Core Clinical Journals Research Articles

The Methodological Quality of Observational Studies Examining the Risk of Pregnancy Drug Use on Congenital Malformations Needs Substantial Improvement: A Cross-Sectional Survey.

An increasing number of observational studies have investigated the risk of using drugs during pregnancy on congenital malformations. However, the credibility of the causal relationships drawn from these studies remains uncertain. This study aims to evaluate the potential methodological issues in existing observational studies. We used a stepwise approach to investigate this issue. First, we identified observational studies published in 2020 that examined the risk of congenital malformations associated with medication use during pregnancy. We assessed the methodological characteristics for establishing causality, including study design, confounding control, and sensitivity analysis, and compared them between "core clinical journals" and "general journals." For studies reporting an increased risk of congenital malformations in core clinical journals, we searched for subsequent studies addressing the same research question published between January 2021 and May 2023 to assess the consistency of the literature. A total of 40 eligible studies were published in 2020, primarily focused on the safety of vitamin B12 and folic acid (n=4), antidepressants (n=4), and others (n=32). Our findings suggest that only two (5.00%) studies used causal models to guide the identification of confounding, and only eight (20.00%) studies assessed the potential dose-response relationship. In all, 15 (37.50%) studies used propensity score analysis strategy to achieve "mimic-randomization." In addition, 22 studies (55.00%) performed sensitivity analyses, while 10 (45.45%) showed inconsistency with the primary outcome. Furthermore, 5 studies reported positive outcomes, whereas only 1 out of 11 studies demonstrated a positive correlation between drug usage during pregnancy and major malformations in subsequent studies. A significant portion of the studies has failed to sufficiently consider the essential methodological characteristics required to improve the credibility of causal inferences. The increased risk of congenital malformations documented in core clinical journal was not adequately replicated in subsequent studies.

PubMed's core clinical journals filter: redesigned for contemporary clinical impact and utility.

The Core Clinical Journals (CCJ) list, produced by the U.S. National Library of Medicine (NLM), has been used by clinicians and librarians for half a century for two main purposes: narrowing a literature search to clinically useful journals and identifying high priority titles for library collections. After documentation of low usage of the existing CCJ, a review was undertaken to assess current validity, followed by an update to current clinical needs. As the subject coverage of the 50-year-old list had never been evaluated, the CCJ committee began its innovative step-wise approach by analyzing the existing subject scope. To determine whether clinical subjects had changed over the last half-century, the committee collected data on journal usage in hospitals and medical facilities, adding journal usage from Morning Report blogs recording the journal article citations used by physicians and residents in response to clinical questions. Patient-driven high-frequency diagnoses and subjects added contextual data by depicting the clinical environment. The analysis identified a total of 80 subjects and selected 241 journals for the updated Clinical Journals filter, based on actual clinical utility of each journal. These data-driven methods created a different framework for evaluating the structure and content of this filter. It is the real-world evidence needed to highlight CCJ clinical impact and push clinically useful journals to first page results. Since the new process resulted in a new product, the name warrants a change from Core Clinical Journals (CCJ) to Clinically Useful Journals (CUJ). Therefore, the redesigned NLM Core Clinical Journals/AIM set from this point forward will be referred to as Clinically Useful Journals (CUJ). The evidence-based process used to reframe evaluation of the clinical impact and utility of biomedical journals is documented in this article.

Evaluating the impact of including non-randomised studies of interventions in meta-analysis of randomised controlled trials: a protocol for a meta-epidemiological study

IntroductionAlthough interest in including non-randomised studies of interventions (NRSIs) in meta-analysis of randomised controlled trials (RCTs) is growing, estimates of effectiveness obtained from NRSIs are vulnerable to greater bias than...

Meta-epidemiological review identified variable reporting and handling of time-to-event analyses in publications of trials included in meta-analyses of systematic reviews

ObjectivesPrevious findings indicate limited reporting of systematic reviews with meta-analyses of time-to-event (TTE) outcomes. We assessed corresponding available information in trial publications included in such meta-analyses. Study Design and SettingWe extracted data from all randomized trials in pairwise, hazard ratio (HR)–based meta-analyses of primary outcomes and overall survival of 50 systematic reviews systematically identified from the Cochrane Database and Core Clinical Journals. Data on methods and characteristics relevant for TTE analysis of reviews, trials, and outcomes were extracted. ResultsMeta-analyses included 235 trials with 315 trial analyses. Most prominently assessed was overall survival (91%). Definitions (61%), censoring reasons (41%), and follow-up specifications (56%) for trial outcomes were often missing. Available TTE data per trial were most frequently survival curves (83%), log-rank P values (76%), and HRs (72%). When trial TTE data recalculation was reported, reviews mostly specified HRs or P values (each 5%). Reviews primarily included intention-to-treat analyses (64%) and analyses not adjusted for covariates (25%). Except for missing outcome data, TTE-relevant trial characteristics, for example, informative censoring, treatment switching, and proportional hazards, were sporadically addressed in trial publications. Reporting limitations in trial publications translate to the review level. ConclusionTTE (meta)-analyses, in trial and review publications, need clear reporting standards.

Use of statistical methods among acupuncture randomized controlled trials was far from satisfactory

ObjectivesTo examine whether appropriate statistical methods were used in acupuncture randomized controlled trials (RCTs). Study Design and SettingWe searched PubMed to identify acupuncture RCTs with continuous outcome as primary outcome published in the core clinical journals and complementary and alternative medicine (CAM) journals between January 2010 and December 2019 (10 years). We compared statistical characteristics of included trials published in core clinical journals and CAM journals. ResultsWe included 262 RCTs, including 46 published in core clinical journals and 216 in CAM journals. Of included RCTs, only 132 (50.4%) clearly predefined the primary outcome, 72 (27.5%) specified the use of intention to treat or modified intention to treat population for primary analysis. In the 167 trials reported missing participant data (MPD), 118 (70.7%) used suboptimal methods (e.g., complete case analysis) for dealing with MPD; 11 (6.6%) conducted sensitivity analysis regarding MPD. Among the 161 trials with repeated measures design, only 21 (13.0%) used advanced statistical models (e.g., mixed-effects models) for handling repeated-measure data in the primary analysis. In the 72 trials involving multiple acupuncturists, only 4 (5.6%) adjusted acupuncturist variable or considered the clustering by acupuncturist in analysis. Trials in core clinical journals were more likely to predefine primary outcome (78.3% vs. 44.4%, P < 0.001), use multiple imputations for handling MPD (40% vs. 1.5%, P < 0.001), and use statistically advanced methods for assessing treatment effect at a single time point (26.1% vs. 2%, P = 0.001). ConclusionThe use of statistical methods among acupuncture RCTs is far from satisfactory. Our findings highlighted the need for researchers to carefully use the optimal statistical methods and for journal editors to strengthen the use of statistical methods.

Specification of interventions and selection of controls in randomized controlled trials of acupuncture: a cross-sectional survey.

Specification of interventions and selection of controls are two methodological determinants for a successful acupuncture trial. However, current practice with respect to these two determinants is not fully understood. Thus, we conducted a cross-sectional survey to examine the specification of interventions and selection of controls among published randomized controlled trials (RCTs) of acupuncture. We searched PubMed for acupuncture RCTs published in core clinical journals and complementary and alternative medicine (CAM) journals from January 2010 to December 2019 (10 years) and included RCTs that assessed treatment effects of acupuncture versus any type of control. We used network meta-analyses to explore whether there were differential treatment effects in patients with chronic pain when using sham acupuncture as a control versus using waiting list or no treatment. Most of the 319 eligible RCTs specified well the style of acupuncture (86.8%), traditional acupuncture point locations (96.2%), type of needle stimulation (90.3%) and needle retention time (85.6%). However, other acupuncture details were less-frequently specified, including response sought (65.5%), needle manipulation (50.5%), number of needle insertions (21.9%), angle and direction of insertion (31.3%), patient posture (32.3%) and co-interventions (22.9%). Sham acupuncture (41.4%) was the most frequently used control, followed by waiting list or no treatment (32.9%). There was no differential treatment effect when using sham acupuncture versus waiting list/no treatment as a control (standardized mean difference = -0.15, 95% confidence interval: -0.91 to 0.62). Over a decade of research practice, important gaps have remained in the specification of acupuncture interventions, including response sought, needle manipulation, and co-interventions. While sham acupuncture has been widely used, waiting list or no treatment may also be considered as an appropriate control.

Missing data were poorly reported and handled in randomized controlled trials with repeatedly measured continuous outcomes: a cross-sectional survey

Background and ObjectivesMissing data are common in randomized controlled trials (RCTs) involving repeatedly measured continuous outcomes. Evidence on the reporting and handling of such outcome data is lacking, which has prevented further improvement in methods and reporting of RCTs. MethodsWe searched PubMed to identify RCTs published in the Core Clinical Journals in 2019 that reported a continuous primary outcome with repeated measures. A team of investigators conducted a study screening and collected data using pilot-tested, standardized questionnaires from a random sample of eligible RCTs. We thoroughly collected information about the reporting of missing data for the repeatedly measured continuous outcome and the methods used to handle the missing data. ResultsWe included 200 eligible trials, whose mean number of repeated measures for the continuous primary outcomes was 5.46 (SD = 3.4). Sixty-one (30.5%) trials explicitly reported missing data at both participant and outcome levels, 116 (58.0%) at the participant level only, and 2 (1.0%) at the outcome level only. Sixty (30.0%) trials reported missing data at the participant level by group and by time point, and 53 (26.5%) at the outcome level by group and by time point. Among 179 trials having reported missing data, 162 (90.5%) did not assess the balance of baseline characteristics, 143 (79.9%) did not assume missing mechanism; 65 (36.3%) used suboptimal methods for handling missing data (e.g., complete case analysis); 41 (22.9%) conducted sensitivity analyses, and 5 (11.9%) assumed alternative missing mechanisms for sensitivity analyses. ConclusionThe reporting of missing data for repeatedly measured continuous outcomes were inadequate and the use of statistical methods for handling missing data was far from optimal. Substantial efforts are warranted to improve the reporting and statistical handling of these outcome data.

Analyses of repeatedly measured continuous outcomes in randomized controlled trials needed substantial improvements

ObjectivesSystematic understanding is lacking regarding how current trials handle repeated measure data and the extent to which appropriate statistical methods are used for such data set. This study investigated the current practice of analyzing the repeated measure data among randomized controlled trials (RCTs). Study Design and SettingWe searched the Core Clinical Journals indexed in PubMed for RCTs published in 2019 and included a continuous primary outcome with repeated measures. We randomly sampled RCTs from the eligible trials. Team of methods trained investigators screened studies for eligibility and collected data using the pilot-tested, standardized questionnaires. We thoroughly documented statistical analyses of the continuous primary outcome with repeated measures and particularly recorded how statistically advanced methods were used to handle these repeated measures. ResultsIn total, 200 trials were included. Of these trials, the mean number of repeated measures for the continuous primary outcome was 5.46 (SD = 3.4); 58 (29.0%) trials did not specify the time point of primary outcome in the method; 113 (56.5%) trials did not use statistically advanced methods for handling repeated measure data in the primary analyses. Among187 trials included the baseline values, 88 (47.1%) trials did not adjust for outcome value at baseline. Among 87 trials using statistically advanced methods, 49 (56.3%) did not specify correlation structure for model. ConclusionsThe statistical analyses of repeatedly measured continuous outcomes in RCTs need substantial improvements. Careful planning of the primary outcome and the use of statistically advanced methods for analyzing data are warranted.

CONSORT Abstract Item Reporting Quality and Altmetrics in the Cardiovascular Core Clinical Journals

CONSORT Abstract Item Reporting Quality and Altmetrics in the Cardiovascular Core Clinical Journals

Adherence to the CONSORT statement and extension for nonpharmacological treatments in randomized controlled trials of bariatric surgery: A systematic survey.

Reporting is critical for establishing the value of randomized controlled trials (RCTs). This study evaluated the adherence of bariatric surgery RCT reporting to the CONsolidated Standards Of Reporting Trials (CONSORT) statement 2010 and its 2017 extension for non-pharmacologic treatments (NPT extension). We identified all RCTs comparing bariatric surgery with conservational therapy or alternative bariatric surgery up to June 30, 2020. Reporting quality was assessed using criteria developed from the CONSORT statement and the NPT extension and scored as a percentage. The factors associated with reporting quality were explored by univariate and multivariate analysis. In total, 102 RCTs of bariatric surgery were included. The median scores according to the CONSORT statement and NPT extension were 63.3 and 26.8 of a maximum possible 100, respectively. Two-thirds of NPT extension items were reported in less than 25% of the RCTs. The median score improved over time for the CONSORT statement but not the NPT extension. A higher CONSORT score was associated with publication in core clinical journals, protocol registration, and funding. No factors associated with the NPT extension score were identified. Substantial efforts are warranted from authors, journals, registration platforms, and funders to overcome the flaws in the reporting of bariatric surgery RCTs.

Exploring engagement with authors of randomised controlled trials to develop recommendations to improve allocation concealment implementation and reporting

Background: Reviews have consistently shown that allocation concealment is frequently implemented and reported suboptimally in randomised controlled trials (RCTs). This research aims to pilot engaging with authors of RCTs to explore their knowledge and understanding of allocation concealment implementation and reporting to ascertain areas and mechanisms for their improvement. Methods: Authors that published RCTs in core clinical journals in one month in 2019 were identified. Authors were invited to complete questionnaires to elicit their views and experiences on the implementation and reporting quality focussing on allocation concealment. Methodological quality of allocation concealment was evaluated in this sample by assessing adherence to the Consolidated Standards of Reporting Trials (CONSORT). Results: Reporting was suboptimal, with only 57% of allocation concealment methods reported to be implemented which were judged as adequate, with 18% using sealed envelopes and more than 40% not adequately reporting allocation methods. When exploring allocation concealment, implementation and reporting questionnaires were found to elicit a low response rate amongst authors of RCTs. Discussion: Following analysis of the themes that emerged from the questionnaires, the main recommendations to improve reporting quality are: journals need to endorse, adhere and promote reporting guidelines, a methodologist could review methodological details of publications simultaneously to peer review, envelopes as a form of allocation concealment are poorly implemented and reported, so careful review of these is required, funders need to insist on more robust allocation concealment methods are employed if the RCT setting allows, and authors need to acknowledge their responsibility for transparent reporting of RCTs.

Journal editors: How do their editing incomes compare?

Background: The work of journal editors is essential to producing high-quality literature, and editing can be a very rewarding career; however, the profession may not be immune to gender pay gaps found in many professions and industries, including academia and clinical medicine. Our study aimed to quantify remuneration for journal editors from core clinical journals, determine if a gender pay gap exists, and assess if there are remuneration differences across publishing models and journal characteristics. Methods: We completed an online survey of journal editors with substantial editing roles including section editors and editors-in-chief, identified from the Abridged Index Medicus "Core Clinical" journals in MEDLINE. We analyzed information on demographics, editing income, and journal characteristics using a multivariable partial proportional odds model for ordinal logistic regression. Results: There were 166 survey respondents (response rate of 9%), which represented editors from 69 of 111 journals (62%). A total of 140 fully completed surveys were analyzed (95 males and 45 females); 50 (36%) editors did not receive remuneration for editorial work. No gender pay gap and no difference in remuneration between editors who worked in subscription-based publishing vs. open access journals were detected. Editors who were not primarily health care providers were more likely to have higher editing incomes (adjusted odds ratio [OR] 2.96, 95% confidence interval [CI] 1.18-7.46). Editors who worked more than 10 hours per week editing earned more than those who worked 10 hours or less per week (adjusted OR 16.7, 95%CI 7.02-39.76). Conclusions: We were unable to detect a gender pay gap and a difference in remuneration between editors who worked in subscription-based publishing and those in open access journals. More than one third of editors surveyed from core clinical journals did not get remunerated for their editing work.

Journal editors: How do their editing incomes compare?

Background: The work of journal editors is essential to producing high-quality literature, and editing can be a very rewarding career; however, the profession may not be immune to gender pay gaps found in many professions and industries, including academia and clinical medicine. Our study aimed to quantify remuneration for journal editors from core clinical journals, determine if a gender pay gap exists, and assess if there are remuneration differences across publishing models and journal characteristics. Methods: We completed an online survey of journal editors with substantial editing roles including section editors and editors-in-chief, identified from the Abridged Index Medicus "Core Clinical" journals in MEDLINE. We analyzed information on demographics, editing income, and journal characteristics using a multivariable partial proportional odds model for ordinal logistic regression. Results: There were 166 survey respondents (response rate of 9%), which represented editors from 69 of 111 journals (62%). A total of 140 fully completed surveys were analyzed (95 males and 45 females); 50 (36%) editors did not receive remuneration for editorial work. No gender pay gap and no difference in remuneration between editors who worked in subscription-based publishing vs. open access journals were detected. Editors who were not primarily health care providers were more likely to have higher editing incomes (adjusted odds ratio [OR] 2.96, 95% confidence interval [CI] 1.18-7.46). Editors who worked more than 10 hours per week editing earned more than those who worked 10 hours or less per week (adjusted OR 16.7, 95%CI 7.02-39.76). Conclusions: We were unable to detect a gender pay gap and a difference in remuneration between editors who worked in subscription-based publishing and those in open access journals. More than one third of editors surveyed from core clinical journals did not get remunerated for their editing work.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

Journal editors: How do their editing incomes compare?

Background: The work of journal editors is essential to producing high-quality literature, and editing can be a very rewarding career; however, the profession may not be immune to gender pay gaps found in many professions and industries, including academia and clinical medicine. Our study aimed to quantify remuneration for journal editors from core clinical journals, determine if a gender pay gap exists, and assess if there are remuneration differences across publishing models and journal characteristics. Methods: We completed an online survey of journal editors with substantial editing roles including section editors and editors-in-chief, identified from the Abridged Index Medicus “Core Clinical” journals in MEDLINE. We analyzed information on demographics, editing income, and journal characteristics using a multivariable partial proportional odds model for ordinal logistic regression. Results: There were 166 survey respondents (response rate of 9%), which represented editors from 69 of 111 journals (62%). A total of 140 fully completed surveys were analyzed (95 males and 45 females); 50 (36%) editors did not receive remuneration for editorial work. No gender pay gap and no difference in remuneration between editors who worked in subscription-based publishing vs. open access journals were detected. Editors who were not primarily health care providers were more likely to have higher editing incomes (adjusted odds ratio [OR] 2.96, 95% confidence interval [CI] 1.18-7.46). Editors who worked more than 10 hours per week editing earned more than those who worked 10 hours or less per week (adjusted OR 16.7, 95%CI 7.02-39.76). Conclusions: We were unable to detect a gender pay gap and a difference in remuneration between editors who worked in subscription-based publishing and those in open access journals. More than one third of editors surveyed from core clinical journals did not get remunerated for their editing work.

A systematic survey showed important limitations in the methods for assessing drug safety among systematic reviews

ObjectivesThis study aimed to examine the design, conduct, and analysis of systematic reviews assessing drug safety through a cross-sectional survey. Study Design and SettingWe searched PubMed to identity systematic reviews published in the Cochrane Database of Systematic Reviews and Core Clinical Journals indexed in 2015 and randomly sampled systematic reviews assessing drug effects at a 1:1 ratio of Cochrane and non-Cochrane reviews. Teams of two investigators independently conducted study screening and collected data, using prespecified, standardized questionnaires. In addition to general information, we collected details about the planning and analyses of safety outcomes. ResultsWe included 120 systematic reviews, including 60 Cochrane and 60 non-Cochrane reviews. Most reviews searched PubMed/MEDLINE (n = 117, 97.5%), EMBASE (n = 105, 87.5%), and Cochrane CENTRAL (n = 110, 91.7%) and conducted independent and duplicate study selection (n = 98, 81.7%), risk of bias assessment (n = 105, 87.5%), and data collection (n = 105, 87.5%). Only nine (7.5%) reviews clearly defined safety outcomes, and seven (5.8%) defined a primary safety outcome; none stated whether the primary safety outcome was predefined. Among the 80 reviews that pooled the primary dichotomous safety data across studies, less than half (41%, n = 33) conducted subgroup analysis to explore for sources of heterogeneity or reported a GRADE assessment for the overall quality of evidence. Cochrane reviews were more likely to provide a study protocol (100% vs. 23.3%; P < 0.001), involve methodologists (53.3% vs. 20.0%; P < 0.001), and report a GRADE assessment for the primary safety outcome (70.6% vs. 19.6%; P < 0.001). ConclusionOur findings highlighted areas for improved planning and analysis in the assessment of drug safety among systematic reviews. Cochrane reviews were superior to non-Cochrane reviews; however, most reviews did not prespecify their safety outcomes or methods for analysis, explore sources of heterogeneity among pooled effects, or assess the overall quality of evidence with the GRADE approach.

Content Analysis of Electronic Nicotine Delivery System Publications in Core Clinical Journals from 2012 to 2018.

There is no consensus if electronic nicotine delivery systems (ENDS) should be used to reduce harm among the smoking population. Physicians, who represent a trusted source of health communication, are exposed to a range of often conflicting ENDS information and this information may be relayed to patients looking to quit smoking. Previous studies have examined ENDS content of various sources of media but there is a lack of knowledge about ENDS content in medical journals. We analyzed 421 ENDS publications printed between 2012 and 2018 from PubMed’s Core Clinical Journal list. Publications were analyzed based on publication type, journal type, study design, geographic focus, theme, terminology, outcomes, and positive/negative statements. The number of ENDS publications grew since 2012, and peaked in 2015. Across all years, negative statements about ENDS outnumbered positive statements, though this difference decreased over time. Over time, negative statements about “toxins and carcinogens” were made less frequently, while negative statements about “gateway effects” and “youth appeal” became more prevalent. UK journals had fewer negative statements relative to US journals. Only 12.6% of publications included guidance for healthcare professionals about ENDS. As published ENDS topics change over time, physicians’ communications with patients may be impacted.

Reporting quality of studies using machine learning models for medical diagnosis: a systematic review

AimsWe conducted a systematic review assessing the reporting quality of studies validating models based on machine learning (ML) for clinical diagnosis, with a specific focus on the reporting of information...

Conclusions from surveys may not consider important biases: a systematic survey of surveys

ObjectivesSurveys can inform important health care questions. However, should decision-makers believe strong conclusions that authors of surveys report? Objectives of this systematic survey of surveys are to describe the characteristics and conduct of surveys and investigate the association of the conduct with the conclusions. Study Design and SettingWe randomly selected 180 surveys published over 1 year in core clinical journals that included a self-report instrument to elicit knowledge, attitudes, behaviors, and experiences regarding health. Study selection and abstraction was independent and in duplicate. We calculated frequencies of descriptive data. We conducted multivariable logistic regression analyses to assess the association of strong or weak conclusions with survey methods. ResultsOur results suggest that authors who validate questions in their survey make strong conclusions. We found that strong conclusions may not be associated with response rates or number of respondents. However, it did not appear that journal impact factor was related to strong conclusions. ConclusionOur results suggest that users of surveys should not rely on the conclusions of authors. A critical appraisal tool for users of surveys and guidance for authors about factors to consider when making conclusions would be helpful.

450P - Supportive care to control nausea and dizziness in malignant tumours: A systematic review

BackgroundPatients with malignant tumours may suffer from nausea as a side-effect of chemo-/radiotherapy. Antiemetic drugs can cause dizziness, which may lead to falls and decrease quality of life. Complementing research on painkiller-associated dizziness [1], we now focus on dizziness in association with antiemetic drugs. MethodsA systematic review is provided on dizziness in association with antiemetic drugs. A PubMed literature search was carried out for all articles in core clinical journals until 30 June 2019. ResultsA total of 411 articles were identified. No study evaluated dizziness caused by antiemetic drugs as a primary endpoint. A focus on dizziness as a secondary endpoint revealed four studies with class 1a (meta-analysis) or 1b (randomized controlled trial) level of evidence (LoE). In cisplatin-based chemotherapy, there is LoE 1b that the 5-hydroxytryptamine 3 receptor antagonists (5-HT(3)RA) ondansetron [2] or the combination of tropisetron and dexamethasone [3] are better in terms of antiemetic potential and dizziness than metoclopramide [2] or metoclopramide plus dexamethasone plus diphenhydramine [3]. Among 5-HT(3)RAs, a meta-analysis with over 6000 patients [4] revealed that palonosetron had the lowest incidence of nausea and dizziness (LoE 1a). The neurokinin-1 receptor rolapitant was associated with less nausea than ondansetron plus dexamethasone in a randomized controlled trial (LoE 1b) including 454 patients and had a descriptively but not significantly higher incidence of dizziness [5]. Conclusions5-HT(3)RAs, particularly palonosetron, have an advantage with regard to antiemetic efficacy and frequency of reported dizziness when compared to metoclopramide [2-4]. The neurokinin-1 receptor rolapitant is a possible alternative [5].