Recommendations for assessing the risk of bias in systematic reviews of health-care interventions

Proposing a model for auditing data quality of long-term periodontal outcome studies

OBJECTIVE

The assessment of the success of conventional periodontal therapy is based on retrospective studies from private practice and university clinics. Due to their marked heterogeneity, it is difficult to assess the data quality and rate these studies. The aim is to test a model for auditing and rating the data quality of periodontal outcome studies.

METHODS

The method was adapted from the NIH Health Care Systems Collaboratory model, which uses three data quality dimensions: completeness (including all the relevant variables), consistency (ensuring that the same variables are compared) and accuracy (proportion of data in error with a gold standard). The model was applied to studies from a Norwegian specialist practice and data from the Norwegian Health database to test if the auditing process was workable using real world data.

RESULTS

Forty-seven risk and prognostic factors were included for completeness. Seven variables were specified for consistency: tooth loss, smoking, systemic conditions, oral hygiene, individual tooth prognosis, maintenance profiles and timing of extractions. The factors tested showed a 95.7% completeness and an average accuracy deviation from the gold standard of -2.3% for each of the risk/prognostic factors and an overall study score of 93.3%.

CONCLUSIONS

It was possible to develop a method for auditing and rating the quality of periodontal outcome studies. The model was tested using both real world data including risk and prognostic factors from individual outcome studies and national big data. The application of the model to these sets of data showed a high accuracy of the risk/prognostic factors and a close relationship with national big data.

Low-voltage area substrate modification for atrial fibrillation ablation: a systematic review and meta-analysis of clinical trials

AIMS

The value of additional ablation beyond pulmonary vein isolation for atrial fibrillation (AF) ablation is unclear, especially for persistent AF. The optimal target for substrate modification to improve outcomes is uncertain. We investigate the utility of low-voltage area (LVA) substrate modification in patients undergoing catheter ablation for AF.

METHODS

This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the Cochrane risk of bias tool. Only randomized studies were included. AF patients who underwent catheter ablation with voltage-guided substrate modification targeting LVA (LVA group) vs. conventional ablation approaches not targeting LVA (non-LVA group) were compared.

RESULTS

Four studies comprising 539 patients were included (36% female). Freedom from arrhythmia (FFA) in patients with persistent AF was greater in the LVA group [risk ratio (RR) 1.30; 95% confidence interval (CI) 1.03-1.64]. There was no difference in FFA in patients with paroxysmal AF between groups (RR 1.30; 95% CI 0.89-1.91). There was no difference in total procedural time (mean difference -17.54 min; 95% CI -64.37 to 29.28 min) or total ablation time (mean difference -36.17 min; 95% CI -93.69 to 21.35 min) in all included patients regardless of AF type between groups. There was no difference in periprocedural complications between groups in all included patients regardless of AF type (RR 0.93; 95% CI 0.22-3.82).

CONCLUSION

This meta-analysis demonstrates improved FFA in persistent AF patients who underwent voltage-guided substrate modification targeting LVA.

Mortality after transcatheter aortic valve replacement for aortic stenosis among patients with malignancy: a systematic review and meta-analysis

BACKGROUND

With advancements in cancer treatment, the life expectancy of oncology patients has improved. Thus, transcatheter aortic valve replacement (TAVR) may be considered as a feasible option for oncology patients with severe symptomatic aortic stenosis (AS). We aim to evaluate the difference in short- and long-term all-cause mortality in cancer and non-cancer patients treated with TAVR for severe AS.

METHODS

Medline, PubMed, and Cochrane Central Register of Controlled Trials were searched for relevant studies. Patients with cancer who underwent treatment with TAVR for severe AS were included and compared to an identical population without cancer. The primary endpoints were short- and long-term all-cause mortality.

RESULTS

Of 899 studies included, 8 met inclusion criteria. Cancer patients had significantly higher long-term all-cause mortality after TAVR when compared to patients without cancer (risk ratio [RR] 1.43; 95% confidence interval (CI) 1.26-1.62; P < 0.01). Four studies evaluated short-term mortality after TAVR and demonstrated no difference in it in patients with and without cancer (RR 0.72; 95% CI 0.47-1.08; P = 0.11).

CONCLUSION

Patients with cancer and severe AS have higher long-term all-cause mortality after TAVR. However, we found no difference in short-term all-cause mortality when comparing patients with and without cancer. The decision to perform TAVR in cancer patients should be individualized based on life expectancy and existing co-morbidities.

SARS-CoV-2 Infection and COVID-19 Outcomes in Rheumatic Diseases: A Systematic Literature Review and Meta-Analysis

OBJECTIVE

The relative risk of SARS-CoV-2 infection and COVID-19 disease severity among people with rheumatic and musculoskeletal diseases (RMDs) compared to those without RMDs is unclear. This study was undertaken to quantify the risk of SARS-CoV-2 infection in those with RMDs and describe clinical outcomes of COVID-19 in these patients.

METHODS

We conducted a systematic literature review using 14 databases from January 1, 2019 to February 13, 2021. We included observational studies and experimental trials in RMD patients that described comparative rates of SARS-CoV-2 infection, hospitalization, oxygen supplementation/intensive care unit (ICU) admission/mechanical ventilation, or death attributed to COVID-19. Methodologic quality was evaluated using the Joanna Briggs Institute critical appraisal tools or the Newcastle-Ottawa scale. Risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated, as applicable for each outcome, using the Mantel-Haenszel formula with random effects models.

RESULTS

Of the 5,799 abstracts screened, 100 studies met the criteria for inclusion in the systematic review, and 54 of 100 had a low risk of bias. Among the studies included in the meta-analyses, we identified an increased prevalence of SARS-CoV-2 infection in patients with an RMD (RR 1.53 [95% CI 1.16-2.01]) compared to the general population. The odds of hospitalization, ICU admission, and mechanical ventilation were similar in patients with and those without an RMD, whereas the mortality rate was increased in patients with RMDs (OR 1.74 [95% CI 1.08-2.80]). In a smaller number of studies, the adjusted risk of outcomes related to COVID-19 was assessed, and the results varied; some studies demonstrated an increased risk while other studies showed no difference in risk in patients with an RMD compared to those without an RMD.

CONCLUSION

Patients with RMDs have higher rates of SARS-CoV-2 infection and an increased mortality rate.

Complications and mortality of non-typhoidal salmonella invasive disease: a global systematic review and meta-analysis

BACKGROUND

Non-typhoidal salmonella can cause serious, life-threatening invasive infections involving the bloodstream and other normally sterile sites. We aimed to systematically review the prevalence of complications and case-fatality ratio (CFR) of non-typhoidal salmonella invasive disease to provide contemporary global estimates and inform the development of vaccine and non-vaccine interventions.

METHODS

We did a global systematic review and meta-analysis of studies investigating the complications and mortality associated with non-typhoidal salmonella invasive disease. We searched Embase, MEDLINE, Web of Science, and PubMed for peer-reviewed, primary research articles published from database inception up to June 4, 2021, with no restrictions on language, country, date, or participant demographics. Only studies reporting the proportion of complications or deaths associated with non-typhoidal salmonella invasive disease, confirmed by culture of samples taken from a normally sterile site (eg, blood or bone marrow) were included. We excluded case reports, case series, policy reports, commentaries, editorials, and conference abstracts. Data on the prevalence of complications and CFR were abstracted. The primary outcomes were to estimate the prevalence of complications and CFR of non-typhoidal salmonella invasive disease. We calculated an overall pooled CFR estimate and pooled CFR stratified by UN region, subregion, age group, and by serovar when available with a random-effects meta-analysis. A risk-of-bias assessment was done, and heterogeneity was assessed with Cochran's Q Test, I2, and τ2. This study was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and is registered with PROSPERO, CRD42020202293.

FINDINGS

The systematic review returned a total of 8770 records. After duplicates were removed, 5837 titles and abstracts were screened, yielding 84 studies from 35 countries after exclusions. Of these included studies, 77 (91·7%) were hospital-based and 66 (78·6%) were located in Africa or Asia. Among 55 studies reporting non-typhoidal salmonella disease-associated complications, a total of 45 different complications were reported and 1824 complication events were identified among 6974 study participants. The most prevalent complication was septicaemia, occurring in 171 (57·2%) of 299 participants, followed by anaemia in 580 (47·3%) of 1225 participants. From 81 studies reporting the CFR of non-typhoidal salmonella invasive disease, the overall pooled CFR estimate was 14·7% (95% CI 12·2-17·3). When stratified by UN region, the pooled CFR was 17·1% (13·6-21·0) in Africa, 14·0% (9·4-19·4) in Asia, 9·9% (6·4-14·0) in Europe, and 9·6% (0·0-25·1) in the Americas. Of all 84 studies, 66 (78·6%) had an overall high risk of bias, 18 (21·4%) had a moderate risk, and none had a low risk. Substantial heterogeneity (I2>80%) was observed in most (15 [65·2%] of 23) CFR estimates.

INTERPRETATION

Complications were frequent among individuals with non-typhoidal salmonella invasive disease and approximately 15% of patients died. Clinicians, especially in African countries, should be aware of non-typhoidal salmonella invasive disease as a cause of severe febrile illness. Prompt diagnoses and management decisions, including empiric antimicrobial therapy, would improve patient outcomes. Additionally, investments in improving clinical microbiology facilities to identify non-typhoidal salmonella and research efforts towards vaccine development and non-vaccine prevention measures would prevent non-typhoidal salmonella invasive disease-associated illness and death.

FUNDING

EU Horizon 2020 research and innovation programme.

Construction and validation of sham insoles used in clinical trials: A systematic review

BACKGROUND

Insoles are commonly prescribed to treat pathologies in a variety of patient groups; however, there is limited evidence to guide clinical decision-making. A well-validated sham insole is critical to conducting a double-blind placebo-controlled trial.

OBJECTIVES

The aims were to establish: (1) How are sham insoles constructed? (2) What measures are undertaken to ensure adequate blinding? (3) What methods are used to validate the biomechanical effects?

STUDY DESIGN

A systematic search of the methodology of level I-II therapeutic evidence.

METHODS

Searches were conducted in MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. Inclusion criteria were placebo-controlled clinical trials, sham insoles used, treatment insoles alter biomechanics, treatment insoles meet the ISO definition of foot orthotics, sham and treatment insoles tested in normal walking, and article available in English.

RESULTS

The search generated 270 results. Twenty-four trials were included. 19% of sham insoles were described sufficiently to be replicated. The most common sham construction characteristics were full length, ethylene-vinyl acetate material, and flat insoles. 58% of studies were double-blinded; however, many did not describe any blinding methods. There is evidence that blinding the intervention details and a similar insole appearance is effective to blind participants. 13% of studies included a shoe-only condition to allow assessment of the biomechanical effects of sham insoles.

CONCLUSIONS

There is inconsistent construction, blinding, and biomechanical validation of sham insoles. This casts a substantial doubt on the quality and reliability of the evidence base to support the prescription of insoles.

Neuromodulation for Storage Lower Urinary Tract Symptoms in Parkinson Disease: A Systematic Review

BACKGROUND

Bladder symptoms are common in Parkinson disease (PD), affecting quality of life. Medications commonly used such as antimuscarinics can cause frequently intolerable side effects, and therefore, new, better tolerated approaches are needed. Neuromodulation techniques have an established role in urologic disorders; these techniques include tibial nerve stimulation (TNS) and sacral neuromodulation (SNM), which are localized therapies lacking the side effects associated with medication.

OBJECTIVES

This study aimed to undertake a systematic review of the literature reporting the use of neuromodulation techniques for the treatment of bladder symptoms in PD and related conditions.

MATERIALS AND METHODS

A systematic search of data bases was conducted including MEDLINE, CENTRAL, and Web of Science. Studies were required to present specific outcomes for individuals with PD for neuromodulation interventions.

RESULTS

Ten primary studies were identified concerning detailed outcomes of neuromodulation on bladder symptoms in PD, including seven for TNS, one for SNM, and one using transcranial magnetic stimulation (TMS). Two further mixed cohort studies documented minimal data on individuals with PD. All studies demonstrated benefit in a range of outcome measures following neuromodulation. Two randomized sham-controlled studies were carried out using TNS, with one clearly demonstrating superiority over sham, although difficulties with achieving believable yet ineffective sham treatment are highlighted. Further studies reported limited, uncontrolled outcomes of SNM in patients with PD, demonstrating benefit.

CONCLUSIONS

Evidence from case series suggests benefit from TNS in PD, with limited literature on SNM or TMS. Placebo effect from neuromodulation is a concern, and only limited controlled data exist. Future well-designed and sham-controlled studies need to be completed to provide definitive data on the benefit of neuromodulation in PD. Definitively proving the utility of a neuromodulation modality will allow better treatment of bladder symptoms without the need for pharmacologic measures that cause side effects.

Impact of Mentoring on Academic Career Success for Women in Medicine: A Systematic Review

PURPOSE

Research has shown that barriers to career success in academic medicine disproportionately affect women. These barriers include inadequate mentoring, which may perpetuate the underrepresentation of women in senior leadership positions. The purpose of this review was to summarize the qualitative and quantitative evidence of the impact of mentoring on women's career outcomes and to inform future interventions to support the promotion and retention of women in academic medicine.

METHOD

The authors conducted a systematic review of original research published in English-language, peer-reviewed journals through March 20, 2020. Search terms related to mentorship, women, and academic medicine. The authors searched MEDLINE, Embase, Scopus, Current Contents Connect via Web of Science, Cochrane Library, and PsycINFO. They excluded studies not specifically addressing women and those without gender-stratified outcomes. They extracted and analyzed the following data: study design, population, sample size, response rate, participant age, percentage of women, mentoring prevalence, and outcomes.

RESULTS

Of 2,439 citations identified, 91 studies met the inclusion criteria, including 65 quantitative and 26 qualitative studies. Mentoring was associated with objective and subjective measures of career success. Women perceived mentorship to be more valuable to their career development yet were more likely to report having no mentor. Additionally, women were more likely to report lower levels of research productivity, less career satisfaction, and greater barriers to promotion. Qualitative results indicated that women had less access to informal mentoring and family responsibilities had a greater effect on their career outcomes. Professional networking, female mentors, and relational aspects of mentoring were common themes.

CONCLUSIONS

This review examined gender disparities in mentoring and the impact on research productivity, promotion success, and career satisfaction for women in academic medicine. Institution-supported mentoring programs are needed to facilitate identification of appropriate mentors and promotion of a more equitable academic career environment for women.

Protein intake in children and growth and risk of overweight or obesity: A systematic review and meta-analysis

Objectives

The aim of this study was to examine the evidence for an association between the dietary protein intake in children and the growth and risk of overweight or obesity up to 18 years of age in settings relevant for the Nordic countries.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus up to February 26, 2021 for randomized controlled trials (RCTs) or prospective cohort studies assessing for protein intake from foods (total and from different sources) in children. The outcomes include weight, height/length, adiposity indices, and/or risk of overweight and/or obesity. The risk of bias was evaluated with instruments for each respective design (Cochrane's Risk of Bias 2.0 and RoB-NObS). A meta-analysis of five cohort studies was performed. The evidence was classified according to the criteria of the World Cancer Research Fund.

Results

The literature search resulted in 9,132 abstracts, of which 55 papers were identified as potentially relevant. In total, 21 studies from 27 publications were included, of which five were RCTs and 16 were cohort studies. The RCTs found generally null effects of high-protein intake in infants on weight gain, nor that lower protein diets negatively affected growth. All included RCTs had some concern regarding the risk of bias and were limited by small sample sizes. Total protein intake and BMI were assessed in 12 cohorts, of which 11 found positive associations. The meta-analysis revealed a pooled effect estimate of 0.06 (95% CI 0.03, 0.1) kg/m2 BMI per one E% increment in total protein (I 2 = 15.5). Therefore, the evidence for a positive relationship between total protein intake and BMI was considered probable. Furthermore, there was probable evidence for an association between higher intake of animal protein and increased BMI. There was limited, suggestive evidence for an effect of total protein intake and higher risk of overweight and/or obesity, while no conclusions could be made on the associations between animal vs. plant protein intake and risk of overweight and/or obesity.

Discussion

In healthy, well-nourished children of Western populations, there is probably a causal relationship between a high-protein intake in early childhood (≤ 18 months) - particularly protein of animal origin - and higher BMI later in childhood, with consistent findings across cohort studies. A lack of RCTs precluded a stronger grading of the evidence.

Coronary Revascularization Versus Optimal Medical Therapy in Renal Transplant Candidates With Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Coronary artery disease (CAD) is highly prevalent in patients with chronic kidney disease and is a common cause of mortality in end‐stage renal disease. Thus, patients with end‐stage renal disease are routinely screened for CAD before renal transplantation. The usefulness of revascularization before transplantation remains unclear. We hypothesize that there is no difference in all‐cause and cardiovascular mortality in waitlisted renal transplant candidates with CAD who underwent revascularization versus those treated with optimal medical therapy before transplantation.

Methods and Results

This meta‐analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta‐Analyses guidelines. MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the modified Newcastle‐Ottawa Scale and Cochrane risk of bias tool. The primary outcome of interest was all‐cause mortality. Eight studies comprising 945 patients were included (36% women, mean age 56 years). There was no difference in all‐cause mortality (risk ratio [RR], 1.16 [95% CI, 0.63–2.12), cardiovascular mortality (RR, 0.75 [95% CI, 0.29–1.89]), or major adverse cardiovascular events (RR, 0.78 [95% CI, 0.30–2.07]) when comparing renal transplant candidates with CAD who underwent revascularization versus those who were on optimal medical therapy before renal transplant.

Conclusions

This meta‐analysis demonstrates that revascularization is not superior to optimal medical therapy in reducing all‐cause mortality, cardiovascular mortality, or major adverse cardiovascular events in waitlisted kidney transplant candidates with CAD who eventually underwent kidney transplantation.

Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis

STUDY OBJECTIVE

The aim of this study was to evaluate the impact of pharmacist presence or pharmacist-led antimicrobial stewardship interventions on appropriate prescribing of antibiotics in the emergency department (ED).

METHODS

Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted. Studies describing the role of pharmacists and their association with antimicrobial stewardship in the ED were included. The comparator for pharmacist intervention was hours without a pharmacist present, preprotocol implementation, and nonpharmacist culture follow-up.

RESULTS

In total, 24 studies (9,984 patients) were included in the qualitative synthesis, and 22 studies (5,791 patients) had data for the primary outcome and were included for the quantitative assessment (meta-analysis). Appropriate prescribing of antibiotics was more likely with pharmacist intervention (22 studies; odds ratio [OR], 3.47; 95% confidence interval [CI] 2.39 to 5.03), particularly among patients with pneumonia (5 studies; OR, 3.74; 95% CI 2.14 to 6.54) or urinary tract infection (4 studies; OR, 1.76; 95% CI 1.24 to 2.50). Time to culture review was similar with or without pharmacist intervention. Time to appropriate antibiotic was shorter with pharmacist intervention (mean difference, 18.9 hours; 95% CI 11.9 to 25.9; P<.001). Repeat ED visit for the same complaint was not significant (10 studies; OR, 0.65; 95% CI 0.39 to 1.10).

CONCLUSION

Pharmacist presence and pharmacist-led antimicrobial stewardship interventions appear to be effective for the appropriate prescribing of antibiotics in adult patients presenting to EDs with a variety of infectious syndromes.

Virtual reality biofeedback interventions for treating anxiety : A systematic review, meta-analysis and future perspective

Background

Virtual reality (VR)-based biofeedback is a relatively new intervention and is increasingly being used for the treatment of anxiety disorders. This is the first research synthesis regarding effects and efficacy of this novel mode of treatment.

Method

We conducted a systematic review and meta-analysis of the VR biofeedback literature on treating anxiety symptoms. The MEDLINE/PubMed, Scopus and Web of Science databases were searched for eligible pre-post comparisons and randomized controlled trials (RCTs). We used self-reported anxiety, heart rate (HR), and heart rate variability (HRV) as primary outcome measures.

Results

A total of 7 studies with 191 participants reported VR biofeedback interventions. Of these studies 5 were RCTs, with 103 participants receiving VR biofeedback and 99 control participants (either 2D biofeedback or waiting list controls). We found that VR biofeedback significantly lowers self-reported anxiety (g = −0.28) and HR (g = −0.45), but not HRV. Furthermore, there were no significant differences in outcomes between VR biofeedback and 2D biofeedback but a significant reduction in HR in the VR biofeedback group compared with the waiting list (g = −0.52).

Conclusion

While the first findings are optimistic, more controlled studies with a wider variety of samples are needed to bring this field forward. Particularly, children and adolescents may profit from the combination of gamification elements, VR, and biofeedback.

Impact of magnesium on bone health in older adults: A systematic review and meta-analysis

BACKGROUND

Magnesium plays a key role in bone health and may, therefore, represent an interesting nutrient for the prevention of bone loss and osteoporosis. The aim of this systematic review and meta-analysis was to investigate the impact of magnesium intake from any source on bone mineral density (BMD), bone mineral content (BMC), bone turnover markers, and fracture risk in older adults.

METHODS

A systematic search was conducted using Embase, Medline Ovid and Cochrane Central from database inception to October 2020. All studies that related magnesium intake with bone health outcomes among adults aged ≥60 years were included. Two investigators independently conducted abstract and full-text screenings, data extractions, and risk of bias assessments. Authors were contacted for missing data.

RESULTS

Once 787 records were screened, six cohort studies, one case-control study and five cross-sectional studies were included. Qualitative evaluation demonstrated a positive trend between higher magnesium intake and higher hip and femoral neck BMD. Meta-analysis of four studies showed a significant positive association between magnesium intake and hip BMD (pooled beta: 0.03, 95% CI: 0.01-0.06, p < 0.05).

CONCLUSIONS

This systematic review indicates that a higher magnesium intake may support an increase in hip and femoral neck BMD. Due to limited research no associations with BMD at other sites or fractures were found. There is a need for properly designed cohort studies to determine the association between magnesium intake and bone health in older adults. Next, large and long-term randomized controlled trials in older adults are needed to determine whether an increase in magnesium (supplementation) intake can improve bone health. The combination of several bone nutrients (calcium, vitamin D, protein, magnesium and potentially more) may be needed for the most optimal effect on bone health and to delay or prevent the development of osteoporosis.

Incidence of non-typhoidal Salmonella invasive disease: A systematic review and meta-analysis

OBJECTIVES

We sought to collate and summarize high-quality data on non-typhoidal Salmonella invasive disease (iNTS) incidence to provide contemporary incidence estimates by location and year.

METHODS

We systematically searched the databases Embase + MEDLINE, Web of Science, and PubMed for articles published on the incidence of iNTS from inception of the database through 8 May 2020 with no language, country, date, or demographic restrictions applied. A meta-analysis was performed to report pooled iNTS incidence as a rate of cases per 100,000 per year.

RESULTS

Among 13 studies eligible for analysis, there were 68 estimates of incidence. Overall pooled incidence (95% CI) was 44.8 (31.5-60.5) per 100,000 persons per year. When stratified by region, pooled incidence was significantly higher in Africa than Asia, 51.0 (36.3-68.0) compared to 1.0 (0.2-2.5), respectively. Incidence was consistently higher in children aged <5 years compared with older age groups. Incidence displayed considerable heterogeneity in both place and time, varying substantially between locations and over consecutive years in the same location.

CONCLUSIONS

iNTS incidence varies by region, location, age group, and over time. Concerted efforts are needed to address the limited high-quality data available on iNTS disease incidence.

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.

Values and other decisional factors regarding treatment of hypercalcaemia of malignancy: a systematic review protocol

INTRODUCTION

Hypercalcaemia of malignancy (HCM) is the second most common cause of hypercalcaemia and is associated with significant morbidity and mortality. Several treatment options are available including pharmacological therapy with bisphosphonates, denosumab, glucocorticoids and calcimimetics, as well as conventional therapy with hydration and possibly calcitonin. While guidelines have previously considered treatment effects, no guideline has yet considered a range of contextual factors impacting recommendations for the management. The aim of this study was to summarise the available evidence on important decisional factors for the development of guidelines for the treatment of HCM. These include patient's values and preferences, cost, acceptability, feasibility and equity.

METHODS AND ANALYSIS

This protocol is registered in PROSPERO (registration number: CRD42021264371). This is a systematic review of observational studies, case series, trials, reviews and qualitative studies involving treatment of adult patients with HCM. We will develop and execute two independent search strategies using five databases: PubMed, Medline (OVID), Embase.com, CINAHL (EBSCO) and Cochrane, and review their combined output. Two reviewers will screen titles and abstracts and full texts and will implement data abstraction from relevant studies independently and in duplicate. The outcomes of interest are the decisional factors that influence drug selection, with possible subgroup summaries by drug class or aetiology of HCM. We will present the data collected in a narrative and thematic approach.

ETHICS AND DISSEMINATION

Ethical approval is not applicable for our study, since we will only collect data from available literature. This systematic review will be submitted to a peer-reviewed journal when completed.

NUQUEST-NUtrition QUality Evaluation Strengthening Tools: development of tools for the evaluation of risk of bias in nutrition studies

BACKGROUND

Dietary exposure assessments are a critical issue in evaluating human nutrition studies; however, nutrition-specific criteria are not consistently included in existing bias assessment tools.

OBJECTIVES

Our objective was to develop a set of risk of bias (RoB) tools that integrated nutrition-specific criteria into validated generic assessment tools to address RoB issues, including those specific to dietary exposure assessment.

METHODS

The Nutrition QUality Evaluation Strengthening Tools (NUQUEST) development and validation process included 8 steps. The first steps identified 1) a development strategy; 2) generic assessment tools with demonstrated validity; and 3) nutrition-specific appraisal issues. This was followed by 4) generation of nutrition-specific items and 5) development of guidance to aid users of NUQUEST. The final steps used established ratings of selected studies and feedback from independent raters to 6) assess reliability and validity; 7) assess formatting and usability; and 8) finalize NUQUEST.

RESULTS

NUQUEST is based on the Scottish Intercollegiate Guidelines Network checklists for randomized controlled trials, cohort studies, and case-control studies. Using a purposive sample of 45 studies representing the 3 study designs, interrater reliability was high (Cohen's κ: 0.73; 95% CI: 0.52, 0.93) across all tools and at least moderate for individual tools (range: 0.57-1.00). The use of a worksheet improved usability and consistency of overall interrater agreement across all study designs (40% without worksheet, 80%-100% with worksheet). When compared to published ratings, NUQUEST ratings for evaluated studies demonstrated high concurrent validity (93% perfect or near-perfect agreement). Where there was disagreement, the nutrition-specific component was a contributing factor in discerning exposure methodological issues.

CONCLUSIONS

NUQUEST integrates nutrition-specific criteria with generic criteria from assessment tools with demonstrated reliability and validity. NUQUEST represents a consistent and transparent approach for evaluating RoB issues related to dietary exposure assessment commonly encountered in human nutrition studies.

Association Between SARS-CoV-2 Cycle Threshold Values and Clinical Outcomes in Patients With COVID-19: A Systematic Review and Meta-analysis

Cycle threshold (C_T) values are correlated with the amount of viral nucleic acid in a sample and may be obtained from some qualitative real-time polymerase chain reaction tests used for diagnosis of most patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, C_T values cannot be directly compared across assays, and they must be interpreted with caution as they are influenced by sample type, timing of sample collection, and assay design. Presently, the correlation between C_T values and clinical outcomes is not well understood. We conducted a systematic review and meta-analysis of published studies through April 19, 2021, that reported an association between C_T values and hospitalization, disease severity, and mortality in patients ≥18 years old with SARS-CoV-2. A meta-analysis of 7 studies showed no significant difference in mean C_T values between hospitalized and nonhospitalized patients. Among hospitalized patients, those with C_T values <25 had a high risk of more severe disease and mortality than patients with C_T values >30 (odds ratio [OR], 2.31; 95% CI, 1.70 to 3.13; and OR, 2.95; 95% CI, 2.19 to 3.96; respectively). The odds of increased disease severity and mortality were less pronounced in patients with C_T values of 25–30 compared with >30.

Catheter directed compared to systemically delivered thrombolysis for pulmonary embolism: a systematic review and meta-analysis

To compare the efficacy and safety of systemic and catheter directed thrombolysis for patients with pulmonary embolism. Pubmed and Cochrane Central Register of Controlled Trials were systematically searched from inception to May 31st 2020 to identify relevant studies. Outcomes of interest were in-hospital mortality and major bleeding including intracranial hemorrhage. We included 8 observational studies comprising 11,932 patients with PE. Catheter directed thrombolysis was associated with lower in-hospital mortality [RR 0.52; 95% confidence interval (CI) 0.40-0.68]. Although there was no difference in major bleeding by treatment strategy (RR 0.80; 95% CI 0.37-1.76), intracranial hemorrhage was lower in patients receiving catheter directed therapy (RR 0.66; 95% CI, 0.47-0.94).The certainty in these estimates was low. Non-randomized studies suggest that catheter directed delivery of thrombolytic therapy may be associated with lower in-hospital mortality and intracranial hemorrhage rates. These results may help inform management strategies for health care and pulmonary embolism response teams (PERT) involved in the management of high risk patients with massive or submassive pulmonary emboli.

Evaluation of spin in the abstracts of systematic reviews and meta-analyses focused on the treatment of obesity

OBJECTIVE

Spin, i.e., the misrepresentation of research findings, has the potential to affect patient care. Evidence suggests that spin is prevalent in obesity randomized controlled trials. Therefore, the primary objective of this study was to evaluate spin in abstracts of systematic reviews covering obesity treatments.

METHODS

MEDLINE and Embase were searched to retrieve systematic reviews on obesity treatments. Each systematic review abstract was inspected for the nine most severe types of spin, i.e., the misrepresentation of study findings by exaggeration or omission, regardless of intentionality. Screening and data extraction occurred in a masked, triplicate fashion. Methodological quality was determined using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2).

RESULTS

Spin was identified in 20 (out of 200, 10%) abstracts, with spin type 5 (claiming efficacy despite high risk of bias among primary studies) being most common (11/200, 5.5%). Spin types 2 and 7, both related to unsupported efficacy claims, were not found. No associations were found between spin and extracted study characteristics. The methodological quality of the sample was rated as follows: critically low (23.0%), low (13.5%), moderate (60.5%), and high (3%).

CONCLUSIONS

Although these findings demonstrate a low proportion of spin in the abstracts of systematic reviews for obesity treatment; increased preventive measures may further reduce its presence.

Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

Suicide and Associations with Air Pollution and Ambient Temperature: A Systematic Review and Meta-Analysis

Given health threats of climate change, a comprehensive review of the impacts of ambient temperature and ar pollution on suicide is needed. We performed systematic literature review and meta-analysis of suicide risks associated with short-term exposure to ambient temperature and air pollution. Pubmed, Scopus, and Web of Science were searched for English-language publications using relevant keywords. Observational studies assessing risks of daily suicide and suicide attempts associated with temperature, particulate matter with aerodynamic diameter ≤10 μm (PM₁₀) and ≤2.5 mm (PM_2.5), ozone (O₃), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), and carbon monoxide (CO) were included. Data extraction was independently performed in duplicate. Random-effect meta-analysis was applied to pool risk ratios (RRs) for increases in daily suicide per interquartile range (IQR) increase in exposure. Meta-regression analysis was applied to examine effect modification by income level based on gross national income (GNI) per capita, national suicide rates, and average level of exposure factors. In total 2274 articles were screened, with 18 studies meeting inclusion criteria for air pollution and 32 studies for temperature. RRs of suicide per 7.1 °C temperature was 1.09 (95% CI: 1.06, 1.13). RRs of suicide per IQR increase in PM_2.5, PM₁₀, and NO₂ were 1.02 (95% CI: 1.00, 1.05), 1.01 (95% CI: 1.00, 1.03), and 1.03 (95% CI: 1.00, 1.07). O₃, SO₂, and CO were not associated with suicide. RR of suicide was significantly higher in higher-income than lower-income countries (1.09, 95% CI: 1.07, 1.11 and 1.20, 95% CI: 1.14, 1.26 per 7.1 °C increased temperature, respectively). Suicide risks associated with air pollution did not significantly differ by income level, national suicide rates, or average exposure levels. Research gaps were found for interactions between air pollution and temperature on suicide risks.

Community-Based Assessment and Treatment of Hepatitis C Virus-Related Liver Disease, Injecting Drug and Alcohol Use Amongst People Who Are Homeless: A Systematic Review and Meta-Analysis

BACKGROUND/AIMS

We performed a systematic review and meta-analysis addressing community-based assessment and treatment of hepatitis C virus (HCV)-related liver disease, injecting drug use (IDU) and alcohol use amongst people who are homeless (PWAH).

METHODS

Using systematic review methodology, databases were searched (MEDLINE/ EMBASE/CINAHL) for studies combining PWAH, HCV-related liver disease and community assessment until December 2019. Studies with a sample size ≥ 30, with PWAH constituting at least 30% of the cohort were included and a quality assessment performed. Pooled estimates of key indicators were analysed using meta-analysis.

RESULTS

We identified 39 studies (n = 13,918), 37 categorised as poor quality (Newcastle-Ottawa Scale). Prevalence of homelessness ranged between 30%-100% (37 studies). Eight studies provided all of the following: HCV screening, alcohol/substance use/liver fibrosis assessment and HCV treatment. No study provided interventions for alcohol use, with two providing opioid substitution treatment. Alcohol use prevalence (24 studies) was 4%-97%, being 59% (95% CI 20%-92%) in four studies that included only PWAH. Recent IDU prevalence (16 studies) was 7%-73%, being 21% (95% CI 17%-26%) in four studies that included only PWAH. HCV seroprevalence (25 studies) was 2.5% - 58%; in 13 studies that included only PWAH, this was 20% (95% CI 12%-30%). Prevalence of F4 fibrosis (nine studies) was 6%-28%, being 7% and 16% in two studies that included only PWAH. Direct acting antiviral-based intention-to-treat sustained virological response (SVR) rates (five studies) were 82%-92%, being 92% in the one study that included only PWAH. In the only two randomised controlled trials (RCT) identified, community-based interventions (mental health/peer mentor) significantly increased linkage to care (p = 0.04), HCV treatment (p = 0.005) and SVR rates (p = 0.018).

CONCLUSION

The burden from alcohol/IDU and HCV, and consequently liver disease in PWAH needs addressing. RCT trials assessing community-based interventions to improve liver health in PWAH are needed.

Methodological frontiers in vaccine safety: qualifying available evidence for rare events, use of distributed data networks to monitor vaccine safety issues, and monitoring the safety of pregnancy interventions

While vaccines are rigorously tested for safety and efficacy in clinical trials, these trials do not include enough subjects to detect rare adverse events, and they generally exclude special populations such as pregnant women. It is therefore necessary to conduct postmarketing vaccine safety assessments using observational data sources. The study of rare events has been enabled in through large linked databases and distributed data networks, in combination with development of case-centred methods. Distributed data networks necessitate common protocols, definitions, data models and analytics and the processes of developing and employing these tools are rapidly evolving. Assessment of vaccine safety in pregnancy is complicated by physiological changes, the challenges of mother-child linkage and the need for long-term infant follow-up. Potential sources of bias including differential access to and utilisation of antenatal care, immortal time bias, seasonal timing of pregnancy and unmeasured determinants of pregnancy outcomes have yet to be fully explored. Available tools for assessment of evidence generated in postmarketing studies may downgrade evidence from observational data and prioritise evidence from randomised controlled trials. However, real-world evidence based on real-world data is increasingly being used for safety assessments, and new tools for evaluating real-world evidence have been developed. The future of vaccine safety surveillance, particularly for rare events and in special populations, comprises the use of big data in single countries as well as in collaborative networks. This move towards the use of real-world data requires continued development of methodologies to generate and assess real world evidence.

Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Migraine is common and can be associated with significant morbidity, and several treatment options exist for acute therapy.

OBJECTIVE

To evaluate the benefits and harms associated with acute treatments for episodic migraine in adults.

DATA SOURCES

Multiple databases from database inception to February 24, 2021.

STUDY SELECTION

Randomized clinical trials and systematic reviews that assessed effectiveness or harms of acute therapy for migraine attacks.

DATA EXTRACTION AND SYNTHESIS

Independent reviewers selected studies and extracted data. Meta-analysis was performed with the DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction or by using a fixed-effect model based on the Mantel-Haenszel method if the number of studies was small.

MAIN OUTCOMES AND MEASURES

The main outcomes included pain freedom, pain relief, sustained pain freedom, sustained pain relief, and adverse events. The strength of evidence (SOE) was graded with the Agency for Healthcare Research and Quality Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

FINDINGS

Evidence on triptans and nonsteroidal anti-inflammatory drugs was summarized from 15 systematic reviews. For other interventions, 115 randomized clinical trials with 28 803 patients were included. Compared with placebo, triptans and nonsteroidal anti-inflammatory drugs used individually were significantly associated with reduced pain at 2 hours and 1 day (moderate to high SOE) and increased risk of mild and transient adverse events. Compared with placebo, calcitonin gene-related peptide receptor antagonists (low to high SOE), lasmiditan (5-HT1F receptor agonist; high SOE), dihydroergotamine (moderate to high SOE), ergotamine plus caffeine (moderate SOE), acetaminophen (moderate SOE), antiemetics (low SOE), butorphanol (low SOE), and tramadol in combination with acetaminophen (low SOE) were significantly associated with pain reduction and increase in mild adverse events. The findings for opioids were based on low or insufficient SOE. Several nonpharmacologic treatments were significantly associated with improved pain, including remote electrical neuromodulation (moderate SOE), transcranial magnetic stimulation (low SOE), external trigeminal nerve stimulation (low SOE), and noninvasive vagus nerve stimulation (moderate SOE). No significant difference in adverse events was found between nonpharmacologic treatments and sham.

CONCLUSIONS AND RELEVANCE

There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited.

A systematic review and meta-analysis of treatment and natural history of popliteal artery aneurysms

OBJECTIVE

To summarize the best available evidence comparing open vs endovascular popliteal artery aneurysm (PAA) repair. We also summarized the natural history of PAAs to support of the Society for Vascular Surgery guidelines.

METHODS

We searched MEDLINE, EMBASE, Cochrane databases, and Scopus for studies of patients with PAAs treated with an open vs an endovascular approach. We also included studies of natural history of untreated patients. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was performed when appropriate.

RESULTS

We identified 32 original studies and 4 systematic reviews from 2191 candidate references. Meta-analysis showed that compared with the endovascular approach, open surgical repair was associated with higher primary patency at 1 year (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.41-3.12), lower occlusion rate at 30 days (OR, 0.41; 95% CI, 0.24-0.68) and fewer reinterventions (OR, 0.28; 95% CI, 0.17-0.45), but a longer hospital stay (standardized mean difference, 2.16; 95% CI, 1.23-3.09) and more wound complications (OR, 5.18; 95% CI, 2.19-12.26). There was no statistically significant difference in primary patency at 3 years (OR, 1.38; 95% CI, 0.97-1.97), secondary patency (OR, 1.59; 95% CI, 0.84-3.03), mortality at the longest follow-up (OR, 0.49; 95% CI, 0.21-1.17), mortality at 30 days (OR, 0.28; 95% CI, 0.06-1.36), or amputation (incidence rate ratio, 0.85; 95% CI, 0.56-1.31). The certainty in these estimates was, in general, low. Studies of PAA natural history suggest that thromboembolic complications and amputation develop at a mean observation time of 18 months and they are frequent. One study showed that at 5 years, approximately one-half of the patients had complications.

CONCLUSIONS

This systematic review provides event rates for outcomes important to patients with PAAs. Despite the low certainty of the evidence, these rates along with surgical expertise and anatomic feasibility can help patients and surgeons to engage in shared decision-making.

Anakinra in hospitalized non-intubated patients with coronavirus disease 2019: a systematic review and meta-analysis

Background

Acute respiratory distress syndrome and cytokine release syndrome are the major complications of coronavirus disease 2019 (COVID-19) associated with increased mortality risk.

Objectives

We performed a meta-analysis to assess the efficacy and safety of anakinra in adult hospitalized non-intubated patients with COVID-19.

Search methods

Relevant trials were identified by searching literature until 24 April 2021 using the following terms: anakinra, interleukin 1, coronavirus, COVID-19, SARS-CoV-2.

Selection criteria

Trials evaluating the effect of anakinra on the need for invasive mechanical ventilation and mortality in hospitalized non-intubated patients with COVID-19.

Results

Nine studies (n = 1,119) were eligible for inclusion in the present meta-analysis. Their bias risk with reference to the assessed parameters was high. In pooled analyses, anakinra reduced the need for invasive mechanical ventilation (odds ratio, OR: 0·38, 95% confidence interval, CI: 0·17–0·85, p= 0.02, I²=67%; 6 studies, n = 587) and mortality risk (OR: 0·32, 95% CI: 0·23–0·45, p< 0·00001, I²=0%; 9 studies, n = 1,119) compared with standard of care therapy. There were no differences regarding the risk of adverse events, including liver dysfunction (OR: 0·75, 95% CI: 0·48–1·16, p> 0·05, I²=28%; 5 studies, n = 591) and bacteremia (OR: 1·07, 95% CI: 0·42–2·73, p> 0·05, I²=71%; 6 studies, n = 727).

Conclusions

Available evidence shows that treatment with anakinra reduces both the need for invasive mechanical ventilation and mortality risk of hospitalized non-intubated patients with COVID-19 without increasing the risk of adverse events. Confirmation of efficacy and safety requires randomized placebo-controlled trials.

Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis

BACKGROUND

Given the widespread nature and clinical consequences of self-harm and suicidal ideation among adolescents, establishing the efficacy of developmentally appropriate treatments that reduce both self-harm and suicidal ideation in the context of broader adolescent psychopathology is critical.

METHODS

We conducted a systematic review and meta-analysis of the Dialectical Behaviour Therapy for Adolescents (DBT-A) literature on treating self-injury in adolescents (12-19 years). We searched for eligible trials and treatment evaluations published prior to July 2020 in MEDLINE/PubMed, Scopus, Google Scholar, EMBASE, and the Cochrane Library databases for clinical trials. Twenty-one studies were identified [five randomized-controlled trials (RCTs), three controlled clinical trials (CCTs), and 13 pre-post evaluations]. We extracted data for predefined primary (self-harm, suicidal ideation) and secondary outcomes (borderline personality symptoms; BPD) and calculated treatment effects for RCTs/CCTs and pre-post evaluations. This meta-analysis was pre-registered with OSF: osf.io/v83e7.

RESULTS

Overall, the studies comprised 1673 adolescents. Compared to control groups, DBT-A showed small to moderate effects for reducing self-harm (g = -0.44; 95% CI -0.81 to -0.07) and suicidal ideation (g = -0.31, 95% CI -0.52 to -0.09). Pre-post evaluations suggested large effects for all outcomes (self-harm: g = -0.98, 95% CI -1.15 to -0.81; suicidal ideation: g = -1.16, 95% CI -1.51 to -0.80; BPD symptoms: g = -0.97, 95% CI -1.31 to -0.63).

CONCLUSIONS

DBT-A appears to be a valuable treatment in reducing both adolescent self-harm and suicidal ideation. However, evidence that DBT-A reduces BPD symptoms was only found in pre-post evaluations.

Effect of physical exercise on the functional capacity of children and adolescents submitted to transplantation of hematopoietic stem cells-A systematic review with meta-analysis

Previous studies have shown beneficial effects of physical exercise (PE) in adults submitted to hematopoietic stem cell transplantation (HSCT). Conduct a systematic review about the effects of PE on the functional capacity of children and adolescents submitted to HSCT. The studies were searched in the databases MEDLINE (via PubMed), Central Register of Controlled Trials (Cochrane CENTRAL), EMBASE, LILACS, and Evidence Database in Physical Therapy (PEDro) (CRD42018080093). Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. Randomized and nonrandomized clinical trials comparing PE with usual treatment in children and adolescents aged 3-18 years were included. The risk of bias was assessed using the Cochrane Collaboration tool and ROBINS-I tool, and the overall quality of the evidence was determined by the GRADE system. We included three studies with 91 patients. PE improved the functional capacity assessed by the timed up and down stairs test (MD -1.23 [95% CI, 2.27 to -.20, I2 = 0%]), but there was no significant effect in the six-minute walk test (MD 44.63 [95% CI, -20.86 to 110.13, I2 = 83%]). The benefits regarding quality of life and peripheral muscle strength of these individuals were not clearly demonstrated, but positive responses were observed in relation to the analyzed data. None of the studies evaluated the fatigue. The limitations found were the high heterogeneity between studies, as well as the sample size and the low methodological rigor. PE might be favorable to improve the functional capacity of children and adolescents treated with HSCT. However, further studies are needed to clarify the best PE program.

Association Between Disturbed Sleep and Depression in Children and Youths: A Systematic Review and Meta-analysis of Cohort Studies

IMPORTANCE

Disturbed sleep represents a potentially modifiable risk factor for depression in children and youths that can be targeted in prevention programs.

OBJECTIVE

To evaluate the association between disturbed sleep and depression in children and youths using meta-analytic methods.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Scopus, Web of Science, and ProQuest Dissertations & Theses Global were searched for articles published from 1980 to August 2019.

STUDY SELECTION

Prospective cohort studies reporting estimates, adjusted for baseline depression, of the association between disturbed sleep and depression in 5- to 24-year-old participants from community and clinical-based samples with any comorbid diagnosis. Case series and reports, systematic reviews, meta-analyses, and treatment, theoretical, and position studies were excluded. A total of 8700 studies met the selection criteria. This study adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews (PRISMA) and Meta-analyses and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statements.

DATA EXTRACTION AND SYNTHESIS

Study screening and data extraction were conducted by 2 authors at all stages. To pool effect estimates, a fixed-effect model was used if I2 < 50%; otherwise, a random-effects model was used. The I2 statistic was used to assess heterogeneity. The risk of bias was assessed using the Research Triangle Institute Item Bank tool. Metaregression analyses were used to explore the heterogeneity associated with type of ascertainment, type of and assessment tool for disturbed sleep and depression, follow-up duration, disturbed sleep at follow-up, and age at baseline.

MAIN OUTCOME AND MEASURES

Disturbed sleep included sleep disturbances or insomnia. Depression included depressive disorders or dimensional constructs of depression. Covariates included age, sex, and sociodemographic variables.

RESULTS

A total of 22 studies (including 28 895 patients) were included in the study, of which 16 (including 27 073 patients) were included in the meta-analysis. The pooled β coefficient of the association between disturbed sleep and depression was 0.11 (95% CI, 0.06-0.15; P < .001; n = 14 067; I2 = 50.8%), and the pooled odds ratio of depression in those with vs without disturbed sleep was 1.50 (95% CI, 1.13-2.00; P = .005; n = 13 006; I2 = 87.7%). Metaregression and sensitivity analyses showed no evidence that pooled estimates differed across any covariate. Substantial publication bias was found.

CONCLUSIONS AND RELEVANCE

This meta-analysis found a small but statistically significant effect size indicating an association between sleep disruption and depressive symptoms in children and youths. The high prevalence of disturbed sleep implies a large cohort of vulnerable children and youths who could develop depression. Disrupted sleep should be included in multifaceted prevention programs starting in childhood.

A Systematic Review Supporting the American Society for Dermatologic Surgery Guidelines on the Prevention and Treatment of Adverse Events of Injectable Fillers

BACKGROUND

As the use of injectable skin fillers increase in popularity, an increase in the reported adverse events is expected.

OBJECTIVE

This systematic review supports the development of American Society for Dermatologic Surgery practice guideline on the management of adverse events of skin fillers.

METHODS AND MATERIALS

Several databases for studies on risk factors or treatments of injection-related visual compromise (IRVC), skin necrosis, inflammatory events, and nodules were searched. Meta-analysis was conducted when feasible.

RESULTS

The review included 182 studies. However, IRVC was very rare (1-2/1,000,000 patients) but had poor prognosis with improvement in 19% of cases. Skin necrosis was more common (approximately 5/1,000) with better prognosis (up to 77% of cases showing improvement). Treatments of IRVC and skin necrosis primarily depend on hyaluronidase injections. Risk of skin necrosis, inflammatory events, and nodules may be lower with certain fillers, brands, injection techniques, and volume. Treatment of inflammatory events and nodules with antibiotics, corticosteroids, 5-FU, and hyaluronidase was associated with high response rate (75%-80%). Most of the studies were small and noncomparative, making the evidence certainty very low.

CONCLUSION

Practitioners must have adequate knowledge of anatomy, elicit history of skin filler use, and establish preemptive protocols that prepare the clinical practice to manage complications.

Evidence-Based Overview of Accelerometer-Measured Physical Activity during School Recess: An Updated Systematic Review

Interest in analyzing physically active behaviors during school recesses has grown in recent years as the school environment has consolidated (recess, physical education classes, lunch-time, before and after school) as a crucial space to bring these levels towards those recommended through intervention programs and improvements in the school environment. Unfortunately, in most of these studies, children do not achieve the 60 min a day of moderate to vigorous physical activity (MVPA) recommended by the World Health Organization. The aim of this systematic review is to analyze the cross-sectional, longitudinal, and intervention studies objectively measured with accelerometers that have emerged in recent years to determine the amount of MVPA of children at recess. This systematic review followed the PRISMA guidelines. The extraction process for the studies included in this systematic review yielded a total of 43 articles. The studies were classified according to the methodological nature of the research: cross-sectional (n = 34), longitudinal (n = 3) and quasi-experimental (n = 6). The results of the studies confirm that during the recess period younger children are physically more active than older ones and that in general, boys are more physically active than girls. In addition, the data show that the school contributes to more than 40% of the total MVPA. The intervention programs led to an increase in MVPA of up to 5%. Providing schools with equipment and facilities shows that intervention programs are beneficial for raising children's levels of physical activity.

Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers and the Risk of SARS-CoV-2 Infection or Hospitalization With COVID-19 Disease: A Systematic Review and Meta-Analysis

BACKGROUND

SARS-CoV-2 infects its target cells via angiotensin converting enzyme 2 receptor, a membrane-bound protein found on the surface of many human cells. Treatment with angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptors blockers (ARB) has been shown to increase angiotensin converting enzyme 2 expression by up to 5-fold.

AREAS OF UNCERTAINTY

These findings coupled with observations of the high prevalence and mortality among SARS-CoV-2-infected patients with underlying cardiovascular disease have led to a speculation that ACEIs/ARBs may predispose to higher risk of being infected with SARS-CoV-2. Therefore, we systematically reviewed the literature and performed a meta-analysis of the association between prior use of ACEIs and ARBs and the risk of SARS-CoV-2 infection or hospitalization due to COVID-19 disease.

DATA SOURCES

We searched Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Medrxiv.org preprint server until June 18, 2020.

THERAPEUTIC ADVANCES

Ten studies (6 cohorts and 4 case control) that enrolled a total of 23,892 patients and 853,369 controls were eligible for inclusion in our meta-analysis. One study was excluded from the analysis because of high risk of bias. Prior use of ACEIs was not associated with an increased risk of acquiring SARS-CoV-2 or hospitalization due to COVID-19 disease, odds ratio 0.98, 95% confidence interval (0.91-1.05), I2 = 15%. Similarly, prior use of ARBs was not associated with an increased risk of acquiring SARS-CoV-2, odds ratio 1.04, 95% confidence interval (0.98-1.10), I2 = 0%.

CONCLUSION

Cumulative evidence suggests that prior use of ACEIs or ARBs is not associated with a higher risk of COVID-19 or hospitalization due to COVID-19 disease. Our results provide a reassurance to the public not to discontinue prescribed ACEIs/ARBs because of fear of COVID-19.

Assessing the risk of ketoacidosis due to sodium-glucose cotransporter (SGLT)-2 inhibitors in patients with type 1 diabetes: A meta-analysis and meta-regression

BACKGROUND

Sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) showed benefits in type 1 diabetes mellitus (T1DM), but the risk of diabetic ketoacidosis (DKA) limits their use. Ability to predict DKA risk and therapeutic responses would enable appropriate patient selection for SGLT2i. We conducted a meta-analysis and meta-regression of randomized controlled trials (RCTs) evaluating SGLT2i in T1DM to assess moderators of the relative risk (RR) of DKA, of glycemic (HbA1c, fasting plasma glucose, continuous glucose monitoring parameters, insulin dose, and insulin sensitivity indices) and non-glycemic (body mass index (BMI), systolic BP, renal function, albuminuria, and diabetic eye disorders) efficacy, and of other safety outcomes (including hypoglycemia, infections, major adverse cardiovascular events, and death).

METHODS AND FINDINGS

We searched MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials, and other electronic sources through August 30, 2020, for RCTs comparing SGLT2i with active comparators or placebo in adult patients with T1DM. Reviewers extracted data for relevant outcomes, performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. The strength of evidence was summarized with the GRADE approach. Among 9,914 records identified, 18 placebo-controlled RCTs (7,396 participants, 50% males, mean age 42 y (range 23 to 55 y), 5 different SGLT2i evaluated), were included. Main outcome measures were effect sizes and moderators of glycemic and non-glycemic efficacy and of safety outcomes. In a multivariable meta-regression model, baseline BMI (β = 0.439 [95% CI: 0.211, 0.666], p < 0.001) and estimated glucose disposal rate (eGDR) (β = -0.766 [-1.276, -0.256], p = 0.001) were associated with the RR of DKA (RR: 2.81; 95% CI:1.97, 4.01; p < 0.001, R2 = 61%). A model including also treatment-related parameters (insulin dose change-to-baseline insulin sensitivity ratio and volume depletion) explained 86% of variance across studies in the risk of DKA (R2 = 86%). The association of DKA with a BMI >27 kg/m2 and with an eGDR <8.3 mg/kg/min was confirmed also in subgroup analyses. Among efficacy outcomes, the novel findings were a reduction in albuminuria (WMD: -9.91, 95% CI: -16.26, -3.55 mg/g, p = 0.002), and in RR of diabetic eye disorders (RR: 0.27[0.11, 0.67], p = 0.005) associated with SGLT2i. A SGLT2i dose-response gradient was consistently observed for main efficacy outcomes, but not for adverse events (AEs). Overall, predictors of DKA and of other AEs differed substantially from those of glycemic and non-glycemic efficacy. A limitation of our analysis was the relatively short (≤52 weeks) duration of included RCTs. The potential relevance for clinical practice needs also to be confirmed by real-world prospective studies.

CONCLUSIONS

In T1DM, the risk of DKA and main therapeutic responses to SGLT2i are modified by baseline BMI and insulin resistance, by total insulin dose reduction-to-baseline insulin sensitivity ratio, and by volume depletion, which may enable the targeted use of these drugs in patients with the greatest benefit and the lowest risk of DKA.

Antirheumatic Disease Therapies for the Treatment of COVID-19: A Systematic Review and Meta-Analysis

Objective

Antirheumatic disease therapies have been used to treat coronavirus disease 2019 (COVID‐19) and its complications. We conducted a systematic review and meta‐analysis to describe the current evidence.

Methods

A search of published and preprint databases in all languages was performed. Included studies described ≥1 relevant clinical outcome for ≥5 patients who were infected with severe acute respiratory syndrome coronavirus 2 and were treated with antirheumatic disease therapy between January 1, 2019 and May 29, 2020. Pairs of reviewers screened articles, extracted data, and assessed risk of bias. A meta‐analysis of effect sizes using random‐effects models was performed when possible.

Results

The search identified 3,935 articles, of which 45 were included (4 randomized controlled trials, 29 cohort studies, and 12 case series). All studies evaluated hospitalized patients, and 29 of the 45 studies had been published in a peer‐reviewed journal. In a meta‐analysis of 3 cohort studies with a low risk of bias, hydroxychloroquine use was not significantly associated with mortality (pooled hazard ratio [HR] 1.41 [95% confidence interval (95% CI) 0.83, 2.42]). In a meta‐analysis of 2 cohort studies with some concerns/higher risk of bias, anakinra use was associated with lower mortality (pooled HR 0.25 [95% CI 0.12, 0.52]). Evidence was inconclusive with regard to other antirheumatic disease therapies, and the majority of other studies had a high risk of bias.

Conclusion

In this systematic review and meta‐analysis, hydroxychloroquine use was not associated with benefit or harm regarding COVID‐19 mortality. The evidence supporting the effect of other antirheumatic disease therapies in COVID‐19 is currently inconclusive.

Early vs Late Use of Anti-TNFa Therapy in Adult Patients With Crohn Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

While anti-tumor necrosis factor alpha (anti-TNFa) therapies for Crohn disease (CD) were initially introduced in 1998 for biologic therapies are often introduced after a minimum of 6 years after diagnosis. The benefit of anti-TNFa early in the course of CD is still controversial, with some studies showing better outcomes but others not. To determine whether earlier introduction of anti-TNFa therapy improves efficacy in clinical trials or clinical series, we aimed to perform a meta-analysis comparing early vs late anti-TNFa use in the management of CD.

METHODS

A comprehensive search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus was conducted from each database's inception to November 3, 2019. We included comparative studies of early vs late use of anti-TNFa therapy in adult patients with CD.

RESULTS

Eleven studies were included in the analysis, with a total of 2501 patients. Meta-analysis demonstrated that the early use of anti-TNFa was associated with a statistically significant decrease in the need for surgery (relative risk [RR] = 0.43; 95% confidence interval [CI], 0.26-0.69; I2 = 68%) and disease progression (RR = 0.51; 95% CI, 0.35-0.75; I2 = 61%). Early use also showed an increase in early remission (RR = 1.94; 95% CI, 1.54-2.46; I2 = 0%) and clinical response. There was no statistically significant difference in achieving late remission (RR = 1.39; 95% CI, 0.94-2.05; I2 = 65%) or mucosal healing (RR = 1.10; 95% CI, 0.63-1.91; I2 = 0%).

CONCLUSION

This systematic review suggests that using anti-TNFa earlier in the treatment of CD (within 3 years) may improve clinical outcomes compared to late administration in terms of achieving early clinical remission, clinical response, disease progression, and the need for surgery.

Midwifery students' experiences of bullying and workplace violence: A systematic review

BACKGROUND

Workplace violence directed at registered midwives in the maternity setting has been a recognised issue since the early 1990s. More recently it has become evident that midwifery students are also victims of bullying and harassment whilst on clinical placement. Due to the short and long-term impacts this has on students, it is likely to have a detrimental effect on the future and sustainability of the midwifery profession. As a basis for designing a response, it is important to understand what is currently known about this phenomenon.

AIM

To systematically review the literature to identify what is known about workplace violence and bullying experienced by midwifery students whilst on clinical placement.

METHOD

Reporting of this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was undertaken of all primary research that focussed upon workplace violence and bullying involving midwifery students whilst on clinical placement, published between January 1990 and December 2019. Pre-defined terms were used to search the following five databases: CINAHL, Web of Science, MEDLINE, Embase, supplemented with Google Scholar. Additional manual searches of reference lists were conducted. An assessment of the quality of each eligible study was then undertaken using an appropriate mixed methods appraisal tool (MMAT). Extracted data were then synthesised using thematic synthesis.

FINDINGS

Nine articles met the criteria for inclusion in the review. Studies were primarily qualitative, with some reporting descriptive statistics that do not enable key issues such as prevalence to be reliably addressed. The synthesis identified four main themes that related to workplace violence and bullying of midwifery students whilst on clinical placement. Results were clustered around the role of power in bullying, prevalence and impacts, the culture of compliance, and the victim's response.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

A broader understanding of the nature of workplace violence and bullying and how it manifests itself is beginning to emerge, but more and higher quality research is required to establish an empirical base on which to design interventions. Studies suggest that bullying is common and has significant impacts at both a personal and professional level.  This strongly reinforces a need for greater policy and organisational responses to bullying in the clinical education context, in order to break the bullying cycle and ensure the midwives of the future remain in the profession and sustain the workforce.

Use of mobile applications to improve nutrition behaviour: A systematic review

BACKGROUND AND OBJECTIVE

Mobile applications could be effectively used for dietary intake assessment, physical activity monitoring, behavior improvement, and nutrition education. The aim of this review is to determine the effectiveness of mobile applications in improving nutrition behaviors through a systematic review of literature.

METHODS

The review protocol was registered with PROSPERO: registration number CRD42018118809, and followed PRISMA guidelines. We involved original articles including mobile electronic devices for improving dietary intake, physical activity, and weight management in adult populations in this review. Data were retrieved from January 2010 to December 2018 with PubMed, Web of Science, Excerpta Medica Database (Embase), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) as data sources. Authors individually screened the titles and abstracts, then full articles in order to obtain papers that met inclusion criteria.

RESULTS

The database search yielded 2962 records. After removing the duplicates and analyzing the full text papers a total of 8 original articles were reviewed. Two articles showed obvious bias and were not included in our results or discussion. The remaining six articles with low to moderate bias risk were included in this systematic review. Three selected studies were randomized control trials (RCTs) with over 180 participants each. The other three studies were a nested trial, a case-control trial, and a pilot RCT with 36, 162, and 24 participants respectively. All larger RCTs and the small case control trail showed significant improvements in some nutritional-health objectives measured. The other two trials showed insignificant improvements in outcomes measured between groups.

CONCLUSION

This study highlights the potential significant health benefits acquirable through mobile health application-assisted nutrition interventions. Some of these studies required significant financial and time input from providers for the application's utilization. Further studies, perhaps with multiple intervention arms, are required to compare across programs the elements that are essential for health benefits observed.

Reliability of digital measurement methods on the marginal fit of fixed prostheses: A systematic review and meta-analysis of in vitro studies

STATEMENT OF PROBLEM

Digital methods have been increasingly used to evaluate the fit of prostheses, but the accuracy of digital methodology has not been fully clarified.

PURPOSE

The purpose of this systematic review and meta-analysis was to assess the reliability of digital measurement methods for evaluating the marginal fit of fixed dental prostheses (FDPs) and to identify the potential factors that can influence the accuracy of the measurement methods.

MATERIAL AND METHODS

The differences between digital and conventional measurement methods were analyzed by searching PubMed, Scopus, Web of Science, and Google Scholar databases for studies reporting the marginal fit of FDPs. The agreement of data collection among the reviewers was confirmed by the Cohen kappa coefficient, and the MINORS scale was used to rate the quality of the included studies. The heterogeneity among the studies was evaluated, and meta-analyses with global and subgroup analyses were performed.

RESULTS

Ten in vitro studies were selected according to the eligibility criteria with substantial interreader concordance (κ=0.88). The standard mean difference of the meta-analysis for marginal discrepancy was 0.12 μm (95% confidence interval: -0.12 to 0.35), indicating that no statistically significant differences were found in the marginal discrepancies observed with digital and conventional methods (P=.343). The subgroup analysis for alloy-based prostheses was not significantly different, nor between the material and measurement methods (P=.060).

CONCLUSIONS

Digital methods appear to be reliable as an alternative to conventional methods for evaluating the marginal fit of FDPs. To confirm the results of this study and to identify the influencing factors on the accuracy of digital measurement methods, further controlled laboratory and clinical studies are needed.

Longitudinal Relationships Between Depression and Chronic Illness in Adolescents: An Integrative Review

INTRODUCTION

Depression is prevalent among adolescents with chronic illness. However, little is known about how depression affects chronic illness over time. This review aimed to synthesize longitudinal relationships between depression and disease control, self-management behaviors, illness-related morbidity, and quality of life.

METHOD

Four databases were searched, including PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and EMBASE. Inclusion criteria were cohort studies examining depression among adolescents aged 10-21 years with a chronic illness and studies published in English. Study quality was appraised using the Newcastle-Ottawa scale and data was synthesized by the outcome.

RESULTS

Of the 3,463 articles identified, 11 were included in the review. For adolescents with diabetes, increased depressive symptoms predicted decreased metabolic control and monitoring, medication adherence, quality of life, and increased hospitalization. Studies on cystic fibrosis, congenital heart disease, sickle cell disease, and juvenile idiopathic arthritis were limited but demonstrated that depressive symptoms affected the quality of life, disability, pain, and hospitalization rates/costs.

DISCUSSION

Evidence supports the need for mental health care strategies suitable for adolescents with chronic illness. Future research is needed to examine the effects of depressive symptoms across diversified chronic illness populations.

The Nordic Nutrition Recommendations 2022 - handbook for qualified systematic reviews

BACKGROUND

Systematic reviews (SRs) constitute a major part of the Nordic Nutrition Recommendations (NNRs). The step-by-step procedure used to develop SRs has evolved considerably over time and is often tailored to fit the exposure and outcomes in focus.

OBJECTIVE

To describe a detailed procedure for developing qualified SRs commissioned by the NNR2022 project.

DESIGN

Scrutinizing procedures of recent SRs commissioned by leading national food and health authorities or international food and health organizations.

RESULTS

The following eight steps must be included when developing qualified SRs for the NNR2022 project: 1) define research question, 2) protocol development, 3) literature search, 4) screening and selection of studies, 5) data extraction, 6) assessing risk of bias, 7) synthesis and grading of total strength of evidence, and 8) reporting according to certain standards.

DISCUSSION

This guide is based on the guidelines developed for the fifth edition of NNR but includes some important new domains in order to adhere to more recent, authoritative standards.

CONCLUSION

All qualified SRs in the NNR2022 project will follow the protocol described here.

The Nordic Nutrition Recommendations 2022 - structure and rationale of qualified systematic reviews

BACKGROUND

Qualified systematic reviews (SRs) will form the main basis for evaluating causal effects of nutrients or food groups on health outcomes in the sixth edition of Nordic Nutrition Recommendations to be published in 2022 (NNR2022).

OBJECTIVE

To describe rationale and structure of SRs used in NNR2022.

DESIGN

The SR methodologies of the previous edition of NNR were used as a starting point. Methodologies of recent SRs commissioned by leading national food and health authorities or international food and health organizations were examined and scrutinized. Methodologies for developing SRs were agreed by the NNR2022 Committee in a consensus-driven process.

RESULTS

Qualified SRs will be developed by a cross-disciplinary group of experts and reported according to the requirements of the EQUATOR network. A number of additional requirements must also be fulfilled, including 1) a clearly stated set of objectives and research questions with pre-defined eligibility criteria for the studies, 2) an explicit, reproducible methodology, 3) a systematic search that attempts to identify all studies that would meet the eligibility criteria, 4) an assessment of the validity of the findings of the included studies through an assessment of 'risk of bias' of the studies, 5) a systematic presentation and synthesis of the characteristics and findings of the included studies, and 6) a grading of the overall evidence. The complete definition and requirements of a qualified SR are described.

DISCUSSION

Most SRs published in scientific journals do not fulfill all criteria of the qualified SRs in the NNR2022 project. This article discusses the structure and rationale for requirements of qualified SRs in NNR2022. National food and health authorities have only recently begun to use qualified SRs as a basis for nutrition recommendations.

CONCLUSION

Qualified SRs will be used to inform dietary reference values (DRVs) and food-based dietary guidelines (FBDGs) in the NNR2022 project.

Quality assessment of systematic reviews and meta-analyses that examine preventive antibiotic uses and management practices designed to prevent disease in livestock

To implement effective stewardship in food animal production, it is essential that producers and veterinarians are aware of preventive interventions to reduce illness in livestock. Systematic reviews and meta-analyses (SR/MA) provide transparent, replicable, and quality-assessed overviews. At present, it is unknown how many SR/MA evaluate preventive antibiotic use or management practices aimed at reducing disease risk in animal agriculture. Further, the quality of existing reviews is unknown. Our aim was to identify reviews investigating these topics and to provide an assessment of their quality. Thirty-eight relevant reviews were identified. Quality assessment was based on the AMSTAR 2 framework for the critical appraisal of systematic reviews. The quality of most of the reviews captured was classified as critically low (84.2%, n = 32/38), and only a small percentage of the evaluated reviews did not contain critical weaknesses (7.9%, n = 3/38). Particularly, a small number of reviews reported the development of an a priori protocol (15.8%, n = 6/38), and few reviews stated that key review steps were conducted in duplicate (study selection/screening: 26.3%, n = 10/38; data extraction: 15.8%, n = 6/38). The development of high-quality reviews summarizing evidence on approaches to antibiotic reduction is essential, and thus greater adherence to quality conduct guidelines for synthesis research is crucial.

Prioritizing Evidence-based Interventions for Dissemination and Implementation Investments: AHRQ's Model and Experience

BACKGROUND

The Agency for Healthcare Research and Quality (AHRQ) is mandated to implement patient-centered outcomes research (PCOR) to promote safer, higher quality care. With this goal, we developed a process to identify which evidence-based PCOR interventions merit investment in implementation. We present our process and experience to date.

MATERIALS AND METHODS

AHRQ developed and applied a systematic, transparent, and stakeholder-driven process to identify, evaluate, and prioritize PCOR interventions for broad dissemination and implementation. AHRQ encouraged public nominations, and assessed them against criteria for quality of evidence, potential impact, and feasibility of successful implementation. Nominations with sufficient evidence, impact, and feasibility were considered for funding.

RESULTS

Between June 2016 and June 2018, AHRQ received 35 nominations from researchers, nonprofit corporations, and federal agencies. Topics covered diverse settings, populations, and clinical areas. Twenty-eight unique PCOR interventions met minimum criteria; 16 of those had moderate to high evidence/impact and were assessed for feasibility. Fourteen topics either duplicated other efforts or lacked evidence on implementation feasibility. Two topics were prioritized for funding (cardiac rehabilitation after myocardial infarction and screening/treatment for unhealthy alcohol use).

CONCLUSIONS

AHRQ developed replicable criteria, and a transparent and stakeholder-driven framework that attracted a diverse array of nominations. We identified 2 evidence-based practice interventions to improve care with sufficient evidence, impact, and feasibility to justify an AHRQ investment to scale up practice. Other funders, health systems or institutions could use or modify this process to guide prioritization for implementation.

Lack of research on efficacy of virtual reality exposure therapy (VRET) for anxiety disorders in children and adolescents : A systematic review

Anxiety disorders are one of the most prevalent mental disorders in children and adolescents which may effectively be treated by several forms of exposure therapy. An emerging approach to exposure is virtual reality exposure therapy (VRET), but a literature search synthesis focusing specifically on the use of VRET in children and adolescents is still lacking. This systematic review sets out to provide an overview concerning VRET for the treatment of anxiety disorders in this age group. Four published trials covering an overall sample of 100 participants between the ages of 8 and 16 years were found during a systematic literature search and were included in the current review. Results reveal that participants show clinical improvements regarding anxiety symptoms after VRET. Nevertheless, the high potential of virtual reality as a tool for treating children and adolescents with anxiety disorders is contrasted by a considerable lack of controlled trials. Despite the evidence of VRET in adult samples, there is a need for more research with younger cohorts in order to be able to support this promising field of application.

Loneliness among people with substance use problems: A narrative systematic review

ISSUES

Despite the serious implications of loneliness on health and wellbeing, little is understood about this experience across people with substance use problems. This systematic review aimed to examine: (i) correlates and predictors of loneliness; (ii) theories underpinning loneliness; (iii) methods employed to measure loneliness; and (iv) loneliness interventions for people with substance use problems.

APPROACH

Empirical sources were identified from key databases for all publications preceding February 2019. Overall, 41 studies met the eligibility criteria and were included in the review.

KEY FINDINGS

Findings from this review suggest that loneliness is related to poor physical and mental health, substance use, the quality of relationships, stigma and perception of ill treatment by others. Although cognitive theories have proposed cognitive patterns underlying the onset and maintenance of loneliness, they had not been investigated in relation to measurement or intervention efforts. Just one loneliness measure (UCLA Loneliness Scale) is valid for use with this population. Finally, only a single loneliness intervention had been trialled and was not found to be efficacious in reducing loneliness for people with substance use problems.

IMPLICATIONS

Understanding possible links between loneliness and substance use and how to alleviate loneliness is important for this population in terms of their wellbeing and recovery.

CONCLUSION

Loneliness is prevalent and experienced as problematic among people with substance use problems. Future research should focus on employing longitudinal designs, using validated, multidimensional measures of loneliness and on developing and trialling loneliness interventions that meet the specific needs of people with substance use problems.

Efficacy of Self-Management Smartphone-Based Apps for Post-traumatic Stress Disorder Symptoms: A Systematic Review and Meta-Analysis

Post-traumatic stress disorder (PTSD) symptoms are prevalent in both civilian and military service members. As the number of smartphone-based applications (apps) grows rapidly in health care, apps are also increasingly used to help individuals with subthreshold PTSD or full PTSD. Yet, if the apps are self-managed, the feasibility and efficacy of such interventions are still rather unclear in these two populations with PTSD symptoms. Hence, the present meta-analysis set out to evaluate the effect of self-management smartphone-based apps on PTSD and depressive symptoms in populations with subthreshold PTSD or full PTSD. Studies were included if they conducted randomized controlled trials or pre-post comparisons. Six studies (n = 2 randomized controlled trials) were identified for meta-analysis. In pre-post comparisons, N = 209 participants were included in the analyses. In randomized controlled trials, N = 87 participants received smartphone-based self-management interventions and N = 82 participants were in waitlist control conditions. Meta-analysis for pre-post comparisons concluded an effect of g = 0.55 (p < 0.001) regarding the overall reduction in PTSD symptoms (n = 6) and g = 0.45 (p < 0.001) for reduction in depressive symptoms (n = 5). Yet, in randomized controlled trials, no significant difference was found between app-based treatment and waitlist control groups (g = 0.09, p = 0.574). The duration of the interventions did not significantly influence the results. Overall, despite positive pre-post effects, current results indicate that smartphone-apps for PTSD patients are not significantly more effective than waitlist control conditions. Nevertheless, a combined smartphone and standard therapy approach may be a fruitful field for future research.