BackgroundA considerable amount of randomized controlled trials (RCTs) have been published on statins and/or fibrates for diabetic retinopathy, a clinical condition associated with high social and economic burden. Adherence to the CONSORT statement items is imperative to ensure transparency and reproducibility in clinical research. The aim of this study is to assess the reporting quality and the adherence to CONSORT of RCTs assessing statins and/or fibrates for diabetic retinopathy.MethodsWe conducted a critical appraisal study at Discipline of Evidence-based Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp). A sensitive literature search was performed to identify all relevant RCTs, with no time or language limits. Two authors independently evaluated the reporting quality of the selected RCTs using the CONSORT statement as a standard.ResultsThirteen reports of RCTs were included in this study. The adherence of the reports to CONSORT items ranged from 24% to 68%. The median score was 11 (interquartile range (IQR) 8 to 13). When analyzed separately, the methods sections of the reports had a median of three items (IQR 2 to 4) judged adherent to the methods items of CONSORT (items 3 to 12). The most underreported items were those related to trial design, title and abstract, allocation concealment, implementation of the randomization sequence, and blinding. Other important items, such as the one related to the description of the inclusion criteria, also had low adherence.ConclusionsThe overall adherence to the CONSORT checklist items was poor, especially in the items related to the methods section. RCT reports on statins and/or fibrates for diabetic retinopathy must be optimized to avoid reporting biases and to improve transparency and reproducibility.
CONTEXT AND OBJECTIVE: Diabetic retinopathy is a disease caused by increased permeability of retinal vessels. Its incidence and prevalence have been increasing due to urbanization, greater life expectancy and the habits of modern life. Its onset is insidious and it may lead to blindness in 75% of individuals who have been diabetic for more than 20 years. The aim here was to evaluate the evidence from Cochrane systematic reviews on interventions relating to diabetic retinopathy. DESIGN AND SETTING: Review of systematic reviews, conducted at Cochrane Brazil. METHODS:We included Cochrane systematic reviews on interventions relating to diabetic retinopathy. Two researchers evaluated the inclusion criteria, summarized the reviews and presented the results narratively. RESULTS: Ten reviews met the inclusion criteria. They showed some evidence of benefits from: (a) photocoagulation for diabetic retinopathy; (b) strict glucose and pressure control for postponing the onset of retinopathy; (c) antiangiogenic drugs for macular edema (high-quality evidence); (d) anti-vascular endothelial growth factor agents for proliferative diabetic retinopathy (very low to low-quality evidence); and (e) intravitreal injection or surgical implantation for treating persistent or refractory macular edema. However, blood pressure control seems to have no benefit after the onset of retinopathy. CONCLUSION: Only a few options are likely to be effective for treating diabetic retinopathy. These include photocoagulation and anti-vascular endothelial growth factor agents. Strict glucose and pressure control seem to postpone the onset of retinopathy. For macular edema, antiangiogenic drugs, intravitreal injection and surgical implantation seem to have some benefit. RESUMO CONTEXTO:A retinopatia diabética é uma doença causada pelo aumento da permeabilidade dos vasos da retina. Sua incidência e prevalência vêm aumentando devido à urbanização, maior expectativa de vida e hábitos de vida modernos. Seu início é insidioso e pode levar à cegueira em 75% dos pacientes diabéti-cos com mais de 20 anos de doença. O objetivo foi avaliar a evidência das revisões sistemáticas Cochrane sobre intervenções para retinopatia diabética.
Evidence from observational studies have found a relationship between serum cholesterol and diabetic retinopathy (DR). Apart of the assumption that cholesterolemic control has benefits for patients with diabetes with or without retinopathy, the effects of lipid-lowering drugs have not been properly mapped and critically assessed so far. The objective of this study was to evaluate the effects of statins and/or fibrates on prevention and progression of DR. We conducted a Systematic review of randomized controlled trials (RCTs) following the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance to PRISMA Statement. GRADE approach was used to summarize the certainty of the evidence. Eight RCTs that fulfilled our eligibility criteria were included, assessing the effects of fibrates (n = 4), statins (n = 3) and fibrate plus statins (n = 1) for therapy (n = 8) or prevention (n = 4) of DR. Overall, the main concern regarding risk of bias assessment was due to incomplete outcome data because high rate of losses in five RCTs. Furthermore, the risk of reporting bias was rated unclear due the lack of previously published protocol in seven RCTs. Fibrates seemed to be associated with a 45% risk reduction of macular edema incidence (Relative Risk 0.55, 95% confidence interval of 0.38 to 0.81, 1309 participants, 2 RCTs, I 2 = 0%, low certainty of the evidence). The certainty of evidence for other outcomes was also very low or low, and we are uncertain regarding the effects of fibrates for DR. Overall, adverse events seemed to be similar between fibrate and placebo, but again based on the width of the confidence intervals, an important increase of adverse events cannot be rule out. The combination statin/fibrate did not seem to have benefit for visual acuity but is likely that further studies can modify this estimate since the current evidence is limited. Adverse events and quality of life were not measured or reported. Concluding, this study found eight RCTs, with limited methodological quality, that assessed the effects of fibrates and/or statins for DR. Based on these findings, we are uncertain about the effects of statins for DR. Fibrates seemed to reduce the incidence of macular edema (low certainty evidence) without increase adverse events (low to very low certainty evidence). Number of Protocol registration PROSPERO CRD42016029746.
BackgroundDiabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus, and more than 75% of patients who have had diabetes for more than 20 years will have some degree of DR. This disease is highly destructive to self-esteem and puts a high burden on public health and pension systems due to the effects that it has on people of working age. The current mainstay of treatment is laser photocoagulation, which causes impairment of vision and discomfort to patients. Thus, finding a systemic drug that could act on all microcirculation and prevent direct manipulation of the eyes would be highly desirable.ObjectiveTo assess the efficacy and safety of the drugs in the statin and/or fibrate groups for the prevention and treatment of DR.MethodsIn this systematic review, we will select randomized controlled trials of fibrates or statins used for the treatment or prevention of DR. Our search strategy will include free text terms and controlled vocabulary (eg, MeSH, Emtree) for, “diabetic retinopathy”, “statins”, “fibrates”, “hypolipidemic agents”, and for drugs from both groups. Databases that will be used include Medical Literature Analysis and Retrieval System/PubMed, Embase, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Center on Health Sciences Information, Clinicaltrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey, and we will not have language or date limits. Two review authors will independently select eligible studies and assess the risk of bias using the Cochrane Collaboration’s tool. We will report structured summaries of the included studies and, if possible, conduct meta-analyses.ResultsThis is a protocol for a systematic review, therefore results are not available. We registered a short version of this protocol before progressing in the review and we are currently in the process of selecting the studies for inclusion.ConclusionsIntensive glucose control and lowering blood pressure and lipids are mechanisms that protect macrocirculation in diabetic patients. Both macrovascular and microvascular events in diabetic patients appear to have a common pathway, starting with endothelial injury. Thus, prevention and treatment of microvascular events may benefit from the same interventions. In the review for which we have written this protocol, we will assess whether the use of lipid-lowering oral drugs of the statin and/or fibrate groups may prevent and/or retard progression of DR, with the added benefit of preserving visual acuity.Trial RegistrationPROSPERO CRD42016029746
Except for some specific uses of apitherapy (honey for burn wounds and for acute coughs and bee venom for allergic reactions to insect stings), the use of ten integrative practices that have recently been incorporated into SUS does not seem to be supported by evidence from Cochrane SRs.
BACKGROUND: Clinical trials are well-designed papers that aim to answer questions in the real world. However, sometimes they present missing, dubious and unclear outcomes that make it difficult to apply in practice. OBJECTIVE: The objective of this work is to evaluate the way and the frequency with which the outcomes in randomized clinical trials of intervention in diabetic retinopathy can be presented in an unclear way to readers. Make an analysis of how these dubious presentations can lead to misinterpretations, why this happens and how they can be remedied. METHODS AND MATERIALS: We conducted a search for RCT about DR intervention in PubMed published over the past five years. RESULTS: Seventy RCT were included, 27 in peripheral diabetic retinopathy (PDR) and 43 in diabetic macular edema (DME). In the DME group we found 25.6% reporting and publication bias; 34.9% subjective outcomes, 44.1% presented a lack of presentation of the baseline and 51.1% underreporting adverse events. In the PDR group we found 29.6% reporting and publication bias; 44.4% subjective outcomes, 14.8% presented a lack of presentation of the baseline and 62.9% underreporting adverse events. CONCLUSION: In addition to the result bias, we found other forms of publication of unclear outcomes in RCT on DR. Most of them occurred due to disrespect for CONSORT parameters. The reader must be attentive to recognize them and know how they can influence the interpretation of the data.
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