were significantly greater for combined treatment compared with psychotherapy alone (RR = 1.35; 95% CI, 1.00-1.81). The difference between combined treatment and pharmacotherapy became significant when limited to studies with low risk of bias and studies limited to cognitive behavior therapy.

CONCLUSIONS

Psychotherapy is likely effective for the treatment of depression when compared with care as usual or waitlist, with effects comparable to those of pharmacotherapy. Combined treatment might be better than either psychotherapy or pharmacotherapy alone.

Clinical Outcomes of Arthroscopic Tenodesis Versus Tenotomy for Long Head of the Biceps Tendon Lesions: A Systematic Review and Meta-analysis of Randomized Clinical Trials and Cohort Studies

Background

Controversy exists concerning whether tenotomy or tenodesis is the optimal surgical treatment option for proximal biceps tendon lesions.

Purpose

To evaluate the clinical outcomes after arthroscopic tenodesis and tenotomy in the treatment of long head of the biceps tendon (LHBT) lesions.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review was performed by searching PubMed, the Cochrane Library, Web of Science, and Embase to identify randomized controlled trials (RCTs) and cohort studies that compared the clinical efficacy of tenotomy with that of tenodesis for LHBT lesions. A standardized data extraction form was predesigned to obtain bibliographic information of the study as well as patient, intervention, comparison, and outcome data. A random-effects model was used to pool quantitative data from the primary outcomes.

Results

A total of 21 eligible studies were separated into 3 methodological groups: (1) 4 RCTs with level 1 evidence, (2) 3 RCTs and 4 prospective cohort studies with level 2 evidence, and (3) 10 retrospective cohort studies with level 3 to 4 evidence. Analysis of the 3 groups demonstrated a significantly higher risk of the Popeye sign after tenotomy versus tenodesis (group 1: risk ratio [RR], 3.29 [95% CI, 1.92-5.49]; group 2: RR, 2.35 [95% CI, 1.43-3.85]; and group 3: RR, 2.57 [95% CI, 1.33-4.98]). Arm cramping pain remained significantly higher after tenotomy only in the retrospective cohort group (RR, 2.17 [95% CI, 1.20-3.95]). The Constant score for tenotomy was significantly worse than that for tenodesis in the prospective cohort group (standardized mean difference [SMD], -0.47 [95% CI, -0.73 to -0.21]), as were the forearm supination strength index (SMD, -0.75 [95% CI, -1.28 to -0.21]) and the Simple Shoulder Test (SST) score (SMD, -0.60 [95% CI, -0.94 to -0.27]).

Conclusion

The results demonstrated that compared with tenodesis, tenotomy had a higher risk of a Popeye deformity in all 3 study groups; worse functional outcomes in terms of the Constant score, forearm supination strength index, and SST score according to prospective cohort studies; and a higher incidence of arm cramping pain according to retrospective cohort studies.

Reconstruction strategies for intraoperative CSF leak in endoscopic endonasal skull base surgery: systematic review and meta-analysis

BACKGROUND

Endoscopic endonasal surgery (EES) is one of the preferred options for skull base pathologies. Cerebrospinal fluid (CSF) leak is a significant complication of EES and neurosurgeons have proposed various reconstructive strategies to decrease this morbidity. We describe and compare the efficacy of these strategies.

METHODS

We searched PubMed, Cochrane Library, and Web of Science for publications between 1990 and November 2019. We defined a reconstruction hierarchy of seven levels from inside to outside: fat graft, intracranial intradural layer (inlay), intracranial extradural layer (onlay), buttress, mucosal flap, nasal packing and lumbar drainage. A single-arm analysis was performed for the primary outcome of CSF leak rate.

RESULTS

Of 3641 records identified, 48 studies met the inclusion criteria. Pituitary tumors had lower postoperative CSF leak rate than other diseases (1.8% vs. 6.5%, RD = -4.7% [-7.1%, -2.1%]). In high CSF flow group, the post-operative leak rate was reduced by application of mucosal flap (4.3% vs. without mucosal flap at 12.8%, RD = -8.5% [-15.1%, -1.9%]). The use of inlay showed potential of decreasing the post-operative leak rate (5.0% vs. 7.2%, RD = -2.2% [-7.7%, 3.3%]). In low CSF flow group, tampon was better than balloon for nasal packing (1.0% vs. 10.5%, RD = -9.5% [-16.5%, -2.4%]).

CONCLUSIONS

Mucosal flap and inlay for high-flow intraoperative CSF leak and tampon (compared with balloon) for low-flow intraoperative CSF leak, improved the postoperative CSF leak rate. Further studies are required to establish more robust evidence.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis

BACKGROUND

Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency.

AIM

To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times.

METHODS

The search of electronic databases on 1^st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data.

RESULTS

The pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time.

CONCLUSION

There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.

Methodological quality of meta-analyses indexed in PsycINFO: leads for enhancements: a meta-epidemiological study

OBJECTIVES

Meta-analyses (MAs) are often used because they are lauded to provide robust evidence that synthesises information from multiple studies. However, the validity of MA conclusions relies on the procedural rigour applied by the authors. Therefore, this meta-research study aims to characterise the methodological quality and meta-analytic practices of MAs indexed in PsycINFO.

DESIGN

A meta-epidemiological study.

PARTICIPANTS

We evaluated a random sample of 206 MAs indexed in the PsycINFO database in 2016.

PRIMARY AND SECONDARY OUTCOMES

Two authors independently extracted the methodological characteristics of all MAs and checked their quality according to the 16 items of the A MeaSurement Tool to Assess systematic Reviews (AMSTAR2) tool for MA critical appraisal. Moreover, we investigated the effect of mentioning Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) on the methodological quality of MAs.

RESULTS

According to AMSTAR2 criteria, 95% of the 206 MAs were rated as critically low quality. Statistical methods were appropriate and publication bias was well evaluated in 87% and 70% of the MAs, respectively. However, much improvement is needed in data collection and analysis: only 11% of MAs published a research protocol, 44% had a comprehensive literature search strategy, 37% assessed and 29% interpreted the risk of bias in the individual included studies, and 11% presented a list of excluded studies. Interestingly, the explicit mentioning of PRISMA suggested a positive influence on the methodological quality of MAs.

CONCLUSION

The methodological quality of MAs in our sample was critically low according to the AMSTAR2 criteria. Some efforts to tremendously improve the methodological quality of MAs could increase their robustness and reliability.

Methodological quality of meta-analyses indexed in PsycINFO: leads for enhancements: a meta-epidemiological study

OBJECTIVES

Meta-analyses (MAs) are often used because they are lauded to provide robust evidence that synthesises information from multiple studies. However, the validity of MA conclusions relies on the procedural rigour applied by the authors. Therefore, this meta-research study aims to characterise the methodological quality and meta-analytic practices of MAs indexed in PsycINFO.

DESIGN

A meta-epidemiological study.

PARTICIPANTS

We evaluated a random sample of 206 MAs indexed in the PsycINFO database in 2016.

PRIMARY AND SECONDARY OUTCOMES

Two authors independently extracted the methodological characteristics of all MAs and checked their quality according to the 16 items of the A MeaSurement Tool to Assess systematic Reviews (AMSTAR2) tool for MA critical appraisal. Moreover, we investigated the effect of mentioning Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) on the methodological quality of MAs.

RESULTS

According to AMSTAR2 criteria, 95% of the 206 MAs were rated as critically low quality. Statistical methods were appropriate and publication bias was well evaluated in 87% and 70% of the MAs, respectively. However, much improvement is needed in data collection and analysis: only 11% of MAs published a research protocol, 44% had a comprehensive literature search strategy, 37% assessed and 29% interpreted the risk of bias in the individual included studies, and 11% presented a list of excluded studies. Interestingly, the explicit mentioning of PRISMA suggested a positive influence on the methodological quality of MAs.

CONCLUSION

The methodological quality of MAs in our sample was critically low according to the AMSTAR2 criteria. Some efforts to tremendously improve the methodological quality of MAs could increase their robustness and reliability.

A network meta-analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression

No network meta-analysis has examined the relative effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression, while this is a very important clinical issue. We conducted systematic searches in bibliographical databases to identify randomized trials in which a psychotherapy and a pharmacotherapy for the acute or long-term treatment of depression were compared with each other, or in which the combination of a psychotherapy and a pharmacotherapy was compared with either one alone. The main outcome was treatment response (50% improvement between baseline and endpoint). Remission and acceptability (defined as study drop-out for any reason) were also examined. Possible moderators that were assessed included chronic and treatment-resistant depression and baseline severity of depression. Data were pooled as relative risk (RR) using a random-effects model. A total of 101 studies with 11,910 patients were included. Depression in most studies was moderate to severe. In the network meta-analysis, combined treatment was more effective than psychotherapy alone (RR=1.27; 95% CI: 1.14-1.39) and pharmacotherapy alone (RR=1.25; 95% CI: 1.14-1.37) in achieving response at the end of treatment. No significant difference was found between psychotherapy alone and pharmacotherapy alone (RR=0.99; 95% CI: 0.92-1.08). Similar results were found for remission. Combined treatment (RR=1.23; 95% CI: 1.05-1.45) and psychotherapy alone (RR=1.17; 95% CI: 1.02-1.32) were more acceptable than pharmacotherapy. Results were similar for chronic and treatment-resistant depression. The combination of psychotherapy and pharmacotherapy seems to be the best choice for patients with moderate depression. More research is needed on long-term effects of treatments (including cost-effectiveness), on the impact of specific pharmacological and non-pharmacological approaches, and on the effects in specific populations of patients.

Meta-analyses indexed in PsycINFO had a better completeness of reporting when they mention PRISMA

OBJECTIVES

To investigate the effect of the explicit mention of PRISMA, a statement designed to help authors report meta-analyses (MAs), on the reporting completeness of MAs.

STUDY DESIGN AND SETTING

Two investigators evaluated a random sample of 206 MAs indexed in PsycINFO in 2016; 100 explicitly mentioned PRISMA and 106 did not. Two authors independently evaluated the 27 PRISMA items and extracted factors that could potentially be associated with reporting completeness. The data were analyzed descriptively.

RESULTS

Among our 206 MAs, perfect adherence to PRISMA was found in less than 4%, of which 87% explicitly followed PRISMA. The following items were encountered significantly more frequently in MAs that explicitly mentioned PRISMA than in those that did not: summary, protocol, information sources, search strategy, study characteristics, results of individual studies, funding, study selection, risk of bias in individual studies, and bias across studies. The journal's impact factor, endorsement of PRISMA by the journal, number of authors, country of author, open access, and design of the included studies were significantly and positively associated with the explicit mention of PRISMA.

CONCLUSIONS

Even if far from optimal, the explicit mention of PRISMA has a positive influence on the reporting completeness of MAs from PsycINFO.

Comparative efficacy and acceptability of antidepressants in the long-term treatment of major depression: protocol for a systematic review and networkmeta-analysis

INTRODUCTION

Pharmacotherapy plays an important role in the treatment of major depression. At the initiation of antidepressant treatment, both improvement of symptoms in the short term and relapse prevention in the long term should be taken into account. However, there is insufficient evidence regarding the efficacy and the acceptability of continuation/maintenance treatments and the relative efficacy/acceptability of antidepressants.

OBJECTIVE

We will conduct a pairwise meta-analysis and a network meta-analysis (NMA) to examine the relative efficacy, tolerability and acceptability of antidepressants in the long-term treatment of major depression.

METHODS AND ANALYSIS

We will include double-blind randomised controlled trials comparing any of the following antidepressants, which we included in our previous NMA of the acute treatment for major depression, with placebo or with another active drug for long-term treatment of major depression: agomelatine, amitriptyline, bupropion, citalopram, clomipramine, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, trazodone, venlafaxine, vilazodone and vortioxetine. Our primary outcomes will be sustained response and all-cause dropouts. We will include four types of designs that are used to investigate long-term treatment. We will conduct two main analyses. First, we will conduct a pairwise meta-analysis comparing all antidepressants versus placebo to investigate whether continuing antidepressants after achieving a positive response in the acute-phase treatment is beneficial and/or safe. Second, we will conduct an NMA to examine the comparative efficacy and acceptability of the drugs. We will use a novel approach that will combine the results of acute-phase treatment NMA with long-term treatment studies to include all related designs in the NMA. We will ensure the validity of combining different designs and our new approach by checking the distribution of important effect modifiers and consistency of network.

ETHICS AND DISSEMINATION

This study did not require ethical approval. We will disseminate our findings by publishing results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018114561; Pre-results.

Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis

OBJECTIVE

To present a clear and comprehensive summary of the published data on unicompartmental knee replacement (UKA) or total knee replacement (TKA), comparing domains of outcome that have been shown to be important to patients and clinicians to allow informed decision making.

DESIGN

Systematic review using data from randomised controlled trials, nationwide databases or joint registries, and large cohort studies.

DATA SOURCES

Medline, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Clinical Trials.gov, searched between 1 January 1997 and 31 December 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies published in the past 20 years, comparing outcomes of primary UKA with TKA in adult patients. Studies were excluded if they involved fewer than 50 participants, or if translation into English was not available.

RESULTS

60 eligible studies were separated into three methodological groups: seven publications from six randomised controlled trials, 17 national joint registries and national database studies, and 36 cohort studies. Results for each domain of outcome varied depending on the level of data, and findings were not always significant. Analysis of the three groups of studies showed significantly shorter hospital stays after UKA than after TKA (-1.20 days (95% confidence interval -1.67 to -0.73), -1.43 (-1.53 to -1.33), and -1.73 (-2.30 to -1.16), respectively). There was no significant difference in pain, based on patient reported outcome measures (PROMs), but significantly better functional PROM scores for UKA than for TKA in both non-trial groups (mean difference -0.58 (-0.88 to -0.27) and -0.32 (-0.48 to -0.15), respectively). Regarding major complications, trials and cohort studies had non-significant results, but mortality after TKA was significantly higher in registry and large database studies (risk ratio 0.27 (0.16 to 0.45)), as were venous thromboembolic events (0.39 (0.27 to 0.57)) and major cardiac events (0.22 (0.06 to 0.86)). Early reoperation for any reason was higher after TKA than after UKA, but revision rates at five years remained higher for UKA in all three study groups (risk ratio 5.95 (1.29 to 27.59), 2.50 (1.77 to 3.54), and 3.13 (1.89 to 5.17), respectively).

CONCLUSIONS

TKA and UKA are both viable options for the treatment of isolated unicompartmental osteoarthritis. By directly comparing the two treatments, this study demonstrates better results for UKA in several outcome domains. However, the risk of revision surgery was lower for TKA. This information should be available to patients as part of the shared decision making process in choosing treatment options.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO number CRD42018089972.

Statistical Guidance for Reviewers of Toxicologic Pathology

Study design, statistical analysis, interpretation of results, and conclusions should be a part of all research papers. Statistics are integral to each of these components and are therefore necessary to evaluate during manuscript peer review. Research published in Toxicological Pathology is often focused on animal studies that may seek to compare defined treatment groups in randomized controlled experiments or focus on the reliability of measurements and diagnostic accuracy of observed lesions from preexisting studies. Reviewers should distinguish scientific research goals that aim to test sufficient effect size differences (i.e., minimizing false positive rates) from common toxicologic goals of detecting a harmful effect (i.e., minimizing false negative rates). This journal comprises a wide range of study designs that require different kinds of statistical assessments. Therefore, statistical methods should be described in enough detail so that the experiment can be repeated by other research groups. The misuse of statistics will impede reproducibility.

Flaws in the application and interpretation of statistical analyses in systematic reviews of therapeutic interventions were common: a cross-sectional analysis

OBJECTIVES

The objective of the study was to investigate the application and interpretation of statistical analyses in a cross-section of systematic reviews (SRs) of therapeutic interventions, without restriction by journal, clinical condition, or specialty.

STUDY DESIGN AND SETTING

We evaluated a random sample of SRs assembled previously, which were indexed in MEDLINE® during February 2014, focused on a treatment or prevention question, and reported at least one meta-analysis. The reported statistical methods used in each SR were extracted from articles and online appendices by one author, with a 20% random sample extracted in duplicate.

RESULTS

We evaluated 110 SRs; 78/110 (71%) were non-Cochrane SRs and 55/110 (50%) investigated a pharmacological intervention. The SRs presented a median of 13 (interquartile range: 5-27) meta-analytic effects. When considering the index (primary or first reported) meta-analysis of each SR, just over half (62/110 [56%]) used the random-effects model, but few (5/62 [8%]) interpreted the meta-analytic effect correctly (as the average of the intervention effects across all studies). A statistical test for funnel plot asymmetry was reported in 17/110 (15%) SRs; however, in only 4/17 (24%) did the test include the recommended number of at least 10 studies of varying size. Subgroup analyses accompanied 42/110 (38%) index meta-analyses, but findings were not interpreted with respect to a test for interaction in 29/42 (69%) cases, and the issue of potential confounding in the subgroup analyses was not raised in any SR.

CONCLUSIONS

There is scope for improvement in the application and interpretation of statistical analyses in SRs of therapeutic interventions. The involvement of statisticians on the SR team and establishment of partnerships between researchers with specialist expertise in SR methods and journal editors may help overcome these shortcomings.

Relationship between implant stability measurements obtained by insertion torque and resonance frequency analysis: A systematic review

BACKGROUND

The primary stability of dental implants can be evaluated by insertion torque (IT) and resonance frequency analysis (RFA).

OBJECTIVE

Assess the supposed relationship between the IT and RFA.

MATERIALS AND METHODS

A systematic review was performed based on the PRISMA. The electronic search was performed in the PubMed, Web of Science, SCOPUS, Cochrane Library electronic, OVID, and Scielo databases. Manual searches were also performed. There was no restrictions regarding year of publication or language. The articles identified were assessed independently by 3 trained researchers. Clinical trials reporting the RFA values by means of implant stability quotient (ISQ) and IT were included.

RESULTS

The electronic and manual searches yielded 2017 studies. Twelve studies were included in the systematic review. There was no statistically significant correlation between ISQ and IT (r_s  = .366; P = .079). The quality of the evidence was downgraded by risk of bias and indirectness; and the certainty of the evidence was low.

CONCLUSION

IT and RFA are independent and incomparable methods of measuring primary stability. Is important for clinicians to define only one method of evaluation for each implant.