Dear editor

We read with great interest the meta-analysis by Wang et al examining the effects of acupuncture and moxibustion on perioperative anxiety in gynecological surgery.¹ While we appreciate the authors’ efforts, several methodological concerns warrant discussion.

First, the majority of included studies were published in Chinese journals. As previous research has shown, Chinese trials often lack complete reporting of methodological details according to the Consolidated Standards of Reporting Trials (CONSORT) statement guidelines.² This incomplete reporting raises concerns about potential bias in study methods and makes it difficult to assess the true quality of the evidence.

Second, the authors did not employ the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the certainty of evidence for each outcome. The GRADE framework is essential for systematic reviews as it considers factors such as risk of bias, inconsistency, indirectness, imprecision, and publication bias.³ Without GRADE assessment, readers cannot make informed judgments about the reliability of the findings and their implications for clinical practice.

Third, most outcomes in this meta-analysis were based on self-reported measures (eg, STAI-S, VAS-anxiety, SAS). While these are validated tools, self-reported outcomes are particularly susceptible to performance bias and detection bias, especially in non-blinded trials.⁴ The authors acknowledged that complete blinding was unfeasible in acupuncture studies, which further compounds this concern. The lack of objective outcomes makes it challenging to draw definitive conclusions about the intervention’s effectiveness.

Given these limitations, we suggest that the findings should be interpreted with caution. Future meta-analyses in this field should prioritize including high-quality trials with complete methodological reporting, incorporate GRADE assessment, and consider including more objective outcome measures when possible.