Age-related changes in the immune system and challenges for the development of age-specific vaccines

BACKGROUND

A better understanding of how the immune system evolves with age and how vaccines work in older people has led to increasing focus on the development of vaccines aimed specifically at older age groups. We discuss strategies used to improve vaccine immunogenicity for older adults, focusing on licensed adjuvants.

FINDINGS

With age-related immune decline (immunosenescence), older adults face increased vulnerability to infections and severe complications. Immunosenescence affects T-cell and B-cell populations and innate immunity, leading to reduced chemotaxis, cytotoxicity, and altered cytokine production. This contributes to inflammaging-low-grade, chronic inflammation linked to aging. However, immune responses vary due to genetics and life-long exposures, making chronological age an imperfect indicator of immune health. Vaccination remains key to prevention, yet immune dysfunction complicates vaccine efficacy. Strategies to enhance responses in older adults include mRNA vaccines, high-antigen content vaccines, intradermal administration, and adjuvants. mRNA COVID-19 vaccines generated strong immune responses in older adults, though lower than in younger groups. High-antigen content influenza vaccines have shown superior efficacy compared to standard vaccination. Adjuvants offer a well-established approach to boosting vaccine responses by enhancing innate immunity.

CONCLUSIONS

Of various strategies used to improve immunogenicity of vaccines for older adults, adjuvants have been the most consistently effective and practical. More recently, mRNA vaccines have also shown great promise.

A qualitative investigation of the modifiable determinants of medication adherence in bipolar disorder (BD): Views of patients and their family and friends

BACKGROUND

Medication nonadherence in bipolar disorder (BD) can lead to adverse outcomes including relapse, hospitalisation and suicidility. Adherence research traditionally excludes mental health populations and their family and friends, contributing to inequity between physical and mental health. We used behavioural science to characterise modifiable adherence determinants in BD from the perspectives of patients and their family and friends.

METHOD

Between April-June 2020, we conducted two focus groups and 26 interviews with adults with BD and their family and friends. We explored modifiable adherence determinants which were mapped to the Theoretical Domains Framework (TDF), followed by a thematic analysis and prioritisation of determinants.

RESULTS

Sixty-three (including 13 new) adherence determinants, mapped to nine TDF domains, were prioritised. Four themes of adherence determinants emerged: the medication itself; practicalities; how patients perceive themselves, their illness, and treatments; and collaboration between patients, their family and friends, and healthcare professionals. Nine prioritised TDF domains were: 'Environmental context and resources', 'Intentions', 'Emotion', 'Social Influences', 'Goals', 'Memory, attention and decision processes', 'Beliefs about consequences', 'Knowledge' and 'Social/professional role and identity'. Respective examples include side effects, treatment preferences, fear of not being 'myself', relationships with healthcare team, medication affecting life goals, forgetfulness, beliefs about negative consequences, not knowing the risk of stopping medication, and involvement in treatment decisions.

CONCLUSION

Targeting antecedents of forgetfulness as well as newly identified determinants linked to 'Emotion' and 'Intentions', may improve adherence. Mapping adherence determinants to TDF domains provides a framework for designing personalised adherence interventions by selecting appropriate behaviour change techniques.

Association between antihypertensive medication use and kidney cancer risk: a meta-analysis accounting for hypertension

BACKGROUND

Evidence that antihypertensive medication (AHTN) use is associated with an increased risk of kidney cancer (KC) is emerging. However, limited evidence is available on disentangling the effects of AHTN use on KC from hypertension, which is a risk factor for KC. We aimed to identify pooled estimates for the associations between AHTN use and KC risk, independent of hypertension.

METHODS

We searched for observational studies that investigated the associations between AHTN use and KC through January 2025. To identify the independent effects of AHTN from hypertension, we conducted stratified analyses with and without accounting for hypertension: any methods (matching, adjustment, or stratification/restriction) versus none. We conducted random-effects meta-analyses with robust variance estimation to calculate pooled relative risk (RR).

RESULTS

In this meta-analysis consisting of 39 eligible studies, AHTN use was associated with an increased risk of KC based on estimates that accounted for hypertension (RR 1.19, 95% confidence interval (CI) 0.93-1.52 for angiotensin-converting enzyme inhibitor; RR 1.15, 95% CI 1.00-1.31 for angiotensin receptor blocker; RR 1.09, 95% CI 1.03-1.16 for beta-blocker, RR 1.40, 95% CI 1.12-1.75 for calcium channel blocker (CCB); RR 1.36, 95% CI 1.20-1.55 for diuretic; and RR 1.40, 95% CI 1.13-1.75 for non-classified AHTN). Findings from duration‒response relationships supported the main findings.

CONCLUSIONS

AHTN use was associated with an increased risk of KC compared to no use, even after accounting for hypertension, with the highest risk observed for CCB. Our findings highlight the potential KC risks associated with different AHTN classes, with optimal cardiovascular care remaining an important consideration.

Outcomes of early high-flow nasal cannula (HFNC) use in pediatric respiratory distress in acute settings: a meta-analysis

With the increasing incidence of pneumonia and acute respiratory distress in pediatric populations, effective oxygen delivery techniques are crucial for improving clinical outcomes. However, a debate exists across current studies on the use of high-flow nasal cannula (HFNC), and whether its benefits outweight the overutilization in a hospital setting. This systematic review and meta-analysis evaluates HFNC therapy in comparison to conventional oxygen therapy and noninvasive ventilation (NIV). A literature search was conducted to identify studies comparing HFNC to other oxygen delivery modalities in pediatric populations with acute respiratory distress were included. Outcomes include intubation rates, hospital and ICU stays, adverse events, and mortality. Statistical analysis was performed using RevMan software. A total of 10 studies comprising 7,762 patients were identified for quantitative analysis. HFNC significantly reduced intubation rates compared to conventional oxygen therapy (OR = 0.55, 95% CI: 0.34-0.89, p = 0.01). It also reduced ICU length of stay compared to NIV (MD = -2.76, 95% CI: -4.98 to -0.53, p = 0.02) and was associated with a lower mortality risk compared to NIV (OR = 0.62, 95% CI: 0.44-0.86, p = 0.005). However, HFNC did not show significant differences in success rates or adverse events when compared to either oxygen therapy or NIV. Conclusion: HFNC demonstrates substantial benefits in reducing intubation rates and ICU stays compared to conventional oxygen therapy and NIV. While HFNC appears promising for pediatric respiratory distress management, increased ICU admissions and longer hospital stays remain areas for further research. What is Known: • Acute respiratory distress syndrome (ARDS) is a leading cause of morbidity and mortality in pediatric populations globally. High-flow nasal cannula (HFNC) therapy is a non-invasive oxygen delivery method that reduces inspiratory resistance and provides higher oxygen flow. • HFNC has been associated with reduced intubation rates compared to conventional oxygen therapy in past studies. • Non-invasive ventilation (NIV) and conventional oxygen therapy are established methods for respiratory support but present with limitations such as higher intubation rates and risks of complications. What is New: • HFNC significantly reduces intubation rates compared to conventional oxygen therapy (OR = 0.55, p = 0.01) and is associated with shorter ICU stays compared to NIV (MD = -2.76 days, p = 0.02). • However, HFNC does not show significant advantages in success rates or adverse events compared to other oxygen delivery methods. HFNC also resulted in longer hospital stays compared to conventional oxygen therapy (MD = 0.38 days, p = 0.01). The study highlights the need for judicious use of HFNC and the establishment of standardized clinical guidelines to optimize its use.

Exploring the gut microbiome’s influence on cancer-associated anemia: Mechanisms, clinical challenges, and innovative therapies

BACKGROUND

Anemia is a prevalent and challenging complication in patients with hematologic and solid malignancies, which stems from the direct effects of malignancy, treatment-induced toxicities, and systemic inflammation. It affects patients’ survival, functional status, and quality of life profoundly. Recent literature has highlighted the emerging role of the gut microbiome in the pathogenesis of cancer-associated anemia. The gut microbiota, through its intricate interplay with iron metabolism, inflammatory pathways, and immune modulation, may either exacerbate or ameliorate anemia depending on its composition, and functional integrity. Dysbiosis, characterized by disruption in the gut microbial ecosystem, is very common in cancer patients. This microbial imbalance is implicated in anemia causation through diminished iron absorption, persistent low-grade inflammation, and suppression of erythropoiesis.

AIM

To consolidate current evidence regarding the interplay between gut microbiome and anemia in the setting of malignancies. It aims to provide a detailed exploration of the mechanistic links between dysbiosis and anemia, identifies unique challenges associated with various cancer types, and evaluates the efficacy of microbiome-focused therapies. Through this integrative approach, the review seeks to establish a foundation for innovative clinical strategies aimed at mitigating anemia and improving patient outcomes in oncology.

METHODS

A literature search was performed using multiple databases, including Google Scholar, PubMed, Scopus, and Web of Science, using a combination of keywords and Boolean operators to refine results. Keywords included “cancer-associated anemia”, “gut microbiome”, “intestinal microbiota”, “iron metabolism”, “gut dysbiosis”, “short-chain fatty acids”, “hematopoiesis”, “probiotics”, “prebiotics”, and “fecal microbiota transplantation”. Articles published in English between 2000 and December 2024 were included, with a focus on contemporary and relevant findings.

RESULTS

Therapeutic strategies aimed at restoration of gut microbial homeostasis, such as probiotics, prebiotics, dietary interventions, and fecal microbiota transplantation (FMT), can inhibit anemia-causing pathways by enhancing microbial diversity, suppressing detrimental flora, reducing systemic inflammation and optimizing nutrient absorption.

CONCLUSION

Gut dysbiosis causes anemia and impairs response to chemotherapy in cancer patients. Microbiome-centered interventions, such as probiotics, prebiotics, dietary modifications, and FMT, have shown efficacy in restoring microbial balance, reducing inflammation, and enhancing nutrient bioavailability. Emerging approaches, including engineered probiotics and bacteriophage therapies, are promising precision-based, customizable solutions for various microbiome compositions and imbalances. Future research should focus on integrating microbiome-targeted strategies with established anemia therapies.

Comparison between the effect of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers and their combination on mortality in maintenance dialysis patients: a systematic review and meta-analysis

INTRODUCTION

Patients undergoing maintenance dialysis have a higher mortality rate compared to the general population. It is known that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have protective effects on the kidney; however, few studies have directly compared their impact on mortality in patients undergoing dialysis. This study aims to evaluate the effectiveness of ACEIs, ARBs, or their combination in reducing all-cause and cardiovascular mortality in maintenance dialysis patients.

METHODS

We systematically searched PubMed, Cochrane Central, Web of Science (WOS), and Scopus databases from inception until August 23rd, 2024. We included all observational studies and clinical trials that assessed the effectiveness of ACEIs versus ARBs or their combination on mortality outcomes, in patients with CKD on maintenance dialysis. We used Review Manager 5.4 for all statistical analyses.

RESULTS

Five observational studies, including 126,612 patients, met the eligibility criteria and were included in the final analysis. Among all patients, no statistically significant difference was found between ACEIs and ARBs in reducing all-cause mortality (RR: 1.12, 95% CI [0.98, 1.27], P = 0.10) or cardiovascular mortality (RR: 1.10, 95% CI [0.92, 1.33], P = 0.30). In patients on hemodialysis, ARBs were associated with a statistically significant reduction in cardiovascular mortality (P < 0.0001).

CONCLUSION

Our results suggest no differences between ACEIs and ARBs in reducing all-cause or cardiovascular mortality in maintenance dialysis patients. However, ARBs may reduce cardiovascular mortality more effectively in hemodialysis patients. Conducting randomized controlled clinical trials to validate our results is warranted.

Effects of Electronic Cigarettes on Periodontal Health: A Systematic Review and Meta-Analysis

OBJECTIVES

The use of electronic cigarettes "e-cigarettes," or vaping is growing in popularity, especially among adolescents and young adults. While the effects of cigarette smoking on oral health are well-established, the exact impact that e-cigarettes may have on dental tissues is still uncertain. The aim of the current review was to summarize evidence related to the effect of vaping on the periodontal health status of e-cigarette users.

METHODS

A comprehensive electronic search was performed using PubMed, Web of Science, and Scopus databases, until January 31st, 2024. Two independent reviewers participated in the screening of studies, data extraction, and assessment of the included studies. Any disagreements were resolved by a third reviewer the quality assessment was done using the Newcastle-Ottawa Scale to assess the risk of bias. A frequentist meta-analysis was performed using R Statistical Software. The random effects model was adopted. Data were described as mean difference (MD) and 95% confidence interval (CI). A p-value of ≤ .05 was deemed statistically significant.

RESULTS

Ten studies met the eligibility criteria. Overall, the findings were consistent, with most studies showing that e-cigarette users are at greater risk of periodontal disease than nonsmokers, but that they have a lower risk than cigarette smokers. Pooling results showed lower mean probing depth (PD) among nonsmokers than e-smokers (MD: -1.91; 95% CI: [-3.36: -0.47]; p-value = .01) while it was higher among cigarette smokers in participants with periodontitis (MD:0.43; 95%CI: [0.08:0.79]; p-value = .02). Compared to e-smoking, nonsmokers had lower PI (MD: -20.63; 95%CI: [-28.04: -13.21]; p-value < .001) while cigarette smokers had higher PI (MD: 4.88; 95% CI: [-1.52:11.29]; p-value = .135). Among participants with periodontitis, only cigarette smokers had significantly higher PI (MD: 4.53; 95%CI: [1.94:7.13]; p-value < .001).

CONCLUSION

Based on the current analysis, conventional cigarette smoking is the most detrimental to periodontal health among the groups compared in all included studies. This indicates that traditional cigarettes have a more severe impact on periodontal tissues than do e-cigarettes. The data suggest a gradient of risk where nonsmokers have the lowest risk, e-cigarette users have a moderate risk, and cigarette smokers have the highest risk for periodontal health issues.

Efficacy and Safety of the Fixed-Dose Combination of Atorvastatin/Fenofibrate Versus Atorvastatin on the Lipid Profile of Patients with Type 2 Diabetes and Dyslipidemia

INTRODUCTION

In dyslipidemia associated with type 2 diabetes (T2DM), elevated triglycerides (TG), increased low-density lipoprotein cholesterol (LDL-C), and decreased high-density lipoprotein cholesterol (HDL-C) levels are commonly found, resulting in a high prevalence of mixed dyslipidemia among patients with T2DM. Therefore, the combination therapy of atorvastatin/fenofibrate may be useful for simplifying pharmacological regimens, enhancing adherence, and requiring fewer doses of each drug to achieve the target, which decreases the number of adverse events.

METHODS

We conducted a randomized multicenter, double-blind clinical trial of patients with T2DM and mixed dyslipidemia to evaluate the magnitude of change in lipid profile with a fixed-dose combination (FDC) therapy group of atorvastatin 20 mg/fenofibrate 160 mg (G_FDC) versus atorvastatin 20 mg monotherapy group (G_M), both oral route, one tablet every 24 h. The magnitude of change in the lipid profile at 2 and 4 months was compared within each group and between groups using the analysis of variance (ANOVA) test. A p value ≤ 0.05 was considered statistically significant.

RESULTS

A total of 76 patients were included (38 per group), with an age of 56.7 ± 10.2 years, and 56.6% were women. The values at 4 months for G_FDC vs. G_M were as follow: TG mg/dL (-144.3 vs. -64.0, p = 0.004), TG percentage change (%C) (-47.9 vs. -33.1, p = 0.007); LDL-C mg/dL (-50.5 vs. -51.7, p = 0.784), LDL-C %C (-42.5 vs. -45.6, p = 0.899). The percentage of patients who achieved the targets for triglycerides (TG) was 56.7% compared to 43.8% (p = 0.309), while for LDL-C, it was 73.3% compared to 78.1% (p = 0.660). Finally, the predictive cardiovascular risk indices (∆ of change) showed a TG/HDL index of -3.9 ± 4.6 vs. -1.5 ± 2.9 (p = 0.015) and a Tg/glucose index of -0.7 ± 0.5 vs. -0.3 ± 0.4 (p = 0.003).

CONCLUSION

The FDC therapy of atorvastatin 20 mg/fenofibrate 160 mg achieved a greater percentage reduction in lipid profile than atorvastatin alone. No differences in adverse events were observed between the groups.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov No. NCT04882293, registration date: February 28, 2022.

Consumption of fruit juice and risk of type 2 diabetes mellitus: A systematic review and meta-analysis of prospective cohort studies: Fruit Juice and Risk of Type 2 Diabetes

BACKGROUND

Previous observational studies on the association between the consumption of fruit juice and the risk of type 2 diabetes mellitus have reported inconsistent findings. We investigated the association using a meta-analysis of prospective cohort studies.

METHODS

Studies were identified through PubMed and EMBASE searches from inception to August 3, 2024. We calculated pooled relative risks (RRs) and 95% confidence intervals (CIs). The consumption of fruit juice was categorized into 100% fruit juice and non-100% fruit juice. The primary outcome was the incidence of type 2 diabetes mellitus.

RESULTS

Out of 1591 articles, 14 prospective cohort studies were included in the final analysis. In the meta-analysis of all studies, there was no significant association between the consumption of overall fruit juice and the risk of type 2 diabetes mellitus (RR, 1.06 [95% CI, 0.98-1.15], P = 0.170). In the subgroup meta-analysis by juice type, non-100% fruit juice was statistically significantly associated with an increased risk of type 2 diabetes mellitus (RR, 1.15 [95% CI, 1.03-1.28], P = 0.012), while there was no significant association between the consumption of 100% fruit juice and the risk of type 2 diabetes mellitus. An increased risk of type 2 diabetes mellitus by fruit juice was observed only in Asian populations (RR, 1.17 [95% CI 1.02-1.34], P = 0.023).

CONCLUSION

The consumption of non-100% fruit juice increased the risk of type 2 diabetes mellitus. Unlike whole fruit consumption, 100% fruit juice had no beneficial effect on the risk of type 2 diabetes mellitus.

Are technological contributions in behavior guidance techniques superior to conventional methods?: Effects on dental anxiety and pain perception

BACKGROUND

To evaluate the effects of three different behavior guidance methods on children's dental anxiety levels and pain perception.

METHODS

This study included 63 children aged 6-8 years who required pulpotomy and were divided into three groups: tell-show-do (TSD; Group 1), TSD with video modeling (Group 2), and TSD with mobile phone application (Group 3). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and hemoglobin oxygen saturation (SPO2) of the participants were recorded before the procedure, after local anesthesia, after pulpotomy, and after the end of the procedure. Faces Version of the Modified Child Dental Anxiety (MCDASf), Wong-Baker Faces Pain Rating Scale (WBFPRS), and Face, Legs, Activity, Cry, Consolability (FLACC) pain scales were applied. Chi-squared test, one-way ANOVA, Kruskal-Wallis test, Friedman's test, and repeated measurement analysis statistical tests were used.

RESULTS

No significant difference was found between the steps in terms of BP, HR, and SPO2 within the groups (p > 0.05). When comparing the groups, there were significant differences in SBP (p = 0.040) and DBP (p = 0.027) measured at the beginning and end of the procedure, and between MCDASf (p = 0.041) and WBFPRS (p = 0.013) scores. These values ​​were lower in Group 3.

CONCLUSION

Dental anxiety and pain perception scores were lowest when using TSD with mobile phone application (Group 3). In line with developing technology, the use of mobile phone applications in pediatric dentistry can contribute to more harmonious treatment management in children.

TRIAL REGISTRATION

The trial protocol was retrospectively registered ID NCT06912789 ( https://clinicaltrials.gov/ ); 2025-03-26.

Effect of Supplementation with Probiotics in Patients with Schizophrenia: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

Supplementation with probiotics seems to confer protective effects in individuals with schizophrenia (SZ), although available results are inconclusive. The aim of this study was to systematically review existing randomized clinical trials (RCTs) to critically assess the effect of probiotics on psychiatric symptoms, anthropometric indicators, lipid profiles, glycemic indices, inflammation, and oxidative stress in adults with SZ. A systematic search was conducted in four databases from inception until January 2025. Six RCTs were included in the quantitative analysis that demonstrated beneficial effects of probiotics on SZ severity determined via the Positive and Negative Syndrome Scale (PANSS), with significant reductions in PANSS (MD = -0.50, p = 0.001), PANSS Negative (MD = -0.31, p = 0.050), and PANSS General scores (MD = -0.33, p = 0.036), alongside reductions in body weight (MD = -0.92, p = 0.000), body mass index (MD = -0.53, p = 0.016), and total cholesterol (SMD = -0.34, p = 0.005). Furthermore, probiotic interventions reduced baseline glucose (SMD = -0.59, p = 0.000), insulin (MD = -0.68, p = 0.000), and measures of insulin sensitivity/resistance and significantly improved biomarkers of inflammation and oxidative stress. To summarize, this meta-analysis suggests that probiotics may confer beneficial effects in patients with SZ through improving psychiatric symptoms as well as markers of body weight, lipid and glucose metabolism, inflammation, and oxidative stress.

Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) and Liver-Directed Therapy for Synchronous Peritoneal and Liver Metastatic Colorectal Cancer: A Systematic Review with Meta-analysis

INTRODUCTION

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can improve survival in colorectal cancer (CRC) patients with peritoneal carcinomatosis (PC). The presence of synchronous liver metastases (LMs) often precludes patients from CRS/HIPEC; however, multiple studies suggest that CRS/HIPEC with liver-directed treatments may be beneficial. This systematic review examines outcomes and selection factors in CRC patients with PC and LM treated with CRS/HIPEC and liver-directed therapy.

METHODS

A systematic review and meta-analysis was performed using the PubMed, EMBASE, and Web of Science databases from 2009 to 2024. The outcomes included patient selection factors, overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 482 articles were retrieved, of which 17 retrospective studies met the inclusion criteria, comprising a total of 988 patients. Liver-directed therapy with CRS/HIPEC for PC and LM was associated with 3- and 5-year OS rates of 47% and 37%, respectively, with a median survival range of 15.3-47.6 months. The adjusted 1- and 3-year DFS rates were 34% and 23%, respectively, with a median DFS range of 6.2-29.4 months. Patients with PC and LM were more likely to have received preoperative systemic therapy (86%), undergone minor liver resection (90%), had a limited burden of LM (mean of three lesions, median size of 1.4-3 cm), and limited PC (mean peritoneal cancer index of 13).

CONCLUSION

This study indicates that CRS/HIPEC with liver-directed therapy can yield favorable survival outcomes for well-selected CRC patients with limited PC and LM. Further trials are needed to confirm its efficacy and refine optimal patient selection.

Association Between Kidney Stones and Subsequent Risk of Upper Tract Urothelial Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the association between a history of kidney stones and the subsequent risk of upper tract urothelial carcinoma (UTUC).

METHODS

We systematically searched Medline and Embase for observational studies reporting risk estimates of UTUC in adults with versus without a history of kidney stones. A random-effects meta-analysis was performed to calculate the pooled risk ratio (RR) with 95% confidence interval. The influence of individual studies on meta-analysis estimates was assessed by sequentially removing one study at a time from the meta-analysis.

RESULTS

Seven studies (four cohort, three case-control) comprising 391,998 subjects were included in the meta-analysis. A history of kidney stones was associated with a significantly higher risk of developing UTUC (RR = 2.42; 95% confidence interval: 1.72, 3.41; P <.001; I2 = 85%). The one-study removed sensitivity analysis demonstrated that no single study significantly influenced the meta-analysis results, with the RR ranging from 2.18 to 2.74 (all P <.001) following the iterative removal of each study. The main limitations of this review were the inability to establish causality and significant heterogeneity among studies.

CONCLUSION

A history of kidney stones is associated with more than twice the risk of developing UTUC, which supports careful examination of the upper tract during imaging studies and maintained awareness of possible urothelial abnormalities during long-term follow-up.

PROtective ileoStomy versus ProtectivE colostomy in anterior Rectal resectIon: study protocol for a multicenter, open-label, randomised conTrolled studY (PROSPERITY)

INTRODUCTION

Loop ileostomy and loop colostomy are both used to form a protective stoma after anterior resection. Evidence regarding which of these two procedures is superior is lacking. Furthermore, no studies comparing changes in the microbiome after loop ileostomy or loop colostomy exist.

METHODS AND ANALYSIS

This multicentre, open-label, superiority, individually randomised controlled trial will include patients who undergo anterior rectal resection with primary anastomosis with a protective stoma. The exclusion criteria are patients who already have a stoma, technical inability to create either type of stoma, aged <18 years and inadequate cooperation. Patients scheduled for anterior rectal resection will be randomised intraoperatively in a 1:1 ratio to undergo either loop ileostomy or loop colostomy. The primary outcome is cumulative stoma-related adverse events within 60 days after primary surgery, measured using the Comprehensive Complication Index (CCI). Secondary outcomes include all postoperative complications (measured using the CCI), number of hospital-free days within 30 days after primary surgery, quality of life at 2 months (measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires-Core 30 and Colorectal 29), complications within 30 days after stoma closure (measured using the CCI) and kidney function (measured using estimated glomerular filtration rate) at 1 year. Tertiary outcomes are survival, kidney function and number of stoma site hernias at 5 years. The sample size was calculated to detect a mean difference of five CCI points between groups, resulting in a final sample size of 350 patients. Microbiome samples will be collected from the faeces and mucous membrane from patients in Helsinki University Hospital.

ETHICS AND DISSEMINATION

The Ethics Committee of Helsinki University Hospital approved the study (approval number 4579/2024). The findings will be disseminated in peer-reviewed academic journals.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06650085, registered on 20 August 2024.

PROTOCOL VERSION

Version 3.0, dated 17 April 2025.

Optimal Duration of Antibiotic Therapy for Primary Osteomyelitis Discitis: A Systematic Review and Network Meta-Analysis

STUDY DESIGN

Systematic review and network meta-analysis.

OBJECTIVE

This study aimed to systematically review the literature on the management of primary osteomyelitis discitis and perform a network meta-analysis comparing the efficacy of different antibiotic treatment durations.

BACKGROUND

Primary osteomyelitis discitis is a challenging condition with varying management strategies.

MATERIALS AND METHODS

A comprehensive literature search was conducted. Studies reporting outcomes for the treatment of primary osteomyelitis discitis were included. A random-effect network meta-analysis was performed comparing antibiotic treatment durations of <4 weeks, 4 to 8 weeks, 8 to 12 weeks, and 12 to 16 weeks. The surface under the cumulative ranking curve (SUCRA) was used to rank treatment effectiveness.

RESULTS

Sixty-three articles with 4233 patients were included. Staphylococcus aureus was the most common causative agent (57.6%). The 4 to 8-week antibiotic duration ranked highest across fixed-effect and random-effect models (SUCRA: 0.8207 and 0.8343). The 12 to 16-week duration ranked highest in the fixed-effect model (SUCRA: 0.8460) but dropped substantially in the random-effect model (SUCRA: 0.3067). The <4-week duration showed mixed results. The 8 to 12-week duration consistently ranked lowest. No statistically significant differences were found between durations for symptomatic relief.

CONCLUSION

Antibiotic therapy for 4 to 8 weeks may provide the optimal balance of efficacy and treatment duration for most patients with primary osteomyelitis discitis. However, treatment should be individualized based on clinical response. Further prospective studies are needed to clarify optimal management strategies for this complex condition.

Cost-Effectiveness Analyses of Bone Morphogenetic Protein 2 (rhBMP-2) in Spinal Fusion: A Systematic Review

Study DesignSystematic Review Study.ObjectivesThe objective of this study is to assess the cost-effectiveness and cost-utility of rhBMP-2 in spine surgeries.MethodsPubMed, MEDLINE, OVID and CENTRAL (Cochrane Central Register of Controlled Trials) databases were systematically searched for studies reporting the use of rhBMP-2 for spinal procedures in comparison to autograft and/or allograft and alternative graft materials under consideration of cost-effectiveness, cost-benefit, cost minimization, and/or cost-utility analysis. Relevant data points were extracted and compiled. The standardization of the selected studies was graded using the CHEERS criteria.ResultsOf the 88 eligible publications, 17 met the inclusion criteria. Overall, 8 studies showed a favorable cost-analysis profile. Three studies performed cost-consequence analyses, none of which reported positive findings. Among 7 cost-utility analyses and 7 cost-effectiveness analyses, 3 and 5, respectively, reported a likely benefit to the usage of rhBMP-2. The CHEERS scores for the included studies ranged from 15 to 23 out of 24 points, with a median score of 19.ConclusionsThere is no consensus regarding the cost-effectiveness or cost-utility of rhBMP-2 in spinal fusion. rhBMP-2 may function as a cost-effective adjunct in spinal fusion surgeries in select cases.

Prognostic and Associative Significance of Malnutrition in Sarcopenia: A Systematic Review and Meta-Analysis

Malnutrition is a common phenomenon, particularly in those at an increased risk of muscle mass and function losses. In this systematic review and meta-analysis, we aimed to explore the association of malnutrition with sarcopenia in middle-aged and older adults and the prognostic association of malnutrition and sarcopenia compared with sarcopenia alone on all-cause mortality. PubMed, Scopus, Web of Science, and Cochrane Library were searched from inception until January 2024. A meta-analysis using a random-effect model was employed, utilizing the Mini Nutritional Assessment malnutrition tool as a continuous and categorical variable. The study protocol was registered in the International Prospective Register of Systematic Reviews (CRD42024501521). Malnutrition was significantly associated with a greater risk of sarcopenia [continuous: k = 12, odds ratio (OR): 1.38, 95% confidence interval (CI): 1.18, 1.61, I2 = 94.8%, P < 0.01; categorical: k = 37, OR: 2.99, 95% CI: 2.26, 3.96, I2 = 78.3%, P < 0.01]. Sarcopenia and malnutrition were associated with a higher risk of mortality compared with sarcopenia alone (k = 5, hazard ratio: 4.04, 95% CI: 1.36, 11.94, I2 = 92.8%, P < 0.01). Metaregression showed age, sex, and number of adjustments did not explain heterogeneity among studies. The included studies had a moderate risk of bias. Malnutrition is associated with higher odds of sarcopenia and their combined presence is a better predictor of all-cause mortality compared with sarcopenia alone, further highlighting the importance of applying interventions to counteract these two closely related phenomena.

Speaking of yourself: A meta-analysis of 80 years of research on pronoun use in schizophrenia

People with schizophrenia experience significant language disturbances that profoundly affect their everyday social interactions. Given its relevance to the referential function of language, aberrations in pronoun use are of particular interest in the study of schizophrenia. This systematic review and meta-analysis, adhering to PRISMA guidelines, examines the frequency of pronoun use in schizophrenia. PubMed, PsycINFO, Scopus, Google Scholar, and Web of Science were searched up to May 1, 2024. All studies analyzing pronoun frequency in various spoken language contexts in schizophrenia were included. Bias was assessed using a modified Newcastle-Ottawa Scale. A Bayesian meta-analysis with model averaging estimated effect sizes and moderating factors. 13 studies with n = 917 unique participants and 13 case-control contrasts were included. 37.9 % of patient samples were women, with a weighted mean (SD) age of 34.45 (9.72) years. 53.85 % of the studies were in languages other than English. We report a medium-sized effect for first-person pronoun impairment in schizophrenia (model-averaged d = 0.89, 95 % CrI (0.44, 1.33)). There was significant heterogeneity moderated by age. Evidence for publication bias was weak, with a strong support for first-person pronoun impairment after accounting for bias and heterogeneity. There was a small reduction of inter-individual variability in first-person pronoun use in patients compared to healthy controls (lnCVR = -0.12, 95 % CrI [-0.35, -0.13]). While all pronoun use was also high in patients, this was not robust due to heterogeneity and publication bias. Individuals with schizophrenia excessively use first-person pronouns. This may be a marker of a disturbed sense of self in this illness.

Vitamin D Deficiency and Clinical Outcomes in Critically Ill Pediatric Patients: A Systematic Review and Meta-Analysis

Context

Vitamin D deficiency (VDD) is common in paediatric populations, and its relationship with critical care outcomes warrants further investigation.

Objective

The aim is to examine the association between VDD and clinical outcomes in children admitted to the Pediatric Intensive Care Unit (PICU).

Methods

This systematic review and meta-analysis investigated the impact of VDD on clinical outcomes in PICU patients. A comprehensive search of Embase, Web of Science, PubMed, and Cochrane databases was conducted. Our primary outcomes were mortality and sepsis incidence, while secondary outcomes included length of stay (LOS), need for inotropic support, and need for and duration of mechanical ventilation. Eligible studies included infants and children aged 1 month to 18 years admitted to the PICU, with baseline 25-hydroxyvitamin D levels measured on admission. Two independent reviewers screened studies, extracted data, and assessed quality. Pooled estimates were obtained using a random-effects model.

Results

Out of 2298 screened studies, 27 met the inclusion criteria, comprising 4682 patients. VDD was defined as 25-hydroxyvitamin D levels <20 ng/mL and <30 ng/mL in 22 and 5 studies, respectively. VDD was associated with increased mortality (odds ratio [OR] 2.05, 95% CI 1.21-3.48) and a greater need for inotropic support (OR 2.02, 95% CI 1.43-2.85) than children with vitamin D sufficiency (VDS). No differences were observed between VDD and VDS groups in terms of sepsis incidence postadmission, LOS, or the need for and duration of mechanical ventilation.

Conclusion

VDD in critically ill pediatric patients was associated with increased mortality and higher need for inotropic support. Further research is warranted to evaluate the potential benefits of vitamin D supplementation in this high-risk population.

Disparities in Access to Minimally Invasive Surgery in Low and Middle-Income Countries

BackgroundAlthough every human being has a basic right to access quality health care, the unfortunate reality is that inequities still exist in the year 2025. The inequities may be readily visible in low and middle-income countries (LMICs), and they are most apparent in the specialties that require significant allocations of human and institutional resources, such as the provision on minimally invasive surgery (MIS).PurposeThis discursive paper explores the reasons for the disparities, taking into account the fundamental differences between the health care environments in LMICs and high-income countries.Research DesignThis is a discursive paper that considers expert opinions on the inequities in healthcare in LMICsStudy SampleThis study discusses the availability of MIS in the health care environments in LMICs of the Anglophone Caribbean.Data Collection and/or AnalysisA literature review of all published data from LMICs in the Anglophone Caribbean.ResultsThis disursive paper explores the reasons for disparity in access to MIS and proposes strategies to restore equity in LMICs.ConclusionsIt is possible to overcome these challenges, but it requires strong leadership, development of creative solutions, and a concerted effort to change the health care environment.

Conservative management of placenta accreta spectrum is associated with improved surgical outcomes compared to cesarean hysterectomy: a systematic review and meta-analysis

OBJECTIVE

To compare maternal and surgical outcomes between patients with placenta accreta spectrum who underwent conservative management and those who underwent cesarean hysterectomy.

DATA SOURCES

We performed a systematic search in PubMed, Embase, and Web of Science from inception up to June 2, 2024.

STUDY ELIGIBILITY CRITERIA

Studies comparing clinical outcomes among patients with placenta accreta spectrum undergoing conservative management vs cesarean hysterectomy were included. Conservative management was defined as leaving the placenta in situ and local myometrial resection.

STUDY APPRAISAL AND SYNTHESIS METHODS

A random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 statistic.

RESULTS

The meta-analysis included 16 studies, with a total of 2300 women diagnosed with placenta accreta spectrum. Of this pooled sample, 1072 patients underwent cesarean hysterectomy and 1228 were managed conservatively. In pregnancies affected by placenta accreta spectrum, cesarean hysterectomy was associated with significantly higher estimated blood loss compared to placenta in situ (mean difference 973.5 mL, 95% confidence interval 615.4-1331.7, 95% prediction interval [PI] -50.2 to 1997.2, P<.001) and local resection (mean difference 739.7 mL, 95% confidence interval 287.7-1191.7, 95% PI -911.5 to 2390.9, P<.001). Additionally, cesarean hysterectomy resulted in more intraoperative transfused red blood cell units than the local resection (mean difference 1.54 units, 95% confidence interval 1.06-2.01, 95% PI 0.27-2.81, P=.001) but had similar rates as compared to placenta in situ group (mean difference 0.72 units, 95% confidence interval -0.21 to 1.64, 95% PI -2.21 to 3.64, P=.065). The risk of genitourinary injury was significantly higher for cesarean hysterectomy compared to both placenta left in situ (odds ratio 3.79, 95% confidence interval 1.88-7.61, 95% PI 1.52-9.46, P<.001) and local resection (odds ratio 4.11, 95% confidence interval 2.57-6.56, 95% PI 2.34-7.22, P<.001). Patients undergoing cesarean hysterectomy, as compared to placenta in situ group, were more likely to be admitted to intensive care unit (odds ratio 7.98, 95% confidence interval 2.23-28.51, 95% PI 0.34-188.50, P<0.001); however, there was no significant difference between cesarean hysterectomy and local resection group in terms of intensive care unit admission. There were no significant differences between cesarean hysterectomy and conservative approaches regarding the risk of gastrointestinal injury and thromboembolic events.

CONCLUSION

This meta-analysis strengthens the evidence supporting conservative management for pregnancies with placenta accreta spectrum, demonstrating that it is associated with reduced surgical morbidity and may offer an effective alternative to cesarean hysterectomy, particularly for patients seeking fertility preservation. However, further research, including randomized controlled trials and longitudinal studies, is necessary to more definitively evaluate conservative management approaches for pregnancies with placenta accreta spectrum and assess long-term clinical outcomes after conservative management.

Harnessing immunotherapy for hepatocellular carcinoma: Principles and emerging promises

HCC is considered as one of the leadin causes of death worldwide, with the ability of resistance towards therapeutics. Immunotherapy, particularly ICIs, have provided siginficant insights towards harnessing the immune system. The present review introduces the concepts and possibilities of immunotherapy for HCC treatment, emphasizing its underlying mechanisms and capacity to enhance patient results, focusing on both pre-clinical and clinical insights. The functions of TME and immune evasion mechanisms typical of HCC would be evaluated along with how contemporary immunotherapeutic approaches are designed to address these challenges. Furthermore, the clinical application of immunotherapy in HCC is discussed, emphasizing recent trial findings demonstrating the effectiveness and safety of drugs. In addition, the problems caused by immune evasion and resistance would be discussed to increase potential of immunotherapy along with combination therapy.

Low Socioeconomic Status Is Associated With Worse Patient-Reported Outcomes Following Total Joint Arthroplasty: A Systematic Review

BACKGROUND

Socioeconomic status (SES)-an individual or group's social standing or class, as measured by education, income, and occupation-has been associated with poor surgical outcomes in orthopaedics. Total knee arthroplasty and total hip arthroplasty (THA) are the most commonly investigated orthopaedic surgeries regarding SES and patient-reported outcome measures (PROMs), yet the results are contradictory. The aim of this systematic review was to assess the impact of SES on PROMs following total joint arthroplasty (TJA).

METHODS

We performed a literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines utilizing MEDLINE (Ovid), EMBASE (Ovid), and Cochrane Library from database inception (1971, 1974, and 1996, respectively) to August 2, 2023, to identify studies investigating SES and PROMs in adults undergoing primary elective TJA. Studies were included if they evaluated one of three SES variables (income, education, or employment status) and reported at least one-year scores using a validated PROM. There were two reviewers who independently screened studies and extracted data.

RESULTS

There were 16 studies included in this systematic review. A total of 55,875 arthroplasties, including 24,055 total knee arthroplasties and 31,820 THAs, were analyzed. Of the studies, eight evaluated income, 15 evaluated education, and two evaluated employment status. The majority of studies investigating income found a statistically significant association between lower income and worse postoperative PROMs. There were ten studies, involving 90% of all patients from the included education studies, which found a statistically significant association between education and postoperative PROMs. There were two studies that found unemployed THA patients had lower improvements in PROMs compared to employed and retired patients.

CONCLUSIONS

Our systematic review found several significant associations between income, education, employment, and PROMs after TJA. Providers should pay special attention to lower-income, less educated, and unemployed patients. These patients may benefit from targeted interventions to achieve substantial clinical benefit after TJA.

A national survey on gastroenterology and hepatology training reveals dissimilar perceptions between trainees and trainers and an important need for improvement in training programs

OBJECTIVE

We aimed to collect data on gastroenterology and hepatology training from the viewpoint of trainees and trainers.

METHODS

A national online survey was distributed among trainees and specialists at certified training institutions between February and May 2024.

RESULTS

Overall, 226 respondents - 98 trainees, 78 trainers, 50 program directors, and department heads responded, with a national coverage of 70% of trainees and 85% of specialty-department heads. A training curriculum was reported by 56% of trainees and 84% of curriculum organizers, regular feedback and training progress meetings by 11% of trainees (57% if considered without assessment of training progress), but 88% of curriculum organizers. Training was rated as very good or good by 65% of trainees, 79% of trainers, and 100% of department heads. Quality of functional diagnostics, endoscopy, and ultrasound training was rated as very good or good by trainees in 16, 61, and 54%, by trainers in 27, 79, and 58%, and by department heads in 74, 89, and 85%. Much agreement was found concerning the wish for external rotations (trainees 65%, trainers 70%, and department heads 89%) and a new postcertification advanced-endoscopy training and accreditation.

CONCLUSION

Department heads seem to overestimate the quality of their training programs. Consequently, we found large discrepancies in the perception of specialty training that should stimulate efforts to standardize training and boost necessary train-the-trainer programs. Diagnosis of functional gastrointestinal disorders and abdominal ultrasound skills are areas with the largest room for improvement. Increased flexibility of hospital providers will be crucial for significant improvement of external training possibilities.

White vs. colored coats: Which reduces dental anxiety better?

BACKGROUNDS

To evaluate the effect of colored vs. white coat wear on dental anxiety in children using psychometric, projective, and physiological methods.

METHODS

The participants were divided into two groups by the pediatric dentist based on the participants' coat color (white vs. colored), and procedures were performed during two separate appointments for both groups: dental examination (DE) and preventive dental treatments (PDT). The blood pressure, pulse rate, and saturation were recorded before and after each appointment. Anxiety was assessed using the Modified Child Dental Anxiety Scale Faces Version (MCDASf) before and after the appointments and the Child Drawing: Hospital (CD: H). Chi-Square, Mann-Whitney U test, Wilcoxon Signed-Rank test, and t-test were used for analysis. The statistical significance level was evaluated as P < 0.05.

RESULTS

Compared to the colored coat group, MCDASf values ​​recorded before both appointments were higher in the white coat group (P = 0.019; P = 0.034). Also, it was observed that the CD: H values of the colored coat group were significantly lower after PDT (P = 0.037). According to the coat groups, there was a significant difference between pulse rates measured before and after both appointments (P = 0.026; P = 0.017; P = 0.008; P = 0.004).

CONCLUSIONS

The clinician's coat color selection impacts children's dental anxiety. The findings suggest that colored coats are more effective than white coats in relieving dental anxiety.

Effect of music on preoperative anxiety and postoperative pain in patients undergoing gynecological surgery: A meta-analysis

BACKGROUND

Preoperative anxiety and postoperative pain often afflict patients and may impact surgical safety and postoperative recovery. Therefore, we studied the influence of music for patients with preoperative anxiety and postoperative pain, in order to provide an effective and safe non-pharmacological intervention for patients.

METHOD

Studies on music and gynecological operation were searched in PubMed, EMBASE, Web of Science, and the Cochrane Library. NOS and the modified Jadad Scale were used to evaluate the quality of the studies, and the evidence quality was evaluated and graded according to GRADE guidelines. Stata 12.0 software was used for data analysis.

RESULTS

We compared the difference in preoperative anxiety between the experimental group and the control group. The results showed that anxiety symptoms were significantly relieved in the experimental group that listened to music(WMD = -6.78, 95% CI (-7.54 - -6.03), P = 0.000). This difference was statistically significant, and the quality of evidence was rated as intermediate. We compared the difference in anxiety symptoms before and after listening to music in the experimental group (WMD = -4.39, 95% CI (-5.14 - -3.64), P = 0.000). The results indicated a significant relief in anxiety symptoms after listening to music. The difference was statistically significant, and the quality of evidence was rated as intermediate and low, respectively. We compared the differences in postoperative pain between the experimental group and the control group (WMD = -0.26, 95% CI (-0.43--0.10), P = 0.002). The results showed that the pain symptoms of the experimental group, who listened to music, were significantly relieved. The difference was statistically significant, and the quality of evidence was rated as intermediate.

CONCLUSION

This meta-analysis showed that listening to music significantly improved preoperative anxiety and postoperative pain during gynecological surgery. Therefore, operating room nurses should perform music intervention in patients undergoing gynecological surgery before and after surgery.

The relationship between Body Mass Index and dental anxiety among pediatric patients in Jeddah, Saudi Arabia: a cross-sectional study

BACKGROUND

Studies suggested a relationship between anxiety and Body Mass Index (BMI). However, dental anxiety and BMI was not previously investigated. This cross-sectional study aimed to assess the impact of BMI levels on dental anxiety and behavior among pediatric patients.

METHODS

Children 6-11 years attending four-referral centers in Jeddah, Saudi Arabia and their parents were interrogated. The BMI level scores, child's behavior (Frankel's classification) and dental-anxiety (Abeer Dental Anxiety Scale (ACDAS)) were evaluated.

RESULTS

Out of 952 children participated in this study, 496 (52.1%) had normal BMI, 264 (27.7%) had high BMI (overweight), and 192 (20.2%) had low BMI (underweight). Regression analysis found that overweight was significantly associated with an increased adjusted odds ratio (AOR) of dental anxiety (AOR = 3.018) and uncooperative dental behavior (AOR = 8.714) with p < 0.001. Also, statistically significant increase in the odds ratio (OR) of the child feeling shy in the clinic (P = 0.002; OR:2.113) and parents/operators reporting child behaving scared (P = 0.004; OR:1.985 and p < 0.001; OR:3.03, respectively) when overweight compared to normal-weight.

CONCLUSIONS

This study highlights the impact of overweight on the emotional and behavioral dimensions of the child's dental experience as they significantly increased the probability of dental anxiety and uncooperative behavior by three and eight times, respectively.

Prevalence of hepatitis C virus infection in Qatar's resident population based on a national screening campaign

Hepatitis C virus (HCV) infection poses a global health challenge, yet its epidemiology in Qatar remains underexplored. This study estimated HCV antibody (Ab) prevalence in Qatar and examined associated socio-demographic factors. From January 2017 to December 2019, the Ministry of Public Health conducted a national HCV awareness and surveillance campaign. A total of 81,615 individuals, including both Qatari nationals and expatriate residents from 137 countries, underwent HCV antibody testing using the Elecsys Anti-HCV II electrochemiluminescence immunoassay. Probability weights were applied to adjust for age, sex, and nationality, to the testing sample. Logistic regression assessed factors associated with HCV Ab positivity. Among individuals tested, 1149 were positive, 80,299 were negative, and 167 were indeterminate. The estimated HCV Ab prevalence in the study sample was 1.4% (95% CI 1.3-1.5%). The weighted HCV Ab prevalence in the resident population of Qatar was also estimated at 1.4% (95% CI 1.2-1.7%). HCV Ab positivity was strongly associated with age, with higher adjusted odds ratios (AORs) in older individuals. Disparities were noted among certain nationalities, with Bangladeshis and Tunisians having lower odds of infection, while Pakistanis, Egyptians, and Yemenis had higher odds of being infected. Males had a 1.97-fold (95% CI 1.47-2.65) higher odds of being HCV Ab positive compared to females. The considerable HCV Ab prevalence in Qatar underscores the need for targeted interventions, prevention and harm reduction strategies, and expanded testing and treatment programs to advance progress toward the 2030 elimination target.

The safety profile of subthalamic nucleus and globus pallidus internus deep brain stimulation for Parkinson's diseases: A systematic review of perioperative complications and psychological impacts

BACKGROUND

Despite its widespread use and acceptance, there is still a significant need for a comprehensive understanding of the safety profile of deep brain stimulation (DBS) for Parkinson's Disease. This study investigates the surgical and psychological complications associated with DBS surgery for movement disorders, aiming to quantify patient risk and promote broader acceptance of the procedure.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It focused on a substantial population of 3,599 patients from various studies who underwent DBS between 2000 and 2024. A thorough literature search was carried out to identify studies on the safety profile of DBS in Parkinson's Disease (PD) across multiple electronic databases. Two reviewers extracted data and independently assessed the risk of bias, and all authors resolved any discrepancies collectively.

RESULTS

This review identified 17,453 studies, but only 26 were thoroughly reviewed after fulfilling all inclusion criteria. DBS showed both therapeutic benefits and significant risks, with complications including neurological deficits, infections, cognitive and psychiatric symptoms, surgical or device-related issues, motor dysfunction, and mortality.

CONCLUSION

Overall, the findings support the cognitive safety of DBS, revealing limited adverse effects on cognitive functions. This review confirms therapeutic advantages and significant risks during and after surgery, including intraoperative and long-term adverse events. Additional reviews are required to evaluate the long-term impact of these complications, thereby enhancing patient safety and quality of life.

CLINICAL TRIAL NUMBER

Not applicable.

Comparative analysis of bacterial abundance and diversity in tumour tissue of oral squamous cell carcinoma and non-tumour tissue: insights from a systematic review of 16S ribosomal RNA sequencing

BACKGROUND

As per the recent research findings, there is a significant difference between the bacteriome of normal tissue (NT) and tumor tissues (TT) of oral squamous cell carcinoma (OSCC). Identifying this distinct bacteriome is crucial for understanding their potential contribution to oral carcinogenesis. This systematic review (SR) aims to identify exclusive and relative bacterial abundance and bacterial diversity in TT and NT.

METHODOLOGY

The review was conducted following the PRISMA guidelines. PUBMED and SCOPUS databases were searched for studies in English published till 31st August 2024. The inclusion criteria focused on identifying bacteriome in NT versus TT at either species,/genus, and/or phylum level through 16 s ribosomal RNA sequencing. Quality assessment was performed using an eleven-parameter tool combining the Newcastle-Ottawa Scale and customized criteria.

RESULT

Evaluating the selected 13 articles, we have identified the exclusive and relative abundance of bacteriome in TT and NT at phylum, genus, and species levels. Three phyla such as Chloroflexota, Deinococcus-Thermus, and Mycoplasmatota, are found exclusively in TT. Seven genus such as Eubacterium, Campylobacter, Aeromonas, Oceanivigra, Rheinheimera, Weissella, and Catonella are exclusively found in TT. Ten species such as Micrococcus luteus, Prevotella melaninogenica, Exiguobacterium oxidotolerans, Fusobacterium naviforme, Staphylococcus aureus, Veillonella parvula, Parvimonas sp oral taxon 110, Eubacterium II G1 infirmum, Eubacterium XI G3 Brachy, Weissella viridescens are found in TT. Six genus such as Capnocytophaga, Selenomonas, Leptothrix, Desulfovibrio, Desulfoplanes, Pelospora are found exclusively in NT. Eleven species, such as Streptococcus sp. Oral taxon 071,Selenomonas sputigena, Treponema pedis, Acholeplasmatales bacterium, Capnocytophaga haemolytica, Eubacterium sp., Syntrophomonadaceae genomosp.,Treponema putidum, Mitsuokella sp., Actinomyces sp. Oral taxon 848 str. F0332, p- 2534 - 18B5-gut-group are found in NT. Seven common genera within which different species are identified in TT and NT, suggesting differences in bacterial behaviour and characteristics within the same genus. A total of 12 phyla, 35 genera, and 54 species were found to be relatively more abundant in TT compared to NT. Conversely, 7 phyla, 32 genera, and 45 species were relatively more abundant in NT than in TT. Considerable variations in diversity metrics were found between TT and NT.

CONCLUSION

This systematic review is the first to identify a distinct bacteriome exclusive to OSCC tumour tissue compared to normal tissue using 16S ribosomal RNA sequencing. This pioneering work lays the foundation for future studies on the oral microbiome as a potential diagnostic or therapeutic target in oral cancer management. It emphasizes the importance of exploring species-level differences for a deeper understanding of their roles in OSCC.

TRIAL REGISTRATION

Not applicable.

The effect of preoperative ureteral stenting on the outcomes and complications of pediatric ureteroscopy: A systematic review and meta-analysis

INTRODUCTION

Small ureteral caliber may prohibit safe primary ureteroscopy (URS), particularly in children. Pre-stenting was proposed to passively dilate the ureter for later safer ureteral access. This meta-analysis aims to analyze outcomes of both primary and deferred ureteroscopy after a period of pre-stenting.

METHODS

PubMed, Scopus, Cochrane Library, and Web of Science were searched for studies comparing outcomes of primary and deferred ureteroscopy in children younger than 18 years with ureteral and/or renal stones. Outcomes of interest were stone free rate (SFR), complication rates, ureteral injury, urinary tract infection (UTI), operative time, stone migration, postoperative stenting use and ureteral access sheath use.

RESULTS

Four studies encompassing 826 patients were included. When attempted, primary ureteroscopic access was successful in 69-83 % of patients. SFR was higher in the pre-stenting group (OR 0.87, 95 % CI [0.81-0.94], P = 0.0005). No significant difference was found between the two groups in terms of the overall complications rate (RR 1.66, 95 % CI [0.93-2.96], P = 0.09), ureteral injury (RR 3.67, 95 % CI [0.43-31.66], P = 0.24) febrile UTI (RR 0.62 (95 % CI [0.15 to 2.5], P = 0.5), use of postoperative stent (OR 0.86, 95 % CI [0.52-1.44], P = 0.58), use of ureteral access sheath (RR 0.94 (95 % CI [0.73 to 1.22], P = 0.65), or stone migration (RR 2.28 (95 % CI [0.48 to 10.80], P = 0.30).

CONCLUSION

Although pre-stenting is associated with a relatively higher SFR, primary URS is successful in most pediatric patients without increased complication risk. We advocate primary URS whenever possible to allow stone treatment under a single anesthetic and minimize healthcare costs.

Role of circulating tumor DNA and cell-free DNA biomarkers in diagnosis and prognosis of oral cancer - a systematic review

BACKGROUND

Oral squamous cell carcinoma is the most common malignant neoplasm of the oral cavity, contributing significantly to cancer-related mortality worldwide. Circulating tumor DNA could be a promising biomarker for the early diagnosis and prognosis of oral cancer.

OBJECTIVE

The aim of this systematic review was to consolidate the existing literature on the role of circulating tumor DNA (ctDNA) and cell-free DNA (cfDNA) in the diagnosis and prognosis of oral cancer.

METHODOLOGY

The review protocol followed PRISMA guidelines. A systematic search was conducted across PubMed, Web of Science, Google Scholar and SCOPUS. Only English-language studies were included, while narrative reviews, HPV-positive OSCC, systematic reviews, meta-analyses, abstracts, and letters to the editor were excluded. Data were extracted on study design, country, sample size, participant characteristics, assessment methods, type of oral cancer and measured outcomes. Risk of bias was evaluated using Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 3,155 records were identified, out of which 17 studies met the inclusion criteria. These comprised eleven cohort studies, one was a case series, two were descriptive studies, and three were case-control studies. The studies primarily addressed oral squamous cell carcinoma (OSCC) and head and neck squamous cell carcinoma (HNSCC). Findings revealed that elevated cfDNA levels are associated with poor prognosis, lymph node metastasis, larger tumor size and advanced disease stages. ctDNA acts as a predictive tool for monitoring cancer progression, treatment response, recurrence risk, and overall survival. Among 12 studies evaluated using NOS, 8 were of good quality, while 4 were fair quality.

CONCLUSION

ctDNA and cfDNA exhibit promising prognostic and diagnostic potential for OSCC and HNSCC. Elevated cfDNA levels correlate with poor prognosis, while ctDNA shows potential for monitoring cancer progression and treatment response.

Prevalence and Diversity of Gastrointestinal Nematodes in Small Ruminants in Iran: a Systematic Review and Meta-analysis

PURPOSE

Gastrointestinal nematodiasis is a significant challenge in small ruminant breeding. The present systematic review and meta-analysis shed light on the frequency and distribution of the infection in a nationwide perspective.

METHODS

The review used 34 animal level datasets retrieved from 26 published articles and the pooled estimates were calculated using a random-effects model analysis.

RESULTS

Altogether, 9690 small ruminants were examined post-mortem or by coproscopy, among which 4193 animals were infected with GINs, showing a weighted prevalence of 55% (95% CI 44-66%). Reports were documented in 12 provinces with the highest frequency in Eastern Azerbaijan (77%), Kermanshah (76.04%), and Guilan (71.62%). Moreover, the highest prevalences were estimated among goats [61% (95% CI 48-74%)] and in coproscopy [67% (95% CI 57-78%)]. The reported GINs represented 15 genera, including Haemonchus contortus, Marshallagia marshalli, Trichuris spp., Trichostrongylus spp., Ostertaginae species, Gongylonema pulchrum, Nematodirus spp., Parabronema skrjabini, Skrjabinema ovis, Chabertia ovina, Cooperia punctata, Camelostrongylus mentulatus, Bunostomum trigonocephalum, and Oesophagostomum venulosum. The most isolated nematode species in sheep and goats belonged to H. contortus [7.44% (95% CI 6.78-8.13%] and Trichuris spp. [18.42% (95% CI 16.54-20.41%)].

CONCLUSION

A considerable parasitic prevalence was calculated in small ruminants in Iran, demanding strategic interventions for better control the GIN infections and decrease the worms burden and their consequences in sheep and goat population in Iran.

Cervical extensor muscle activity during neck tasks in individuals with and without neck pain: A systematic review

BACKGROUND

In the context of neck pain, neck muscle activity adapts through diverse regional coordination modifications during tasks. Although patterns of cervical flexor muscle impairment are well-documented, patterns in the cervical extensor muscles are less clear, hindering assessment and treatment. Despite studies revealing adaptations in the cervical extensor muscles, outcome measure heterogeneity complicates interpretation, particularly between superficial and deep muscles. To address this, we conducted a systematic review comparing neck extensor muscle activity between symptomatic and asymptomatic groups during tasks, aiming to inform clinical practice.

OBJECTIVES

To compare the cervical extensor muscle activity during neck tasks between symptomatic and asymptomatic groups, using complementary examination tools.

METHODS

Up to January 2024, experimental studies assessing cervical extensor muscle activity during neck tasks in adults with idiopathic or traumatic neck pain, or cervicogenic headache compared to healthy controls were included. Study selection involved 2 blinded reviewers. Electronic databases (Medline, Scopus, and Embase), reference lists, and relevant reviews were screened. Data extraction focused on the results of the between-group motor activity comparisons. Critical appraisal used the JBI appraisal checklist for analytical cross-sectional studies.

RESULTS

Twenty-three studies met the inclusion criteria, involving 932 participants and reporting 170 comparative assessments of 8 muscle groups, encompassing 4 main motor activity outcomes: recruitment, timing, fatigue, and directional activation. Significant differences were noted for motor recruitment in 51 % of comparisons, for timing in 35 %, and fatigue in 33 %, with consistent differences in directional activation. Impaired activity in individuals with neck pain compared to those without was found in 47 % of comparisons for superficial muscles and 65 % for deep muscles.

CONCLUSIONS

Motor activity adaptations during neck tasks appear to be unpredictable in individuals with neck pain, with a tendency for change in the deep cervical extensor muscles. Further high-quality studies are needed to confirm these findings, considering various contraction parameters, multiple muscle analyses, and several motor activity outcomes.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Review CRD42022285864.

How do we define normal bowel frequency from newborn to teens?: A Bayesian meta-analysis

OBJECTIVES

Defecation disorders are a common pediatric problem and bowel frequency is crucial in identifying them. The aim of this analysis is to define normal bowel frequencies in healthy children ranging from newborns to adolescents.

METHODS

A literature search was conducted using MEDLINE, SCOPUS, EMBASE, Cochrane Library, and Web of Science from their inception to February 2024, aiming to identify studies reporting bowel habits of healthy children (0-18 years). A Bayesian distribution modeling approach was adopted to pool the mean frequency of bowel opening using inverse-variance weighing. A subgroup analysis and a meta-regression were performed with Bayesian generalized additive mixed distributional models. The methodological quality of the articles was evaluated using the Newcastle-Ottawa Scale modified for cross-sectional studies.

RESULTS

Seventeen studies were included in the analysis, including 22,698 children aged from 0 to 18 years. The subgroup meta-analysis showed mean bowel frequencies for newborns, 1-6 months, 6-12 months, 1-2 years, 2-5 years, and over 5 years are 3.24 (95% credible interval [CrI]: 2.83-3.63), 1.99 (95% CrI: 1.77-2.19), 1.66 (95% CrI: 1.45-1.88), 1.53 (95% CrI: 1.37-1.7), 1.15 (95% CrI: 0.99-1.31), and 1.02 (95% CrI 0.88-1.18), respectively. Between studies, heterogeneity demonstrated a near-normal distribution with a mean of 0.16 and a 95% CrI of 0.04-0.28. The variance of the distribution of mean bowel frequency reduced with age.

DISCUSSION

In this Bayesian meta-analysis, we found that younger children have a higher bowel frequency. The reported bowel frequencies for each age group could serve as normal values in clinical practice to differentiate health and disease.

Single-visit endodontic treatment under general anaesthesia in adult and adolescent patients with special needs: a systematic review

To improve dental care for individuals with special needs, it is crucial to understand the effectiveness of endodontic treatments under general anaesthesia. This systematic review explores the feasibility, prognostic factors, and outcomes of root canal treatment and pulpotomy performed under general anaesthesia in adult and adolescent patients with special needs. A comprehensive search of Cochrane Library and MEDLINE databases was conducted until July 2024. The quality of evidence was assessed using the Newcastle-Ottawa scale (NOS). Among the 637 initially identified studies, 5 met the inclusion criteria. Treatment outcomes, radiographic findings, and clinical survival rates were evaluated. Root canal treatment success rates ranged from 81.5 to 90% over a minimum observation period of 12 months. Survival rates varied from 87.7% (9 year cumulative survival rate) to 89.8% (5 year survival rate). One study showed a lower failure risk in endodontic treatment under general anaesthesia compared to local anaesthesia. Another study found no significant difference in root canal treatment quality between general and local anaesthesia. Influencing factors identified by multivariate regression analyses included soft diet, periodontal status, oral hygiene status, pulp vitality, and length of root canal filling. Limited evidence suggests that endodontic treatment under general anaesthesia is feasible and can yield favourable outcomes in patients with special needs. However, the scarcity of studies and concerns about publication bias and methodological limitations emphasize the need for further research.

Off-pump versus on-pump coronary artery bypass grafting in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

INTRODUCTION

Off-pump coronary artery bypass graft surgery (OPCAB) has been suggested as superior to on-pump coronary artery bypass graft surgery (ONCAB) in certain high-risk subgroups, but its benefit in patients with chronic obstructive pulmonary disease (COPD) remains controversial. This meta-analysis aimed to evaluate OPCAB versus ONCAB outcomes in COPD patients.

METHODS

We followed PRISMA guidelines and searched PubMed, Embase, and the Cochrane Library in August 2024 for studies comparing OPCAB and ONCAB in COPD patients. Statistical analysis was conducted using Review Manager 5.4.1 and Rstudio with a fixed or random effects model.

RESULTS

Six studies with a total of 1,687 patients were included, of which 1,062 (62.95%) underwent OPCAB. The mean patient age was 63.6 years. OPCAB did not significantly affect all-cause mortality compared to ONCAB (OR 1.14; 95% CI 0.65-1.99). There were no significant differences in reintubation (OR 0.81; 95% CI 0.53-1.23), prolonged ventilation (OR 0.54; 95% CI 0.24-1.22), post-operative atrial fibrillation (OR 0.90; 95% CI 0.70-1.15), or ARDS (OR 0.43; 95% CI 0.14-1.33). However, ventilation time was significantly shorter in the OPCAB group (MD - 5.30 h; 95% CI - 7.22 to - 3.38).

CONCLUSION

OPCAB is associated with reduced ventilation time in COPD patients though it shows no significant difference in all-cause mortality or other post-operative complications compared to ONCAB.

The Efficacy and Safety of Botulinum Neurotoxin Type A in Treating Chronic Low Back Pain: A Systematic Review, Meta-Analysis, Trial Sequential Analysis, and Meta-Regression

BACKGROUND

Chronic low back pain (CLBP) is a leading cause of disability. Botulinum neurotoxin type A (BoNT-A) has strong anti-spasmodic and analgesic effects, suggesting that its local muscular injection can reduce CLBP compared to other therapies. In this systematic review and meta-analysis, we investigated the efficacy and safety of BoNT-A on patients with CLBP.

METHODS

We searched PubMed, Scopus, Cochrane, and Web of Science databases for studies comparing BoNT-A to other therapies in terms of functional improvement and pain improvement as measured by visual analog scale (VAS) and clinically significant improvement in pain (50% or greater reduction in VAS score). We employed trial sequential analysis (TSA) to confirm the findings. The GRADE approach was employed to assess the overall quality of the evidence.

RESULTS

The search yielded nine studies, seven randomised clinical trials (RCTs), and two prospective observational studies. Compared to the control, BoNT-A increased the incidence of clinically significant improvement in pain (RR = 4.82, 95% CI (3.00, 7.76), p < 0.00001) and functional improvement (RR = 3.81, 95% CI (2.40, 6.04), p < 0.00001) (low-certainty evidence), and reduced VAS score (MD = -1.62, 95% CI (-3.13, -0.11), p = 0.04) (very low-certainty evidence). Subgroup analysis showed that BoNT-A is effective against normal saline (moderate-certainty evidence), and it was comparable to steroids and local anaesthetics (very low-certainty evidence). TSA confirmed the findings regarding clinical improvement in pain and functional improvement.

CONCLUSION

BoNT-A is a tolerable and effective treatment for CLBP with a longer duration of action. Future high-quality studies are needed to confirm our findings.

SIGNIFICANCE

This paper provides good evidence that BoNT-A may be employed in patients suffering from resistant chronic low back pain not responding to normal saline injection due to its higher efficacy and longer duration of action. Compared to steroids and local anaesthetics injections, there is not enough data to draw a firm conclusion and future studies are needed.

"Veins first" versus "artery first" approach for management of mixed arterial venous leg ulcers (MAVLU): Systematic review and meta-analysis

IntroductionMixed Arterial and Venous Leg Ulcers (MAVLU) are challenging. The optimal intervention sequence (artery-first vs vein first) is unclear. This review evaluates current evidence on surgical intervention sequencing.MethodsMEDLINE, PUBMED, SCOPUS and EMBASE were searched using the term 'mixed arterial venous leg ulcers.' Studies were eligible if they reported ulcer healing outcomes in MAVLU patients. Pooled proportions were calculated by random effects modelling.ResultsThe search yielded 606 studies, eight of which contained sufficient data to include in the analysis. There were no randomized controlled trials. Initial modified compression (MCT) and rescue revascularisation in MAVLU with ABI 0.5 to 0.85 achieved a pooled healing rate of 75% (95% CI 69% to 80%) compared to 79% (95% CI 61% to 93%) in patients with standard VLUs. The pooled rescue revascularisation rate for MAVLU patients with moderate arterial disease was 25% (95% CI 6% to 51%). Patients with severe arterial disease (ABI <0.5) who underwent arterial intervention first were less likely to heal (pooled proportion 40%; 95% confidence interval 16% to 66%). No studies compared either MCT or venous ablation with arterial revascularisation as first-line in patients with moderate arterial disease (ABI 0.5 to 0.85) alone or severe arterial disease (ABI <0.5) alone. There was marked heterogeneity between studies with respect to ulcer healing outcomes reported, definitions of ulcer healing, duration and size of ulcers at presentation, use of adjunct procedures such as skin grafting, unit of measurement (legs vs patients) and duration of follow up.ConclusionA 'veins first' approach to MAVLU is plausible but robust data are lacking and should be evaluated in a randomized controlled trial.

Impact of Salpingotomy on Intrauterine Pregnancy and Recurrent Ectopic Pregnancy Rates: A Meta-Analysis

Ectopic pregnancy poses significant risks to future fertility and recurrence, and can be surgically resolved if the traditional approach is ineffective. Salpingotomy has emerged as a preferred surgical option to treat ectopic pregnancy, as it has been shown to preserve fertility and prevent recurrence. This meta-analysis assessed whether salpingotomy impacts the intrauterine pregnancy (IUP) and recurrent ectopic pregnancy (REP) rates. A literature search was conducted using PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online), Ovid Discovery, and ClinicalTrials.gov. The studies meeting the inclusion criteria were reviewed, and data from 2,220 patients were pooled. The statistical analysis was carried out using the Comprehensive Meta-Analysis Software version 4 (Biostat, Inc., Englewood, New Jersey, United States). The results showed that following salpingotomy, patients reported significantly higher IUP rates (95%CI: 0.487-0.724, p=0.000). The data analysis indicated significant variation in REP rates across the studies, suggesting a high probability of patients not experiencing REP (mean effect size=0.109, 95%CI: 0.074-0.157, p=0.03). A sub-analysis of factors was also conducted, including the impact of age, follow-up time, year of study publication, and geographic location on the IUP and REP rates following salpingotomy. There was a significantly higher number of IUPs in studies published before 2020 than those published after 2020 (mean effect size=0.598, 95%CI: 0.495-0.694, p=0.013). Also notable was a significantly higher IUP rate in patients under 30 (mean effect size=0.58, 95% CI: 0.442-0.706, p=0.007). There was no significant difference in IUP rates due to follow-up time or geographic location (mean effect size=0.613, 95%CI: 0.482-0.730, p=0.964; mean effect size=0.612, 95%CI: 0.541-0.681, p=0.341). Furthermore, REP rates were significantly higher in studies with a follow-up time longer than three years (mean event rate=0.127, 95%CI: 0.098-0.162, p=0.005). There was no significant difference in REP rates across geographic locations, age, or year of publication (p=0.380, p=0.257, and p=0.134, respectively). Overall, salpingotomy provides a higher likelihood of IUP in patients below the age of 30 and has a low risk of REP. The findings underscore the importance of individualized patient counseling, balancing the benefits of salpingotomy for fertility preservation against the risks of REP.

Prevalence of CVD Among Indian Adult Population: Systematic Review and Meta-Analysis

Cardiovascular disease is among the leading causes of mortality and morbidity globally. Over three-quarters of CVD-related deaths now occur in low- and middle-income countries (LMICs); India accounts for one-fifth of global CVD-related deaths, especially among the younger population. The objective of this study was to evaluate the prevalence of CVD among the Indian adult population. We systematically searched Scopus and PubMed from January 2000 to December 2024 to identify relevant articles and pooled the prevalence of CVD using random-effects meta-analysis. Among the 14,647 records screened, 501 full-text articles were assessed for eligibility and 15 studies were included in the final analysis. The pooled prevalence of CVD was 11% (95% CI: 0.09-0.17). Subgroup analysis showed prevalence rates of 12% among males and 14% among females. Urban areas had a higher prevalence (12%) compared to rural areas (6%), with a significant difference. Our study shows the significant prevalence of cardiovascular disease (CVD) in India, particularly in urban areas, with slightly higher rates among females. Focused public health strategies are required to mitigate the growing burden of CVD, along with preventive measures, to reduce further increases in disease prevalence and related fatalities.

Anticholinergic Burden and Cognitive Function in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

The authors synthesized evidence from studies quantifying the relationship between anticholinergic medication and cognitive function in psychosis, and additionally explored studies that investigated whether reducing anticholinergic medications affects cognitive function in individuals with psychosis.

METHODS

A database search was conducted in MEDLINE, Embase, and PsycINFO, from database inception to October 2023, for studies reporting objective cognitive assessment and quantification of anticholinergic burden using clinical scales, serological anticholinergic activity, or tapering of anticholinergic medications. Analyses were carried out in R using the metafor package. Random-effects meta-analysis models were employed, along with assessment of heterogeneity, study quality, and meta-regressions (age, sex, and antipsychotic dosage in chlorpromazine equivalents).

RESULTS

Of 1,337 citations retrieved, 40 met inclusion criteria, comprising 25 anticholinergic burden studies (4,620 patients), six serological anticholinergic activity studies (382 patients), and nine tapering studies (186 patients). A negative correlation was identified between anticholinergic burden and global cognition (r=-0.37, 95% CI=-0.48, -0.25), verbal learning (r=-0.28, 95% CI=-0.36, -0.21), visual learning (r=-0.17, 95% CI=-0.28, -0.06), working memory (r=-0.22, 95% CI=-0.29, -0.14), processing speed (r=-0.24, 95% CI=-0.35, -0.13), attention (r=-0.19, 95% CI=-0.29, -0.08), executive functions (r=-0.17, 95% CI=-0.27, -0.06), and social cognition (r=-0.12, 95% CI=-0.19, -0.05), and between serological anticholinergic activity and verbal learning (r=-0.26, 95% CI=-0.38, -0.14), working memory (r=-0.19, 95% CI=-0.35, -0.03), and executive functions (r=-0.16, 95% CI=-0.27, -0.04). Finally, tapering off anticholinergic medication improved the scores in verbal learning (d=0.77, 95% CI=0.44, 1.1), working memory (d=0.94, 95% CI=0.63, 1.26), and executive functions (d=0.44, 95% CI=0.26, 0.62).

CONCLUSIONS

Anticholinergic burden is associated with the cognitive impairments observed in psychosis. From a clinical perspective, tapering off anticholinergic medication in patients with psychosis may improve cognition. However, randomized clinical trials are needed for an unbiased quantification of benefit.

Post-living donor liver transplant biliary strictures: prevalence, predictors, and long-term outcomes in a retrospective study

Background

Post-liver transplant biliary strictures are a common cause of morbidity among patients who have undergone living donor liver transplantation (LDLT). Limited data are available concerning the response rates to various treatment modalities and the long-term outcomes for these individuals.

Methods

This study was a retrospective analysis of a prospectively collected database, including adult patients aged 18 years or older who underwent LDLT between 2006 and 2022.

Results

Between 2006 and 2022, a total of 3,550 patients underwent liver transplantation. After applying exclusion criteria, 2,956 patients were included in the analysis. During the study period, 344 patients (11.6%) developed biliary strictures. Of these, 77.0% underwent endoscopic retrograde cholangiopancreatography as the primary treatment for biliary strictures, while the remainder received percutaneous transhepatic biliary drainage. Identified risk factors for post-liver transplant biliary strictures included the presence of multiple biliary anastomoses, bile leak, and older donor and recipient ages. The overall graft and patient survival rates were comparable between patients with and without biliary strictures, at both 1 year (93.0% vs. 96.3%) and 5 years (82.3% vs. 79.2%).

Conclusions

Biliary strictures are observed in approximately 11% of recipients following LDLT. While the presence of biliary strictures is associated with increased morbidity, it does not significantly impact patient survival.

Estimating lung cancer risk from e-cigarettes and heated tobacco products: applications of a tool based on biomarkers of exposure and of potential harm

BACKGROUND

Reliable epidemiological data are limited on the lung cancer risk of groups using e-cigarettes (ECIGs) and groups using heated tobacco products (HTPs).

AIM

We describe a methodology to estimate the lung cancer risk of these groups according to their levels of biomarkers of exposure (BOEs) and of potential harm (BOPHs).

METHODS

Using 28 search terms for BOEs and 82 for BOPHs we sought publications reporting biomarker-specific data from North America and Europe comparing individuals who smoke cigarettes and individuals who use other established products (ETPs; cigars, pipes, smokeless tobacco (ST) and/or snuff/snus). Publications were selected using defined inclusion/exclusion criteria. Additionally using lung cancer relative risk (RR) estimates for users of specific ETPs derived from recent meta-analyses of epidemiological studies in these regions, we derived a regression model predicting the lung cancer RR by level of each specific biomarker. Separately for groups using ECIGs and using HTPs the lung cancer risk was then estimated by combining RR estimates for selected biomarkers. Our primary estimates only considered biomarkers statistically significantly (p < 0.01) related to lung cancer risk which showed no significant (p < 0.01) misfit to the RR of 1.0 for non-users-those with no use of ETPs, ECIGs or HTPs.

RESULTS

Based on 38 available publications, we extracted biomarker-specific data for ETPs for 56 BOEs within 21 of the 28 search terms considered and for 54 BOPHs within 29 of the 82. The regression slope fitted to the lung cancer risk was significant (p < 0.01) for 22 BOEs and six BOPHs. However, the predicted RR for non-users significantly (p < 0.01) differed from 1.0 for 16 of these biomarkers. We estimated the lung cancer RR for using ECIGs, derived from 30 estimates for 10 biomarkers, as 1.88 (95% CI 1.60-2.22), the excess risk (ER = RR - 1) being 6.8% of that for smokers of cigarettes. The RR estimate varied little in most sensitivity analyses conducted, but increased markedly after removing the restriction to significant model fit. We estimated the lung cancer RR for using HTPs, combining estimates for four BOEs, as 1.44 (0.41-5.08), the ER being 3.4% of that for smokers of cigarettes.

CONCLUSIONS

Despite some methodological limitations, our approach estimates risk when reliable epidemiological data are unavailable. Using the biomarkers considered here, the model indicates that the lung cancer risk for individuals using ECIGs is much lower than for smokers of cigarettes, and suggests that the risk for those using HTPs is also low. Research using additional data could add precision to these findings.

Optimizing ward rounds: systematic review and meta-analysis of interventions to enhance patient safety

BACKGROUND

Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds.

METHODS

This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42023394325). MEDLINE, Embase, Emcare, and PsycInfo were searched for studies with interventions aiming to improve ward round processes or patient outcomes in hospital settings. Studies were excluded if there was no baseline comparator or they were not in the ward round setting. Interventions were coded as checklist interventions (that is electronic or paper-based pro formas, templates, and checklists), structure interventions (that is defined rules or protocol to guide or standardize conduct), or other interventions. Outcomes were assessed via meta-analyses using the I2 statistic, Cochran's Q P value, and random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the Newcastle-Ottawa scale for non-randomized studies.

RESULTS

This review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. Checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay.

CONCLUSION

This is the first systematic review with meta-analyses synthesizing the evidence of all ward round interventions targeted at improving patient and process outcomes. Results from this review should be used to inform guidelines for the 'ideal ward round'.

Association between proton pump inhibitor use and migraine: a systematic review and meta-analysis

BACKGROUND

Migraine is a common neurological disorder with potential pharmacological triggers. Proton pump inhibitors (PPIs), commonly prescribed for managing gastroesophageal reflux disease and other acid-related gastrointestinal disorders, have been linked to headaches. However, their association with migraine remains unclear. This systematic review and meta-analysis assessed the association between PPI use and the incidence of migraine.

METHOD

A systematic search of PubMed, Embase, and Web of Science was conducted in accordance with the PRISMA framework and registered with PROSPERO (ID: CRD42025644604) to enhance transparency. The search, conducted up to January 2024, included studies focusing on the association between migraine and PPI use. Data screening and extraction were performed using Nested Knowledge software. Meta-analyses were conducted in R software, with heterogeneity assessed through the I² statistic. Pooled adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Sensitivity analyses were also performed to assess the robustness of the results. Gender and migraine subtype were considered in subgroup analyses. Additionally, the GRADE approach was applied to assess the certainty of the evidence across the pooled outcomes.

RESULTS

Five studies involving over 1.5 million participants met the inclusion criteria. The overall pooled adjusted odds ratio (aOR) was 2.508 (95% CI, 0.790-7.969; I² = 91.2%). However, there was a significant association in males (aOR, 3.875; 95% CI, 2.413-6.222; I² = 0%) but not in females (aOR, 2.475; 95% CI, 0.563-10.890; I² = 91.1%). No significant differences were found between migraine types: with aura (aOR, 2.079; 95% CI, 0.945-4.576; I² = 25.4%) and without aura (aOR, 2.524; 95% CI, 0.807-7.896; I² = 96.5%). The GRADE assessment indicated a very low certainty of the evidence.

CONCLUSION

This review found no significant overall association between PPI use and migraine. However, a significant association was observed in males but not in females. Further research is needed to clarify this association and explore the underlying causality mechanisms, and migraine subtypes, particularly why the association appears more pronounced in males.

CLINICAL TRIAL NUMBER

Not applicable.

Prognostic Significance of B7H3 Expression in Solid Tumors: A Systematic Review and Meta-Analysis

B7H3 (CD276), an immunoregulatory molecule known for its role in immune evasion by transmitting inhibitory signals to T lymphocytes, has garnered significant attention in recent years as a promising target for cancer immunotherapy. This interest is largely due to its high expression in various types of solid tumors, coupled with low protein levels in normal tissues. However, studies examining the impact of B7H3 on survival outcomes have shown inconsistent results, leaving its prognostic significance not fully clarified. Therefore, this meta-analysis aimed to assess the relationship between B7H3 expression and various prognostic parameters in patients with solid malignancies. PubMed, Web of Science (WOS), Cochrane, SCOPUS, and Embase databases were searched for eligible articles published until November 2024. Statistical analysis was performed using R studio (version 4.3.2). The analysis included a total of 51 eligible studies comprising 11,135 patients. Results showed that overexpression of B7H3 is a negative predictor for all examined survival outcomes: OS (HR = 1.71, 95% CI = 1.44-2.03, p < 0.0001), DFS (HR = 2.02, 95% CI = 1.49-2.73, p < 0.0001), PFS (HR = 2.10, 95% CI = 1.44-3.06, p < 0.0001), RFS (HR = 1.66, 95% CI = 1.11-2.48, p = 0.01), and DSS (HR = 1.70, 95% CI = 1.24-2.32, p < 0.01). Despite the high heterogeneity observed across the studies, the sensitivity analysis confirmed the robustness of these results. This research suggests that B7H3 may serve as an effective biomarker for prognosis in solid tumors.

From gut to liver: organoids as platforms for next-generation toxicology assessment vehicles for xenobiotics

Traditional toxicological assessment relied heavily on 2D cell cultures and animal models of study, which were inadequate for the precise prediction of human response to chemicals. Researchers have now shifted focus on organoids for toxicological assessment. Organoids are 3D structures produced from stem cells that mimic the shape and functionality of human organs and have a number of advantages compared to traditional models of study. They have the capacity to replicate the intricate cellular microenvironment and in vivo interactions. They offer a physiologically pertinent platform that is useful for the researchers to monitor cellular responses in a more realistic manner and evaluate drug toxicity. Additionally, organoids can be created from cells unique to a patient, allowing for individualized toxicological research and providing understanding of the inter-individual heterogeneity in drug responses. Recent developments in the use of gut and liver organoids for assessment of the xenobiotics (environmental toxins and drugs) is reviewed in this article. Gut organoids can reveal potential damage to the digestive system and how xenobiotics affect nutrient absorption and barrier function. Liver is the primary site of detoxification and metabolism of xenobiotics, usually routed from the gut. Hence, these are linked and crucial for evaluating chemical or pollutant induced organ toxicity, forecasting their metabolism and pharmacokinetics. When incorporated into the drug development process, organoid models have the potential to improve the accuracy and efficiency of drug safety assessments, leading to safer and more effective treatments. We also discuss the limitations of using organoid-based toxicological assays, and future prospects, including the need for standardized protocols for overcoming reproducibility issues.