Three-armed trials including placebo and no-treatment groups may be subject to publication bias: systematic review

Effectiveness and Tolerability of Different Recommended Doses of PPIs and H2RAs in GERD: Network Meta-Analysis and GRADE system

Proton pump inhibitors (PPIs) and histamine-2-receptor antagonists (H₂RAs) are used for gastro-esophageal reflux disease (GERD); however, the clinical evidence for treatment is poor. We evaluated the effectiveness and tolerability of different doses of PPIs, H₂RAs and placebo in adults with GERD. Six online databases were searched through September 1, 2016. All related articles were included and combined with a Bayesian network meta-analysis from randomized controlled trials (RCTs). The GRADE systems were employed to assess the main outcome. Ninety-eight RCTs were identified, which included 45,964 participants. Our analysis indicated that the full/standard dose of esomeprazole at 40 mg per day was the most efficient in healing among nine different dosages of PPIs and H₂RAs. The main efficacy outcome did not change after adjustments for the area, age, level of disease from endoscopy, year of publication, pharmaceutical industry sponsorship, Intention-to-treat (ITT)/per-protocol (PP), withdrawal rate, pre-set select design bias, single blinded and unblinded studies, study origination in China, study arms that included zero events, inconsistency node or discontinued drug were accounted for in the meta-regressions and sensitivity analyses. This research suggests that the full/standard doses (40 mg per day) of esomeprazole should be recommended as first-line treatments for GERD in adults for short-term therapy.

Expectancy Effect in Three Mind-Body Clinical Trials

Expectancy, arguably the prime component of the placebo effect, has been shown to significantly modify the effects of many treatments. Furthermore, various forms of mind-body interventions have demonstrated effective improvements in outcomes. The aim of this study was to examine the relationship between pretreatment expectations and symptom reduction in a secondary analysis of 3 mind-body intervention programs. An adjusted correlation and regression analysis compared data from a 6-question expectancy questionnaire to a self-reported clinical impression of change score. Only 1 of the 6 expectancy questions in 1 of the 3 studies reached significance (B = 0.087; P = .025). The combined data from all 3 studies did not reveal significant expectancy effects. The positive effects of mindfulness meditation appear to be independent of an expectancy effect.

Acupoints Stimulation for Anxiety and Depression in Cancer Patients: A Quantitative Synthesis of Randomized Controlled Trials

This study aims at concluding the current evidence on the therapeutic effects of acupoints stimulation for cancer patients with anxiety and depression. Randomized controlled trials using acupoints stimulation for relieving anxiety and/or depression in cancer patients were searched, and 11 studies were finally included, of which eight trials compared acupoints stimulation with standard methods of treatment/care, and acupoints stimulation showed significantly better effects in improving depression than using standard methods of treatment/care. Four studies compared true acupoints stimulation with sham methods, and no significant differences can be found between groups for either depression or anxiety, although the pooled effects still favored true intervention. For the five studies that evaluated sleep quality, the results were conflicting, with three supporting the superiority of acupoints stimulation in improving sleep quality and two demonstrating no differences across groups. Acupoints stimulation seems to be an effective approach in relieving depression and anxiety in cancer patients, and placebo effects may partially contribute to the benefits. However, the evidence is not conclusive due to the limited number of included studies and the clinical heterogeneity identified among trials. More rigorous designed randomized, sham-controlled studies are necessary in future research.

Acupuncture for Aromatase Inhibitor–Induced Arthralgia

Background. Aromatase inhibitors (AIs) are commonly used as adjunctive hormone treatment for early breast cancer patients. The major side effect of AIs is arthralgia, which affects adherence. Previous reviews suggested that acupuncture is effective in the management of cancer-related pain. The aim of this review is to evaluate the effects of acupuncture on arthralgia caused by AIs. Methods. This article examined randomized controlled trials (RCTs) measuring the effects of acupuncture on joint symptoms caused by AIs within 8 medical databases till May 2014. The quality of the articles was evaluated according to the Cochrane risk of bias (ROB) tool. Results. Four RCTs were identified in medical journals. Two studies were conducted with manual acupuncture and 2 studies were electroacupuncture. The range of sample size was between 32 and 67. One RCT showed significant improvement in the acupuncture group compared with the sham control group and another RCT showed a statistical difference between the electroacupuncture and waitlist group. The other 2 studies showed no statistical differences between control and acupuncture groups. Two studies conducted blood analysis to elucidate the mechanism of efficacy of acupuncture for arthralgia. The 2 positive studies had a lower ROB and 2 studies had a high ROB. Conclusions. The systematic review suggests that acupuncture has potential benefits to improve arthralgia caused by AIs. However, further trials of adequate sample size, appropriate control group, and longer follow-up are necessary to investigate the efficacy of acupuncture in AI-induced arthralgia.

Nonspecific adverse events in knee osteoarthritis clinical trials: a systematic review

Background

Adverse events (AEs) derived from nonspecific activity of treatments can impair the validity of trials, and even make it difficult to identify specific AEs associated with treatments. To better understand these nonspecific AEs, we investigated the AEs in placebo groups by using knee osteoarthritis clinical trials.

Methods

Randomized, placebo-controlled, knee osteoarthritis trials were identified by searching electronic databases. We determined the rate of patients with AEs and the rate of dropouts caused by AEs in the active and placebo groups. Furthermore, we calculated the rate of patients for individual AEs in the placebo groups. Finally, we performed secondary analyses to identify the factors associated with these rates.

Results

Overall, 272 papers reporting 281 trials were included in the analysis. The rates of patients with AEs were 31.8% in the active groups and 27.4% in the placebo groups. The rate of the placebo groups accounted for 86.2% of the rate of the active groups. The rates of dropouts caused by AEs were 5.2% in the active groups and 4.8% in the placebo groups. The rate of the placebo groups accounted for 92.3% of the rate of the active groups. AEs in the placebo groups included a number of clinical conditions, with elevated alanine aminotransferase (0.59%; 95% CI: 0.46 to 0.77) being the most common objective outcome and headache (4.48%; 95% CI: 4.20 to 4.79) being the most frequent subjective outcome. The rate of patients with AEs and the rate of dropouts caused by AEs were associated with the treatment type, delivery route, and study design.

Conclusions

The nonspecific AEs substantially accounted for the development of AEs in the active groups and included conditions involving the entire body.

Clinically meaningful nocebo effect occurs in acupuncture treatment: a systematic review

OBJECTIVE

To investigate the nocebo effect using randomized acupuncture trials that include sham and no-treatment groups.

STUDY DESIGN AND SETTING

Electronic databases were searched to retrieve eligible trials from their inception until June 2013. Risk differences were then calculated using the acupuncture and sham groups to determine the treatment effect and the sham and no-treatment groups to determine the nocebo effect.

RESULTS

In total, 58 eligible trials were analyzed. On the basis of the rate of patients with any adverse event in 31 trials reporting available data, the treatment effect was 0.012 (95% confidence interval [CI]: 0.003, 0.021), with a number needed to harm (NNH) of 83 (95% CI: 48, 333). The nocebo effect was 0.049 (95% CI: 0.012, 0.086), with an NNH of 20 (95% CI: 12, 83). By contrast, the rate of dropouts due to adverse events in 39 trials reporting available data showed no differences for both effects. In addition, nearly 70% of the trials reported zero dropouts in the sham and no-treatment groups.

CONCLUSION

Our findings suggest that (1) the nocebo effect of acupuncture is clinically meaningful and (2) the rate of patients with any adverse event may be a more appropriate indicator of the nocebo effect.

Why critically ill patients are protein deprived

Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore.

Time Course of Placebo Effect of Acupuncture on Pain: A Systematic Review

Objectives. Our objective was to investigate the time course of the placebo effect of acupuncture on pain and the factors affecting the placebo effect. Methods. Previously we retrieved three-armed randomized acupuncture trials including sham and no-treatment groups which were published until October 2009. We searched electronic databases again to identify additional trials from October 2009 to December 2011. After a screening of trials, fifteen three-armed acupuncture trials for pain were included in the analysis. Standardized mean differences between the sham and no-treatment groups were calculated for placebo effect. We then plotted the magnitude of the placebo effect over time. Results. The placebo effect gradually has increased for 12 weeks with a standardized mean difference of 0.74 (95% CI: 0.54 to 0.94). Then it decreased after 12 weeks as time passed. When the placebo effects were compared for factors including methodological qualities, they were not affected by all factors, except patient blinding. Trials with sufficient patient blinding showed a larger placebo effect at 8 weeks than those with insufficient patient blinding (P = 0.0009). Conclusion. The placebo effect of acupuncture showed a unique pattern, which was affected by insufficient patient blinding.

Acupuncture for insomnia

BACKGROUND

Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are widely practised. However, it remains unclear whether current evidence is rigorous enough to support acupuncture for the treatment of insomnia.

OBJECTIVES

To determine the efficacy and safety of acupuncture for insomnia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts International, CINAHL, AMED, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the World Health Organization (WHO) Trials Portal (ICTRP) and relevant specialised registers of the Cochrane Collaboration in October 2011. We screened reference lists of all eligible reports and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised controlled trials evaluating any form of acupuncture for insomnia. They compared acupuncture with/without additional treatment against placebo or sham or no treatment or same additional treatment. We excluded trials that compared different acupuncture methods or acupuncture against other treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We used odds ratio (OR) and mean difference for binary and continuous outcomes respectively. We combined data in meta-analyses where appropriate.

MAIN RESULTS

Thirty-three trials were included. They recruited 2293 participants with insomnia, aged 15 to 98 years, some with medical conditions contributing to insomnia (stroke, end-stage renal disease, perimenopause, pregnancy, psychiatric diseases). They evaluated needle acupuncture, electroacupuncture, acupressure or magnetic acupressure.Compared with no treatment (two studies, 280 participants) or sham/placebo (two studies, 112 participants), acupressure resulted in more people with improvement in sleep quality (compared to no treatment: OR 13.08, 95% confidence interval (CI) 1.79 to 95.59; compared to sham/placebo: OR 6.62, 95% CI 1.78 to 24.55). However, when assuming that dropouts had a worse outcome in sensitivity analysis the beneficial effect of acupuncture was inconclusive. Compared with other treatment alone, acupuncture as an adjunct to other treatment might marginally increase the proportion of people with improved sleep quality (13 studies, 883 participants, OR 3.08, 95% CI 1.93 to 4.90). On subgroup analysis, only needle acupuncture but not electroacupuncture showed benefits. All trials had high risk of bias and were heterogeneous in the definition of insomnia, participant characteristics, acupoints and treatment regimen. The effect sizes were generally small with wide confidence intervals. Publication bias was likely present. Adverse effects were rarely reported and they were minor.

AUTHORS' CONCLUSIONS

Due to poor methodological quality, high levels of heterogeneity and publication bias, the current evidence is not sufficiently rigorous to support or refute acupuncture for treating insomnia. Larger high-quality clinical trials are required.

Placebo effect was influenced by publication year in three-armed acupuncture trials

OBJECTIVES

We investigated the relationship between the placebo effect and the trial or patient characteristics.

DATA SOURCES

We identified randomized clinical trials with acupuncture, sham and no-treatment groups in which no-treatment or conventional therapy was applied to the no-treatment group. Thirty-one trials in which no treatment was applied in the no-treatment group were categorised as 'strict' trials. Thirty-nine trials in which no-treatment or conventional therapy was applied to the no-treatment group were categorised as 'less strict' trials. We calculated the treatment effect, defined as the difference in the effect size between the acupuncture and no-treatment groups, and the placebo effect, defined as the difference in the effect size between the sham and no-treatment groups. Then, a random effect meta-regression analysis was performed on the two effects with respect to trial or patient characteristics.

RESULTS

The treatment effect was not found to be associated with any factors in both the strict and less strict trials. However, the placebo effect was found to be associated with the publication year in both the strict and less strict trials (P=0.009 and 0.005, respectively). The placebo effect increased by 0.05 in effect size per year in trials that were published more recently.

CONCLUSION

While the treatment effect was not influenced by any trial or patient characteristics, the placebo effect was associated with the publication year.