Measuring inconsistency in meta-analyses

The impact of feedback elements in serious games on nursing learning outcomes: A systematic review and meta-analysis

OBJECTIVE

This study evaluates the impact of different feedback elements in serious games (SGs) on nursing education outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

6546 English-language studies published between 2000 and 2023 were retrieved from seven electronic databases.

REVIEW METHODS

This systematic review and meta-analysis followed the PRISMA guidelines. The Cochrane Risk of Bias tool was used for quality assessment. Meta-analysis and subgroup analysis were conducted using RevMan 5.4, and the certainty of evidence for each outcome was assessed using the GRADE approach.

RESULTS

Eight studies were included in the meta-analysis. Findings showed that, compared to traditional learning methods, outcome feedback had a moderate effect size on knowledge (SMD = 0.51, 95 % CI [0.09, 0.92]), while comparative feedback had a small, non-significant effect size (SMD = 0.38, 95 % CI [-0.36, 1.12]). Immediate feedback had a large effect size on skills (SMD = 0.87, 95 % CI [0.61, 1.14]), and outcome feedback had a moderate effect size (SMD = 0.50, 95 % CI [0.21, 0.79]). Serious games with feedback had a large effect size on motivation (SMD = 1.31, 95 % CI [0.45, 2.17]). For confidence, outcome feedback had a moderately large effect size (SMD = 0.64, 95 % CI [-0.22, 1.51]), and comparative feedback had a small effect size (SMD = 0.24, 95 % CI [-0.44, 0.91]), but neither reached statistical significance. GRADE assessment showed high certainty for immediate feedback on skills, moderate certainty for outcome feedback on knowledge and skills, and very low certainty for comparative feedback on knowledge. Evidence certainty for motivation and confidence was low or very low.

CONCLUSION

Serious games incorporating feedback elements can enhance nursing students' motivation. Immediate feedback significantly improves nursing skills, while outcome feedback improves knowledge acquisition. However, further research is needed to validate these findings due to the limited number of studies and high heterogeneity.

Craniosynostosis among children with X-linked hypophosphatemia: A systematic review and meta-analysis

BACKGROUND

X-linked hypophosphatemia (XLH) is a rare genetic disorder caused by PHEX gene variants, leading to elevated FGF23 levels and impaired phosphate reabsorption, resulting in abnormal bone growth. Skull abnormalities, including craniosynostosis, are often reported in children with XLH, but the true prevalence of craniosynostosis among children with XLH is unknown.

METHODS

We performed a systematic review and meta-analysis to estimate craniosynostosis prevalence in children with XLH. We searched PubMed, Embase, and Web of Science for cohort studies or large case series published before June 2024. Eligible studies included at least ten children with XLH and reported craniosynostosis prevalence without selection based on skull abnormalities. Pooled prevalence was calculated using a random-effects model, with heterogeneity assessed.

RESULTS

Of 517 studies initially identified, ten studies with 461 patients met the criteria for inclusion. The pooled prevalence of craniosynostosis among children with XLH was 22 % (95 % confidence interval (CI) 9.0 % to 44 %) with significant heterogeneity across studies (I2 = 88.5 %, p < 0.01). This prevalence is far greater than the prevalence of craniosynostosis in the general pediatric population, which is estimated to be one in 2100-2500 births. We confirmed an expected female predominance among children with XLH (median 65.9 % female, interquartile range [IQR] 53.7 % to 68.4 %) but not among children with XLH and craniosynostosis (median 42 % female, range 21 % to 48 %).

CONCLUSION

Craniosynostosis is more common among children with XLH compared to the general pediatric population and may be disproportionately common among males. Increased vigilance for craniosynostosis is warranted for children with XLH.

A meta-analytic review examining the validity of executive functioning tests to predict functional outcomes in individuals with a traumatic brain injury

OBJECTIVES

Deficits in executive functioning are a common consequence of Traumatic Brain Injury (TBI) and the severity of TBI is known to predict functional outcomes. In this review, the authors examine the ability of three commonly used tests of executive functioning [The Trail Making Test (TMT-B), The Wisconsin Card Sorting Test (WCST), and Verbal Fluency (VF)] to predict domains of function.

METHODS

Seven hundred and twenty articles were identified and twenty-four met inclusion criteria (original articles published in English examining an adult TBI population). Data were subject to a study quality analysis and then meta-analyzed to assess whether tests of executive functioning (TMT-B, WCST, and VF) can predict functional, employment, and driving outcomes following a TBI.

RESULTS

The TMT-B (r = 0.29; 95% CI 0.17-0.41) and the WCST (r = 0.20; 95% CI 0.02-0.37) were significantly associated with functional outcomes. The TMT-B was also associated with a person's ability to return to driving (r = 0.3890; 95% CI 0.2678-0.5103). No test of executive functioning was associated with employment outcomes following a TBI.

CONCLUSION

These findings are important to guide rehabilitation strategies and future planning. This review has also highlighted the scarcity of research on specific outcomes.

Paravertebral block is not superior to the interpectoral and pectoserratus plane block for patients undergoing breast surgery: An updated meta-analysis of randomised controlled trials with meta-regression and trial sequential analysis

BACKGROUND

Breast surgery is frequently associated with significant acute postoperative pain, necessitating effective pain management strategies. Both thoracic paravertebral block (PVB) and interpectoral plane and pectoserratus plane (IP+PS) blocks have been used to relieve pain after breast surgery.

OBJECTIVE

In this systematic review and meta-analysis with trial sequential analysis, we aimed to identify the optimal analgesic technique for achieving effective pain relief in breast surgery. The primary outcome of this study was postoperative opioid consumption expressed as morphine milligram equivalent (MME) at 24 h. Secondary outcomes included resting and movement pain scores at 0, 6, 12 and 24 h, postoperative nausea and vomiting (PONV), and rescue analgesic requirements within the first 24 h.

DESIGN

A meta-analysis of randomised controlled trials (RCTs) with meta-regression and trial sequential analysis (TSA).

DATA SEARCH

We systematically searched Pubmed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, Medline (from inception to until 1 October 2024).

ELIGIBILITY CRITERIA

RCTs that include patients undergoing breast surgery with PVB or IP+PS block, with no language restriction.

RESULTS

Eighteen RCTs with 924 patients were included. No significant difference in MME consumption at 24 h was observed between the two techniques; mean difference (MD) -1.94 (95% confidence interval (CI) -4.27 to 0.38, P = 0.101). Subgroup analyses revealed a minor advantage for IP+PS in patients without axillary involvement; MD -2.42 (95% CI -3.56 to -1.29, P  < 0.001), though below the threshold of clinical significance. Secondary outcomes, including pain scores, PONV incidence and rescue analgesic requirements were comparable. Trial sequential analysis (TSA) confirmed sufficient sample size, suggesting further studies may not alter conclusions.

CONCLUSION

PVB and IP+PS blocks offer comparable analgesic efficacy and opioid-sparing effects after breast surgery, with no meaningful differences in 24-h MME consumption, pain scores, or PONV incidence.

An Updated Systematic Review and Meta-Analysis on the Efficacy and Safety of Metformin as Add-on Therapy to Insulin in Patients With Type 1 Diabetes

INTRODUCTION

This study aims to perform an updated meta-analysis evaluating the efficacy and safety of metformin adjunct therapy in type 1 diabetes mellitus (T1DM) patients.

METHOD

Cochrane, PubMed and Embase were searched for randomised controlled trials (RCTs) that reported the efficacy and safety of metformin in T1DM patients. Statistical analyses were performed using STATA software.

RESULTS

Twenty-nine placebo-controlled RCTs enrolling 2051 T1DM patients were included. Adolescents experienced a notable reduction in total insulin daily dose (TIDD) (mean difference [MD] = -0.61 [95% confidence interval (CI): -1.02, -0.20] units/kg per day) and levels of haemoglobin A1c (HbA1c) (MD = -0.45 [95% CI: -0.79, -0.11]), total cholesterol (TC) (MD = -0.78 [95% CI: -1.54, -0.02]), and low-density lipoprotein (LDL) (MD = -0.69 [95% CI: -1.36, -0.02]) at 3 months of follow-up with metformin. In adults, metformin significantly reduced Body Mass Index (BMI) (MD = -0.71 [95% CI: -1.23, -0.19]), TIDD (MD = -0.44 [95% CI: -0.73, -0.16]), and levels of HbA1c (MD = -0.70 [95% CI: -1.10, -0.30]) and TC (MD = -0.60 [95% CI: -1.09, -0.10]) at 6 months. The risk of gastrointestinal adverse events (GIAEs) was significantly higher in both adolescents (Relative Risk [RR] = 1.74 [95% CI: 1.38, 2.21]) and adults (RR = 3.24 [95% CI: 1.49, 7.02]). All of the above had p-values less than 0.05. The metformin group showed no differences in BMI Z-score, high-density lipoprotein (HDL) level, or diabetic ketoacidosis (DKA) risk. No statistical difference was identified for any of the outcomes at other follow-up endpoints.

CONCLUSIONS

Metformin may reduce TIDD and levels of HbA1c, TC, triglycerides (TG), and LDL in T1DM adolescents. BMI, TIDD, and levels of HbA1c and TC may decrease in adults. Moreover, it may raise the risk of GIAEs in both age groups.

Effects of Fermented Kimchi Consumption on Anthropometric and Blood Cardiometabolic Indicators: A Systematic Review and Meta-Analysis of Intervention Studies and Prospective Cohort Studies

CONTEXT

Increasing global kimchi consumption has prompted interest in its health impact. However, comprehensive reviews of the influence of kimchi on cardiometabolic risk factors, especially meta-analyses, remain limited.

OBJECTIVE

This review assessed the impact of fermented kimchi consumption on cardiometabolic risk factors by systematically reviewing human intervention and prospective cohort studies, and conducting a meta-analysis of intervention studies.

DATA SOURCES

A literature search of PubMed, EMBASE, Scopus, Web of Science, RISS, KISS, and ScienceON databases was conducted through April 30, 2024. The inclusion criteria encompassed studies that examined the effects of fermented kimchi, without any added ingredients or lactic acid bacteria, on health outcomes, including anthropometric measures, blood pressure, cardiometabolic and glycemic indicators, inflammatory cytokines, and the incidence of related chronic diseases.

DATA EXTRACTION

Data extraction and quality evaluation were conducted independently by 3 researchers.

DATA ANALYSIS

Pooled effect sizes were calculated as weighted mean differences (WMDs) with 95% CIs employing random-effects models.

RESULTS

Five intervention studies (205 participants) and 4 prospective cohort studies (42 455 participants) were selected. A meta-analysis of the intervention studies revealed a significant reduction in fasting blood glucose (WMD: -1.93 mg/dL; 95% CI: -3.82, -0.03; I2 = 17.4%) following the consumption of fermented kimchi. After excluding studies that contributed to increased heterogeneity, significant inverse associations were observed between fermented kimchi consumption and triglycerides (WMD: -28.9 mg/dL; 95% CI: -53.2, -4.5; I2 = 0.0%), systolic blood pressure (WMD: -3.48 mmHg; 95% CI: -5.95, -1.01, I2 = 0.0%), and diastolic blood pressure (WMD: -2.68 mmHg; 95% CI: -4.75, -0.62; I2 = 0.0%). Prospective cohort studies linked higher kimchi intake with a lower incidence of cancer and metabolic syndrome and an increased likelihood of achieving normal body weight.

CONCLUSION

This review supports beneficial effects of fermented kimchi on cardiometabolic health. However, due to the limited number of studies, these findings should be interpreted cautiously, highlighting the need for further research in diverse populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42024532020.

Comparative outcomes video-assisted thoracic surgery versus open thoracic surgery in pulmonary echinococcosis: a systematic review and meta-analysis

AIM

This meta-analysis aimed to evaluate and compare the outcomes of video-assisted thoracic surgery (VATS) and open thoracic surgery (OT) in the management of pulmonary echinococcosis.

METHODS

We conducted a comprehensive search of PubMed, Embase, and Cochrane databases for studies comparing VATS and OT. Odds ratios (ORs) for binary outcomes and mean differences (MDs) for continuous variables were calculated with 95% confidence intervals (CIs) using the DerSimonian and Laird random-effects model. Heterogeneity was assessed using I2 statistics.

RESULTS

Seven studies involving 2292 patients were included. VATS demonstrated significant advantages over OT, with reductions in intraoperative blood loss (MD - 81.65 mL, 95% CI - 129.90 to - 33.40), duration of thoracic drainage (MD - 2.29 days, 95% CI - 3.61 to - 0.98), operative time (MD - 45.73 min, 95% CI - 68.41 to - 23.05), narcotic use (MD -3.98 days, 95% CI - 6.21 to - 1.75), length of hospital stay (MD - 3.66 days, 95% CI - 5.66 to - 1.67), postoperative drainage volume (MD - 124.77 mL, 95% CI - 206.27 to - 43.27), and visual analogic score pain at 24 h after surgery (MD - 2.05 points, 95% CI - 2.40 to - 1.70). However, VATS was associated with a higher incidence of atelectasis (OR 3.27, 95% CI 1.03-10.35). No significant differences were observed in other complications, such as bronchopulmonary fistula, surgical wound infection, prolonged air leak, or failure of lung expansion.

CONCLUSIONS

VATS was associated with perioperative benefits, including reduced recovery times and resource utilization. Nonetheless, the higher risk of atelectasis suggests OT may remain favorable in complex cases requiring broader surgical access. Tailoring the surgical approach to the patient's needs remains crucial.

TRIAL REGISTRY

International Prospective Register of Systematic Reviews; Nº: CRD42025630187; URL: https://www.crd.york.ac.uk/prospero/ .

Mesh for immediate implant-based prepectoral breast reconstruction following mastectomy

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of mesh (biological and synthetic) in immediate prosthetic (implant or expander) prepectoral breast reconstruction following mastectomy for women with breast cancer or breast cancer risk-reduction surgery.

Interventions for central serous chorioretinopathy: a network meta-analysis

BACKGROUND

Central serous chorioretinopathy (CSC) is characterized by a thickened and dysfunctional choroid which is accompanied by a serous detachment of the neural retina. The effects on the retina are usually self-limiting, although some people are left with irreversible vision loss due to progressive and permanent photoreceptor damage or atrophy of the retinal pigment epithelium (RPE). There has been a variety of interventions used in CSC, including, but not limited to, laser treatment, photodynamic therapy (PDT), and drug therapy with mineralocorticoid receptor antagonists or intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents. However, it is not known whether these treatments offer significant long-term advantages over observation or each other. At present, there is no evidence-based consensus on the management of CSC.

OBJECTIVES

This is an update of a Cochrane review first published in 2015 where 25 studies with 1098 participants were included. Since then, many trials have been conducted and reports published. Our primary objective was to assess the comparative effectiveness of multiple interventions for CSC. The secondary objective was to provide the relative ranking of the interventions for CSC using network meta-analysis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and three trial registries in 29 March 2024, together with reference checking.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared any intervention for CSC with any other intervention for CSC or control.

DATA COLLECTION AND ANALYSIS

Two review authors (CL, LP) independently selected studies and extracted data. Our outcomes of interest were best corrected visual acuity (BCVA), recurrence of CSC, persistent CSC, contrast sensitivity, central retinal subfield thickness, quality of life, and adverse events. We used standard methodological procedures expected by Cochrane. We used Cochrane's statistical software, Review Manager, to perform pairwise analyses and Stata to perform network meta-analysis (NMA). For pairwise comparisons, we pooled data from studies using fixed or random-effects models if there were fewer or more than three studies, respectively. We conducted NMAs using a multivariate meta-analyses approach and ranked interventions using the surface under the cumulative ranking (SUCRA). We used the Confidence in Network Meta-Analysis (CINeMA) approach to assess and present the certainty of evidence for NMA results.

MAIN RESULTS

This review includes 4015 participants from 67 RCTs in total. Additionally, we identified 31 ongoing clinical trials. Trials compared aflibercept, crocin, lutein, eplerenone, spironolactone, prednisolone eye drops, PDT, subthreshold micropulse laser (SML) (577 nm) between each other or respective control groups (e.g. observation, sham injection, or placebo). Studies were conducted in Europe, North and South America, the Middle East, and Asia. Most of the trials were small, enrolling fewer than 50 participants, and poorly reported. A substantial proportion of trials were not masked, and it remained unclear whether key aspects of the trial, such as allocation concealment, had been done. Eight (13%) studies were funded by industry and 21 (31%) by non-industry sources. Overall, 23 (34%), 34 (51%), and 10 (15%) studies were rated at high, moderate, and low risk of bias. Twenty-two studies were included in the pairwise meta-analyses, contributing data to at least one prespecified outcome (change in best corrected visual acuity, recurrence or persistence of CSC, change in contrast sensitivity or central retinal thickness, quality of life, or adverse events) with a follow-up of six to 18 months. These RCTs assessed the effect of oral medication treatments (such as antioxidants, beta-blockers, carbonic anhydrase inhibitors and mineralocorticoid receptor antagonists), intravitreal anti-VEGF injections, laser-assisted treatments (such as pulsed and non-pulsed laser approaches), PDT, and meditation. Most studies had a moderate risk of bias. Pairwise meta-analyses mostly failed to find evidence of differences in effect. We did not have any comparisons with more than 10 studies per analysis to assess the risk of publication biases. Regarding harms, most studies did not report harms in a standardized way and reported no treatment-related harms. Specific harms reported included significant RPE damage among those receiving conventional SML and Grade 1 choroidal ischemia in 3/51 eyes receiving PDT, but the evidence is very uncertain. We were unable to conduct an NMA of recurrence or harms due to sparse data. To enable fuller data for our network of change in BCVA, we classified the interventions into seven unique groups by the types of pharmacologics, laser treatments, and levels of PDT. We excluded interventions for which the assumption of transitivity was not met (i.e. focal unpulsed laser treatment, H. pylori eradication therapy), and performed a NMA with 17 trials of the seven treatment groups (21 comparisons). The NMA did not find any evidence of differences between the treatments that were analyzed. The SUCRA analysis for BCVA suggested the following order for the highest ranking treatments: < 50% PDT (SUCRA = 81.1), supplement (59.0), eplenerone (57.7), anti-VEGF (50.3), control (47.9), ≥ 50% PDT (36.5), and pulsed laser (17.5). SUCRA also suggested low-dose PDT, eplenerone, and supplement had the highest probabilities of being the best (≥ 19.6%), compared to the others (≤ 6.3%). However, the reliability of these SUCRA estimates is limited due to poor overall connectivity in the network, leading to an increased risk of inconsistency between direct and indirect comparisons and increased influence of individual studies. We judged most comparisons as being at moderate (13/21) or low (7/21) confidence, mostly because of imprecision and within-study bias. No comparisons had high certainty.

AUTHORS' CONCLUSIONS

CSC remains an enigmatic condition, in large part due to a natural history of spontaneous improvement in a high proportion of people and also because no single treatment has provided overwhelming evidence of efficacy in published RCTs. While a number of interventions have been proposed as potentially efficacious, the risks of biases and the relatively small number of participants enrolled and successfully followed limit the utility of existing data. Our results did not show the superiority of any treatment option over another. Low-dose photodynamic therapy, supplements, and eplenerone had the greatest SUCRA values and probabilities of being the best treatments for improving visual acuity, although our confidence in the evidence for these interventions is very low to moderate. Larger and high-quality RCTs comparing these treatments are warranted.

Correlation Between Metabolic Syndrome and Hyperuricemia: A Systematic Review and Meta-analysis

BACKGROUND

The main goal of this study was to conduct a meta-analysis and systematic review to examine the correlation between metabolic syndrome (MetS) and hyperuricemia.

METHODS

All studies available in PubMed, Cochrane Library, Embase, and Web of Science were obtained within the retrieval timeframe ending on 9 December 2023. Utilizing the Agency for Healthcare Research and Quality (AHRQ) and the Newcastle-Ottawa Scale (NOS), the included studies underwent quality appraisal, and Stata v14 software was employed for the subsequent data analysis.

RESULTS

A total of 40 studies, covering 214,091 patients, were selected based on specified inclusion and exclusion criteria. The analysis revealed a substantial association between MetS and hyperuricemia (odds ratio (OR) = 2.25, 95% confidence interval (CI) 1.19-4.26, P < 0.001). The metabolically abnormal overweight/obese group (MUHOWO) exhibited a heightened risk of hyperuricemia (OR = 3.54, 95% CI 2.66-4.71, P = 0.002). Additionally, hyperuricemia increased the likelihood of developing MetS (OR = 2.13, 95% CI 1.63-2.79, P < 0.001). Stratified by gender, hyperuricemia elevated the risk of MetS in both men (OR = 1.92, 95% CI 1.43-2.58, P < 0.001) and women (OR = 2.13, 95% CI 1.62-2.8, P < 0.001).

CONCLUSIONS

This meta-analysis and systematic review robustly affirm a significant bidirectional association between MetS and hyperuricemia. The increased risk observed, especially in MUHOWO and across gender lines, underscores the clinical relevance. Addressing MetS emerges as crucial in preventing and managing hyperuricemia, and vice versa. These findings offer valuable insights, urging further research into underlying mechanisms for more targeted interventions and personalized treatments in clinical practice.

Paternal Perinatal Depression, Anxiety, and Stress and Child Development: A Systematic Review and Meta-Analysis

Importance

This systematic review and meta-analysis comprehensively synthesizes the extant literature on the association of paternal perinatal mental distress (ie, depression, anxiety, and stress) with offspring development from birth to adolescence.

Objective

To provide a meta-analytic synthesis of the literature on the association between paternal perinatal depression, anxiety, and stress and offspring development during the first 18 years of life.

Data Sources

We searched MEDLINE Complete, Embase, PsycINFO, CINAHL Complete, and the gray literature for studies published up to November 2024.

Study Selection

Inclusion criteria included availability in English, a human sample, quantitative data, longitudinal design, and having a measure of paternal perinatal mental distress and offspring development.

Data Extraction and Synthesis

Of the 9572 studies identified, 48 cohorts (from 84 studies) with 674 effect sizes met criteria for quantitative synthesis (including 286 unpublished associations sourced from doctoral theses or through contact with authors of eligible studies). Univariate random-effects models were used to quantitatively synthesize the associations between paternal perinatal mental distress and offspring development. Study quality was assessed using the US National Institutes of Health quality assessment tool for observational, cohort, and cross-sectional studies. Data analysis was completed in January 2025.

Main Outcomes and Measures

The primary outcomes were global, social-emotional, adaptive, cognitive, language, physical, and motor development in offspring in the first 18 years of life.

Results

Paternal perinatal mental distress was associated with poorer global (r = -0.12; 95% CI, -0.22 to -0.01), social-emotional (r = 0.09; 95% CI, 0.07-0.11), cognitive (r = -0.07; 95% CI, -0.13 to -0.01), language (r = -0.15; 95% CI, -0.25 to -0.05), and physical development (r = 0.04; 95% CI, 0.00-0.08) in offspring. No evidence was found for adaptive and motor outcomes. Associations were generally stronger for postnatal than antenatal mental distress, suggesting that a father's mental state may exert a more direct influence on the developing child after birth.

Conclusions and Relevance

Evidence from this systematic review and meta-analysis indicates that paternal mental distress is a potentially modifiable predictor of child development. Reducing mental distress in fathers perinatally is thus an important target for preventative interventions aiming to support fathers during the transition to parenthood and promote the health and well-being of next-generation offspring.

Association between drinking water disinfection byproducts exposure and human bladder cancer: A time-updated meta-analysis of trihalomethanes

Drinking water disinfection byproducts (DBPs) have received widespread attention due to their high concentrations and toxicity. However, the correlation between exposure to disinfection byproducts and bladder cancer in published papers is inconsistent. In this study, a time-updated meta-analysis was conducted, which aimed to elucidate the relationship between the historical exposure time and exposure levels of trihalomethanes (THMs) in drinking water and the associated risk of bladder cancer. A total of 433 relative publications was obtained from databases, however only 16 publications satisfied the inclusive criteria, including 13 case-control studies and 3 cohort studies. The case-control studies encompassed 8126 bladder cancer cases and 13,843 controls, while the cohort studies included 112,654 cases and 955 bladder cancer patients. In comparison to individuals who have never been exposed to or have only experienced brief exposure to THMs, the odds ratio (OR) for medium-term and long-term exposure of THMs was 1.30 (95 % CI = (1.11, 1.53)), and 1.59 (95 % CI = (1.40, 1.81)), respectively. This suggests a statistically significant positive correlation between long-term exposure to chlorinated drinking water and an increased risk of bladder cancer. The pooled OR for low and high exposure group was 1.28 (95 % CI = (1.06, 1.55)) and 1.45 (95 % CI = (1.14, 1.85)), respectively, indicating an increased risk of bladder cancer occurrence compared to the unexposed group. Interestingly, subgroup analysis revealed that high levels of THM exposures of males caused an increased risk of bladder cancer (OR= 1.59, 95 % CI = (1.11, 1.53)), while this association was not significant for females (OR = 1.05, 95 % CI = (0.61, 1.80)). More importantly, although the case-control studies were consistent with the overall findings, the cohort studies suggest that there is insufficient evidence to establish a definitive causal link between THMs exposure levels and bladder cancer. In general, long-term consumption of chlorinated drinking water was associated with the occurrence of bladder cancer of male rather than female.

Resilience and its association with mental health among forcibly displaced populations: A systematic review and meta-analyses

BACKGROUND

Forcibly displaced populations are growing exponentially and are at increased risk of experiencing mental health difficulties. However, it remains unclear if, and how, their resilience and mental health are associated. This systematic review and meta-analyses investigated the relationship between resilience and mental health outcomes among forcibly displaced groups.

METHODS

MEDLINE Ultimate, APA PsycInfo and SCOPUS were searched up until January 2024. Peer-reviewed studies measuring a statistical association between resilience and mental health among forced migrants were eligible for inclusion. Random-effects meta-analyses for each identified mental health category were conducted. Study quality was evaluated using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

Thirty-one studies were included in the review (n = 6656). Meta-analyses revealed a significant negative association between resilience and symptoms of post-traumatic stress (k = 13, n = 2446, r = -0.15, 95 % CI [-0.23; -0.06]), depression (k = 14; n = 2952, r = -0.34, 95 % CI [-0.41; -0.26]), anxiety (k = 7, n = 1516, r = -0.19, 95 % CI [-0.27; -0.11]), and psychological distress (k = 10; n = 2712, r = -0.29, 95 % CI [-0.36; -0.23]).

LIMITATIONS

Effect sizes were highly heterogenous, most studies recruited small samples using non-random sampling strategies, and data was collected cross-sectionally.

CONCLUSIONS

Our findings point to an association between resilience and mental health difficulties in forcibly displaced groups. Directions for future research are discussed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42023395925).

Mental health problems and influencing factors of parent-child separated children: An umbrella review of meta-analysis

BACKGROUND

An increasing number of parents are forced to part with their children due to the pressures of life or unpredictable circumstances. This forced separation often has a devastating effect on children's minds, leading to a range of mental health problems.

METHODS

We searched five databases (EBSCO, PubMed, Scopus, Web of Science, and China National Knowledge Infrastructure) from inception to November 17, 2023, and performed a systematic analysis using Comprehensive Meta-Analysis (CMA) 3.0.

RESULTS

We identified 28 eligible meta-analyses with 746,175 participants across 170 outcomes. Parent-child separated (PcS) children were at higher risk for emotional problems (d = 0.22 [95 % CI 0.17-0.28]), cognitive problems (d = 0.20 [95 % CI 0.10-0.29]), behavioral problems (d = 0.21 [95 % CI 0.15-0.27]) and psychosis (d = 0.22 [95 % CI 0.15-0.29]) than non-PcS children. Regarding influencing factors, both personal and social factors were moderately positively correlated with emotional and behavioral problems. Family factors had a moderate positive correlation between emotional problems (z = 0.20, [95CI% 0.12-0.28]), and a low positive correlation with behavioral problems (z = 0.13, [95CI% 0.04-0. 22]). After addressing the issue of overlapping data, there were no significant differences in emotional problems in children with PcS compared to non-PcS children.

LIMITATIONS

The majority of studies included in our umbrella review were from China, which may limit the generalizability of our findings.

CONCLUSION

PcS children suffer more mental health problems than non-PcS children. The community needs to act and intervene proactively to promote the improvement of the mental health of these children.

Associations between major depressive disorders and Parkinson's Disease and impact of their comorbidity sequence

BACKGROUND

The comorbidity of major depressive disorder (MDD) and Parkinson's disease (PD) were prevalent and has a profound impact on patients. However, whether this comorbidity results from specific pathological processes or a mutual cause-and-effect relationship was largely controversial. Additionally, although MDD can appear before or after PD, the health impact of the comorbidity sequence is poorly understood.

METHODS

We used mendelian randomization (MR) and UK biobank (UKB) cohort to explore the associations between MDD and PD. MR was also utilized to investigate potential confounders. By classifying UKB patients into MDD first and PD first groups, we evaluated the health impact of the comorbidity sequence using Cox regression.

RESULTS

Bidirectional MR and cohort study showed conflicting results. MR did not find associations between MDD followed by PD (odds ratio [OR] = 1.28, 95 % confidence interval [CI] = 0.85-1.94) or PD followed by MDD (OR = 0.99, 95 % CI = 0.97-1.01). However, the cohort study found a significant effect of MDD on PD (hazard ratio [HR] = 1.75, 95 % CI = 1.55-1.97) and PD on MDD (HR = 4.35, 95 % CI = 3.65-5.19). By performing MR on 4709 proteins, we identified ESD, LEAP2, NDRG3, NRXN3, and PLXNB2 as potential common causes of MDD and PD. Additionally, PD first group had higher risks of all-cause mortality (HR = 1.65, 95 % CI = 1.03-1.90), dementia (HR = 1.88, 95 % CI = 1.16-3.04), and aspiration pneumonia (HR = 1.89, 95 % CI = 1.09-3.27).

CONCLUSIONS

Our study suggested the comorbidity of MDD and PD is likely the result of certain pathological processes. Additionally, patients with PD first had higher risks of several adverse outcomes.

Meta-Analysis of Racial and Ethnic Disparities in Rhythm Control Strategies for Atrial Fibrillation in the United States

Rhythm control strategies are a key component of atrial fibrillation (AF) therapy, with recent reports suggesting racial and ethnic disparities in their utilization. We aimed to determine differences in the utilization of catheter ablation (CA), direct current cardioversion (DCCV), and anti-arrhythmic drugs (AAD) among different racial and ethnic groups. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library (from inception to January 31st, 2024) for studies including adults with AF and reporting CA, DCCV, or AAD utilization rates in at least 2 racial and ethnic groups. Our primary outcome was the likelihood of Black, Hispanic, and Asian individuals undergoing each rhythm control strategy compared to White patients. Pooled estimates were calculated with a random-effects model and were reported as odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs). Nineteen studies were included comprising 12,598,109 patients. The pooled ORs (95% CI) of undergoing CA for Black individuals was 0.68 (95% CI 0.56 to 0.83), for Hispanic individuals was 0.72 (95% CI 0.63 to 0.82), and for Asian individuals was 0.64 (95% CI 0.48 to 0.86), compared to White individuals. The likelihood of undergoing DCCV (OR [95% CI]) was lower in Black (0.69 [95% CI 0.57 to 0.82]), Hispanic (0.67 [95% CI 0.57 to 0.80]), Asian (0.68 [95% CI 0.64 to 0.72]) patients compared to White patients. Our results identified that racial and ethnic minoritized groups with AF are significantly less likely to undergo treatment with a rhythm control strategy. In conclusion, these findings highlight a significant gap in healthcare delivery that stakeholders, healthcare systems, and clinicians should address.

Spiritual Interventions to Improve Quality of Life and Spiritual Well-Being: A Systematic Review and Meta-analysis

This study aimed to systematically assess the evidence regarding the efficacy of spiritual interventions on quality of life and spiritual well-being among patients with cancer. PubMed, CINAHL, PsycINFO, Embase, MEDLINE (via EBSCOhost), and Web of Science databases were searched. Studies were included if these reported spiritual interventions for adult patients with cancer. Quality assessment of the included studies were conducted using the Critical Appraisal Tool for Randomized Controlled Trials from Joanna Briggs Institute. The review was registered in PROSPERO (CRD42021277873). A total of ten randomized controlled trials that enrolled 1332 patients with cancer were included. Spiritual interventions of the included studies involve: meaning-centered, mindfulness, dignity therapy, yoga, spiritual counseling, and body-mind-spirit group therapy. The length of the interventions ranged from 2 to 12 sessions. Further analysis shows spiritual interventions improve spiritual well-being (N = 479, 95% CI = 0.36 to 1.97, p < 0.0001), and Quality of Life (N = 706, 95% CI = 0.07 to 0.40, p = 0.004). Spiritual interventions are proved to be effective to improve spiritual well-being and quality of life. It is important for nurses and healthcare professionals to integrate spiritual interventions to improve the quality of care including patients' spiritual well-being and quality of life.

Intravenous ketamine to prevent post-partum depression following cesarean under neuraxial anesthesia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Postpartum depression (PPD) significantly affects well-being and the ability to function normally, making preventive strategies crucial. The role of intravenous ketamine in preventing PPD, especially after cesarean sections under neuraxial anesthesia, remains unclear and controversial.

OBJECTIVES

This systematic review and meta-analysis aimed to assess the efficacy and safety of perioperative intravenous ketamine administration in preventing postpartum depression among women undergoing cesarean section under neuraxial anesthesia.

SEARCH STRATEGY

A comprehensive electronic search was conducted for literature published from 2000 to January 1, 2023, in multiple databases, including PubMed/MEDLINE and the Cochrane Database of Systematic Reviews, using relevant keywords. Language restrictions were not applied.

SELECTION CRITERIA

The included studies were randomized controlled trials (RCTs) that met the following criteria: adult patients (<18 years) undergoing elective cesarean section under neuraxial anesthesia, peripartum intravenous administration of ketamine, placebo as a comparison group, and postpartum depression as the primary outcome.

DATA COLLECTION AND ANALYSIS

Data were extracted on various parameters, including study characteristics, ketamine protocol, control group details, results, and quality assessment scores. Meta-analysis was performed using the RevMan 5.4 statistical package, and outcomes were assessed using odds ratios (ORs) for dichotomous data and mean differences (MD) for continuous data, using a random effects model.

MAIN RESULTS

Ten studies involving 2219 patients (1094 in the ketamine group and 1125 in the control group) were included. The meta-analysis did not show significant differences in the incidence of PPD or EPDS scores between the ketamine and control groups postoperatively. However, ketamine administration resulted in a reduction in postoperative pain scores and total opioid consumption but increased the incidence of headaches.

CONCLUSION

Perioperative intravenous administration of ketamine does not have a prophylactic effect on postpartum depression in patients undergoing cesarean section under neuraxial anesthesia but does reduce postoperative pain and total opioid consumption. The increased incidence of side effects, such as headaches, dizziness, and drowsiness, warrants further investigation. Additional large RCTs are necessary to further explore ketamine's potential prophylactic effect on PPD.

The effect of exercise on cognitive function in breast cancer survivors: systematic review and meta-analysis of randomized controlled trials

PURPOSE

Cancer-related cognitive impairment (CRCI) is a common side effect among breast cancer survivors. Emerging evidence suggests that exercise may help manage CRCI. This systematic review and meta-analysis evaluated the impact of exercise programs on cognitive function in breast cancer survivors.

METHODS

PubMed, Cochrane, Embase, and Web of Science were searched in May 2023 for randomized controlled trials (RCTs). Two independent reviewers conducted the screening and selection of studies based on predefined eligibility criteria, including title/abstract and full-text screening, using the Rayyan platform. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Meta-analyses were conducted in R using the "meta" package, comparing experimental and control groups for cognitive domains and self-reported cognitive outcomes post-intervention.

RESULTS

Eleven RCTs with 890 breast cancer survivors showed significant exercise effects on attention and working memory (SMD 0.43, 95% CI [0.20; 0.66], p < 0.001, I² = 51%), executive function (SMD -0.29, 95% CI [-0.46; -0.13], p < 0.001, I² = 0%), perceived cognitive abilities (SMD 0.95, 95% CI [0.32; 1.57], p = 0.003, I² = 69%), and cognitive complaints (SMD -0.75, 95% CI [-1.07; -0.44], p < 0.001, I² = 0%).

CONCLUSION

This systematic review with meta-analysis demonstrates that exercise improves cognitive function in breast cancer survivors, particularly attention, working memory, executive function, and self-reported cognitive outcomes. However, the heterogeneity in cognitive assessment tools underscores the need for greater standardization, including the combined use of validated self-report questionnaires and neuropsychological tests, as well as a stronger emphasis on cognitive function as a primary outcome, to enhance comparability and strengthen the evidence base.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise programs should be integrated into survivorship care to address CRCI, support cognitive health, and improve overall quality of life.

Inverse association between eicosapentaenoic acid and incident colorectal cancer: a dose-response meta-analysis of twenty-six independent prospective cohorts

PURPOSE

While individual n-3 polyunsaturated fatty acids (PUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) exhibited distinct mechanisms in attenuating colorectal cancer (CRC) progression, their prospective associations with CRC risk remain inconsistent. This study aimed to determine the dose-response relationships between total and individual n-3 PUFAs and incident CRC.

METHODS

We systematically searched PubMed, Embase, and Cochrane Library though April 2024 for pertinent prospective cohorts assessing dietary or blood-based n-3 PUFAs in relation to CRC risk. The shape of nonlinear dose-response relationships was modeled using one-stage random-effects meta-analyses. Study-specific risk ratios (RRs) with 95% confidence intervals (CIs) for per unit increase in PUFAs exposure were pooled to assess the strength of linear trends using random-effects inverse-variance weighting meta-analyses.

RESULTS

Twenty-six cohorts were included, comprising 18 dietary cohorts (19,763 events and 1,663,721 participants) and 8 biomarker cohorts (3,443 events and 14,316 participants). Each 100-mg/day increase in EPA intake was slightly associated with 5% reductions in CRC risk (RR: 0.95, 95% CI: 0.91-1.00), whereas no significant association was observed for DHA. A strong inverse linear trend was observed for per 1% increase in circulating LC n-3 PUFA levels (p for linearity < 0.001), with a pooled RR of 0.86 (95% CI: 0.80-0.92) for EPA and 0.95 (95% CI: 0.91-0.99) for DHA.

CONCLUSION

Circulating EPA levels demonstrated a significant inverse dose-dependent association with CRC risk. These findings suggest that increasing intake of EPA through diet or supplementation to elevate PUFAs' levels in circulating may contribute to preventing against the incident CRC.

Comparative association between NAFLD and MAFLD with cardiovascular events and mortality: Evidence from observational studies

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) are increasingly recognized as multisystemic conditions with significant extrahepatic manifestations. Although both diseases have been linked to cardiovascular events and mortality, the strength of these associations remains controversial. This review aims to compare the risks of cardiovascular disease (CVD) events in individuals with NAFLD and MAFLD.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched to identify studies investigating the risk of CVD, CVD death, and all-cause death associated with NAFLD and MAFLD through April 28th, 2024. Data extraction and study quality assessment were performed using the Newcastle-Ottawa Scale. Statistical analysis utilized random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

Eleven cohort studies with 11,995,994 patients were included. Both NAFLD and MAFLD were associated with an increased risk of cardiovascular events (NAFLD group vs. non-NAFLD group: HR = 1.30, 95% confidence interval (CI): 1.13-1.49, I2 = 91%; MAFLD group vs. non-MAFLD group: HR = 1.54, 95% CI: 1.32-1.81, I2 = 92%) and all-cause death (NAFLD group vs. non-NAFLD group: HR = 1.18, 95% CI: 1.04-1.33, I2 = 55%; MAFLD group vs. non-MAFLD group: HR = 1.30, 95% CI: 1.20-1.40, I2 = 0%). The MAFLD-only group had a stronger association with cardiovascular death than the NAFLD-only group (MAFLD-only group vs neither MAFLD nor NAFLD group: HR = 1.46, 95% CI: 1.40-1.51, I2 = 0%; NAFLD-only group vs neither MAFLD nor NAFLD group: HR = 1.10, 95% CI: 0.95-1.28, I2 = 0%, P for interaction < 0.01). The GRADE assessment revealed low certainty for cardiovascular disease (CVD) (NAFLD only group vs. neither NAFLD nor MAFLD group), cardiovascular death (NAFLD only group vs. neither NAFLD nor MAFLD group), and all-cause death (MAFLD group vs non-MAFLD group), and very low certainty for other results.

CONCLUSION

MAFLD and NAFLD are both associated with cardiovascular events and all-cause mortality. However, the odds of cardiovascular death seems to be greater in patients with MAFLD than in those with NAFLD, suggesting that the use of MAFLD criteria may identify more at-risk individuals.

PROSPERO REGISTRATION

CD42022361164.

Is there a bidirectional relationship between allergic rhinitis and irritable bowel syndrome? A meta-analysis

Background

Some studies suggest a link between allergic rhinitis (AR) and irritable bowel syndrome (IBS), but evidence is insufficient. This meta-analysis aimed to explore the relationship between AR and IBS.

Methods

We searched the relevant literature in six electronic databases. We included a total of nine articles, seven of which took AR as the research object, two of which took IBS as the research object. We performed a meta-analysis using random effects and estimated the resultant odds ratio (OR).

Results

A total of 10 627 patients with AR were included in seven studies, including 956 patients diagnosed with AR in the IBS population and 9671 patients diagnosed with AR in the non-IBS population. By heterogeneity test, X2 = 10.12, F-statistic (F) = 6, P = 0.12, I2 = 41%, OR = 2.88, and Z-score (Z) = 21.97 (P < 0.00001), the results were statistically significant. Patients with AR have an increased risk of developing IBS compared to patients without AR. A total of 1099 patients with IBS were included in two studies, including 384 patients with IBS in AR patients and 715 patients with IBS in the healthy population. After the heterogeneity test, X2 = 0.11, F = 1, P = 0.74, I2 = 0%, OR = 2.15, and Z = 11.81 (P < 0.00001), the results were statistically significant. Patients with IBS have an increased risk of developing AR compared to patients without IBS.

Conclusions

The bidirectional association between AR and IBS provides a basis for exploring potential new mechanisms between the two.

Registration

No. INPLASY202440057.

Outcomes in Pediatric Thyroid Surgery Across Multiple Institutions

INTRODUCTION

Surgical management plays a crucial role in managing thyroid disease in the pediatric population as evidenced by the increasing volume of such cases over the years. This study aims to evaluate the outcomes of thyroid surgery in children, adolescents, and young adults by meta-analyzing outcomes across several institutions.

METHODS

A comprehensive literature search for single institutional studies was performed across PubMed, Science Direct, Embase, Scopus, and Google Scholar. Key variables like mean hospital stay and both transient and permanent complications were recorded. Transient hypocalcemia or hypoparathyroidism was defined as a drop in serum calcium below laboratory reference range postthyroidectomy that resolved within 6 mo. Transient laryngeal nerve injury was characterized by hoarseness or dysphonia arising from neuropraxia or trauma to the nerve that resolved within 6 mos postsurgery. Complications persisting beyond 6 mo were classified as permanent. We performed meta-analysis on complication rates using the metaprop library on R studio.

RESULTS

A total of 2339 studies were retrieved through our search strategy across five databases. Excluding duplicates, the remaining studies were screened resulting in 88 studies being selected for a full text review. Fifty-six studies were excluded due to a lack of outcome specific data leaving a total of thirty-two studies that were included, amounting to 2747 patients with a mean of 86 patients per study. The overall weighted mean age of patients in our study pool was 12.9 ± 4.1 (95% confidence interval [CI]: 12.8-13.1) years. Mean hospital stay was 2.6 ± 1.9 (95% CI: 2.5-2.7) days. Common complications like transient hypocalcemia or hypoparathyroidism was found in 24% (95% CI: 0.2-0.3, I2 = 91%) and transient laryngeal nerve injury was 2% (95% CI: 0.01-0.02, I2 = 35%) of patients. Permanent hypocalcemia or hypoparathyroidism was found in 3% (95% CI: 0.02-0.04, I2 = 65%) patients. Rare complications included permanent laryngeal nerve injury in 1% (95% CI: 0.00-0.01) and hematoma formation in 1% (95% CI: 0.00-0.01).

CONCLUSIONS

Pediatric thyroid surgery, although safe, has a high risk of transient hypocalcemia or hypoparathyroidism. Other complications remain under 3%.

Diagnostic Accuracy of Hepatic MRI-PDFF and R2* for the Evaluation of Liver Steatosis and Liver Iron Overload: A Meta-analysis

RATIONALE AND OBJECTIVES

To evaluate the diagnostic accuracy of hepatic magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) and R2* using the multi-echo Dixon technique for the evaluation of liver steatosis (LS) and liver iron overload (LIO). The study focuses on the determination of optimal cutoff values and the area under the summary receiver operating characteristic curve (AUROC) as primary measures of diagnostic performance.

MATERIALS AND METHODS

A systematic literature search was conducted by two independent researchers. The diagnostic accuracy of studies was assessed using the quality assessment of diagnostic accuracy studies-2. The AUROCs of MRI-PDFF (for LS grades: 0 versus 1-3, 0-1 versus 2-3, and 0-2 versus 3) and R2* (for LIO grades: 0 versus 1-4) were compared and analyzed. Meta-regression analyses were performed to explore sources of heterogeneity in MRI-PDFF. The review followed the preferred reporting items for systematic reviews and meta-analyses guidelines.

RESULT

29 studies with 4548 subjects (2565 males) were investigated. The summary AUROC values of MRI-PDFF for classifying LS grades 0 versus 1-3, 0-1 versus 2-3, and 0-2 versus 3 were 0.95 (95% confidence interval (CI): 0.93-0.97), 0.93 (95% CI: 0.91-0.95), and 0.93 (95% CI: 0.91-0.95), respectively. The summary AUROC values of R2* for classifying LIO grades 0 versus 1-4 was 0.81 (95% CI: 0.78-0.84). The optimal MRI-PDFF cutoffs for diagnosing LS were identified as 4.4% (LS ≥ G1), 13.34% (LS ≥ G2), and 16.9% (LS ≥ G3), while the optimal R2* cutoffs for LIO ≥ G1 were 60.5 s⁻¹ (3 T MRI).

CONCLUSION

MRI-PDFF and R2* demonstrate high diagnostic accuracy for evaluating LS and LIO, with established optimal cutoff values supporting their clinical utility as non-invasive diagnostic tools. These findings provide a standardized reference for MRI-based liver fat and iron quantification in clinical practice.

Global burden of human noroviruses contamination in drinking water sources and drinking water: A systematic review and meta-analysis identifying GII.4 and GII.17 as dominant genotypes

Human Noroviruses (HuNoVs) are the leading etiologic agents responsible for viral gastroenteritis. Drinking water (DW) serves as a significant vehicle for the transmission of HuNoVs. This study aimed to assess the occurrence of HuNoVs in drinking water sources (DWS) and DW. A systematic search spanning Web of Science, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials was executed up to July 15, 2024. Following rigorous screening, 76 eligible studies underwent meta-analysis with heterogeneity assessment via Stata 14.0 using a random-effects model. The results indicated that the pooled occurrence of HuNoVs was 11 % (95 % CI: 8-14), with occurrence of 15 % (95 % CI: 10-21) in DWS and 6 % (95 % CI: 3-9) in DW. Subgroup meta-analysis demonstrated that genogroup II (GII) of HuNoVs exhibited the highest contamination occurrence of 7 % (95 % CI: 4-10), with GII.4 and GII.17 being the predominant genotypes. The two continents with the highest number of studies were Asia (n = 27) and Europe (n = 19), with HuNoVs occurrence of 14 % (95 % CI: 8-22) and 15 % (95 % CI: 7-26), respectively. Furthermore, the occurrence showed no significant differences across the four seasons: in spring, the occurrence was 11 % (95 % CI: 3-23); in summer, 15 % (95 % CI: 7-25); in autumn, 11 % (95 % CI: 2-24); and in winter, 18 % (95 % CI: 10-27). These findings provided valuable epidemiological insight into the global occurrence, seasonal variation, and genotypic distribution of HuNoVs in DWS and DW, aiding policy development and public health strategies.

Sex disparities in chlamydia and gonorrhea treatment in U.S. adult emergency departments: A systematic review and meta-analysis

BACKGROUND

Empiric antibiotic treatment for gonorrhea (GC) and chlamydia (CT) is common in U.S. emergency departments (EDs) due to the delayed availability of test results. Local studies have identified sex-based disparities in sexually transmitted infection (STI) care, with females potentially receiving less empiric treatment than males. This study evaluates how STI treatment aligns with laboratory-confirmed results to quantify potential overtreatment and undertreatment rates and investigates sex differences for these outcomes.

METHODS

We conducted a preregistered (PROSPERO #241429) systematic review and meta-analysis of studies published between January 2010 and January 2025 in U.S. EDs, excluding studies conducted exclusively in pediatric settings. Searches were performed in Medline, Cochrane, Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Data from 19 studies encompassing 32,593 tested patients were analyzed using a random-effects model to calculate pooled estimates. Primary outcomes included GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex.

RESULTS

Overall GC/CT positivity was 14% (95% confidence interval [CI] 12%-16%): 11% (95% CI 8%-14%) in females and 25% (95% CI 23%-26%) in males. Antibiotics were given to 46% (95% CI 38%-54%) of patients: 31% (95% CI 24%-37%) of females and 73% (95% CI 65%-80%) of males. Among patients with negative test results, 38% (95% CI 30%-47%) received antibiotics (i.e., potential overtreatment): 27% (95% CI 20%-34%) of females and 64% (95% CI 55%-73%) of males. Conversely, 39% (95% CI 31%-46%) of laboratory-positive patients did not receive antibiotics (i.e., potential undertreatment): 52% (95% CI 46%-57%) of females and 15% (95% CI 12%-17%) of males.

CONCLUSIONS

Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially undertreated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy. Interpretation is limited by study heterogeneity and incomplete sex-specific data.

Arm Based on LEg blood pressures (ABLE-BP): can systolic ankle blood pressure measurements predict systolic arm blood pressure? An individual participant data meta-analysis from the INTERPRESS-IPD Collaboration

OBJECTIVES

To determine associations between arm and ankle systolic blood pressures (SBPs), develop and validate a multivariable model predicting arm SBP from ankle SBP, and investigate associations between ankle SBP, cardiovascular disease and mortality.

DESIGN

Ankle-arm SBP differences were examined in two-stage individual participant data (IPD) meta-analyses using multivariable hierarchical linear regression models. Models were used to derive and validate a prediction model for arm SBP based on ankle SBP. Model performance was assessed using area under the receiver operating characteristic (AUROC) curve analyses. Prognostic associations of ankle SBP with outcomes were examined using Cox proportional hazards models.

DATA SOURCES

Searches identified cohorts for the Inter-arm Blood Pressure Difference IPD (INTERPRESS-IPD) Collaboration from Medline, Old Medline, Medline in process, Embase and CINAHL databases from inception until January 2017; unpublished data were also sought. Required primary outcomes were all-cause mortality, cardiovascular mortality, and/or fatal and non-fatal cardiovascular events.

ELIGIBILITY CRITERIA

Prospective studies from community, primary care or general clinic settings, without language restriction, that recorded SBP in both arms were eligible. Adults aged ≥18 years with SBP measured in all four limbs, in a supine position, were included in the current analyses. People with peripheral artery disease were excluded.

DATA EXTRACTION AND SYNTHESIS

Anonymised datasets were individually cleaned and then combined into a single dataset for the INTERPRESS-IPD Collaboration.

RESULTS

The current dataset included 33 710 participants from 14 studies; mean age 58 years, 45% female, mean baseline arm blood pressure 138/80 (SD: 20/12) mm Hg. Mean ankle SBP was 12.0 mm Hg (95% CI 8.8 to 15.2) higher than arm SBP. The multivariable model predicting arm SBP from ankle SBP demonstrated excellent performance (AUROC curves, sensitivities and specificities were >0.82, 0.80 and 0.82, respectively, at all BP thresholds from 130 to 160 mm Hg). Model performance was superior to existing arithmetic formulae.Ankle SBP was neither associated with all-cause nor cardiovascular mortality (HR 1.000 (0.997 to 1.002; p=0.682) and 1.001 (0.996 to 1.005; p=0.840), respectively). However, lower-reading ankle SBP was associated with fatal or non-fatal cardiovascular events (HR 1.005 (1.002 to 1.007; p<0.001).

CONCLUSIONS

On average, ankle SBP is 12 mm Hg higher than arm SBP. Estimating individual arm SBP from ankle SBP measurements with a multivariable model is more accurate than existing fixed arithmetic formulae. This model, operationalised in an online calculator (https://ablebp.

RESEARCH

exeter.ac.uk/), could facilitate hypertension management and cardiovascular care for people unable to have arm SBP measured.

PROSPERO REGISTRATION NUMBER

CRD42015031227.

Survivorship and Patient-Reported Outcomes in Femoral Impaction Bone Grafting for Revision Hip Arthroplasty: A Systematic Review and Meta-Analysis of 4,102 Hips

BACKGROUND

Femoral impaction bone grafting (IBG) is widely used in revision total hip arthroplasty (rTHA) for cases with severe bone loss. The purpose of this systematic review and meta-analysis was to assess survivorship and patient-reported outcomes (PROMs) following femoral IBG.

METHODS

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on femoral IBG in revision THA with a minimum follow-up of 12 months were included. A random-effects model and the inverse-variance weighting method were used for meta-analysis. Heterogeneity was assessed using Higgins and Thompson's I2 statistic and Cochran's Q test.

RESULTS

The systematic search included a total of 45 studies, comprising 4,102 hips in 3,805 patients. The overall 10-year survivorship for femoral IBG was 95% (CI [confidence interval] 92 to 97), with significant data heterogeneity (I2 = 79%, P < 0.01). Patients who had higher Endo-Klinik (EK) grades of femoral bone loss (III and IV) had significantly lower 10-year survival rates (90.9 versus 97.4% for EK grades I and II, P = 0.048). Neither patient age (≥ 65 years: 94.5 versus < 65 years: 96.6%, P = 0.230) nor stem length (short stems: 95.5 versus long stems: 94.8%, P = 0.86) significantly affected 10-year survival outcomes. Patient-reported outcomes (PROMs) included the Harris hip score, which notably improved post-surgery (SMD [standardized mean difference]: 10.7, 95% CI: 8.26 to 13.05, I2 = 99%).

CONCLUSIONS

Hip revision arthroplasty with femoral IBG demonstrates high long-term (10-year) survivorship rates (95%, 92 to 97%, I2 = 79%) and significant improvements in patient-reported outcomes, specifically the Harris Hip Score (I2 = 92%), especially in cases with moderate bone loss (Endo-Klinik stages I and II). There was a lower survivorship (90%) in hips with severe bone defects (Endo-Klinik stages III and IV), regardless of additional fixation.

The value of nanocarbon contrast methylene blue based on dye-based tracer technology in sentinel lymph node biopsy for breast cancer: a systematic review and meta-analysis

Objective

The purpose of this study was to compare the diagnostic value of nanocarbon suspensions and methylene blue injections in sentinel lymph node biopsies of patients with breast cancer based on the dye method.

Methods

A systematic search of the PubMed, Embase, Cochrane Library (Central) and Web of Science (SCI Expanded) databases was performed to determine the diagnostic value of carbon nanoparticles in Chinese databases (China National Knowledge Infrastructure (CNKI), VIP, Wanfang, Chinese Biomedical Literature Database (CBM)) for identifying methylene blue in sentinel lymph node biopsies of patients with breast cancer. The QUADAS2 quality evaluation tool of Review Manager 5.4 was used to evaluate the quality of the included studies. Meta-Disc 1.4 software was used to calculate the extracted valid data and perform a heterogeneity test. STATA 14.0 software was selected to conduct a sensitivity analysis, and Deek's publication bias test was used for the included studies.

Results

In 17 articles, the binding sensitivity of nanocarbons was 0.93 (0.90-0.95), the binding specificity was 0.98 (0.97-0.99), the binding sensitivity of methylene blue was 0.89 (0.85-0.92), and the binding specificity was 0.94 (0.92-0.95). The AUC value of the nanocarbon SROC was 0.9827 (SE = 0.0062), and the AUC value of methylene blue was 0.9495 (SE = 0.0139).

Conclusion

Nanocarbon versus methylene blue is a more satisfactory dye tracer for sentinel lymph node biopsy in breast cancer patients and should be considered a first-line diagnostic agent.

Comparative Effectiveness of Different Prehabilitation Strategies in Patients Undergoing Digestive System Cancer Surgery: A Network Meta-Analysis

OBJECTIVE

This network meta-analysis evaluated the efficacy of different prehabilitation modalities for patients undergoing digestive system cancer surgery.

METHODS

A systematic search of PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science was conducted from inception to March 1, 2025. Randomized controlled trials assessing exercise-based (EX), nutrition-based (NU), or multimodal (Mul) prehabilitation were included. Primary clinical outcomes were length of hospital stay (LOS) and postoperative complications, while functional outcomes included 6-minute walking distance (6MWD), anxiety, depression, and quality of life (QoL). Pairwise meta-analyses estimated mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CIs). A network meta-analysis was performed to rank interventions using surface under the cumulative ranking (SUCRA) probabilities.

RESULTS

Twenty-six RCTs involving 2042 patients were included. Pairwise meta-analyses showed that prehabilitation significantly reduced LOS (MD = -1.12, 95%CI = -1.99, -0.26) and postoperative complications (OR = 0.71, 95%CI = 0.59, 0.86), while improving 6MWD (MD = 35.59, 95%CI = 20.47, 50.72) and QoL (MD = 5.96, 95%CI = 2.00, 9.92). Subgroup analyses indicated that gastric cancer patients benefited more in terms of complication reduction. The network meta-analysis ranked EX as the most effective for reducing postoperative complications (SUCRA = 88.9%), followed by Mul (SUCRA = 74.0%). For functional outcomes, EX ranked highest for postoperative 6MWD improvement (SUCRA = 81.0%), while Mul was superior in improving presurgery 6MWD (SUCRA = 74.9%), QoL (SUCRA = 99.2%), and depressive symptoms (SUCRA = 87.9%).

CONCLUSION

Prehabilitation, particularly EX and Mul, effectively reduces postoperative complications and enhances functional recovery in digestive system cancer surgery. Clinicians should consider patient-specific factors when selecting prehabilitation strategies. Future research should standardize intervention protocols and outcome measures to optimize perioperative care.

Progestogen for preventing miscarriage in women with recurrent miscarriage of unclear etiology

RATIONALE

Progesterone, a female sex hormone, is known to induce secretory changes in the lining of the uterus essential for successful implantation of a fertilized egg. Miscarriage is an early pregnancy loss. For women who have recurrent miscarriage, it has been suggested that a causative factor may be inadequate secretion of progesterone. Therefore, clinicians sometimes use progestogens (drugs that interact with the progesterone receptors), beginning in the first trimester of pregnancy, in an attempt to prevent spontaneous miscarriage. It is important to understand if this is beneficial or harmful. This is an update of the review, last published in 2019. Previous versions included two trials that have since been retracted. This update included an updated trial search and evaluation of all trials using the Cochrane Trustworthiness Screening Tool.

OBJECTIVES

To assess the benefits and harms of progestogens as a preventative therapy against recurrent miscarriage.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, CINAHL, Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (July 2024). We also searched reference lists from relevant articles, attempted to contact trial authors where necessary, and contacted experts in the field for unpublished works.

ELIGIBILITY CRITERIA

We included randomized or quasi-randomized controlled trials in pregnant participants comparing progestogens with placebo or no treatment, given in an effort to prevent miscarriage. We included trials of participants who were diagnosed with recurrent miscarriage (usually of unknown origin) and who began treatment with progestogens in the first trimester of pregnancy. We excluded trials treating participants with threatened miscarriage or who had conceived by in-vitro fertilization.

OUTCOMES

The critical outcome was miscarriage. The main important outcomes were live birth rate and preterm birth (< 37 weeks' gestation). Other important outcomes were neonatal death, fetal genital abnormalities, stillbirth, low birthweight (< 2500 g), maternal adverse events and neonatal intensive care unit admission. Other maternal outcomes of interest were severity of 'morning sickness', thromboembolic events, depression, admission to special care unit and subsequent fertility.

RISK OF BIAS

Two review authors assessed the studies using the RoB 1 tool for selection, performance, detection, attrition, incomplete outcome data, selective reporting and other bias.

SYNTHESIS METHODS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two reviewers assessed the certainty of the evidence using the GRADE approach. We utilized a random-effects model to synthesize the results.

INCLUDED STUDIES

Nine trials with 1426 randomized participants met the inclusion criteria. Eight trials included analyzable data for 1276 participants. Overall, the risk of bias was low for six trials, while three had areas of concern. Because few studies reported on important outcomes, imprecision was high for those outcomes, limiting the certainty of those analyses.

SYNTHESIS OF RESULTS

Seven of the included trials compared treatment with placebo and the other two compared progestogen administration with no treatment. The trials were a mix of multicenter and single-center trials, conducted in Jordan, the UK, the Netherlands, and the USA. In three trials, participants had three or more consecutive miscarriages and in six trials, participants had two or more consecutive miscarriages. Route, dosage and duration of progestogen treatment varied across the trials. The majority of trials were at low risk of bias for most domains. Eight trials with 1276 participants contributed data to the analyses. Meta-analysis suggests that there is probably little to no difference in the miscarriage rate for women given progestogen supplementation compared to placebo or no treatment (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.07; I2 = 0%; 8 studies, 1276 participants; moderate-certainty evidence). Subgroup analyses comparing placebo-controlled versus non-placebo-controlled trials, trials of participants with three or more prior miscarriages compared to women with two or more miscarriages, and different routes of administration showed no clear differences between subgroups for miscarriage. For women with recurrent miscarriage of unclear etiology receiving progestogen, there was probably little to no difference in live birth rate compared to placebo (RR 1.04, 95% CI 0.96 to 1.12; 5 trials, 1063 participants; moderate-certainty evidence). We are uncertain about the effect on the rate of preterm birth; there was probably little to no difference (RR 1.15, 95% CI 0.55 to 2.41; 3 trials, 256 participants; very low-certainty evidence). No clear differences were seen for women receiving progestogen for the other important outcomes, including neonatal death, fetal genital abnormalities, or stillbirth. There was little or no data on other important outcomes of low birth weight, maternal adverse events, teratogenic effects, or admission to a special care unit. None of the trials reported on any other important maternal outcomes, including severity of morning sickness, thromboembolic events, depression, admission to a special care unit, or subsequent fertility.

AUTHORS' CONCLUSIONS

For women with unexplained recurrent miscarriage, progestogen supplementation therapy probably results in little to no effect on outcomes in subsequent pregnancies.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Previous versions of this review were published in the Cochrane Library, available at doi.org/10.1002/14651858.CD003511.pub5.

Effects of probiotic supplementation on growth performance and feed intake of dairy calves: A meta-analysis

The objective of this systematic review and meta-analysis was to evaluate the effect of probiotic supplementation on ADG, feed intake, and feed efficiency (FE) of dairy calves. A secondary objective was to assess outcomes stratified by probiotic type. Our study included quasirandomized and randomized controlled trials written in English, Spanish, or Portuguese that assessed the effects of probiotic supplementation on the growth of dairy calves. No restrictions were placed on the publication year. A total of 5,480 records were initially identified after conducting searches in Biosis, CAB Abstracts, Medline, Scopus, and the Dissertations and Theses Database. After applying inclusion criteria, 55 studies (56 trials) were included in the analysis. Multilevel random-effects models were fitted for a single dataset combining all trials regardless of probiotic type and for 4 datasets stratified by 4 probiotic types (Bacillus, Lactobacillus, Saccharomyces, and multiple genera probiotics). Meta-analyses showed that probiotic supplementation did not result in significant difference in FE compared with the control group (no treatment or placebo). Probiotic supplementation improved total DMI, starter intake, and ADG and tended to decrease milk intake. A meta-regression analysis indicated a significant association between starter intake and probiotic type and the duration of probiotic supplementation. Analyses by probiotic type revealed no significant effects on DMI or FE for Lactobacillus spp., Saccharomyces spp., or multiple genera probiotics, whereas Bacillus spp. showed no effect on DMI but a tendency to improve FE. Supplementation with Lactobacillus spp. and multiple genera probiotics tended to increase starter intake. Supplementation with Bacillus spp. and Lactobacillus spp. increased the ADG of calves, whereas Saccharomyces spp. and multiple genera probiotic supplementation did not yield significant differences. Substantial and significant heterogeneity was observed for most outcomes; thus, results must be interpreted carefully. Probiotics may be beneficial for enhancing DMI, starter intake, and ADG in dairy calves; however, current evidence remains limited due to high heterogeneity. Results of analyses by probiotic type should be interpreted carefully due to the limited number of studies per category. To develop appropriate recommendations, additional research is required to address the sources of heterogeneity in existing studies.

Lonely Older Adults in the Era of Social Media: A Meta-Analytic Review

OBJECTIVES

In an increasingly digital modern society, the loneliness of older adults is a pressing public health concern, and social media is considered a potential solution. Despite past reviews that have attempted to synthesize the association between social media usage (SMU) and loneliness in older adults, the precise connection between the 2 remains unclear. The purpose of this study was to quantify the direct relationship between SMU and loneliness in older adults.

METHODS

As of August 2023, 3 databases (Web of Science, ProQuest, PubMed) were used for the literature search. A study was included if it measured the relationship between loneliness and SMU in older people over 50 years old. In total, the present study identified 29 effect sizes, representing data from 19 distinct research reports and over 24,877 participants.

RESULTS

The meta-analysis applying a random model, shows a weak negative correlation between SMU and loneliness (r = -0.06). The region development moderated the relationship, and specifically, the negative correlation between SMU and loneliness increased to a medium size (r = -0.24) when the samples were in developing regions.

DISCUSSION

SMU is negatively correlated with loneliness in old age, which suggests that promotion of SMU among older adults should be implemented, with attention to the inequality between regions and the privacy and availability concerns of older adults. Future research needs to make more efforts in terms of terminology consistency and potential moderators to obtain a more robust understanding of the association between SMU and the loneliness of older adults.

The effect of emotion on prospective memory: a three-level meta-analytic review

Prospective memory (PM), or the ability to remember to perform planned actions in the future, is fundamental in daily life. As a potential influencing factor of prospective memory, emotion has garnered significant attention. However, prior studies examining the impact of emotion on PM yield mixed findings. This study systematically reviewed 37 studies examining the effects of emotion on prospective memory, extracting a total of 171 effect sizes. The main effect analysis from the three-level meta-analysis revealed that positive emotions enhance prospective memory performance, supporting the positive effect theory. However, the facilitating effect of emotion varied depending on factors such as prospective memory task type, participant age, emotion induction method, study design, and the ecological validity of the experiment. The current study represents the first comprehensive review and meta-analysis of emotion's impact on PM and proposes directions for future research on emotional effects on PM.

Gonadotropin-releasing hormone (GnRH) analogues for premenstrual syndrome (PMS)

BACKGROUND

Premenstrual syndrome (PMS) is a psychological and somatic disorder affecting 20% to 30% of women of reproductive age. PMS results from ovulation: symptoms recur during the luteal phase of the menstrual cycle and remit by the end of menstruation. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS experienced by three to eight per cent of menstruating women. In this review, we use the term PMS to cover all core premenstrual disorders, including PMDD. The symptoms of all types are severe enough to affect daily functioning, interfering with work, school performance or interpersonal relationships. Gonadotropin-releasing hormone (GnRH) analogues are a pharmacological treatment to suppress ovulation. They can be administered as GnRH-agonists or GnRH-antagonists, though currently, GnRH-antagonists are not generally used to treat PMS. Suppressing ovarian function induces a hypo-oestrogenic state that can cause menopausal side effects such as hot flushes and mood changes. Having menopausal side effects instead of PMS symptoms can be distressing and can confuse clinical management. Longer-term GnRH therapy carries the risk of osteoporosis. To counteract these adverse effects, oestrogen or progestogen can be added to the PMS treatment; this is known as 'add-back' therapy or simply 'add-back'. Add-back may reduce menopausal side effects, allowing GnRH therapy to be used for a longer period without reducing efficacy.

OBJECTIVES

To evaluate the therapeutic effectiveness and safety (adverse effects) of GnRH analogues (agonists or antagonists), with or without add-back, in the management of PMS.

SEARCH METHODS

A Cochrane Information Specialist searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and two trials registers on 29 May 2023. We also checked reference lists and contacted study authors and subject experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of GnRH analogues used in the management of PMS in women of reproductive age with PMS diagnosed by at least two prospective menstrual cycles and no current psychiatric disorder. Control conditions could be no treatment, placebo, another type of GnRH, another dosage of GnRH or add-back.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures recommended by Cochrane. Our primary outcomes were overall severity of PMS symptoms (global symptoms), quality of life and adverse events.

MAIN RESULTS

The review found 11 RCTs that analysed results from 275 women. The evidence is of very low to high certainty. The evidence is limited by serious imprecision due to low sample sizes and a high risk of bias related to blinding and attrition. Quality of life and long-term effects on bones were not reported in the studies. Most studies did not report on all our adverse events of interest; some did not report on any of them. We found no RCTs that evaluated GnRH antagonists. GnRH agonists (without add-back) versus placebo GnRH agonists (without add-back) improve global symptoms compared to placebo (SMD -1.23, 95% CI -1.76 to -0.71; 9 RCTs, 173 women, effective sample size 278; I2 = 72%; high-certainty evidence). GnRH agonists may increase the risk of menopausal side effects compared to placebo (RR 1.93, 95% CI 0.83 to 4.48; 2 RCTs, 23 women, effective sample size 31; low-certainty evidence). If the risk of menopausal side effects with placebo is 21%, the risk with GnRH agonist without add-back would be between 18% and 96%. Seven RCTs reported on withdrawals from the study due to adverse events (though data extraction was not possible for one of these studies). Women using GnRH agonists have a higher risk of withdrawing due to adverse events than women using placebo (RR 4.24, 95% CI 1.10 to 16.36; 6 RCTs, 140 women, effective sample size 252; high-certainty evidence). If the risk of withdrawal from the study is 0.8% with placebo, the withdrawal risk with GnRH agonist without add-back would be between 0.8% and 13%. GnRH agonists (with add-back) versus placebo GnRH agonists with add-back may improve global symptoms compared to placebo (MD -3.89, 95% CI -6.19 to -1.59; 1 RCT, 31 women; low-certainty evidence). We are very uncertain of the effect on withdrawal due to adverse events (RR 2.86, 95% CI 0.12 to 66.44; 1 RCT, 41 women; very low-certainty evidence). Add-back versus placebo add-back during GnRH agonist treatment The evidence of add-back versus placebo during GnRH agonist treatment was too imprecise to decide if there was an effect on global symptoms. The analysis was stratified by type of add-back (tibolone or oestrogen/progesterone). One RCT investigated the effect of tibolone as add-back and found insufficient information to decide if there was an effect on global symptoms (SMD -0.37, 95% CI -0.11 to 0.38; 1 RCT, 28 women; very low-certainty evidence). One RCT investigated the effect of oestrogen plus cyclical progestogen as add-back and found evidence that it may worsen global symptoms compared to placebo (SMD 0.90, 95% CI 0.17 to 1.63; 1 RCT, 32 women; low-certainty evidence). We are very uncertain of the effect of tibolone on withdrawal due to adverse events (RR not estimable; 1 RCT, 28 women; very low-certainty evidence), and of oestrogen plus cyclical progestogen (RR 0.90, 95% CI 0.06 to 13.48; 1 RCT, 40 women; very low-certainty evidence). Add-back dose comparison (low dose versus standard dose) The evidence was too imprecise to determine if a lower add-back dose during GnRH agonist treatment affected global PMS symptoms (MD -11.90, 95% CI -28.51 to 4.71; 1 RCT, 15 women; low-certainty evidence).

AUTHORS' CONCLUSIONS

This review found that GnRH agonists without add-back improved global symptoms of premenstrual syndrome. However, the induced menopausal side effects and potential complications preclude long-term use. We found insufficient evidence to suggest that side effects can be reduced by 'add-back' without decreasing the global efficacy of GnRH agonists. Further RCTs of GnRH agonists with add-back and long-term follow-up are therefore needed to provide firm conclusions about long-term use. Until data are available to confirm or refute the safety of this combination, GnRH agonists with or without add-back can be administered to provide a short-term break from PMS symptoms. Future studies should attempt to assess the risk of osteoporosis.

Lifting Limits: The Impact of Strength Training in Down Syndrome-A Systematic Review and Meta-Analysis

BACKGROUND

People with Down syndrome (DS) may exhibit several musculoskeletal disorders, including alterations in muscle tone and activation. Strength training could mitigate the loss of muscle strength and, therefore, improve strength values in this population. Additionally, it may influence health-related outcomes such as physical function, body composition and biochemical markers.

OBJECTIVE

This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to analyse the characteristics and effects of strength training in people with DS.

METHODS

A search was conducted from inception to 22 April 2025. The methodological quality of the included RCTs was assessed using the 15-item Tool for the assEssment of Study qualiTy and reporting in EXercise (TESTEX). In addition, the risk of bias was assessed using the Cochrane's risk of bias 2 (RoB2).

RESULTS

A total of 10 RCTs (n = 233 participants) were included in the systematic review, of which three (n = 111 participants) could be meta-analysed. The pooled effect showed statistically significant benefits for upper (mean difference [MD] = 5.66 kg, 95% CI 2.42-8.91) and lower (MD = 20.43 kg, 95% CI 1.76-39.10) body strength. The TESTEX scores for most RCTs ranged from 3 to 12 points. The risk of bias analysis indicated that eight RCTs had a low risk of bias, whereas the remaining studies were classified as high risk.

CONCLUSION

Strength training may significantly improve muscle strength in people with DS. However, further research is needed to assess the long-term effects on physical function, body composition and biochemical markers.

Maternal exposure to lamotrigine and the risk of orofacial clefts in offspring: A systematic review and meta-analysis

Lamotrigine is used to treat epilepsy, migraine, and psychiatric disorders during pregnancy. However, concerns remain regarding whether lamotrigine exposure increases the risk of orofacial clefts (OFCs) in offspring. A systematic literature search was conducted to identify relevant studies published from inception to February 2025. Random-effects models were used to estimate the overall relative risk. Eight observational studies were included in the analysis. The overall results indicated that maternal lamotrigine exposure during pregnancy was associated with a significantly increased risk of OFCs in offspring (odds ratio [OR] = 1.42, 95 % confidence interval [CI] = 1.05-1.92, P < 0.001, I2 = 39.8 %). However, this association disappeared when data were pooled from cohort studies (OR = 1.4, 95 % CI = 0.67-2.9, P = 0.37) or from studies adjusting for at least five variables (OR = 0.97, 95 % CI = 0.63-1.48, P = 0.871, I2 = 0.0 %). Our findings suggest that in utero exposure to lamotrigine does not increase the risk of OFCs in offspring.

Dose-dependent effect of coconut oil supplementation on obesity indices: a systematic review and dose-response meta-analysis of clinical trials

BACKGROUND

Coconut oil has been suggested as a potential dietary intervention for weight management. However, the evidence regarding the effects of coconut oil supplementation on anthropometric measures (body weight, body mass index (BMI) and waist circumference (WC)) remains inconclusive.

OBJECTIVE

we aimed to assess the overall effect of coconut oil supplementation on these anthropometric parameters and explore potential sources of heterogeneity.

METHODS

We comprehensively searched electronic databases using appropriate keywords. We included 15 studies with the following criteria: (1) clinical trials in adults, with parallel or cross-over design, (2) evaluated the effect of coconut oil on body weight, BMI or WC, (3) compared the effect of a specific dose of coconut oil against a coconut oil-free diet or other types of oils, (4) considered the change in anthropometric parameters as the primary or one of the secondary outcomes, (5) provided mean and standard deviation (SD) of change in anthropometric parameters across study arms, (6) reported the number of participants in each study arm.

RESULTS

The trials included 620 participants and assessed the effects of coconut oil supplementation on body weight, BMI and WC. Our meta-analysis revealed statistically significant effects of coconut oil supplementation on weight and BMI, with mean differences of 0.04 kg (95% CI: 0.01 to 0.08 kg) and 0.01 kg/m2 (95% CI: 0.00 to 0.02). However, the effects were not clinically meaningful. There was no significant effect of coconut oil on WC. Subgroup analyses suggested that the duration of the intervention may influence the effect of coconut oil on body weight. In the sensitivity analysis, we found that the result of one study influenced the associations between coconut oil supplementation and weight or BMI.

CONCLUSIONS

Overall, our findings suggest no clinically significant effects of coconut oil supplementation on weight loss. Further research is needed to clarify the issue.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD420251031291.

Efficacy and safety of posterior short-segment versus long-segment pedicle screws fixation for thoracolumbar burst fractures: A systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of fixation levels with pedicle screw fixation for thoracolumbar burst fractures (TLBF).

METHODS

A systematic and comprehensive literature search was performed from inception to May 2024 in both English and Chinese databases, involving Medline, Cochrane Library, Embase, China National Knowledge Infrastructure Database, Wanfang Database, Chongqing VIP information, and SinoMed. Clinical trials of short-segment fixation and long-segment fixation (LSF) in the treatment of thoracolumbar burst fractures were included. Quality of included trials were assessed according to the methodological index for non-randomized studies (MINORS). Data analysis was conducted by using Review Manager 5.4 software and Stata. The quality of evidence in this systematic review was evaluated using the GRADE evidence quality evaluation system.

RESULTS

Seventeen eligible trials with a total of 1031 patients were included in this meta-analysis. Meta-analysis revealed that intraoperative bleeding (MD = -36.64, 95% CI = -56.36 to -16.92, Z = 3.64, P = .0003) and operation time (MD = -25.73, 95% CI = -46.56 to -4.90, Z = 2.42, P = .02) in the LSF group were higher than those in the short-segment fixation group. There were no significant differences in terms of the final follow-up sagittal index (MD = 1.64, 95% CI = -0.75 to 4.03, Z = 1.35, P = .18) and the final follow-up Oswestry disability index (MD = -2.94, 95% CI = -9.74 to 3.85, Z = 0.85, P = .40) between the 2 groups. The LSF group had the advantages of better the final follow-up Cobb angle (MD = 2.52, 95% CI = 0.35-4.70, Z = 2.27, P = .02), the final follow-up visual analog scale (MD = 0.09, 95% CI = 0.04-0.14, Z = 3.59, P = .0003) and lower the final follow-up implant failure (MD = 3.43, 95% CI = 1.78-6.62, Z = 3.69, P = .0002). The funnel plots and Egger test showed some evidence of asymmetry, suggesting publication bias or small sample effect was existed.

CONCLUSION

For thoracolumbar burst fractures, LSF can better improve patients' low back pain and better maintain postoperative orthopedic effect.

The association of lead and cadmium exposure with periodontitis: a systematic review and meta-analysis

OBJECTIVE

Periodontitis, a microbiome-driven chronic inflammatory disease that destroys the supporting structures of the teeth, is influenced by various environmental factors, including exposure to heavy metals such as lead and cadmium. This systematic review and meta-analysis aimed to evaluate the association between exposure to lead and cadmium and periodontitis.

METHODS

A comprehensive literature search was conducted in PubMed, Web of Science, Scopus, and Embase up to February 1, 2025, following PRISMA guidelines. Observational studies examining the association between lead and/or cadmium exposure and periodontitis were included. Required clinical data were extracted, and study quality was assessed using the Newcastle-Ottawa Scale. Random-effects models were used to compute either standardized mean differences (SMD) of concentration or pooled adjusted odds ratios (aORs). Heterogeneity was assessed with I².

RESULTS

Fourteen studies (13 datasets for either lead or cadmium) comprising 72,467 participants were eligible for inclusion. The meta-analysis found that cadmium and lead exposure were significantly associated with higher odds of periodontitis, with pooled aORs of 1.22 (95% CI: 1.08-1.37) and 1.85 (95% CI: 1.42-2.41), respectively. Sensitivity analyses confirmed the robustness of the findings.

CONCLUSION

This study provides evidence that exposure to lead and cadmium is significantly associated with periodontitis. These findings highlight the importance of reducing environmental exposure to these heavy metals as part of preventive strategies for periodontal disease. Further research is needed to explore the underlying biological mechanisms and evaluate potential interventions to reduce exposure-associated periodontitis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Screening accuracy of Single-Point Insulin Sensitivity Estimator (SPISE) for metabolic syndrome: a systematic review and meta-analysis

BACKGROUND

Metabolic syndrome (MetS) is a multifactorial condition linked to increased risk of cardiovascular disease and type 2 diabetes. The Single-Point Insulin Sensitivity Estimator (SPISE), a non-invasive index calculated via 600 × HDL-C^0.185 / (TG^0.2 × BMI^1.338), offers a practical alternative. This systematic review and meta-analysis aim to evaluate the accuracy of SPISE as an indicator for MetS.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines. We searched databases such as MEDLINE, Scopus, Web of Science, and Embase, focusing on studies evaluating SPISE's screening accuracy for MetS. Eligible studies were observational, reporting mean SPISE values and its predictive performance. Meta-analyses were performed using Hedges' g standardized mean differences (SMD) and pooled area under the curve (AUC) estimates.

RESULTS

Seven studies comprising 12,919 participants were included, with an age range of 9.2 ± 2.1 to 52.4 ± 11.0. Individuals with MetS had significantly lower SPISE scores than controls (SMD = -0.94, 95% CI: -1.25 to -0.63). The pooled AUC for SPISE as a predictor of MetS was 0.86 (95% CI: 0.83 to 0.90), surpassing other insulin resistance indices like HOMA-IR and the triglyceride/HDL-C ratio. Meta-regression showed that systolic and diastolic blood pressure were potential sources of heterogeneity and age, gender, BMI, waist circumference, fasting blood glucose, triglyceride, and HDL did not contribute to heterogeneity.

CONCLUSIONS

SPISE is a highly accurate and non-invasive tool for predicting MetS, potentially outperforming traditional indices like HOMA-IR. Its ease of use and precision make it a valuable clinical screening tool, especially in diverse populations.

Potential of CETP inhibition in treating dyslipidemia in systemic lupus erythematosus: Novel and comprehensive evidence from clinical studies and Mendelian randomization

OBJECTIVE

Cardiovascular diseases from abnormal lipid metabolism significantly increase mortality in systemic lupus erythematosus (SLE). The causal link between dyslipidemia and SLE is unclear.

METHODS

Lipid metabolism in patients with SLE was evaluated based on clinical data from 511 patients with SLE and 706 healthy individuals. Bidirectional Mendelian randomization (MR) was employed to assess causal links between 179 plasma lipid metabolites, lipid-lowering drug targets, and SLE risk. Genetic instruments from GWAS and eQTL data were used to evaluate CETP and APOA4 effects. Peripheral blood CETP and apolipoprotein levels in SLE patients were validated via ELISA.

RESULTS

SLE patients exhibited reduced HDL-C (P < 0.0001), APOA1 (P < 0.0001), and APOA4 (P < 0.0001), alongside elevated triglycerides (TG, P < 0.0001), APOC3, APOD, and APOF. MR identified three lipid metabolites-PC(18:2_20:4), TG(56:6), and TG(58:7)-as causal factors for SLE (P < 2.79E-5). CETP inhibition significantly reduced SLE risk via HDL-C modulation (OR = 0.72, P = 3.38E-08) and influenced LDL-C, TG, and apolipoproteins. Clinical validation confirmed elevated CETP and reduced APOA4 in SLE, correlating with disease activity. APOA4 activation showed protective effects, while PCSK9 inhibition lacked relevance.

CONCLUSION

Bidirectional Mendelian randomization analyses confirmed dyslipidemia as a causal antecedent to SLE, with no evidence of reverse causation. A variety of MR analyses and clinical validation indicated that targeting HDL-C regulation offers significant advantages for managing dyslipidemia in patients with SLE, with CETP identified as the optimal pharmacological target.

Adjuvant Radiotherapy for Intermediate-Risk Early-Stage Cervical Cancer Post Radical Hysterectomy: A Systematic Review and Meta-Analysis

Background: The risk of recurrence of early-stage cervical cancer (CC) is associated with prognostic factors such as tumor size, lymphovascular space invasion (LVSI), and deep stromal invasion (DSI). However, the adjuvant pelvic radiotherapy (RT) following surgery to reduce the risk of recurrence in "intermediate risk" remains controversial. This study aims to evaluate the role of adjuvant RT in the recurrence and identify prognostic factors. Methods: A systematic search of PubMed, Embase, and Cochrane databases was performed to identify studies comparing adjuvant RT versus no adjuvant treatment in early-stage CC patients with intermediate-risk factors defined by GOG-92 criteria. Outcomes were recurrence, local recurrence, death, 5-year overall survival (5y-OS), and 5-year disease-free survival (5y-DFS). Tumor size ≥ 4 cm, LVSI, and DSI were also evaluated as prognostic factors for recurrence. Statistical analysis was performed using Review Manager 7.2.0. Heterogeneity was assessed with I2 statistics. Results: A total of 1504 patients from nine studies were included; only one study was a randomized controlled trial, while the others were retrospective cohorts. Adjuvant RT was used to treat 781 patients (52%). Median follow-up ranged from 48 to 120 months. Recurrence (OR 0.75; 95% CI 0.38-1.46; p = 0.39), local recurrence (OR 0.73; 95% CI 0.44-1.20; p = 0.22), death (OR 0.97; 95% CI 0.52-1.80; p = 0.91), 5y-OS (OR 1.22; 95% CI 0.36-4.18; p = 0.75), and 5y-DFS (OR 0.78; 95% CI 0.42-1.43 p = 0.42) revealed no statistically significant differences between adjuvant RT and observation groups. TS ≥ 4 cm was an independent prognostic risk factor for recurrence (HR 1.83; 95% CI 1.12-2.97; p = 0.02). Conclusions: Our findings suggest that adjuvant RT does not reduce recurrence risk in early-stage cervical cancer. Consider TS ≥ 4 cm as a significant prognostic factor for recurrence. Adjuvant RT in intermediate-risk patients should be considered with caution due the lack of significant improvement in recurrence until the CERVANTES and GOG-0263 trial results become available.

A systematic review and meta-analysis of advanced oxidative protein products levels (AOPP) levels in endometriosis: Association with disease stage and clinical implications

Endometriosis is a common cause of chronic pelvic pain and lacks precise pathophysiological mechanisms. Advanced oxidation protein products (AOPPs), markers of oxidative stress and inflammation, are implicated in pain-related diseases and have been suggested to play a crucial role in endometriosis pathophysiology. We aim to assess the significance of AOPP in endometriosis by analyzing their levels across serum, follicular fluid, peritoneal fluid, and ovarian endometrioma tissue, and their association with different disease stages. A systematic review of articles published up to Nov 2024 examining AOPP levels in endometriosis patients compared to controls was conducted (PROSPERO: CRD42022343714). Using the Newcastle-Ottawa Scale (NOS), the quality and risk of bias of included studies were assessed, and publication bias was evaluated using Egger's and Begg's tests. The analysis 12 studies involving 561 control patients without endometriosis and 670 patients with endometriosis. Compared to controls, elevated AOPP levels were observed in endometriosis patients' serum and peritoneal fluid. Patients with type III/IV endometriosis exhibited higher AOPP levels in serum and plasma compared to control patients, suggesting a potential association with disease severity. The study underscores the potential of AOPP levels as biomarkers for endometriosis severity and proposes them as pharmacological targets for disease management, including pelvic pain treatment.

Ambient air pollution and the risk of cancer: Evidence from global cohort studies and epigenetic-related causal inference

The correlation between air pollution and cancer incidence has been a longstanding concern, understanding the need to elucidate the specifics of this relationship. Thus, this study aimed to assess the association between exposure to air pollution and cancer incidence, and to identify the possible biological links between the two. We examined global cohort studies investigating the association between air pollution and cancer and performed a univariate Mendelian randomization (MR) analysis. Our analysis revealed that the presence of particulate matter (PM)2.5, PM10, NO2, and NOx substantially impacted the risk of developing cancer. MR analysis identified 130 CpGs sites associated with three ambient air pollutants that have significant casual effects on the risk of 14 cancer sites (false discovery rate<0.05). Gene annotation was conducted using g-Profiler by screening for single nucleotide polymorphisms significantly associated with outcome, followed by analysis of the gene interaction network using GeneMANIA, and visualization using igraph. In conclusion, this study demonstrates that air pollution has a significant impact on cancer incidence, provides strong evidence for an epigenetic causal link between the two, and provides new insights into the molecular mechanisms by which air pollution affects cancer development.

Effects of combinations of diagnostic and treatment strategies for postpartum haemorrhage: a network meta-analysis

RATIONALE

Postpartum haemorrhage (PPH) is a major cause of maternal mortality worldwide. The combination of accurate diagnosis and effective treatment is necessary to improve outcomes. There is uncertainty about which combination of diagnostic and treatment strategies is most effective.

OBJECTIVES

To assess the comparative effectiveness of various combinations of 'diagnostic and treatment' strategies for PPH in women giving birth, and rank them. To explore the relative effects of various diagnostic strategies, when the treatment strategies are the same or similar. To explore the relative effects of various treatment strategies, when the diagnostic strategies are the same or similar.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform to 18 October 2024.

ELIGIBILITY CRITERIA

Randomised controlled trials or cluster-randomised trials comparing the effects of different combinations of 'diagnostic and treatment' strategies for PPH were eligible. We included studies of women having vaginal or caesarean birth in any setting.

OUTCOMES

Critical outcomes were: PPH ≥ 500 mL within 24 hours after birth; additional blood loss of ≥ 500 mL following diagnosis of PPH and within 24 hours after birth; PPH ≥ 1000 mL within 24 hours after birth; need for blood transfusion; use of additional uterotonics, and PPH treatment rate. Important outcomes included maternal death.

RISK OF BIAS

We used the Cochrane risk of bias tool (RoB 1).

SYNTHESIS METHODS

At least two review authors independently assessed trials for inclusion, trustworthiness, risk of bias, and certainty of the evidence using GRADE. We calculated direct and indirect effect estimates, where possible, for critical and important outcomes. Due to limited data, we were unable to perform pairwise meta-analyses and network meta-analyses for the available combinations, or generate rankings.

INCLUDED STUDIES

We included five trials (10 trial arms, 236,771 women); all included women giving birth vaginally and four had a hospital setting. The combinations of diagnostic and treatment strategies were: visual estimation-based diagnosis plus usual care for treatment; 3-option trigger PPH diagnosis with calibrated drape (1. clinical concern, or 2. blood loss ≥ 300 mL to < 500 mL plus abnormal observations, or 3. blood loss ≥ 500 mL) plus MOTIVE (uterine Massage, Oxytocics, Tranexamic acid, IntraVenous fluids, and Examination and Escalation of care) treatment bundle; 2-option trigger PPH diagnosis with calibrated drape (1. clinical concern, or 2. blood loss ≥ 500 mL) plus MOTIVE treatment bundle; calibrated drape-based diagnosis plus usual care for treatment; gravimetric method-based diagnosis plus usual care for treatment; MaternaWell tray-based diagnosis plus usual care for treatment.

SYNTHESIS OF RESULTS

3-option trigger PPH diagnosis plus MOTIVE bundle versus visual estimation-based diagnosis plus usual care (direct evidence; 1 study, 170,956 participants) reduces PPH ≥ 500 mL (RR 0.48, 95% CI 0.39 to 0.58; high-certainty evidence), and PPH ≥ 1000 mL (RR 0.34, 95% CI 0.26 to 0.44; high-certainty). Moderate-certainty evidence suggests it probably makes little or no difference to the need for blood transfusion (RR 0.82, 95% CI 0.62 to 1.08) or additional uterotonics (RR 1.19, 95% CI 0.94 to 1.50), and maternal death (RR 0.73, 95% CI 0.36 to 1.48). 2-option trigger PPH diagnosis plus MOTIVE bundle versus visual estimation-based diagnosis plus usual care (direct evidence; 1 study, 39,176 participants) reduces PPH ≥ 500 mL (RR 0.73, 95% CI 0.60 to 0.89; high-certainty). It probably makes little or no difference to PPH ≥ 1000 mL (RR 0.88, 95% CI 0.69 to 1.12; moderate-certainty), and the need for blood transfusion (RR 1.06, 95% CI 0.55 to 2.04; moderate-certainty), and may make little or no difference to maternal death (RR 1.01, 95% CI 0.00 to 4.0 × 107; low-certainty). High-certainty evidence suggests it increases the need for additional uterotonics (RR 3.54, 95% CI 2.27 to 5.52). 3-option trigger PPH diagnosis plus MOTIVE bundle versus 2-option trigger PPH diagnosis plus MOTIVE bundle (indirect evidence) reduces PPH ≥ 500 mL (RR 0.65, 95% CI 0.49 to 0.86; high-certainty), PPH ≥ 1000 mL (RR 0.38, 95% CI 0.27 to 0.55; high-certainty), and the need for additional uterotonics (RR 0.34, 95% CI 0.20 to 0.55; high-certainty). It probably makes little or no difference to the need for blood transfusion (RR 0.78, 95% CI 0.38 to 1.59; moderate-certainty), and may make little or no difference to maternal death (RR 0.72, 95% CI 0.00 to 2.9 × 107; low-certainty). Calibrated drape-based diagnosis plus usual care (in a European setting (E)) versus visual estimation-based diagnosis plus usual care (E) (direct evidence; 1 study, 25,381 participants) probably makes little or no difference to the need for blood transfusion (RR 0.83, 95% CI 0.57 to 1.21; moderate-certainty). Gravimetric method-based diagnosis plus usual care versus calibrated drape-based diagnosis plus usual care (direct evidence; 1 study, 1195 participants) reduces PPH ≥ 500 mL (RR 0.54, 95% CI 0.32 to 0.90; high-certainty), and may make little or no difference to need for blood transfusion (RR 1.00, 95% CI 0.06 to 15.94; low-certainty). MaternaWell tray-based diagnosis plus usual care versus calibrated drape-based diagnosis plus usual care (direct evidence; 1 study, 63 participants) may make little or no difference to PPH ≥ 500 mL (RR 0.61, 95% CI 0.11 to 3.38; low-certainty), and PPH ≥ 1000 mL (RR 0.30, 95% CI 0.01 to 7.19; low-certainty). Gravimetric method-based diagnosis plus usual care versus MaternaWell tray-based diagnosis plus usual care (indirect evidence) may make little or no difference to PPH ≥ 500 mL (RR 0.89, 95% CI 0.15 to 5.35; low-certainty). No data were available for other critical and important outcomes.

AUTHORS' CONCLUSIONS

Both 3-option trigger PPH diagnosis plus MOTIVE bundle and 2-option trigger PPH diagnosis plus MOTIVE bundle were more effective than visual estimation-based diagnosis plus usual care (direct evidence). 3-option trigger PPH diagnosis plus MOTIVE bundle was more effective than 2-option trigger PPH diagnosis plus MOTIVE bundle (indirect evidence). As the treatment strategy (MOTIVE bundle) is the same in these combinations, the increased effectiveness is likely due to the 3-option trigger PPH diagnosis, which adds blood loss of ≥ 300 mL to < 500 mL in the drape plus abnormal clinical observations as a PPH diagnostic trigger. None of the comparisons demonstrated differences in blood transfusion or maternal mortality outcomes. Future research should assess the effectiveness of combination diagnostic and treatment strategies in non-hospital settings, and for women having a caesarean birth. Studies should provide more data on side effects, and maternal experience of care.

FUNDING

Gates Foundation REGISTRATION: PROSPERO (CRD42024600189).

Primary closure and prophylactic antibiotics for treatment of traumatic wounds caused by mammals, a systematic review and meta-analysis

PURPOSE

To compare primary closure (PC) with delayed/no closure (DC/NC), and compare prophylactic use of antibiotics (PUA) with no use of antibiotics (NUA) in the treatment of traumatic wounds caused by mammals by a systematic review and meta-analysis.

METHODS

PubMed and Embase databases were searched for eligible randomized clinical trials (RCTs) and observational studies. Qualities of RCTs were assessed according to Cochrane risk of bias tool, qualities of observational studies were assessed according to Newcastle-Ottawa Scale. Primary outcomes included the incidence of wound infection or poor wound healing and the rate of wound cosmesis satisfaction. The relative risks (RRs) of RCTs, odds ratios (ORs) of observational studies and their 95% confidence interval (CI) were extracted directly from included studies or calculated according to the 2 × 2 table obtained by the incidence. The sensitivity analysis, meta-regression and subgroup analysis were performed to identify clinical factors that caused the heterogeneity between studies.

RESULTS

Of 26 included studies, 17 studies (8 RCTs and 9 observational studies, 8091 patients) compared PC with DC/NC and 14 studies (7 RCTs and 7 observational studies, 2508 patients) compared PUA with NUA. The pooled OR of all studies (PC versus DC/NC) for wound infection or poor wound healing was 0.79 (95%CI: 0.54, 1.17), the pooled RR of RCTs for wound infection was 0.73 (0.51, 1.06). The pooled OR for cosmesis satisfaction was 3.68 (1.27, 10.68) of 2 studies (PC versus DC) that did not use the negative pressure sealing drainage technique. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) comparison of PC and DC (pooled OR: 0.49 [0.27, 0.90]), (2) prophylactic use of antibiotics (0.56 [0.33, 0.94]), (3) no use of antibiotics (0.63 [0.41, 0.98]), (4) wounds located in limbs/trunk (0.41 [0.23, 0.73]), (5) time to the first medical presentation (TTP) ≤ 10 h (0.59 [0.39, 0.89]). While the pooled OR (PC versus NC) was not significant (0.84 [0.51, 1.37]). The pooled OR of all studies for wound infection (PUA versus NUA) was 0.73 (95%CI: 0.46, 1.17), the pooled RR of RCTs for wound infection was 0.81 (0.46, 1.44). No included studies (PUA versus NUA) reported the outcome of wound cosmesis. Subgroup analysis demonstrated that the pooled OR was significant under specific clinical conditions: (1) injury caused by other type of mammals other than dog (pooled OR: 0.24 [0.06-0.98]), (2) wounds located in face/head (0.13 [0.03, 0.52]).

CONCLUSIONS

Regardless of whether prophylactic antibiotics are used or not, compared to delayed closure, primary closure should be given priority in treating traumatic wounds caused by mammals which can decrease the incidence of wound infection or poor wound healing and obtain the better wound cosmesis, but it does not show the superiority compared to no closure, unless under some specific clinical conditions. Prophylactic use of antibiotics may not benefit in prevention of wound infection unless under specific clinical conditions, such as wounds caused by mammals other than dogs or wounds located in face/head.

Cycle regimens for endometrial preparation prior to frozen embryo transfer

BACKGROUND

Frozen-thawed embryo transfer (FET) use increases the cumulative pregnancy rate, reduces cost and is relatively simple to undertake. FET is performed using different cycle regimens: spontaneous ovulatory (natural) cycles; cycles in which the endometrium is artificially prepared by oestrogen and progesterone hormones, commonly known as hormone therapy (HT) FET cycles; and cycles in which ovulation is induced by drugs (ovulation induction FET cycles). HT can be used with or without a gonadotrophin-releasing hormone agonist (GnRHa). This is an update of a Cochrane review; previous versions were published in 2008 and 2017.

OBJECTIVES

To compare the effectiveness and safety of natural cycle FET, HT cycle FET and ovulation induction cycle FET, and compare subtypes of these regimens.

SEARCH METHODS

We used Cochrane Gynaecology and Fertility's Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, four other electronic sources and two trials registers, together with reference checking, citation searching and contact with study authors to identify the studies included in the review. The latest search date was 19 December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the various cycle regimens and different methods used to prepare the endometrium during FET.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcomes were live birth and miscarriage rates.

MAIN RESULTS

We included 32 RCTs comparing different cycle regimens for FET in 6352 women. The certainty of the evidence was moderate to very low. The main limitations were failure to report important clinical outcomes, poor reporting of study methods and imprecision due to low event rates. Natural cycle FET comparisons Natural cycle FET versus HT FET We are uncertain of a difference in live birth rate (LBR) (odds ratio (OR) 1.18, 95% confidence interval (CI) 0.67 to 2.08; 1 study, 233 participants; low-certainty evidence), miscarriage rate (OR 0.10, 95% CI 0.01 to 1.90; 1 study, 233 participants; low-certainty evidence), ongoing pregnancy rate (OR 1.23, 95% CI 0.7 to 2.16; 1 study, 233 participants; low-certainty evidence) or multiple pregnancy rate (OR 1.26, 95% CI 0.58 to 2.75; 2 studies, 333 participants; very low-certainty evidence) between women in natural cycles and those in HT FET cycles. Natural cycle FET versus HT plus GnRHa suppression There is probably little or no difference in LBR (OR 0.89, 95% CI 0.58 to 1.36; 2 studies, 400 participants; moderate-certainty evidence) or multiple pregnancy rate (OR 1.23, 95% CI 0.60 to 2.51; 2 studies, 400 participants; moderate-certainty evidence) between women who had natural cycle FET and those who had HT FET cycles with GnRHa suppression. We are uncertain of a difference in miscarriage rate (OR 0.09, 95% CI 0.00 to 1.61; 1 study, 241 participants; low-certainty evidence) and ongoing pregnancy rate (OR 1.01, 95% CI 0.59 to 1.74; 1 study, 241 participants; low-certainty evidence). Natural cycle FET versus modified natural cycle FET (human chorionic gonadotrophin (HCG) trigger) We are uncertain of a difference in LBR (OR 0.97, 95% CI 0.65 to 1.45; 3 studies, 442 participants; low-certainty evidence) or multiple pregnancy rate (OR 1.14, 95% CI 0.52 to 2.52; 1 study, 237 participants; low-certainty evidence) between women in natural cycles and women in natural cycles with HCG trigger. There is probably little or no difference in ongoing pregnancy rate (OR 1.29, 95% CI 0.90 to 1.85; 3 studies, 653 participants; moderate-certainty evidence) or in miscarriage rate (OR 0.83, 95% CI 0.43 to 1.61; 4 studies, 798 participants; moderate-certainty evidence). Modified natural cycle FET comparisons Modified natural cycle FET (HCG trigger) versus HT FET We are uncertain of a difference in LBR (OR 1.26, 95% CI 0.90 to 1.77; 2 studies, 1189 participants; low-certainty evidence), ongoing pregnancy (OR 1.22, 95% CI 0.88 to 1.68; 3 studies, 1276 participants; low-certainty evidence), and multiple pregnancy rate (OR 1.05, 95% CI 0.46 to 2.42; 1 study, 230 participants; low-certainty evidence) between the two groups. We are uncertain whether the use of HT FET decreases miscarriage rate compared to modified natural cycle FET (OR 0.51, 95% CI 0.14 to 1.87; 2 studies, 317 participants; very low-certainty evidence). Modified natural cycle FET (HCG trigger) versus HT plus GnRHa suppression We are uncertain of a difference between the two groups in LBR (OR 1.06, 95% CI 0.77 to 1.47; 3 studies, 644 participants; low-certainty evidence), ongoing pregnancy rate (OR 1.03, 95% CI 0.68 to 1.55; 2 studies, 408 participants; low-certainty evidence), miscarriage rate (OR 0.71, 95% CI 0.31 to 1.63; 3 studies, 644 participants; low-certainty evidence) and multiple pregnancy rate (OR 1.39, 95% CI 0.58 to 3.30; 1 study, 238 participants; low-certainty evidence). HT FET comparisons HT FET versus HT plus GnRHa suppression We are uncertain of a difference between the two groups in LBR (OR 0.92, 95% CI 0.71 to 1.19; 5 studies, 1132 participants; moderate-certainty evidence), miscarriage rate (OR 0.85, 95% CI 0.59 to 1.22; 11 studies, 2036 participants; low-certainty evidence), ongoing pregnancy (OR 0.94, 95% CI 0.64 to 1.39; 4 studies, 640 participants; low-certainty evidence) and multiple pregnancy rate (OR 0.86, 95% CI 0.42 to 1.74; 2 studies, 422 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

As the evidence was often of low certainty, and the confidence intervals were wide and therefore consistent with possible benefit and harm, we are uncertain whether one cycle regimen is more effective and safer than another in preparation for FET in subfertile women.

Child maltreatment and resilience in adulthood: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis to quantify associations between overall and subtypes of CM, global/trait resilience, and five resilience domains (coping, self-esteem, emotion regulation, self-efficacy, and well-being) in adults, and to examine moderators and mediators of these associations. A systematic search was undertaken on 12 June 2024 to identify published peer-reviewed articles in five databases (PROSPERO-CRD42023394120). Of 15,262 records, 203 studies were included, comprising 145,317 adults (M age = 29.62 years; 34.96% males); 183 studies and 557 effect sizes were pooled in random-effect meta-analyses. Overall CM and its subtypes were negatively associated with global/trait resilience and its domains (r = -0.081 to -0.330). Emotional abuse/neglect showed the largest magnitude of effect (r = -0.213 to -0.321). There was no meta-analytic evidence for an association between sexual abuse and coping, and physical abuse/neglect and self-esteem. Meta-regressions identified age, sample size, and study quality as moderators. Subgroup analyses found that associations between emotional abuse and emotion regulation were stronger, while associations between emotional abuse and self-esteem were weaker, in western versus non-western countries. No differences were found in associations between CM and resilience in clinical versus non-clinical samples. Narrative synthesis identified several mediators. Associations were of small magnitude and there were a limited number of studies, especially studies assessing CM subtypes, such as physical neglect, bullying, or domestic violence, and resilience domains, such as coping or self-efficacy, in males, and clinical samples. CM exposure negatively impacts resilience in adults, an effect observed across multiple maltreatment types and resilience domains. Interventions focused on resilience in adults with CM histories are needed to improve health and psychosocial outcomes.