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• W4309343983 abstract "Dear Editor, Lateral epicondylitis (LE), commonly known as Tennis Elbow, is a most common cause of musculoskeletal pain involving the common extensor origin of forearm [1]. The disorder arises as a result of repetitive manual work involving overexertion of wrist and finger extensors and imparts significant disability in quality of daily life activities [2]. Numerous methods have been advocated to treat elbow tendinosis including rest, nonsteroidal anti-inflammatory medication, bracing, physical therapy, extracorporeal shockwave therapy and botulinum toxin injection [3]. Corticosteroid (CS) injections are the gold standard, but they have only a short-term effect lasting 2–6 weeks [4]. Autologous platelet-rich plasma (PRP) when delivered into various tissues to achieve a high local concentration of platelet-derived growth factors has been shown to enhance healing in wounds, tendons, and bones [5]. Currently, whether CS or PRP is better in LE remains controversial in published clinical trials. We have great pleasure in reading the article titled “Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials” published by Xu et al. [6], they indicated that PRP injection yielded statistically superior results in pain score and elbow joint function at 6-month follow up when compared with local corticosteroid injection. No significant difference was identified between the two groups regarding post-injection adverse events. They drew a conclusion that local PRP injections to be associated with superior outcomes in reducing pain and improving elbow joint function when compared with local corticosteroids treatment for LE at a follow-up of 6 months. At the outset, we would like to congratulate the authors for writing such an informative article with novelty. However, we have several suggestions and comments that we would like to communicate with the authors. First, several flaws in the study design and statistical methods are worth pointing out. Study protocol registration is a key element of a systematic review and it is considered to be a reliable approach not only to enhance and maintain clarity of a successful review, but also to reduce the risk of selective reporting bias [7]. However, the authors did not register the study protocol in the International Prospective Register of Systematic Reviews (PROSPERO). The authors showed that they searched the relevant studies in electronic databases including PubMed, Embase, Ovid, Cochrane Library, Web of Science, Wan Fang, China National Knowledge Internet. Two Chinese databases (Wan Fang and China National Knowledge Internet) were included, but the authors did not include any Chinese studies in their meta-analysis. However, we found some Chinese [8,9] studies that conform to the criteria were left out by the authors, which may increase selection biases. In addition, there were some mistakes in the search string: “(Lateral epicondylitis OR Tennis elbow [Title/Abstract]) AND (Platelet rich plasma AND Corticosteroid OR Steroid [Title/Abstract])”. This should instead be “(Lateral epicondylitis OR Tennis elbow [Title/Abstract]) AND (Platelet rich plasma [Title/Abstract]) AND (Corticosteroid OR Steroid [Title/Abstract]) AND (Randomized Controlled Trial OR RCT [Title/Abstract])”. A search using a combination of Medical Subject Headings (MeSH) and free-text terms is more preferable. In addition, a detailed search strategy should include searching articles by reading the published articles and supplementary materials. Essential published articles can be missed if the manual search protocol is incomplete. Since only 515 patients were included in this meta-analysis, the results would be more convincing if the authors had included other databases such as Medline, NLM Gateway, Google Scholar, BIOSIS previews and Clinicaltrials.gov to obtain more studies, with less chances of published articles being missed. Also, the authors stated that the mean and standard deviation (SD) were estimated based on sample size, median and range if not reported. How did the authors estimate the SD? Does any literature support this? Second, there were some mistakes in their table of characteristics of the included RCTs. For instance, under Gautam et al. these are some mistakes in “Doses of PRP”, “Doses of corticosteroids” and “Follow up”. The follow up of Gosens et al. and Gautam et al. were not correct, which should be “2 years” and “6 months”, respectively. Besides, we suggest that the outcome index such as VAS-1st, VAS-2nd, VAS-6th, MAYO and DASH should be included in the table of characteristics of the included RCTs. The table of the risk of bias assessment summary and risk of bias graph also have some mistakes. We have carefully reviewed the included studies and evaluated their risks of bias according to the Cochrane tool, we found some of our results to be inconsistent with the results of the authors. Our results are shown in Fig. 1. A low risk of publication bias was identified by funnel plot for the VAS at 1st month by the authors and this was not exactly correct. We suggest the authors to perform the Egger test to detect publication bias.Fig. 1.: Risk of bias summary and risk of bias graph.Third, a high degree of heterogeneity should not lead to any definitive conclusions as based on the Cochrane Handbook for Systematic Reviews [10], as a high heterogeneity can reduce reliability of the conclusions. We found significant heterogeneity to exist in the outcomes MAYO at 1st month, MAYO at 2nd month and DASH score. With such large heterogeneities in some of these outcomes, subgroup analysis and sensitivity analysis should have been conducted to find the sources of heterogeneity by performing subgroup analysis as stratified by sample size (>60 or ≤60), age (>40 years or ≤ 40 years), doses of PRP, type of corticosteroids and follow-up (>3 months or ≤3 months). Besides, sensitivity analysis by excluding individual studies one by one to determine the strength and stability of the pooled data has not been performed in this meta-analysis. A more robust model, the Inverse Variance Heterogeneity (IVhet) model, has been introduced in the study by Doi et al. [11]. They examined an improved alternative to the random effects (RE) model for meta-analysis of heterogeneous studies. Therefore, we suggest the authors to use the IVhet model to re-analyze the outcomes of this study. Fourth, we are very suspicious of the authenticity of the extracted data. For the outcome VAS at 1st month, VAS at 2nd month and VAS at 6th month, we carefully reviewed the included studies, and found the following differences from the authors' reported data: Krogh et al. [12] reported the Patient-Rated Tennis Elbow Evaluation (PRTEE) pain score instead of the VAS score, and they used ▵pain data (pain reduction); Gautam et al. [13] only reported VAS at 2nd week, 6th week, 3rd month and 6th month and they did not report on VAS at 1st month and VAS at 2nd month; The patients were only followed up for 3 weeks in the study by Khaliq et al. [14] and where did the authors extract the data of VAS at 1st month, VAS at 2nd month and VAS at 6th month? The same concern also existed in the outcome MAYO score: Gautam et al. [13] only reported MAYO score at 2nd week, 6th week, 3rd month and 6th month and there was a lack of data of MAYO score at 1st month and MAYO score at 2nd month; Yadav et al. [15] did not report MAYO score in their study; Also, the patients were only followed up for 3 weeks in the study by Khaliq et al. [14], and where did the data of MAYO score at 1st month, 2nd month and 6th month come from? As for the outcome DASH score: Varshney et al. [16] did not report the DASH score in their study. The authors stated that four included studies showed the incidence of adverse effects after local injection, however, they only included three studies to analyze. Indeed, only two included studies reported adverse effects, and Yadav et al. [15] did not report on adverse effects. Based on the above issues, we extracted the data from the included studies and pool them to analyze. As shown in Fig. 2, the pooled results showed that VAS at 1st month in the PRP group were significantly higher than that in the CS group (SMD = 0.347; 95%CI = 0.111 to 0.584; P = 0.004; heterogeneity χ2 = 1.68, df = 2; I2 = 0%, P = 0.431), which was inconsistent with the authors' results. Besides, no significant difference was found in the PRP group and the CS group regarding VAS at 2nd month (SMD = 0.182; 95%CI = −0.053 to 0.417; P = 0.129; heterogeneity χ2 = 0.15, df = 2; I2 = 0%, P = 0.929, Fig. 3), which was also inconsistent with the authors' results. However, a significant decrease in VAS at 6th month was observed in the PRP group compared with the CS group (SMD = −1.406; 95%CI = −2.194 to −0.619; P < 0.001; heterogeneity χ2 = 27.39; df = 3; I2 = 89%, P < 0.001, Fig. 4). As for the MAYO score, only MAYO score at 6th month could be pooled and our results showed that PRP significantly improved the MAYO score at 6th month when compared with CS (SMD = 3.072; 95%CI = 0.978 to 5.166; P = 0.004; heterogeneity χ2 = 12.69; df = 1; I2 = 92.1%, P < 0.001, Fig. 5), which was in line with the authors' results. On the DASH score, only DASH score at 6th month could be pooled and our results showed PRP visibly reduced the DASH score at 6th month as compared with CS (WMD = −7.728; 95%CI = −0.992 to −5.465; P < 0.001; heterogeneity χ2 = 0.2; df = 1; I2 = 0%, P = 0.655, Fig. 6), which was reported by the authors. With high heterogeneities found in the outcome VAS at 6th month, sensitivity analysis was conducted to detect the source of heterogeneity. As shown in Fig. 7, the results of sensitivity analysis showed that a significant effect was observed after excluding any one single study, suggesting that the results of our results were relatively robust. Moreover, we evaluated the potential publication bias of VAS at 6th month through the Egger test (Fig. 8). The P values from the Egger's tests indicated that there was no significant publication bias (P = 0.368).Fig. 2.: Forest plot of VAS at 1st month.Fig. 3.: Forest plot of VAS at 2nd month.Fig. 4.: Forest plot of VAS at 6th month.Fig. 5.: Forest plot of MAYO at 6th month.Fig. 6.: Forest plot of DASH at 6th month.Fig. 7.: Sensitivity analysis of VAS at 6th month.Fig. 8.: Egger test of VAS at 6th month.Finally, the quality assessment of evidence according to the GRADE criteria [17] was reported in this study. Nevertheless, the results of most outcomes were not correct because of the inaccurately extracted data. We recently re-evaluated the quality of evidence of the included studies using the GRADE criteria by GRADE profiler 3.6 version. As shown in Table 1, most outcomes are graded as “very low” or “low” because of the risk of bias and inconsistency. Therefore, the authors should be extremely cautious when drawing conclusions.Table 1: The GRADE evidence quality for each outcome.We thank Xu et al. again for their meaningful work in summarizing the evidence of PRP and CS in treating LE. However, a more clear and meticulous methodology, an exhaustive search strategy, and scrutinized analysis of the data provided could have enhanced the robustness and accuracy of the findings and reinforced the clinical impact of this extensive literature review and meta-analysis. Provenance and peer review Commentary, internally reviewed. Ethical approval Not Applicable. Sources of funding None. Author contribution Zhou Lin: statistical analysis and writing. Fan Lin: statistical analysis and literature search. Jiejun Lin: study design. Research Registration Unique Identifying Number (UIN) None. Guarantor Jiejun Lin. Declaration of competing of interest None. Zhou Lin Fan Lin Jiejun Lin 1Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, PR China 2Department of Gastroenterology, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou, Zhejiang, 325000, PR China E-mail addresses:[email protected]" @default.
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• W4309343983 title "A commentary on Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials (Int J Surg 2019;67:37–46)" @default.
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