Efficacy of Ginger for Alleviating the Symptoms of Primary Dysmenorrhea: A Systematic Review and Meta-analysis of Randomized Clinical Trials

OBJECTIVE

There has been no attempt to date to synthesize the available evidence for the efficacy of ginger for treating primary dysmenorrhea. This systematic review evaluates the current evidence for the effectiveness of ginger for treating primary dysmenorrhea.

METHODS

Literature searches were conducted using 12 electronic databases including PubMed, EMBASE, Cochrane Library, Korean databases, Chinese medical databases, and Indian scientific database. Search terms used were: "ginger" or "Zingiber officinale" and "dysmenorrhea" and "pain." Studies using ginger as a treatment of primary dysmenorrhea were considered for inclusion. The major outcome of primary dysmenorrhea was assessed using a pain visual analogue score (PVAS).

RESULTS

Initial searches yielded 29 articles. Of these original results, seven met specific selection criteria. Four of the RCTs compared the therapeutic efficacy of ginger with a placebo during the first 3-4 days of the menstrual cycle and were included in the meta analysis. The meta-analysis of these data showed a significant effect of ginger in reducing PVAS in subjects having primary dysmenorrhea (risk ratio, -1.85; 95% CI of -2.87, -0.84, P = 0.0003). Six RCTs out of 7 exhibited low to moderate of risk of bias.

CONCLUSION

Collectively these RCTs provide suggestive evidence for the effectiveness of 750-2000 mg ginger powder during the first 3-4 days of menstrual cycle for primary dysmenorrhea.

Association of patient recall, satisfaction, and adherence to content of an electronic health record (EHR)-generated after visit summary: a randomized clinical trial

OBJECTIVE

Most electronic health record (EHR) systems have the capability of generating a printed after-visit summary (AVS), but there has been little research on optimal content. We conducted a qualitative study and a randomized trial to understand the effect of AVS content on patient recall and satisfaction.

METHODS

Adult primary care patients (n = 272) with at least 1 chronic condition were randomly assigned to 4 AVS content conditions: minimum, intermediate, maximum, or standard AVS. Demographics and health literacy were measured at an index clinic visit. Recall and satisfaction were measured by telephone 2 days and 2 to 3 weeks after the clinic visit.

RESULTS

Average age was 52 years; 75% of patients were female, 61% were Hispanic, and 21% were African American, and 64% had adequate health literacy. Average medication recall accuracy was 53% at 2 days and 52% at 3 weeks, with no significant difference among groups at either time. Satisfaction with AVS content was high and did not differ among groups. Recall of specific content categories was low and unrelated to group assignment. Health literacy was unrelated to recall and satisfaction.

CONCLUSION

Primary care patients like to receive an AVS, but the amount of information included does not affect content recall or satisfaction with the information.

On the use of the Positive and Negative Syndrome Scale in randomized clinical trials

In the last 25 years, the Positive and Negative Syndrome Scale (PANSS) has been largely used to assess schizophrenia symptom intensity, but little information is available on how this scale was generally applied when evaluating the efficacy of schizophrenia therapies in randomized clinical trials. In the attempt to address this topic, a systematic PubMed Search was carried out using the keywords "PANSS" and "Randomized Clinical Trials". The analysis of retrieved articles highlighted that PANSS has constituted a suitable psychometric instrument to investigate the efficacy of pharmacological and non-pharmacological therapies. However, the information potentially provided by this scale was only partially reported in research articles, when characterizing the symptomatic features of patients at baseline. Furthermore, a consensus is needed to identify methodological strategies that may properly adapt PANSS-subscale structure with the symptomatic profiles of individuals enrolled in randomized controlled trials. The possibility that PANSS interview procedures and enrollment eligibility criteria may influence the symptomatic composition of patients involved in these studies is also discussed.

Reasons for Exclusion from a Smoking Cessation Trial: An Analysis by Race/Ethnicity

Objective

The exclusion criteria of tobacco cessation randomized clinical trials (RCTs) may have unintended consequences on inclusion and cessation disparities. We examined racial/ethnic differences in: a) exclusion from a group-based cessation RCT; and b) reasons for exclusion.

Design

Quasi-experimental. Inclusion criteria were self-identification as African American/Black, non-Hispanic White, or Hispanic (any race), adults, minimum five cigarettes/day or carbon monoxide reading of ≥ 8 parts per million (ppm), interest in quitting, and spoke/read English. Data were obtained from a parent trial, which is ongoing and will be completed in 2019. Analyses for our present study on participant screening and enrollment were conducted in 2018.

Main Outcome Measures

Study ineligibility, and reasons for exclusion (contraindications for nicotine patch use, serious mental illness [SMI, eg, bipolar disorder or schizophrenia], alcohol dependence or illicit drug use, current tobacco treatment, attendance barriers [eg, transportation], and other concerns [eg, aggressive, intoxicated, disruptive, visibly ill]).

Results

Of 1,206 individuals screened, 36% were ineligible. The most frequent reasons were SMI (28%), alcohol dependence or drug use (10%), and attendance barriers (7%). Ineligibility was greater among African Americans (42%) and Hispanics (37%), compared with Whites (24%; P<.001). Compared with African Americans and Hispanics, Whites were more likely to be excluded for single reasons, including attendance barriers, and medical conditions (P<.05). African Americans were more than twice as likely as Whites to be excluded for 3 or more reasons (12% vs 5% respectively, P<.05).

Conclusions

A notable proportion of smokers were ineligible for this RCT, with SMI as the greatest single cause. Racial/ethnic minorities were more likely to be excluded, with African Americans deemed ineligible for multiple reasons. Findings have implications for RCT generalizability, addressing tobacco disparities and health equity.

Trends in the number and the quality of trial protocols involving children submitted to a French Institutional Review Board

Background

There is a great need for high quality clinical research for children. The European Pediatric Regulation aimed to improve the quality of clinical trials in order to increase the availability of treatments for children. The main purpose of this study was to assess the evolution of both the number and the quality of pediatric trial protocols that were submitted to a French Institutional Review Board (IRB00009118) before and after the initiation of the EU Pediatric Regulation.

Methods

All protocols submitted to the IRB00009118 between 2003 and 2014 and conducting research on subjects under eighteen years of age were eligible. The quality of randomized clinical trials was assessed according to the guidelines developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network and ranked using the Jadad score.

Results

Out of 622 protocols submitted to the Institutional Review Board (IRB), 21% (133/622) included children. Among these 133 pediatric protocols, the number of submitted pediatric protocols doubled between the two studied periods. From 2003 to 2008, 47 protocols including 21 institutionally sponsored were submitted to the IRB and from 2009 until 2014, 86 protocols including 48 institutionally sponsored were submitted. No significant trend was observed on the quality of RCTs. The overall median score of RCTs on the Jadad scale was high (3.5), 70.0% of protocols had a Jadad score ≥ 3, and 30.0% had a score < 3.

Conclusion

Following the EU Pediatric Regulation, the number of pediatric protocols submitted to the IRB00009118 tends to increase, but no change was noticed regarding their quality.

Randomized Clinical Trials in Pediatric Dentistry: Application of Evidence-Based Dentistry through the CONSORT Statement

In order to include appropriate informed decisions on dental therapeutic or preventive procedures in children, Pediatric Dentists should apply the fundamentals of "Evidence-Based Dentistry" (EBD). This oral health approach assists clinicians in understanding and applying the most relevant research published on evidence in the clinical setting when treating their patients. One of the crucial steps of EBD is to critically appraise and use the primary articles about therapy or prevention, namely, Randomized Clinical Trials (RCT), the study design that best addresses the questions related with these clinical areas. The aim of the present paper was to provide the basic concepts and an example of how to critically read and understand articles on RCT studies in Pediatric Dentistry employing the CONSORT statement, a process that involves assessing the reliability of results, risk of bias (internal validity), and applicability of reported clinical findings (external validity).

Lessons learned from the preclinical discovery and development of sarilumab for the treatment of rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) pathogenesis is driven by a complex network of proinflammatory cytokines, among which interleukin-6 (IL-6) plays a key role in inducing and perpetuating chronic inflammation. Targeting the IL-6 pathway has shown to be an invaluable treatment strategy, as demonstrated by the results accrued in the last decade with the first IL-6 inhibitor, tocilizumab. More recently, a second monoclonal antibody blocking IL-6, sarilumab, has enriched our armamentarium by proving outstanding efficacy in RA treatment.

AREAS COVERED

After exploring the IL-6 pathway under physiological conditions and in the RA pathogenesis, in this review we discuss the pharmacologic properties of sarilumab and the clinical trials that constitute the sarilumab development program and have enabled its licensed application.

EXPERT OPINION

Results from clinical trials confirmed the efficacy and safety of sarilumab for the treatment of RA, similar to its precursor tocilizumab. Blocking IL-6 pathway results in comprehensive control of the disease, from both physician's and patient's perspective, and of RA comorbidities and extra-articular manifestations which are largely IL-6 driven. Finally, the proven efficacy of sarilumab as monotherapy arises the drug as a required therapeutic alternative considering the large proportion of patients intolerant or inadequate to receive conventional synthetic disease-modifying drugs (csDMARDs).

Survival rate of primary molar restorations is not influenced by hand mixed or encapsulated GIC: 24 months RCT

BACKGROUND

Glass ionomer cements (GIC) have been considered the top option to restore primary teeth by dentists. The most common supply forms are hand mixed and encapsulated GIC. There is a lack of information about the impact of different GIC supply forms on restoration survival.

METHODS

This randomized clinical trial compared the survival rate of occlusal and occlusoproximal restorations in primary molars using two glass ionomer cements versions: hand-mixed (H/M) and encapsulated (ENC) after 24 months. Children aged 3-10 years who presented dentin caries lesions in primary molars were selected at School of Dentistry, University of São Paulo, Brazil. They were randomly assigned to groups: H /M (Fuji IX^®, GC Europe) or ENC (Equia Fill^®, GC Europe). The occurrence of restoration failure was evaluated by two blinded and calibrated examiners. The analyses were performed in Stata 13 (StataCorp, USA). To evaluate the primary outcome (restoration survival), we  performed a survival analysis. Additionally an intention to treat (ITT) analysis were done at 24 months of follow-up. Cox Regression with shared frailty was performed to assess association between restoration failure and independent variables (α = 5%).

RESULTS

A total of 324 restorations were performed in 145 children. The survival for H/M group was 58.2% and 60.1% for ENC, with no difference (p = 0.738). Occlusoproximal restorations had lower survival rate when compared to occlusal ones (HR = 3.83; p < 0.001).

CONCLUSIONS

The survival rate in primary molars is not influenced by the different supply forms of GIC. Also, occlusoproximal restorations present reduced performances when compared to occlusal cavities.

TRIAL REGISTRATION

This randomized clinical trial was registered on ClinicalTrials.Gov on 10/15/2014 under protocol (NCT02274142).

Effects of AKT Inhibitors for PIK3CA/AKT1/PTEN-Altered Advanced or Metastatic Breast Cancer: A Meta-Analysis of Randomized Clinical Trials

PURPOSE

We aimed to answer the following question: How effective is the addition of AKT inhibitors to the treatment of advanced or metastatic breast cancer?

METHODS

We searched PubMed, Embase and Cochrane for randomized controlled trials (RCTs) that investigated AKT inhibitors for advanced or metastatic BC. We computed hazard-ratios (HRs) for binary endpoints.

RESULTS

A total of 5 RCTs were included in the meta-analysis, comprising 1,334 patients with BC. The use of AKT inhibitors demonstrated a significant improvement in OS (HR 0.70; 95% CI, 0.58-0.85; P < .001) and PFS (HR 0.6797; 95% CI, 0.5499-0.8403; P < .001) in the overall population. Within the PIK3CA/AKT1/PTEN-altered subgroup (n = 645), the OS rate also significantly favored AKT inhibitors over the control group (HR 0.62; 95% CI, 0.42-0.92; P = .019), as well as PFS (HR 0.5224; 95% CI, 0.3366-0.8105; P = .004).

CONCLUSIONS

Our findings suggest that the incorporation of AKT inhibitors holds promise for treating patients with advanced or metastatic PIK3CA/AKT1/PTEN-altered BC.

Review and Practical Excursus of the Propensity Score: Low Protein Diet Compared to Mediterranean Diet in Patients With Chronic Kidney Disease

Although Randomized clinical trials (RCT) represent the gold standard to compare two or more treatments, the impact of observational studies cannot be ignored. Obviously, these latter are performed on unbalanced sample, and differences among the compared groups could be detected. These differences could have an impact on the estimated association between our allocation and our outcome. To avoid it, some methods should be applied in the analysis of observational cohort. Propensity score (PS) can be considered as a value which sums up and balances the known variables. It aims to adjust or balance the probability of receiving a specific allocation group, and could be used to match, stratify, weight, and perform a covariate adjustment. PS is calculated with a logistic regression, using allocation groups as the outcome. Thanks to PS, we compute the probability of being allocated to one group and we can match patients obtaining two balanced groups. It avoids computing analysis in unbalanced groups. We compared low protein diet (LPD) and the Mediterranean diet in CKD patients and analysed them using the PS methods. Nutritional therapy is fundamental for the prevention, progression and treatment of Chronic Kidney Disease (CKD) and its complications. An individualized, stepwise approach is essential to guarantee high adherence to nutritional patterns and to reach therapeutic goals. The best dietary regimen is still a matter of discussion. In our example, unbalanced analysis showed a significant renal function preservation in LPD, but this correlation was denied after the PS analysis. In conclusion, although unmatched analysis showed differences between the two diets, after propensity analysis no differences were detected. If RCT cannot be performed, balancing the PS score allows to balance the sample and avoids biased results.

Critical appraisal of reporting randomized clinical trials published in Iranian dental journals during 2003-2010

OBJECTIVE

Considering the importance of randomized clinical trials (RCTs) in the evidence-based approach, the objective of this study was critical appraisal of reporting RCTs in Iranian dental journals.

MATERIALS AND METHODS

After adequate searching, 113 RCT articles published during 2003-2010 were reviewed for quality of reporting with the CONSORT scale. The quality of each paper was assessed on 20.

RESULTS

Although statistical analysis was described in 93.8%, acceptable methods for randomization and blinding were found in only 8% and 11.5% of the papers, respectively. Reasons for withdrawal were also given in just 20.4% of the articles.

CONCLUSION

This study revealed that the quality of reporting RCTs in Iranian dental journals does not meet the recommended standards generally and needs to be improved.

Effectiveness of "Centaurea behen" root on quality of life in patients with systolic heart failure: A randomized clinical trial

Introduction: The effect of Centaurea behen (Cb) on patients with systolic heart failure is not known academically. This study was conducted to evaluate the effect of Cb on improving the quality of life (QoL) and echocardiographic and biochemical blood parameters in patients with systolic heart failure. Methods: This study was a parallel double-blind, placebo-controlled randomized trial of 60 patients with systolic heart failure, was conducted from May 2018 up to August 2019. Intervention group received 150 mg twice daily Cb capsules for two months + Guideline directed medical therapy (GDMT), and control group received GDMT + placebo capsules for two months. The main aim of the present study were to assess the QoL based on the 6-minute walk test (6MWT) and the Minnesota living with heart failure questionnaire (MLHFQ). Independent T-test, paired T-test, and ANOVA were used for the analysis. Results: At the beginning of the present study there were no significant differences between study groups in terms of QoL and clinical results. After treatment, the average values of QoL based on MLHFQ and 6MWT instruments were significantly improved 15.5 and 36.18, respectively (P<0.05). Conclusion: Based on the MLHFQ, and 6MWT tests, the consumption of Centaurea behen root extract was associated with significant improvement in the quality of life of patients with systolic heart failure.

The overlooked impact of background diet and adherence in nutrition trials

Importance

Randomized controlled trials in nutrition (RCTN) face unique challenges such as the influence of participants' background diets and varying adherence to the intervention, factors that are difficult to quantify and can mask true intervention effects. However, the exact impact of these factors remains unclear.

Objective

To quantify the impact of background diet and adherence, estimated using validated nutritional biomarkers of flavanol intake, on the outcomes of a large-scale RCTN.

Design Setting and Participants

This study was nested within the COcoa Supplement and Multivitamin Outcomes Study (COSMOS; NCT02422745), a randomized, double-blind, placebo-controlled, 2×2 factorial trial conducted among 21,442 older adults in the United States. Analyses focused on participants (n=6,532) in the placebo and cocoa-extract intervention arms who had available biospecimens and outcome data.

Exposures

Daily supplementation with a cocoa flavanol (CF).

Main Outcomes and Measures

We used validated flavanol biomarkers in urine to assess background dietary flavanol intake and adherence to the cocoa extract intervention. Outcomes included total cardiovascular disease (CVD) events, CVD mortality, all-cause mortality, and major CVD events. Hazard ratios (HRs) with 95% CIs were estimated using intention-to-treat, per-protocol, and biomarker-based analyses.

Results

Of the 6,532 participants, 20% in both the placebo and intervention arms had a background flavanol intake similar to that provided by the intervention; only 5% had no background flavanol intake. In the intervention group, 33% of participants were not adherent based on expected biomarker levels, that was larger than the15% estimated based on self-reported pill-taking. Accounting for biomarker-estimated background diet and adherence resulted in a significant impact on effect sizes. For total CVD events, the HR (95% CI) of 0.79 (0.59-1.05) in the per-protocol analysis (PP), was reduced to 0.65 (0.47-0.89) in the biomarker-based analysis. Similar changes were observed for CVD mortality (from 0.51 (0.23; 1.14) to 0.44 (0.20; 0.97)), all-cause mortality (0.69 (0.45; 1.05) to 0.54 (0.37; 0.80)) and major CVD events (from 0.62 (0.43; 0.91) to 0.48 (0.31; 0.74)). Overall, biomarker-based analyses consistently produced stronger effect estimates than ITT and PP analyses that do not consider the impact of background diet or assess adherence using self-reported methods.

Conclusions and Relevance

These results highlight the importance of considering diet and adherence in RCTN using nutritional biomarker-based analyses. This may help to improve consistency and reliability of outcomes of RTC testing nutritional interventions.

Factors That Predict Magnitude, Timing, and Persistence of Placebo-Like Response in Patients With Irritable Bowel Syndrome

BACKGROUND AND AIMS

Placebo response impedes the development of novel irritable bowel syndrome (IBS) therapies and the interpretability of randomized clinical trials. This study sought to characterize the magnitude, timing, and durability of IBS symptom relief in patients undergoing a non-drug placebo-like control.

METHODS

One hundred forty-five Rome III-diagnosed patients (80% F, M age = 42 years) were assigned to education/nondirective support delivered over a 10-week acute phase. Treatment response was based on the IBS version of the Clinical Global Improvement Scale completed 2 weeks after treatment ended. Candidate predictors were assessed at baseline (eg, emotion regulation, pain catastrophizing, distress, neuroticism, stress, somatization, gastrointestinal-specific anxiety) or clinically relevant points during treatment (patient-provider relationship, treatment expectancy/credibility).

RESULTS

Midtreatment response was associated with lower levels of stress and somatization at baseline and greater patient-provider agreement on treatment tasks (P < .001). Treatment response was associated with baseline gastroenterologist-rated IBS severity, anxiety, ability to reappraise emotions to reduce their impact [cognitive reappraisal], and agreement that provider and patient shared goals from provider perspective (P < .001). The day-to-day ability to reappraise emotions at baseline distinguished rapid from delayed placebo responders (P = .011).

CONCLUSION

Patient beliefs (eg, perceived stress, cognitive reappraisal) impacted the magnitude, timing, and persistence of placebo response measured at midway point of acute phase and 2 weeks after treatment discontinuation. Baseline beliefs that patients could alter the impact of stressful events by rethinking their unpleasantness distinguished rapid vs delayed placebo responders. Collaborative agreement between doctor and patient around shared tasks/goals from the clinician perspective predicted placebo response.