Randomized trials are frequently fragmented in multiple secondary publications.

OBJECTIVE: To assess the frequency and features of secondary publications of randomized controlled trials (RCTs). STUDY DESIGN AND SETTING: For 191 RCTs published in high-impact journals in 2009, we searched for secondary publications coauthored by at least one same author of the primary trial publication. We evaluated the probability of having secondary publications, characteristics of the primary trial publication that predict having secondary publications, types of secondary analyses conducted, and statistical significance of those analyses. RESULTS: Of 191 primary trials, 88 (46%) had a total of 475 secondary publications by 2/2014. Eight trials had >10 (up to 51) secondary publications each. In multivariable modeling, the risk of having subsequent secondary publications increased 1.32-fold (95% CI 1.05-1.68) per 10-fold increase in sample size, and 1.71-fold (95% CI 1.19-2.45) in the presence of a design article. In a sample of 197 secondary publications examined in depth, 193 tested different hypotheses than the primary publication. Of the 193, 43 tested differences between subgroups, 85 assessed predictive factors associated with an outcome of interest, 118 evaluated different outcomes than the original article, 71 had differences in eligibility criteria, and 21 assessed different durations of follow-up; 176 (91%) presented at least one analysis with statistically significant results. CONCLUSIONS: Approximately half of randomized trials in high-impact journals have secondary publications published with a few trials followed by numerous secondary publications. Almost all of these publications report some statistically significant results.

Meta-analyses with industry involvement are massively published and report no caveats for antidepressants.

OBJECTIVES: To identify the impact of industry involvement in the publication and interpretation of meta-analyses of antidepressant trials in depression. STUDY DESIGN AND SETTING: Using MEDLINE, we identified all meta-analyses evaluating antidepressants for depression published in January 2007-March 2014. We extracted data pertaining to author affiliations, conflicts of interest, and whether the conclusion of the abstract included negative statements on whether the antidepressant(s) were effective or safe. RESULTS: We identified 185 eligible meta-analyses. Fifty-four meta-analyses (29%) had authors who were employees of the assessed drug manufacturer, and 147 (79%) had some industry link (sponsorship or authors who were industry employees and/or had conflicts of interest). Only 58 meta-analyses (31%) had negative statements in the concluding statement of the abstract. Meta-analyses including an author who were employees of the manufacturer of the assessed drug were 22-fold less likely to have negative statements about the drug than other meta-analyses [1/54 (2%) vs. 57/131 (44%); P < 0.001]. CONCLUSION: There is a massive production of meta-analyses of antidepressants for depression authored by or linked to the industry, and they almost never report any caveats about antidepressants in their abstracts. Our findings add a note of caution for meta-analyses with ties to the manufacturers of the assessed products.

Measures of Symptom Exaggeration for Mental Health Disorders: A Systematic Review.

Introduction .- Measures that help detect exaggeration of symptoms can be valuable for informing more accurate diagnoses and aid in treatment and case management. We completed a systematic review to identify measures that assess symptom exaggeration in mental health disorders. Methods .- Eligible studies assessed exaggeration of symptoms with a psychometrically validated measure in patients presenting with a mental health disorder. We searched MEDLINE and PsycINFO from inception to June 2013 for relevant studies. To determine study eligibility, reviewers screened title and abstracts of identified citations, and reviewed full texts of all potentially eligible citations. Data extractors completed data abstraction of eligible studies. Results .- Of 8435 unique citations, 105 studies consisting of 112 cohorts were eligible, and we identified 36 unique, validated measures assessing exaggeration of symptoms. The most frequently used measures were symptom validity indicators embedded in the Minnesota Multiphasic Personality Inventory (MMPI-2) (n=48, 46%), the Structured Interview of Reported Symptoms (SIRS) (n=12, 11%), and the Personality Assessment Inventory (PAI) (n=11, 10%). Most studies (n=96; 91%) failed to test reliability of their measure of symptom exaggeration. The symptom validity indicators in the MMPI/MMPI-2 and the SIRS both showed moderate to high internal consistency, range 0.47 to 0.85 and 0.48 to 0.95, respectively. Conclusions .- Multiple measures assessing symptom exaggeration have been used in patients with mental health disorders. The symptom validity indicators of the MMPI/MMPI-2 are the most widely used measures to assess symptom exaggeration. Assessment and reporting of reliability is poor across studies; we require further assessment of psychometric properties for existing measures of symptom exaggeration.

Measures of patients' expectations about recovery: a systematic review.

INTRODUCTION: Patients' expectations regarding their prognosis has been shown to affect recovery. We completed a systematic review to identify measures that assess patients' expectations of recovery. METHODS: Eligible studies explored the association between patients' expectations of recovery, and return to work or claim resolution. We searched electronic databases (MEDLINE and PSYCInfo) from inception to June 21, 2014, bibliographies of eligible studies, relevant systematic reviews and our personal files. Reviewers determined study eligibility and study quality, and completed data extraction. RESULTS: Of 14,509 unique citations, 46 studies were eligible with majority of the studies (n = 27; 59 %) rated as low quality, primarily due to substantial missing data and inappropriate adjustment for age, gender and illness severity in their regression models. We identified 5 measures and 41 individual items assessing recovery expectations. Three of seven (43 %) studies using a measure to assess recovery expectations reported psychometric properties, with only one reporting both reliability and construct validity. Only two measures (Expectations of Recovery Scale and the Work-related Recovery Expectations Questionnaire) were externally validated in different populations. Overall, 44 (96 %) studies found that patient recovery expectations was a significant predictor of return to work or sick leave/disability claim resolution. CONCLUSIONS: Very few studies assessing recovery expectations use a psychometrically valid measure. Current evidence suggests that patients with lower recovery expectations are less likely to resolve their disability claim or return to work versus patients with higher recovery expectations. Further validation of existing measures for assessing patient recovery expectations, or development of a new measure that addresses the limitations of existing ones, is required.

Low-intensity pulsed ultrasonography versus electrical stimulation for fracture healing: a systematic review and network meta-analysis.

BACKGROUND: To best inform evidence-based patient care, it is often desirable to compare competing therapies. We performed a network meta-analysis to indirectly compare low intensity pulsed ultrasonography (LIPUS) with electrical stimulation (ESTIM) for fracture healing. METHODS: We searched the reference lists of recent reviews evaluating LIPUS and ESTIM that included studies published up to 2011 from 4 electronic databases. We updated the searches of all electronic databases up to April 2012. Eligible trials were those that included patients with a fresh fracture or an existing delayed union or nonunion who were randomized to LIPUS or ESTIM as well as a control group. Two pairs of reviewers, independently and in duplicate, screened titles and abstracts, reviewed the full text of potentially eligible articles, extracted data and assessed study quality. We used standard and network meta-analytic techniques to synthesize the data. RESULTS: Of the 27 eligible trials, 15 provided data for our analyses. In patients with a fresh fracture, there was a suggested benefit of LIPUS at 6 months (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.97-1.41). In patients with an existing nonunion or delayed union, ESTIM had a suggested benefit over standard care on union rates at 3 months (RR 2.05, 95% CI 0.99-4.24). We found very low-quality evidence suggesting a potential benefit of LIPUS versus ESTIM in improving union rates at 6 months (RR 0.76, 95% CI 0.58-1.01) in fresh fracture populations. CONCLUSION: To support our findings direct comparative trials with safeguards against bias assessing outcomes important to patients, such as functional recovery, are required.

CONTEXTE: Pour mieux orienter les soins fondés sur des données probantes, il est souvent souhaitable de comparer des traitements entre eux. Nous avons procédé à une méta-analyse réseau pour comparer indirectement l'effet des ultrasons pulsés de faible intensité (UPFI) et de l'électrostimulation (ÉS) sur la guérison des fractures. MÉTHODES: Nous avons interrogé les listes bibliographiques de revues récentes ayant évalué les UPFI et l'ÉS, en incluant des études publiées jusqu'en 2011 à partir de 4 bases de données électroniques. Nous avons actualisé les interrogations de toutes les bases de données électroniques jusqu'à avril 2012. Les essais admissibles étaient ceux qui incluaient des patients victimes d'une fracture récente ou présentant un retard de soudure ou une non soudure de fracture ayant été assignés aléatoirement aux UPFI ou à l'ÉS ou à un groupe témoin. Deux paires d'examinateurs ont passé en revue indépendamment et en duplicata les titres, les résumés et les textes complets des articles potentiellement admissibles. Ils en ont extrait les données et ont évalué la qualité des études. Nous avons utilisé des techniques de méta-analyse standard et réseau pour synthétiser les données. RÉSULTATS: Parmi les 27 essais admissibles, 15 ont fourni des données pour notre analyse. Chez les patients présentant une fracture récente, les UPFI auraient produit un avantage à 6 mois (risque relatif [RR] 1,17, intervalle de confiance [IC] de 95 % 0,97­1,41). Chez les patients qui présentaient un problème de non soudure ou de retard de soudure osseuse et par rapport aux soins classiques, l'ÉS aurait conféré un avantage sur les taux de soudure osseuse à 3 mois (RR 2,05, IC de 95 % 0,99­4,24), et nous avons noté des preuves de très faible qualité selon lesquelles les UPFI conféreraient un avantage potentiel par rapport à l'ÉS pour ce qui est d'améliorer les taux de soudure osseuse à 6 mois (RR 0,76, IC de 95% 0,58­1,01) chez les populations dont les fractures étaient récentes. CONCLUSION: Pour confirmer nos conclusions, il faudra procéder à des essais comparatifs directs en veillant à écarter tout biais lors de l'évaluation des paramètres importants liés aux patients, tels que le rétablissement fonctionnel.

Postgraduate anaesthesiology education: protocol for a scoping review.

INTRODUCTION: The link between education and clinical practice is vital, yet the current state of research suggests there is a substantial gap between medical education research and practice. This too is the case in the domain of anaesthesiology education research, as much of the research focuses on simulation studies, and a narrow range of research methods. The aim of this study is to comprehensively review the existing literature in postgraduate anaesthesiology education research in order to identify key research priorities. The findings from this review will be used to establish a base for developing a strategic research programme in anaesthesia education and practice. METHODS AND ANALYSIS: We will employ the scoping review methodology outlined by Arksey and O'Malley (2005) to comprehensively search the literature pertaining to postgraduate anaesthesiology education. We will search relevant electronic databases (eg, MEDLINE, EMBASE) and grey literature. After conducting calibration exercises, two authors will independently apply inclusion criteria to all titles and abstracts and perform full-text review of all eligible articles. Data to be extracted will include basic information about the study (eg, location, design) as well as detailed information regarding the context of the research and type of education examined. Our results will be used to develop a framework of themes that outline the research currently being conducted and identify gaps in research. ETHICS AND DISSEMINATION: This review is the first step in a strategic research plan in postgraduate anaesthesiology education. We plan to disseminate this research through publications, presentations and meetings with relevant stakeholders. Ethical approval was not sought for this scoping review.

Help-seeking in transit workers exposed to acute psychological trauma: a qualitative analysis.

BACKGROUND: Traumatic events often occur in workplace settings and can lead to stress reactions such as Post-Traumatic Stress Disorder (PTSD). One such workplace is the transportation industry, where employees are often exposed to trauma. However, extant research shows that a considerable proportion of people with PTSD do not seek specialty mental health treatment. OBJECTIVE: In this qualitative study, we sought to better understand the experience of a traumatic event at work and the barriers and motivating factors for seeking mental health treatment. PARTICIPANTS: Twenty-nine Toronto Transit Commission (TTC) employees participated in a one-on-one interview, 18 soon after the traumatic event and 11 after entering a specialized treatment program. METHODS: Semi-structured, one-on-one interviews were conducting using qualitative description and analyzed using content analysis. RESULTS: Participants described emotional responses after the trauma such as guilt, anger, disbelief as particularly difficult, and explained that barriers to seeking help included the overwhelming amount and timing of paperwork related to the incident as well as negative interactions with management. Motivating factors included family and peer support, as well as financial and emotional issues which persuaded some to seek help. CONCLUSIONS: Seeking treatment is a multifactorial process. Implications and recommendations for the organization are discussed.

The epidemiology of competence: protocol for a scoping review.

INTRODUCTION: Factors that are important to the competence of healthcare providers have important consequences for quality of healthcare. Although some previous research has discussed risks or supports to the competence of clinicians, a thorough exploration is currently lacking. The purpose of this review is to examine the literature examining risks and supports to clinical competence of healthcare practitioners and trainees engaged in field-based education. In this study, field-based education refers to teaching or training in a real-world/work-based setting. METHODS AND ANALYSIS: We will employ an established scoping review methodology. Eligible studies will include those that mention (1) a healthcare professional, (2) competence from field-based education throughout the lifespan/career and (3) a risk or support to competence. Four authors will independently apply the inclusion criteria to all studies, regardless of study design. Our data extraction will include information on study design, location and type of study and we will develop a comprehensive list of risks and supports that are discussed in the literature. ETHICS AND DISSEMINATION: Since this is a review of the literature, ethics approval is not indicated. We will disseminate the findings from this study in publications in peer-reviewed journals as well as presentations at relevant national and international conferences.

Correcting and interpreting the effect of cognitive therapy versus exposure in anxiety disorders.

Dr. Ougrin's evaluation of cognitive therapy versus exposure in anxiety disorders reported a standardised mean difference [SMD] (95% confidence interval [CI]) of 0.52 (0.37, 0.74) for short-term outcomes and 0.46 (0.29, 0.73) for long-term outcomes in social phobia, and 0.88 (0.69, 1.11) for short-term outcomes and 1.05 (0.80, 1.37) for long-term outcomes in posttraumatic stress disorder (PTSD). These were incorrectly meta-analysed. Upon re-analysis, we found that the correct SMD (95% CI) was -0.66 (-1.19, -0.14) for short-term outcomes and mean difference (95% CI) of -29.66 (-46.13, -13.19) on the Social Phobia subscale from the Social Phobia Anxiety Inventory for long-term outcomes in Social Phobia. For PTSD, the SMD (95% CI) for short-term outcomes was -0.13 (-0.36, 0.11) and 0.05 (-0.22, 0.32) for long-term outcomes. However, correcting the errors did not change the interpretation of the findings considerably.