18/n I'm also worried about the heterogeneity of the 'usual care' groups across studies. Some of the usual care: - coffee - paracetamol - syrup - diphenhydramine - placebo - prednisolone These are very much not the same!
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19/n That's a big issue because you can't really combine the effect of coffee with diphenhydramine and expect it to make sense, but that's what the authors did
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20/n Ultimately, I think the only real conclusion you can draw here is that we have very little idea whether honey reduces symptoms for URTI/cough, and that the research is quite problematic
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21/n Not something that'll make headlines, perhaps, but sadly that's often how these things go
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22/n N.B. this study has already hit ~800 on Altmetric, been covered internationally, and made huge newspic.twitter.com/bj72yqShfA
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23/n Something else I didn't mention. Every study that I've looked at so far used a per-protocol analysis, which is a huge and worrying issue All of these should be at a high risk of attrition bias, yet none were rated as such. Most of them were green (low risk)pic.twitter.com/Y6sXlnkJHe
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24/n I've gotta say, for anyone teaching students about how finicky bias can be in systematic reviews, this is a beautiful example of getting it wrong
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25/n Somehow there are more issues here. This study was included in the risk of bias, but even though it assessed honey vs placebo/salbutamonl (and found no effect) it is not in any of the meta-analyses Very weirdpic.twitter.com/8AaMA85ERm
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26/n This is even weirder when you consider that the authors report excluding a study for not providing data So they exclude one study and report it, but another just...disappears? So strangepic.twitter.com/oyrp57yP1Y
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27/n Another included study using a per-protocol analysis. This was at least rated correctly as at a high risk of biaspic.twitter.com/t2mRMIq539
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28/n Another one. This study was rated at low risk of bias for most domains. Here's how they described their randomization and allocation concealment. What do you think?pic.twitter.com/1NM606xcRg
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29/n I'll give you a head-start - if they literally don't report ~how~ patients were randomized, by definition this should be unclear or high risk of bias for the domain of random sequence generation
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