Network meta-analysis: a technique to gather evidence from direct and indirect comparisons

PsychOpen CAMA: Publication of community-augmented meta-analyses in psychology

To enable optimal decision‐making based on the best evidence available, open syntheses are called for. To make data accessible and comprehensible even for decision‐makers without proficient knowledge in meta‐analysis, a graphical user interface (GUI) provides flexible data visualizations including interpretation aids. Moreover, due to a growing number of research findings, efficient and easy updating of meta‐analyses is crucial to prevent waste in research. One label for a concept to meet these needs is community‐augmented meta‐analysis (CAMA). The research community at the one hand feeds the data repository of a CAMA with new data and on the other hand benefits from easy access to data and meta‐analyses on a GUI. PsychOpen CAMA has been released recently to serve the psychological research community as a whole by covering a broad scope of potential research domains. PsychOpen CAMA relies on a web application with an OpenCPU server for the R calculations. To achieve interoperability of different datasets with the analysis functions used in PsychOpen CAMA, a template for meta‐analytic data and machine‐readable metadata are used. In the future, the automation of workflows, flexibility of analysis options, and the scope of the platform will be further developed by making use of synergies with other resources and tools at ZPID. The article provides an overview on the rationale for the necessity of open syntheses and the CAMA approach, as well as a presentation of the architecture, user interface, functionalities and future challenges of PsychOpen CAMA.

Antibacterial data synthesis challenges: a systematic review of treatments for complicated gram-negative urinary tract infections

Aim: To determine the suitability of network meta-analysis (NMA) using antibacterial treatment evidence in complicated urinary tract infection. Materials & methods: We conducted a systematic literature review to identify published clinical trial data for complicated urinary tract infection treatments. We performed a feasibility assessment to determine whether the available evidence would support the creation of a robust NMA, considering key assumptions of homogeneity, similarity and consistency. Results: Twenty-five trials met eligibility criteria. Risk of bias was low, and individual studies met their primary end point(s). Assumptions central to the conduct of a robust NMA were not met. Heterogeneity was ubiquitous, including baseline pathogen, treatment and patient characteristics. Conclusion: Limited and heterogeneous data identified make the use of NMA to compare novel antibacterial agents impractical and likely unreliable.

Effectiveness comparisons of various therapies for FIGO stage IB2/IIA2 cervical cancer: a Bayesian network meta-analysis

BACKGROUND

Cervical cancer is a common malignancy of the female genital tract. Treatment options for cervical cancer patients diagnosed at FIGO (2009) stage IB2 and IIA2 remains controversial.

METHODS

We perform a Bayesian network meta-analysis to directly or indirectly compare various interventions for FIGO (2009) IB2 and IIA2 disease, in order to improve our understand of the optimal treatment strategy for these women. Three databases were searched for articles published between 1971 and 2020. Data on included study characteristics, outcomes, and risk of bias were abstracted by two reviewers.

RESULTS

Seven thousand four hundred eighty-six articles were identified. Thirteen randomized controlled trials of FIGO (2009) IB2 and IIA2 cervical cancer patients were included in the final analysis. These trials used six different interventions: concomitant chemoradiotherapy (CCRT), radical surgery (RS), radical surgery following chemoradiotherapy (CCRT+RS), neoadjuvant chemotherapy followed by radical surgery (NACT+RS), adjuvant radiotherapy followed by Radical surgery (RT + RS), radiotherapy alone (RT).SUCRA ranking of OS and Relapse identified CCRT+RS and CCRT as the best interventions, respectively. Systematic clustering analysis identified the CCRT group as a unique cluster.

CONCLUSION

These data suggest that CCRT may be the best approach for improving the clinical outcome of cervical cancer patients diagnosed at FIGO (2009) stage IB2/IIA2. Phase III randomized trials should be performed in order to robustly assess the relative efficacy of available treatment strategies in this disease context.

Efficacy and safety of Qingre-Chushi therapies in active ulcerative colitis: A network meta-analysis

Background

Ulcerative colitis (UC) is a chronic inflammatory disease with an increasing incidence in the world. Qingre-Chushi therapies (QC) can alleviate clinical symptoms. Therefore, a network meta-analysis was conducted to systematically evaluate the efficacy and safety of QC in the treatment of active UC patients.

Methods

7 databases were screened and relevant randomized controlled trials were selected. The tools of Cochrane Handbook and the GRADE system were conducted to assess the quality of outcomes. Pooled risk ratio or standard mean difference was calculated with 95% credible interval for outcomes measurement using the random-effects model. The surface under the cumulative ranking curve (SUCRA) was performed to rank the treatments. The larger SUCRA scores, the more effective interventions.

Results

A total of 3560 articles were identified and 21 studies including 1829 participants were included for further analysis. Totally, 9 therapies regimens were compared: oral mesalazine, mesalazine enema, mesalazine suppository, oral mesalazine + mesalazine enema, oral QC, oral QC + oral mesalazine, QC enema, oral QC + QC enema, and oral mesalazine + QC enema. Based on the SUCRA plot, oral QC + oral mesalazine was the best treatment in inducing clinical response; oral QC + QC enema had the best efficacy in the improvement of Mayo scores and alleviating abdominal pain; oral mesalazine + mesalazine enema was the optimal therapy in the endoscopic improvement and reducing diarrhea; QC enema + oral mesalazine was the best option in preventing bloody stool.

Conclusion

This study confirmed the efficacy and safety of QC in treating active UC and suggested that the combination of oral medications with topical can achieve more benefits.

Do reporting guidelines have an impact? Empirical assessment of changes in reporting before and after the PRISMA extension statement for network meta-analysis

BACKGROUND

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for network meta-analysis (NMA) published in 2015 promotes comprehensive reporting in published systematic reviews with NMA. PRISMA-NMA includes 32 items: 27 core items as indicated in the 2009 PRISMA Statement and five items specific to the reporting of NMAs. Although NMA reporting is improving, it is unclear whether PRISMA-NMA has accelerated this improvement. We aimed to investigate the impact of PRISMA-NMA and highlight key items that require attention and improvement.

METHODS

We updated our previous collection of NMAs with articles published between April 2015 and July 2018. We assessed the completeness of reporting for each NMA, including main manuscript and online supplements, using the PRISMA-NMA checklist. The PRISMA-NMA checklist originally includes 32 total items (i.e. a 32-point scale original PRISMA-NMA score). We also prepared a modified version of the PRISMA-NMA checklist with 49 items to evaluate separately at a more granular level all multiple-content items (i.e. a 49-point scale modified PRISMA-NMA score). We compared average reporting scores of articles published until and after 2015.

RESULTS

In the 1144 included NMAs the mean modified PRISMA-NMA score was 32.1 (95% CI 31.8-32.4) of a possible 49-excellence-score. For 1-year increase, the mean modified score increased by 0.96 (95% CI 0.32 to 1.59) for 389 NMAs published until 2015 and by 0.53 (95% CI 0.02 to 1.04) for 755 NMAs published after 2015. The mean modified PRISMA-NMA score for NMAs published after 2015 was higher by 0.81 (95% CI 0.23 to 1.39) compared to before 2015 when adjusting for journal impact factor, type of review, funding, and treatment category. Description of summary effect sizes to be used, presentation of individual study data, sources of funding for the systematic review, and role of funders dropped in frequency after 2015 by 6-16%.

CONCLUSIONS

NMAs published after 2015 more frequently reported the five items associated with NMA compared to those published until 2015. However, improvement in reporting after 2015 is compatible with that observed on a yearly basis until 2015, and hence, it could not be attributed solely to the publication of the PRISMA-NMA.

Lag times in the publication of network meta-analyses: a survey

OBJECTIVE

We assessed the extent of lag times in the publication and indexing of network meta-analyses (NMAs).

STUDY DESIGN

This was a survey of published NMAs on drug interventions.

SETTING

NMAs indexed in PubMed (searches updated in May 2020).

PRIMARY AND SECONDARY OUTCOME MEASURES

Lag times were measured as the time between the last systematic search and the article submission, acceptance, online publication, indexing and Medical Subject Headings (MeSH) allocation dates. Time-to-event analyses were performed considering independent variables (geographical origin, Journal Impact Factor, Scopus CiteScore, open access status) (SPSS V.24, R/RStudio).

RESULTS

We included 1245 NMAs. The median time from last search to article submission was 6.8 months (204 days (IQR 95-381)), and to publication was 11.6 months. Only 5% of authors updated their search after first submission. There is a very slightly decreasing historical trend of acceptance (rho=-0.087; p=0.010), online publication (rho=-0.080; p=0.008) and indexing (rho=-0.080; p=0.007) lag times. Journal Impact Factor influenced the MeSH allocation process, but not the other lag times. The comparison between open access versus subscription journals confirmed meaningless differences in acceptance, online publication and indexing lag times.

CONCLUSION

Efforts by authors to update their search before submission are needed to reduce evidence production time. Peer reviewers and editors should ensure authors' compliance with NMA standards. The accuracy of these findings depends on the accuracy of the metadata used; as we evaluated only NMA on drug interventions, results may not be generalisable to all types of studies.

Evaluation of Tooth Sensitivity of In-office Bleaching with Different Light Activation Sources: A Systematic Review and a Network Meta-analysis

OBJECTIVES

A systematic review and network meta-analysis were performed to answer the following research question: Are there differences in the risk and the intensity of tooth sensitivity (TS) among eight light activation systems for in-office bleaching in adults?

METHODS

Randomized controlled trials (RCTs) that compared at least two different in-office bleaching light activations were included. The risk of bias (RoB) was evaluated with the RoB tool version 1.0 from the Cochrane Collaboration tool. A random-effects Bayesian mixed treatment comparison (MTC) model was used independently for high- and low-concentration hydrogen peroxide. The certainty of the evidence was evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. A comprehensive search was performed in PubMed, Bridge Base Online (BBO), Latin American and Caribbean Health Sciences Literature database (LILACS), Cochrane Library, Scopus, Web of Science, and grey literature without date and language restrictions on April 23, 2017 (updated on September 26, 2019). Dissertations and theses, unpublished and ongoing trials registries, and IADR (International Association for Dental Research) abstracts (2001-2019) were also searched.

RESULTS

After title and abstract screening and the removal of duplicates, 32 studies remained. Six were considered to be at low RoB, three had high RoB, and the remaining had an unclear RoB. The MTC analysis showed no significant differences among the treatments in each network. In general, the certainty of the evidence was graded as low due to unclear RoB and imprecision.

CONCLUSION

There is no evidence that the risk and intensity of TS are affected by light activation during in-office bleaching.

Comparative Effectiveness of Western and Eastern Manual Therapies for Chronic Obstructive Pulmonary Disease: A Systematic Review and Network Meta-Analysis

Background: Manual therapy (MT) is considered a promising adjuvant therapy for chronic obstructive pulmonary disease (COPD). Comparing the effectiveness among different Western and Eastern MTs being used for the management of COPD could potentially facilitate individualized management of COPD. This systematic review attempted to estimate the comparative effectiveness of Western and Eastern MTs for COPD patients using a network meta-analysis (NMA) methodology. Methods: Nine electronic databases were comprehensively searched for relevant randomized controlled trials (RCTs) published up to February 2021. Pair-wise meta-analysis and NMA were conducted on the outcomes of COPD, which included lung function and exercise capacity. Results: The NMA results from 30 included RCTs indicated that the optimal treatment for each outcome according to the surface under the cumulative ranking curve was massage, acupressure, massage, and tuina for forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, and 6 min walking distance, respectively. Conclusions: MTs such as massage, acupressure, and tuina have shown comparative benefits for lung function and exercise capacity in COPD. However, the methodological quality of the included studies was poor, and the head-to-head trial comparing the effects of different types of MTs for COPD patients was insufficient. Therefore, further high-quality RCTs are essential.

Network Meta-Analysis of Once Weekly Selinexor-Bortezomib-Dexamethasone in Previously Treated Multiple Myeloma

Background: Despite the availability of new treatments, multiple myeloma (MM) is an incurable cancer with nearly all patients relapsing and undergoing multiple lines of treatment. Performing head-to-head comparisons of all treatment options is not feasible. Thus, network meta-analyses play an important role in allowing health-care decision makers to compare the effectiveness of treatment options. Objectives: A Bayesian network meta-analysis (NMA) was developed from studies identified from a systematic literature review (SLR) to evaluate the efficacy of once weekly oral selinexor with once weekly bortezomib and low-dose dexamethasone (XVd) relative to other therapies in previously treated MM. Methods: Ovid was systematically searched for phase 2-3 randomized clinical trials (RCTs) in MM that assessed progression-free survival (PFS), overall survival (OS) and overall response rates (ORR). Two population subsets were assessed: second-line patients (2L) and third-line or greater patients (3L+). Base case results compared all regimens against twice weekly bortezomib and dexamethasone (Vd) as the anchored comparator regimen. Results: Forty-seven RCTs met inclusion. For 2L PFS, OS and ORR, XVd had, on average, out of all iterations, the 6th (out of 21), 4th (out of 15), and 5th (out of 20) best result, respectively, versus Vd. For 3L+ PFS, OS and ORR, XVd had the 12th (out of 24), 11th (out of 22), and 8th (out of 25) best result, respectively, versus Vd. There was no statistically significant difference between XVd and other top-ranking therapies for PFS, OS, and ORR in either 2L and 3L+ except for daratumumab/bortezomib/dexamethasone [DVd], which was favorable versus XVd (2L PFS only). Discussion: Results for XVd were more favorable in 2L, having a higher probability of being a top 5 regimen, compared with 3L+ therapies based on the reported clinical trial results. However, in typical clinical practice, most triplet regimens have been modified using weekly bortezomib dosing, raising questions about the actual efficacy of these regimens versus the reported results using twice weekly bortezomib dosing. Conclusions: The addition of XVd, which was designed with once weekly bortezomib dosing, to the treatment landscape for previously treated MM provides a regimen that may potentially be noninferior to the other top 5 regimens in both 2L and 3L+ settings and is associated with less peripheral neuropathy.

A network meta-analysis of direct oral anticoagulants for portal vein thrombosis in cirrhosis

BACKGROUND

Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants.

METHODS

Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment.

RESULTS

A total of 10 articles were included in the study. 79.5% (CI 38.8-95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50-20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037-5.093, p = 0.040), warfarin (RR 1.762, CI 1.017-3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394-8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments.

CONCLUSION

The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.

The Optimal Second-Line Systemic Treatment Model for Recurrent and/or Metastatic Head and Neck Squamous Cell Carcinoma: A Bayesian Network Meta-Analysis

Background

The optimal second-line systemic treatment model for recurrent and/or metastatic head and neck squamous cell carcinoma (R/M HNSCC) remains controversial. A Bayesian network meta-analysis (NMA) was performed to address this issue with regard to efficacy and toxicity.

Methods

By searching MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials and Web of Science, we extracted eligible studies. Efficacy, represented as overall survival (OS) and progression-free survival (PFS), and overall toxicity, represented as ≥ grade 3 severe acute events (sAE), were assessed to compare the following 7 treatment models through an NMA: standard-of-care therapy (SoC), single targeted therapy different from SoC (ST), double targeted therapy (DT), targeted therapy combined with chemotherapy (T+C), single immune checkpoint inhibitor therapy (SI), double immune checkpoint inhibitor therapy (DI) and single chemotherapy different from SoC (SC). Rank probabilities according to the values of the surface under the cumulative ranking curve (SUCRA) were separately determined for efficacy and toxicity.

Results

In total, 5285 patients from 24 eligible studies were ultimately screened, with 5184, 4532 and 4026 involved in the NMA of OS, PFS and sAE, respectively. All qualifying studies were absent from first-line immune checkpoint inhibitor therapy. In terms of OS, SI was superior to the other treatments, followed by DI, ST, T+C, SoC, DT and SC. Other than SI and SC, all treatments tended to be consistent, with hazard ratios (HRs) close to 1 between groups. For PFS, ST ranked first, while DT ranked last. For the toxicity profiles, compared with the other models, SI resulted in the lowest incidences of sAE, with statistical significance over SoC (odds ratio [OR] 0.31, 95% credible interval [CrI] 0.11 to 0.90), ST (OR 0.23, 95% CrI 0.06 to 0.86) and DT (OR 0.11, 95% CrI 0.02 to 0.53), while DT was the worst. When the SUCRA values of OS and sAE were combined, a cluster plot illustrated the superiority of SI, which demonstrated the best OS and tolerability toward sAE.

Conclusion

For R/M HNSCC patients without immune checkpoint inhibitors in the first-line setting, SI may serve as the optimal second-line systemic treatment model, demonstrating the best OS and least sAE.

Effectiveness of Pharmacological Intervention Among Men with Infertility: A Systematic Review and Network Meta-Analysis

Background. Infertility is an emerging health issue for men. Comparative efficacy of different pharmacological interventions on male infertility is not clear. The aim of this review is to investigate the efficacy of various pharmacological interventions among men with idiopathic male infertility. All randomized control trials evaluating the effectuality of interventions on male infertility were included for network meta-analysis (NMA) from inception to 31 April 2020, systematically performed using STATA through the random effect model. The protocol was registered at PROSPERO (CRD42020152891). Results. The outcomes of interest were semen and hormonal parameters. Treatment effects (p < 0.05) were estimated through WMD at the confidence interval of 95%. Upon applying exclusion criteria, n=28 RCTs were found eligible for NMA. Results from NMA indicated that consumption of supplements increases sperm concentration levels [6.26, 95% CI 3.32, 9.21] in comparison to SERMs [4.97, 95% CI 1.61, 8.32], hormones [4.14, 95% CI 1.83, 6.46], and vitamins [0.15, 95% CI -20.86, 21.15)] with placebo, whereas the use of SERMs increased percentage sperm motility [6.69, 95% CI 2.38, 10.99] in comparison to supplements [6.46, 95% CI 2.57, 10.06], hormones [3.47, 95% CI 0.40, 6.54], and vitamins [-1.24, 95% CI -11.84, 9.43] with placebo. Consumption of hormones increased the sperm morphology [3.71, 95% CI, 1.34, 6.07] in contrast to supplements [2.22, 95% CI 0.12, 4.55], SERMs [2.21, 95% CI -0.78, 5.20], and vitamins [0.51, 95% CI -3.60, 4.62] with placebo. Supplements boosted the total testosterone levels [2.70, 95% CI 1.34, 4.07] in comparison to SERMs [1.83, 95% CI 1.16, 2.50], hormones [0.40, 95% CI -0.49, 1.29], and vitamins [-0.70, 95% CI -6.71, 5.31] with placebo. SERMs increase the serum FSH levels [3.63, 95% CI 1.48, 5.79] better than hormones [1.29, 95% CI -0.79, 3.36], vitamins [0.03, 95% CI -2.69, 2.76], and supplements [-4.45, 95% CI -7.15, -1.76] in comparison with placebo. Conclusion. This review establishes that all interventions had a significantly positive effect on male infertility. Statistically significant increased sperm parameters were noted in combinations of zinc sulfate (220 mg BID), clomiphene citrate (50 mg BID), and testosterone undecanoate and CoQ10; tamoxifen citrate and FSH were shown to improve the hormonal profile in infertile males.

Comparative efficacy of single-inhaler triple therapies for COPD: A protocol for systematic review and network meta-analysis

INTRODUCTION

2021 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Reports recommends that patients with clinically significant symptoms and exacerbations of chronic obstructive pulmonary disease (COPD) should escalate to triple therapy, a combined use of inhaled corticosteroids (ICS), long-acting muscarinic antagonists (LAMA) and long-acting b2-agonists (LABA)(ICS/LAMA/LABA). Triple therapy in fixed-dose combinations (FDCs), i.e., combining ICS, LABA with LAMA and administrating by a single inhalation device, has appeared in recent years. This study aims to compare the efficacy of triple therapy in FDCs in treating patients with moderate to severe COPD.

METHODS AND ANALYSES

Literature search will be conducted on PubMed, Embase and Web of science, according to pre-specified and corresponding search strategies, for relevant reports published since the inception dates of the databases. Randomised controlled trials (RCT) which compared the triple therapy in FDCs with other pharmacological therapies will be included. The Cochrane risk of bias assessment tool (RoB 2) will be used to assess the RCT quality. The outcomes will be analyzed as rate ratios and mean differences under a random-effects model in a frequentist network meta-analysis (NMA). Additional statistical analyses including subgroup analysis, sensitivity analysis, and publication bias analysis will be performed to assess the evidential heterogeneity and robustness. The strength of evidence from the NMA will be evaluated with the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) methods.

ETHICS AND DISSEMINATION

No ethics approval is required as this systematic review and network meta-analysis do not collect confidential personal data and do not carry out interventions in treating patients.

PROTOCOL REGISTRATION NUMBER

CRD42021240823.

Comparative Efficacy and Safety of Lorlatinib and Alectinib for ALK-Rearrangement Positive Advanced Non-Small Cell Lung Cancer in Asian and Non-Asian Patients: A Systematic Review and Network Meta-Analysis

Simple Summary

The treatment of anaplastic lymphoma kinase (ALK) rearrangement-positive (ALK-p) advanced non-small cell lung cancer (NSCLC) remains a challenge. We compared the safety and efficacy of lorlatinib and alectinib in patients with ALK-p ALK-inhibitor‒naïve advanced NSCLC (in overall participants and in the Asian and non-Asian subgroups). The results showed that in the overall participant group, the efficacy of lorlatinib and alectinib was not significantly different in terms of progression-free survival (PFS) and overall survival (OS). Although in the Asian subgroup, PFS was not significantly different upon treatment with lorlatinib or alectinib, in the non-Asian subgroup, PFS was significantly better in response to lorlatinib than with alectinib. Grade 3 or higher adverse events in the overall participant group were significantly more frequent with lorlatinib than with alectinib. These results will provide valuable information that would enable the improvement of treatment strategies for ALK-p ALK-inhibitor‒naïve advanced NSCLC.

Abstract

To date, there have been no head-to-head randomized controlled trials (RCTs) comparing the safety and efficacy of lorlatinib and alectinib in anaplastic lymphoma kinase (ALK) rearrangement-positive (ALK-p) ALK-inhibitor‒naïve advanced non-small cell lung cancer (NSCLC). We performed a network meta-analysis comparing six treatment arms (lorlatinib, brigatinib, alectinib, ceritinib, crizotinib, and platinum-based chemotherapy) in overall participants and in Asian and non-Asian subgroups. Primary endpoints were progression-free survival (PFS), overall survival (OS), and grade 3 or higher adverse events (G3-AEs). There were no significant differences between lorlatinib and alectinib in overall participants for both PFS (hazard ratio [HR], 0.742; 95% credible interval [CrI], 0.466–1.180) and OS (HR, 1.180; 95% CrI, 0.590–2.354). In the Asian subgroup, there were no significant differences in PFS between lorlatinib and alectinib (HR, 1.423; 95% CrI, 0.748–2.708); however, in the non-Asian subgroup, PFS was significantly better with lorlatinib than with alectinib (HR, 0.388; 95% CrI, 0.195–0.769). The incidence of G3-AEs in overall participants was significantly higher with lorlatinib than with alectinib (risk ratio, 1.918; 95% CrI, 1.486–2.475). These results provide valuable information regarding the safety and efficacy of lorlatinib in ALK-p ALK-inhibitor‒naïve advanced NSCLC. Larger head-to-head RCTs are needed to validate the study results.

Voice Rehabilitation by Voice Prostheses After Total Laryngectomy: A Systematic Review and Network Meta-Analysis for 11,918 Patients

Purpose Our aim was to assess the different voice prostheses (VPs) to identify the most efficient, safest, patient-tailored, longest lifetime, and inexpensive VPs and assess the different factors affecting their quality. Method In September 2017, 15 databases were searched to include all randomized controlled trials. A new search was done in May 2019 to include all other study design articles, which include all the new-era VPs subtypes. Network meta-analysis (NMA) was applied to all 27 outcomes, besides NMA overall and partial order setting was done by using Hasse scatter plots. p values were used in NMA, where the best VPs are approaching one and the least approaches zero. Meta-analysis was done for the rest of the outcomes. Results Two hundred one articles were eligible for inclusion in our study (N = 11,918). Provox-2 was significantly the most efficient and safest device concerning the most patient preference (odds ratio [OR] = 33.88 [0.65, 1762.24]; p = .92), the least dislodgement (risk ratio [RR] = 0.27 [0.13, 0.57]; p = .79), the least airflow resistance (RR = 0.42 [0.08, 2.11]; p = .84), the least granulation formation (RR = 0.73 [0.02, 26.32]; p = .60), and the least VPs' inaccurate size (RR = 0.77 (0.23, 2.61); p = .66). Heat and moisture exchanger addition showed a significant increase in maximum phonation time and breathing experience, with p values (1 and .59), respectively. While heat and moisture exchanger addition showed a significant decline in stoma cleaning frequency, coughing frequency, forced expectoration, sputum production, sleeping problems, and loosening of adhesive, with p values (.99, .72, .69, .96, 1, and 0.96), respectively, Groningen low resistance and Nijdam were considered the worst devices with both overall mean p value of .44. Conclusions Provox-2 is considered the best choice as being the most preferable for patients, with the least airflow resistance, dislodgment, granulation formation, and prosthesis inaccurate size. Groningen low resistance and Nijdam were considered the worst devices according to our analysis. Supplemental Material https://doi.org/10.23641/asha.14802903.

Current Status of Probiotics for Preterm Infants

Probiotics have been shown to reduce the risk of all-cause mortality, necrotizing enterocolitis (NEC ≥ stage II), late onset sepsis (LOS), and feeding intolerance in preterm infants. Considering the substantial health burden imposed by these conditions, the importance of probiotics in preterm infants cannot be overemphasized. Based on the data from experimental studies, and systematic reviews of randomized controlled trials (RCTs) and non-RCTs, the uptake of this intervention in neonatal medicine has been increasing over the last few years. However, many are still hesitating to adopt this intervention for various reasons, including concerns about probiotic sepsis, product quality, and lack of clarity on optimal strain/s or their combinations. Some question the validity of meta-analyses of studies involving different probiotic strains or their combinations because probiotics effects are considered to be strain-specific. Some of the early concerns about probiotics in preterm infants have been shown to be unjustified. However, the resistance to probiotics continues in many neonatal units around the world. The future of probiotics for preterm infants depends on continued efforts to develop high-quality probiotic products using stringent quality control, improving access to such products, and robust head-to-head comparisons to know the optimal strains or their combinations. Monitoring for adverse effects such as probiotic sepsis and development of antibiotic resistance is crucial. The authors review the current status of probiotics in preterm infants and discuss the scope for further research in this field.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions

BACKGROUND

Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures.

METHODS

A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.

CONCLUSION

This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

A network meta-analysis of psychosocial interventions for refugees and asylum seekers with PTSD

INTRODUCTION

Refugees and asylum seekers are vulnerable to common mental disorders, including post-traumatic stress disorder (PTSD). Using a network meta-analysis (NMA) approach, the present systematic review compared and ranked psychosocial interventions for the treatment of PTSD in adult refugees and asylum seekers.

METHODS

Randomised studies of psychosocial interventions for adult refugees and asylum seekers with PTSD were systematically identified. PTSD symptoms at postintervention was the primary outcome. Standardised mean differences (SMDs) and ORs were pooled using pairwise and NMA. Study quality was assessed with the Cochrane Risk of Bias (RoB) tool, and certainty of evidence was assessed through the Confidence in Network Meta-Analysis application.

RESULTS

A total of 23 studies with 2308 participants were included. Sixteen studies were conducted in high-income countries, and seven in low-income or middle-income countries. Most studies were at low risk of bias according to the Cochrane RoB tool. NMA on PTSD symptoms showed that cognitive behavioural therapy (CBT) (SMD=-1.41; 95% CI -2.43 to -0.38) and eye movement desensitisation and reprocessing (EMDR) (SMD=-1.30; 95% CI -2.40 to -0.20) were significantly more effective than waitlist (WL). CBT was also associated with a higher decrease in PTSD symptoms than treatment as usual (TAU) (SMD -1.51; 95% CI -2.67 to -0.36). For all other interventions, the difference with WL and TAU was not significant. CBT and EMDR ranked best according to the mean surface under the cumulative ranking. Regarding acceptability, no intervention had less dropouts than inactive interventions.

CONCLUSION

CBT and EMDR appeared to have the greatest effects in reducing PTSD symptoms in asylum seekers and refugees. This evidence should be considered in guidelines and implementation packages to facilitate dissemination and uptake in refugee settings.

Employment Instability and Fertility in Europe: A Meta-Analysis

The relationship between employment instability and fertility is a major topic in demographic research, with a proliferation of published papers on this matter, especially since the Great Recession. Employment instability, which most often manifests in unemployment or time-limited employment, is usually deemed to have a negative effect on fertility, although different fertility reactions are hypothesized by sociological theories, and micro-level evidence is fragmented and contradictory. We used meta-analytic techniques to synthesize European research findings, offer general conclusions about the effects of employment instability on fertility (in terms of direction and size), and rank different sources of employment instability. Our results suggest that employment instability has a nonnegligible negative effect on fertility. Men's unemployment is more detrimental for fertility than men's time-limited employment; conversely, a woman having a fixed-term contract is least likely to have a child. Next, the negative effect of employment instability on fertility has become stronger over time, and is more severe in Southern European countries, where social protection for families and the unemployed is least generous. Finally, meta-regression estimates demonstrate that failing to account for income and partner characteristics leads to an overestimation of the negative effect of employment instability on fertility. We advance the role of these two factors as potential mechanisms by which employment instability affects fertility. Overall, this meta-analysis provides the empirical foundation for new studies on the topic.

The adjunct of transcranial direct current stimulation to Robot-assisted therapy in upper limb post-stroke treatment

Transcranial direct current stimulation (TDCS) and robot-assisted therapy (RAT) proved to be promising interventions in post-stroke rehabilitation. However, the effects of combining the two treatments are not significantly clear. To determine the effects of combined therapy using transcranial direct current stimulation (tDCS) with robot-assisted therapy (RAT) in the impairment of the upper limb in stroke rehabilitation. The Cochrane Library, MEDLINE, Embase, Google Scholar, and Trial Registries were systematically searched for randomised controlled trials in May 2020. As the outcome, the Fugl-Meyer Assessment score (FMS) was used. A pairwise and a network meta-analysis were performed. 5 RCTs with RAT versus RAT + tDCS groups and 21 RCTs with RAT versus the control group with 892 people were analysed. Of these studies, 10 RCTs evaluated acute-subacute (<8 weeks) people, while 16 chronic people. By analysing the FMS with a pair-wise meta-analysis, we demonstrate significant improvements only in the RAT alone compared to the control (acute-subacute, SMD:4.09 (1.31, 6.87) and chronic, SMD:2.22 (0.99, 3.45)). Instead, performing a network meta-analysis, through an analysis of the surface under the cumulative ranking curve (SUCRA) we report a ranking of the effectiveness of the interventions. We assess SUCRA in acute-subacute stroke: Control:0.23, RAT + tDCS:0.31, RAT:0.96 and in chronic stroke: Control:0.06, RAT + tDCS:0.62, RAT:0.82. RAT is, respectively, 96% and 82% likely to be the best-ranked treatment. Despite the limitations, this network meta-analysis appears to demonstrate through the rank of interventions that adding tDCS to RAT is not useful in upper-limb stroke rehabilitation.

A population-adjusted indirect comparison of cardiovascular benefits of once-weekly subcutaneous semaglutide and dulaglutide in the treatment of patients with type 2 diabetes, with or without established cardiovascular disease

Introduction

Cardiovascular (CV) effects of once‐weekly subcutaneous (s.c.) semaglutide 0.5 and 1 mg and dulaglutide 1.5 mg are reported in their respective placebo‐controlled cardiovascular outcome trials (CVOTs), SUSTAIN 6 and REWIND. There is no head‐to‐head CVOT comparing these treatments and heterogeneity between their CVOTs renders conventional indirect comparison inappropriate. Therefore, a matching‐adjusted indirect comparison (MAIC) was performed to compare the effects of s.c. semaglutide and dulaglutide on major adverse cardiovascular events (MACE) in patients with and without established cardiovascular disease (CVD).

Methods

Individual patient data from SUSTAIN 6 were matched with aggregate data from REWIND, using a propensity score method to balance baseline effect‐modifying patient characteristics. Hazard ratios (HRs) for three‐point (3P) MACE (CV death, non‐fatal myocardial infarction, non‐fatal stroke), anchored via placebo, were then indirectly compared between balanced populations. Sensitivity analyses were performed to test the robustness of the main analysis.

Results

After matching, included effect modifiers were balanced. In the main analysis, s.c. semaglutide was associated with a statistically significant 35% reduction in 3P MACE versus placebo (HR, 0.65 [95% confidence interval [CI]; 0.48, 0.87]) and nonsignificantly greater reduction (26%) versus dulaglutide (HR, 0.74 [95% CI; 0.54, 1.01]). Results were supported by all sensitivity analyses.

Conclusions

This study demonstrated a statistically significant lower risk of 3P MACE for s.c. semaglutide versus placebo, in a population with lower prevalence of pre‐existing CVD than that in the pre‐specified primary analysis in SUSTAIN 6. Reduction in 3P MACE with s.c. semaglutide was greater than with dulaglutide, although not statistically significant.

Non-pharmacological interventions for older adults with depressive symptoms: a network meta-analysis of 35 randomized controlled trials

Objective: To assess the effectiveness of non-pharmacological interventions for seniors with depressive symptoms.Methods: A comprehensive literature search was performed. We conducted network meta-analysis in two ways, intervention classes (psychosocial, psychotherapy, physical activity, combined, treatment as usual) and individual intervention (11 categories). Whenever included studies used different scales, the different instruments were converted to the units of the scale most frequently used (the Geriatric Depression Scale), such that the effect size was reported as a mean difference (MD) with 95% confidence interval (CI). The risk of bias of RCTs included in this review was assessed according to the Cochrane Handbook. Bayesian NMA was conducted using R-3.4.0 software.Results: A total of 35 RCTs with 3,797 enrolled patients were included. Compared to conventional treatment, physical activity and psychotherapy resulted in significant improvements in depressive symptoms (MD: 2.25, 95%CrI: 0.99-3.56; SUCRA = 86.07%; MD: 1.75, 95% CrI: 0.90-2.64; SUCRA = 66.44%, respectively). Similar results were obtained for music (MD: 2.6; 95% CrI: 0.84-4.35;SUCRA = 80.53%), life review (MD:1.92; 95% CrI:0.71-3.14; SUCRA = 65.62%), cognitive behavioral therapy (MD: 1.27; 95% CrI: 0.23-2.38; SUCRA = 45.4%), aerobic (MD: 1.84; 95% CrI: 0.39-3.36; SUCRA = 63%) and resistance training (MD: 1.72; 95% CrI: 0.06-3.42; SUCRA = 59.24%). Network meta-regression showed that there were no statistically significant subgroup effects.Conclusions: Physical activity and psychotherapy demonstrated statistically significant superiority over conventional treatment. Music and life review therapy proved the most promising individual interventions. However, conclusions are limited by the lack of sufficient sample size and consensus regarding intervention categories and so an adequately powered study is necessary to consolidate these findings.

Ticagrelor vs Clopidogrel in addition to Aspirin in minor ischemic stroke/ transient ischemic attack-Protocol for a systematic review and network meta-analysis

INTRODUCTION

Patients with minor ischemic stroke or transient ischemic attack represent a high-risk population for recurrent stroke. No direct comparison exists comparing dual antiplatelet therapy regimens-namely, Ticagrelor and Aspirin versus Clopidogrel and Aspirin. This systematic review and network meta-analysis (NMA) will examine the efficacy of these two different antiplatelet regimens in preventing recurrent stroke and mortality up to 30 days.

METHODS AND ANALYSIS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) will be searched with the assistance of a medical information specialist. Two independent reviewers will screen studies for inclusion; eligible studies will include randomized controlled trials that enrolled adults presenting with acute minor ischemic stroke or transient ischemic attack and compared one or more of the interventions against each other and/or a control. The primary outcomes will be recurrent ischemic stroke up to 30 days from symptom onset. Secondary outcomes will include safety outcomes (I.e. major bleeding and mortality), functional disability, and outcomes up to 90 days from symptom onset. A Bayesian approach to NMA will be implemented using the BUGSnet function in R Software. Between group comparisons for time-to-event (TTE) and dichotomous outcomes will be presented in terms of hazard ratios and odds ratios with 95% credible intervals, respectively. Secondary effect measures of treatment ranking will also be estimated.

ETHICS AND DISSEMINATION

No formal research ethics approval are necessary. We will disseminate our findings through scientific conference presentations, peer-reviewed publications, and social media/the press. The findings from this review will aid clinicians in decision-making on the choice of antithrombotic therapy in a high-risk stroke population and could be important in the development of future treatment trials and guidelines. Registration ID with Open Science Framework: 10.17605/OSF.IO/XDJYZ.

Indirect comparison between ferric carboxymaltose and oral iron replacement in heart failure with reduced ejection fraction: a network meta-analysis

Treatment of iron deficiency (ID) in patients with heart failure (HF) has improved symptoms, quality of life, exercise capacity and has reduced hospitalizations in randomized controlled trials (RCTs) and meta-analyses. Intravenous ferric carboxymaltose (FCM) provided convincing results in this field, while oral iron supplementation failed. However, FCM and oral iron were compared to placebo, and a comparison between the two strategies is still lacking. We aimed to fill this gap of knowledge with an indirect comparison between them by means of a network meta-analysis of RCTs. Five studies measuring exercise capacity (i.e. 6-minute walking test) and quality of life (i.e. Kansas City Cardiomyopathy Questionnaire) were eligible to be included in our review. Given the limitations of a network meta-analysis, our findings support the better efficacy of FCM than oral iron as regards exercise capacity, with a trend towards an improvement in quality of life, suggesting that FCM seems to be strategy of choice to correct ID in HF patients.

A systematic review with network meta-analysis on mono strategy of anaesthesia for preeclampsia in caesarean section

The aim of this study was to reveal the effects of anaesthesia strategies on maternal mean arterial pressure (MAP), heart rate, vasopressor consumption, adverse events, and neonatal resuscitation when women with preeclampsia (PE) undergo caesarean section (CS). Three major databases were searched for randomized controlled trials (RCTs) and prospective controlled studies (PCSs). Two authors independently screened, extracted, and checked eligibility and outcome data. Outcomes involved MAP, vasopressor use, maternal adverse events, APGAR scores, and neonatal resuscitation. Pooled estimates were carried out by contrast-based network meta-analysis, and pooled effect sizes were presented with 95% confidence interval (CI). Eleven RCTs and one PCS (n = 782) formed three-node network meta-analysis, and non-significant differences were observed in MAP, 5-min APGAR score, and neonatal intubation rate among the three anaesthesia strategies. General anaesthesia had significantly lower vasopressor consumption than spinal anaesthesia did (standardised mean difference =  - 1.19, 95% confidence interval [CI]: - 1.76 to - 0.63), but it had higher maternal adverse event rate (risk ratio = 2.00, 95% CI 1.16-3.47). Because no optimal anaesthesia strategy has been shown to achieve a balanced maternal and neonatal outcome, therefore a shared decision-making process may be required regarding the most suitable choice of anaesthetic strategy for individual preeclamptic mother undergoing CS. Future larger studies may need to focus on evaluating the role of vasopressors on maternal hemodynamic as well as factors affecting maternal outcomes for different anaesthetic techniques in preeclamptic women undergoing CS.

Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.

Comparative Efficacy and Safety of Immunotherapeutic Regimens with PD-1/PD-L1 Inhibitors for Previously Untreated Extensive-Stage Small Cell Lung Cancer: A Systematic Review and Network Meta-Analysis

Improving therapeutic strategies for extensive-stage small cell lung cancer (ES-SCLC) remains a challenge. To date, no reports have directly compared the efficacy and safety of immune checkpoint inhibitors plus platinum–etoposide (ICIs+EP) with platinum–irinotecan (IP) or directly compared different ICIs+EP for previously untreated ES-SCLC. This study used a Bayesian approach for network meta-analysis to compare efficacy and safety between ICIs+EP and IP and between each pair of three ICIs+EP. The six treatment arms were: pembrolizumab plus platinum–etoposide (Pem+EP), durvalumab plus platinum–etoposide (Dur+EP), atezolizumab plus platinum–etoposide (Atz+EP), platinum–amrubicin (AP), IP, and platinum–etoposide (EP). No significant differences in overall survival were observed between ICIs+EP and IP and between each pair of three ICIs+EP. The incidence of ≥grade 3 adverse events (G3-AEs) was significantly higher in ICIs+EP than IP, whereas no significant difference was found in G3-AEs between each pair of three ICIs+EP. The incidence of ≥grade 3 neutropenia and thrombocytopenia was significantly higher in ICIs+EP than IP, whereas the incidence of ≥grade 3 diarrhea was significantly lower in ICIs+EP than IP. These findings will help clinicians better select treatment strategies for ES-SCLC.

Network meta-analysis comparing the effectiveness of anticoccidial drugs and anticoccidial vaccination in broiler chickens

With the trend to organic production and concerns about using antibiotic feed additives, the control of infections with Eimeria spp. in broiler flocks has become more difficult. Vaccination against coccidia is an alternative, but there are concerns that the live vaccines used might have negative effects on production parameters and intestinal health. Reports of experiments directly comparing anticoccidial drugs and anticoccidial vaccines are rare. This network meta-analysis (NMA) identified and analyzed 61 articles reporting 63 experiments testing anticoccidial drugs and anticoccidial vaccines under conditions resembling commercial broiler production. The effect sizes were mean differences in body weight/body weight gain (BW/BWG) and feed conversion rate (FCR) between the 175 included groups. The results show that groups vaccinated against coccidia have a similar BW/BWG and FCR at processing age compared to groups given anticoccidial drugs. However, the results tended to be more favorable for anticoccidial drugs than for vaccines. The analysis of eight subsets, containing only groups (1) groups that had not received an AGP in addition to an anticoccidial drug, (2) groups that had not received ionophores, (3) groups that had not received chemicals, (4) groups that had not received an attenuated vaccine, (5) groups that had not received a fully virulent vaccine, (6) groups that were not additionally challenged with bacteria or not challenged, (7) groups that had received a severe challenge as defined by a total infection dose of more than 100,000 oocysts or were not challenged, (8) groups that were challenged on day 15 or earlier or not challenged brought similar results and confirmed the robustness of the NMA. In addition, the analysis exposes unnecessary, as well as inherent, problems with data quality, which every researcher working with coccidia should carefully consider, and identifies under-researched areas that should be addressed in future research.

A network meta-analysis of psychological interventions for schizophrenia and psychosis: Impact on symptoms

BACKGROUND

Evidence for the effectiveness of psychological interventions for schizophrenia/psychosis is growing, however there is no consensus on the psychological intervention most likely to reduce symptoms.

METHODS

A network meta-analysis was conducted to identify all randomised controlled trials (RCTs) of psychological interventions for adults with schizophrenia/psychosis. A systematic review of the literature using MEDLINE, PsycINFO, EMBASE and CENTRAL led to an analysis of 90 RCTs with 8440 randomised participants across 24 psychological intervention, and control groups. Psychological interventions were categorised and rated for treatment fidelity and risk of bias. Data for total symptoms were extracted and network meta-analysis, using a frequentist approach, was undertaken using Stata SE v15 to compare the direct and indirect evidence for the effectiveness of each psychological intervention.

FINDINGS

Psychological interventions were more likely to reduce symptoms than control groups, and one intervention, mindfulness-based psychoeducation, was consistently ranked as most likely to reduce total symptoms. Subgroup analyses identified differential effectiveness in different settings and for different subgroups.

INTERPRETATION

Mindfulness-based psychoeducation was consistently ranked as most likely to reduce symptoms; however all studies were based in China. More RCTs in a variety of cultural contexts would help to elucidate whether these findings generalise internationally. A number of psychological interventions could potentially be more effective than interventions recommended by NICE guidelines, such as CBT and family therapy, and additional RCTs and meta-analyses are needed to generate more conclusive evidence in this regard.

Assessing the Quality and Coherence of Network Meta-Analyses of Biologics in Plaque Psoriasis: What Does All This Evidence Synthesis Tell Us?

INTRODUCTION

A range of treatments are available for moderate-to-severe psoriasis; however, there remains a paucity of direct comparisons of these in head-to-head trials. Network meta-analyses (NMA) allow comparisons of these to support clinical decision making. This systematic literature review assesses the methodological quality of NMAs available for moderate-to-severe psoriasis and compares their methods and results. Their validity and applicability for current practice is also assessed.

METHODS

A systematic review of published NMAs of at least two biologics for moderate-to-severe psoriasis was undertaken. Embase, MEDLINE, MEDLINE In-Process, and the Cochrane Library were last searched on 19 February 2020. The quality of NMAs was assessed using the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) criteria. NMA methodology, funding, and results were compared and differences in results explored.

RESULTS

Twenty-five analyses evaluating up to 19 different treatments at 8-24 weeks, and two analyses at 1 year, were included. Psoriasis Area Severity Index (PASI) response was assessed in 23, facilitating comparisons between NMAs. All NMAs met at least half of the ISPOR criteria. The major limitations were explaining the rationale for methodology, exploring effect modifiers, and consistency between direct and indirect estimates. The analyses differed in model type (Bayesian or frequentist), analysis of PASI response (binomial or multinomial), and analysis of different treatment doses (separate or pooled). PASI results were broadly similar, except for the Cochrane Collaboration NMA which provided lower estimates of treatment efficacy versus placebo. This analysis differed methodologically from others, including pooling data for different doses.

CONCLUSIONS

Based on PASI 90 at induction, the majority of recent NMAs came to similar conclusions: interleukin (IL) 17 inhibitors (brodalumab, ixekizumab, secukinumab), IL-23 inhibitors (guselkumab and risankizumab) and infliximab were most efficacious, supporting the validity of NMAs in this clinical area. Decisions should be made using high-quality, up-to-date NMAs with assumptions relevant to clinical practice.

Network meta-analysis of nivolumab plus ipilimumab in the second-line setting for advanced hepatocellular carcinoma

Aims: To compare the efficacy of nivolumab 1 mg/kg + ipilimumab 3 mg/kg with regorafenib 160 mg, cabozantinib 60 mg and nivolumab 3 mg/kg monotherapy for second-line treatment of advanced hepatocellular carcinoma. Materials & methods: Indirect comparison using network meta-analysis and propensity score weighting. Results: Nivolumab 1 mg/kg + ipilimumab 3 mg/kg had significantly higher objective response rate (median 31.2% [95% credible interval: 19.6-44.5%]) than cabozantinib (4.2% [2.0-6.5%]) and regorafenib (4.8% [1.1-8.3%]), and significantly longer overall survival (cabozantinib: hazard ratio: 0.46 [95% credible interval: 0.27-0.79]; regorafenib: 0.56 [0.32-0.97]). Nivolumab 1 mg/kg + ipilimumab 3 mg/kg had significantly better objective response rate (difference 21.0% [4.5-37.5%]) and overall survival (hazard ratio: 0.58 [0.35-0.96]) than nivolumab monotherapy. Conclusion: Nivolumab 1 mg/kg + ipilimumab 3 mg/kg had a superior efficacy versus cabozantinib 60 mg, regorafenib 160 mg and nivolumab 3 mg/kg monotherapy as second-line therapy for advanced hepatocellular carcinoma.

Physical relaxation for occupational stress in healthcare workers: A systematic review and network meta-analysis of randomized controlled trials

OBJECTIVES

Work related stress is a major occupational health problem that is associated with adverse effects on physical and mental health. Healthcare workers are particularly vulnerable in the era of COVID-19. Physical methods of stress relief such as yoga and massage therapy may reduce occupational stress. The objective of this systematic review and network meta-analysis is to determine the effects of yoga, massage therapy, progressive muscle relaxation, and stretching on alleviating stress and improving physical and mental health in healthcare workers.

METHODS

Databases were searched for randomized controlled trials on the use of physical relaxation methods for occupational stress in healthcare workers with any duration of follow-up. Meta-analysis was performed for standard mean differences in stress measures from baseline between subjects undergoing relaxation vs non-intervention controls. Network meta-analysis was conducted to determine the best relaxation method.

RESULTS

Fifteen trials representing 688 healthcare workers were identified. Random-effects meta-analysis shows that physical relaxation methods overall reduced measures of occupational stress at the longest duration of follow-up vs baseline compared to non-intervention controls (SMD -0.53; 95% CI [-0.74 to -0.33]; p < .00001). On network meta-analysis, only yoga alone (SMD -0.71; 95% CI [-1.01 to -0.41]) and massage therapy alone (SMD -0.43; 95% CI [-0.72 to -0.14]) were more effective than control, with yoga identified as the best method (p-score = .89).

CONCLUSION

Physical relaxation may help reduce occupational stress in healthcare workers. Yoga is particularly effective and offers the convenience of online delivery. Employers should consider implementing these methods into workplace wellness programs.

Comparative Efficacy and Safety of Anti-PD-1/PD-L1 Immune Checkpoint Inhibitors for Refractory or Relapsed Advanced Non-Small-Cell Lung Cancer-A Systematic Review and Network Meta-Analysis

The efficacy and safety of immune checkpoint inhibitors (ICIs) in refractory or relapsed advanced non-small-cell lung cancer (NSCLC) have not yet been compared with those of ramucirumab (Ram) plus docetaxel (Doc). Furthermore, comprehensive comparisons between ICIs have not been conducted to date. In the current study, a Bayesian network meta-analysis of related phase III clinical trials was performed to compare the efficacy and safety of Ram+Doc, Niv, Atz, and Doc treatments in patient groups lacking the PD-L1 constraint. Surface under the cumulative ranking area (SUCRA) revealed that the overall survival (OS) of patients treated with Niv was the highest, followed by Atz, Ram+Doc, and Doc. Regarding grades 3-5 treatment-related adverse events (G3-5AEs), the use of Niv was ranked the safest, followed by Atz, Doc, and Ram+Doc. Significant differences in OS were observed between Niv and Ram+Doc, while significant differences in G3-5AEs were observed between Ram+Doc and Niv or Atz. In the PD-L1 positive (≥1%) patient subgroup, Pem (10 mg/kg) ranked the highest in efficacy for OS, followed by Niv, Pem (2 mg/kg), Atz, and Doc. These findings may expectedly provide oncologists with useful insights into therapeutic selection for refractory or relapsed advanced NSCLC.

A systematic review and network meta-analysis of second-line therapy in hepatocellular carcinoma

Background

In patients with advanced hepatocellular carcinoma (hcc) following sorafenib failure, it is unclear which treatment is most efficacious, as treatments in the second-line setting have not been directly compared and no standard therapy exists. This systematic review and network meta-analysis (nma) aimed to compare the clinical benefits and toxicities of these treatments.

Methods

A systematic review of randomized controlled trials (rcts) was conducted to identify phase iii rcts in advanced hcc following sorafenib failure. Baseline characteristics and outcomes of placebo were examined for heterogeneity. Primary outcomes of interest were extracted for results, including overall survival (os), progression-free survival (pfs), objective response rate (orr), grade 3/4 toxicities, and subgroups. An nma was conducted to compare both drugs through the intermediate placebo. Comparisons were expressed as hazard ratios (hrs) for os and pfs, and as risk difference (rd) for orr and toxicities. Subgroup analyses for os and pfs were also performed.

Results

Two rcts were identified (1280 patients) and compared through an indirect network; celestial (cabozantinib vs. placebo) and resorce (regorafenib vs. placebo). Baseline characteristics of patients in both trials were similar. Both trials also had similar placebo outcomes. Cabozantinib, compared with regorafenib, showed similar os [hazard ratio (hr): 1.21; 95% confidence interval (ci): 0.90 to 1.62], pfs (hr: 1.02; 95% ci: 0.78 to 1.34) and orr (-3.0%; 95% ci: -7.6% to 1.7%). Both treatments showed similar toxicities, but there were marginally higher risks of grade 3/4 hand-foot syndrome (5%; 95% ci: 0.1% to 9.8%), diarrhea (4.8%; 95% ci: 1.1% to 8.5%), and anorexia (4.4%; 95% ci: 0.8% to 8.0%) for cabozantinib. Subgroup results for os and pfs were consistent with overall results.

Conclusions

Overall, this nma determined that cabozantinib and regorafenib have similar clinical benefits and toxicities for second-line hcc.

Application of network meta-analysis in the field of physical activity and health promotion

Continued advancement in the field of physical activity and health promotion relies heavily on the synthesis of rigorous scientific evidence. As such, systematic reviews and meta-analyses of randomized controlled trials have led to a better understanding of which intervention strategies are superior (i.e., produce the greatest effects) in physical activity-based health behavior change interventions. Indeed, standard meta-analytic approaches have allowed researchers in the field to synthesize relevant experimental evidence using pairwise procedures that produce reliable estimates of the homogeneity, magnitude, and potential biases in the observed effects. However, pairwise meta-analytic procedures are only capable to discerning differences in effects between a select intervention strategy and a select comparison or control condition. In order to maximize the impact of physical activity interventions on health-related outcomes, it is necessary to establish evidence concerning the comparative efficacy of all relevant physical activity intervention strategies. The development of network meta-analysis (NMA)-most commonly used in medical-based clinical trials-has allowed for the quantification of indirect comparisons, even in the absence of direct, head-to-head trials. Thus, it stands to reason that NMA can be applied in physical activity and health promotion research to identify the best intervention strategies. Given that this analysis technique is novel and largely unexplored in the field of physical activity and health promotion, care must be taken in its application to ensure reliable estimates and discernment of the effect sizes among interventions. Therefore, the purpose of this review is to comment on the potential application and importance of NMA in the field of physical activity and health promotion, describe how to properly and effectively apply this technique, and suggest important considerations for its appropriate application in this field. In this paper, overviews of the foundations of NMA and commonly used approaches for conducting NMA are provided, followed by assumptions related to NMA, opportunities and challenges in NMA, and a step-by-step example of developing and conducting an NMA.

Bayesian network meta-analysis of efficacy and safety of neoadjuvant therapy for non-small-cell lung cancer

Objective:

Neoadjuvant chemotherapy has increased the survival benefit of non-small cell lung cancer (NSCLC) patients. The effects of different neoadjuvant therapies are still controversial. We carried out the study to evaluate the efficacy and safety of neoadjuvant therapy.

Methods:

We performed a search of electronic databases (PubMed, Embase, MEDLINE, Cochrane) for randomized controlled trials (RCTs) comparing neoadjuvant treatment. After literature screening and data extraction, efficacy, and safety were analyzed by the Bayesian network meta-analysis (NMA).

Results:

A total of 19 RCTs were included, covering 3276 patients and six kinds of neoadjuvant therapies, including immunotherapy, targeted therapy, chemotherapy drugs and radiotherapy. Erlotinib, the first-generation epidermal growth factor receptor tyrosine inhibitors (EGFR TKIs), neoadjuvant targeted therapy is best for improving overall survival (OS) and progression-free survival (PFS), which is superior to other neoadjuvant therapy, such as neoadjuvant chemotherapy with platinum drugs [hazard ratio (HR) 0.39, 95% confidence intervals (CIs) 0.16–0.96], neoadjuvant chemoradiotherapy (HR 0.37, 95% CI 0.14–0.96) and neoadjuvant chemotherapy with non-platinum drugs (HR 0.25, 95% CI 0.07–0.90). OS of all neoadjuvant therapies is superior to surgery alone, but only neoadjuvant chemotherapy with platinum drugs showed a significant advantage (HR 0.76, 95% CI 0.59–0.93). Besides, for the stage IIIA N2 NSCLC patients, no significant difference was found between neoadjuvant therapies.

Conclusions:

Targeted neoadjuvant therapy is the best treatment for prolonging PFS. The neoadjuvant chemotherapy with platinum drugs was associated with the better OS benefits for patients with NSCLC, compared with surgery alone. There is no significant difference in the efficacy of neoadjuvant therapy for the stage IIIA N2 NSCLC.

Systematic review and network meta-analysis comparing Chinese herbal injections with chemotherapy for treating patients with esophageal cancer

Objective

Methods

Results

Conclusions

Efficacy and safety of non-pharmacological interventions for irritable bowel syndrome in adults

BACKGROUND

Although nonpharmacological interventions (NPI) for irritable bowel syndrome (IBS) have been applied clinically, their relative efficacy and safety are poorly understood.

AIM

To compare and rank different NPI in the treatment of IBS.

METHODS

Five electronic databases were searched from their inception to January 12, 2020. Data of included publications were analyzed using network meta-analysis (NMA). Quality of endpoints were assessed by tools of the Cochrane Handbook and the GRADEpro software. Pooled relative risk or standardized mean difference with their corresponding 95% confidence intervals were used for statistical analysis. Surface under the cumulative ranking curve (SUCRA) probability value was conducted to rank the examined interventions. Sensitivity analysis was performed to verify the robustness of results and test the source of heterogeneity.

RESULTS

Forty randomized controlled trials with 4196 participants were included in this NMA. Compared with routine pharmacotherapies and placebo, acupuncture and cognitive behavioral therapy (CBT) had better efficacy in relieving IBS symptoms. Based on the SUCRA values, acupuncture ranked first in improving overall clinical efficacy and avoiding adverse effects. CBT ranked first in lowering the scores of IBS symptom severity scale, self-rating anxiety scale and self-rating depression scale.

CONCLUSION

This study confirmed the efficacy and safety of NPI for improving IBS symptoms, which to some extent recommended several interventions for clinical practice.

Comparison of Poly (ADP-ribose) Polymerase Inhibitors (PARPis) as Maintenance Therapy for Platinum-Sensitive Ovarian Cancer: Systematic Review and Network Meta-Analysis

Simple Summary

Poly (ADP-ribose) polymerase inhibitors (PARPis; inhibitors of a family of enzymes that are primary involved in DNA repair) are considered to be the drug of choice in maintenance therapy for platinum-sensitive ovarian cancer. However, despite the FDA approval of three such agents and their availability in clinical practice, thus far, no clinical trial investigated them in a head-to-head direct comparison. In this study, we used a statistical approach that allows comparing direct and indirect evidence (network meta-analysis) in order to compare the three FDA-approved PARPis (olaparib, niraparib and rucaparib). To this end, we used data from six randomized control trials involving a total of 2270 ovarian cancer patients. Interestingly, we found no significant differences in clinical outcomes (overall survival and progression-free survival) between the three agents. However, niraparib was found to be associated with higher risk of certain adverse events (thrombocytopenia, neutropenia, constipation, and headaches) compared to the other two PARPis.

Abstract

Background: Three PARPis (olaparib, niraparib and rucaparib) are currently FDA-approved as maintenance therapy in newly diagnosed and recurrent ovarian cancer. However, thus far, no trial has compared the three approved PARPis in the overall population, in patients with BRCA mutations, or in those with wild-type BRCA. Methods: A frequentist network meta-analysis was used for indirect comparisons between the different PARPis with respect to progression free survival (PFS), overall survival (OS), and adverse events. Results: Overall, six randomized clinical trials involving 2,770 patients, were included in the analysis. Results from the indirect comparisons revealed no statistically significant differences between the three PARPis with respect to PFS or OS in the entire population and in patients with mutated and wild-type BRCA, separately. Niraparib showed a statistically significant increased risk for grade 3 and 4 thrombocytopenia (risk-difference [RD] from placebo: 0.3; 95% confidence interval [CI], 0.27‒0.34) and any grade neutropenia (RD from placebo: 0.22; 95% CI, 0.18‒0.25) as compared with the other PARPis. Conclusion: No statistically significant difference was found between the three PARPis with respect to PFS or OS (overall and in subpopulations by BRCA status). There is, however, a statistical difference in toxicity as niraparib is associated with a greater risk for thrombocytopenia and neutropenia.

Critically important antimicrobials are generally not needed to treat nonsevere clinical mastitis in lactating dairy cows: Results from a network meta-analysis

There is ongoing debate regarding whether critically important antimicrobials (CIA) should be used to treat infections in food-producing animals. In this systematic review, we determined whether CIA and non-CIA have comparable efficacy to treat nonsevere bovine clinical mastitis caused by the most commonly reported bacteria that cause mastitis worldwide. We screened CAB Abstracts, Web of Science, MEDLINE, Scopus, and PubMed for original epidemiological studies that assessed pathogen-specific bacteriological cure rates of antimicrobials used to treat nonsevere clinical mastitis in lactating dairy cows. Network models were fit using risk ratios of bacteriological cure as outcome. A total of 30 studies met inclusion criteria. Comparisons of cure rates demonstrated that CIA and non-CIA had comparable efficacy for treatment of nonsevere clinical mastitis in dairy cattle. Additionally, for cows with nonsevere clinical mastitis caused by Escherichia coli and Klebsiella spp., bacteriological cure rates were comparable for treated versus untreated cows; therefore, there was no evidence to justify treatment of these cases with CIA. Our findings supported that CIA in general are not necessary for treating nonsevere clinical mastitis in dairy cattle, the disease that accounts for the majority of antimicrobial usage in dairy herds worldwide. Furthermore, our findings support initiatives to reduce or eliminate use of CIA in dairy herds.

A Systematic Review and Mixed Treatment Comparison of Pharmaceutical Interventions for Multiple Sclerosis

Background

Since 2010, 27 mixed-treatment comparisons (MTCs) of disease-modifying therapies (DMTs) for multiple sclerosis have been published. However, there has been continued evolution in the field of MTCs. Additionally, limitations in methodological approach and reporting transparency, even in the most recent publications, makes interpretation and comparison of existing studies difficult.

Objectives

The objectives of this study are twofold: (1) to estimate the efficacy and safety of DMTs at European Commission-approved doses compared with placebo in adults with relapsing–remitting multiple sclerosis (RRMS) using MTC, and (2) to identify and address methodological challenges when performing MTC in RRMS, thereby creating a baseline for comparisons with future treatments.

Methods

Searches were completed in 14 databases, including MEDLINE, Embase, CENTRAL, CDSR and DARE, from inception to June 2018 to identify published or unpublished prospective, randomised controlled trials of all European Union-approved DMTs or DMTs expected to be approved in the near future in RRMS or rapidly-evolving severe RRMS. No language or date restrictions were applied. Studies were included in the MTC if they were judged to have sufficiently similar characteristics, based on the following: patient age; proportion of male participants; Expanded Disability Status Scale (EDSS) score; duration of disease; number of relapses prior to enrolment and proportion of previously treated patients. Background information from the included studies, as well as effect size and confidence intervals (where relevant) of defined outcomes were extracted. Reporting of the MTC was consistent with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) network meta-analysis guidelines.

Results

In total, 33 studies were included in the MTC. Annualised relapse rate (ARR 28 trials) was significantly reduced in all treatments compared with placebo. Alemtuzumab had the highest probability (63%) of being the most effective treatment in terms of ARR compared with placebo (rate ratio [RR] 0.28, 95% credible interval [CrI] 0.21–0.38), followed by natalizumab (30% probability; RR 0.32, 95% CrI 0.23–0.43). The risk of 3- and 6-month confirmed disability progression (CDP3M, 13 trials; CDP6M, 14 trials) were similar; CDP6M was significantly reduced for alemtuzumab (hazard ratio [HR] 0.365; 95% CrI 0.165–0.725), ocrelizumab (HR 0.405, 95% CrI 0.188–0.853) and natalizumab (HR 0.459, 95% CrI 0.252–0.840) relative to placebo. There were no significant differences in the odds of serious adverse events (SAEs, 6 trials) between any treatment and placebo. The results of the MTC were limited by the lack of studies reporting direct comparisons between the included treatments and by heterogeneous reporting of key outcome data.

Conclusions

Meta-analyses confirmed the benefit of all DMTs in terms of relapse rate compared with placebo with a comparable rate of SAEs for the DMTs that could be included in the network. The rigor and transparency of reporting in this study provide a benchmark for comparisons with future new agents.

Electronic Supplementary Material

The online version of this article (10.1007/s40120-020-00212-5) contains supplementary material, which is available to authorized users.

Social Cognition Training for People With a Psychotic Disorder: A Network Meta-analysis

Deficits in social cognition are common in people with psychotic disorders and negatively impact functioning. Social Cognition Training (SCT) has been found to improve social cognition and functioning, but it is unknown which interventions are most effective, how characteristics of treatments and participants moderate efficacy, and whether improvements are durable. This meta-analysis included 46 randomized studies. SCTs were categorized according to their focus (targeted/broad-based) and inclusion of cognitive remediation therapy (CRT). Network meta-analysis was conducted, using both direct (original) and indirect (inferred from the network of comparisons) evidence. All SCT types were compared to treatment as usual (TAU; the chosen reference group). Moderators of outcome were investigated with meta-regression and long-term efficacy with multivariate meta-analysis. Compared to TAU, emotion perception was improved by targeted SCT without CRT (d = 0.68) and broad-based SCT without CRT (d = 0.46). Individual treatments worked better for emotion perception. All treatments significantly improved social perception (active control, d = 0.98, targeted SCT with and without CRT, d = 1.38 and d = 1.36, broad-based SCT with and without CRT, d = 1.45 and d = 1.35). Only broad-based SCT (d = 0.42) improved ToM. Broad-based SCT (d = 0.82 without and d = 0.41 with CRT) improved functioning; group treatments worked significantly better. Male gender was negatively related to effects on social functioning and psychiatric symptoms. At follow-up, a moderate effect on social functioning (d = 0.66) was found. No effect was found on attribution, social cognition (miscellaneous), and psychiatric symptoms. While targeted SCT is the most effective for emotion perception and social perception, broad-based SCT produces the best overall outcomes. CRT did not enhance SCT effects.

Clinical review of the efficacy and safety of oral semaglutide in patients with type 2 diabetes considered for injectable GLP-1 receptor agonist therapy or currently on insulin therapy

Injectable therapies such as glucagon-like peptide-1 receptor agonists (GLP-1RAs) and insulin are high-efficacy options for people with type 2 diabetes (T2D) who require treatment intensification. In addition to high glycemic efficacy, GLP-1RAs offer weight loss benefits, and some agents have been shown to reduce cardiovascular risk. This article summarizes data from two clinical studies with the first oral GLP-1RA, oral semaglutide, in situations where injectable therapy is often considered, and provides guidance on use in primary care. PIONEER 4 compared oral semaglutide 14 mg with an injectable GLP-1RA, liraglutide 1.8 mg, or placebo in patients uncontrolled on oral glucose-lowering therapies. PIONEER 8 compared oral semaglutide with placebo in patients with T2D already on insulin therapy. Treatment with oral semaglutide gave similar reductions in glycated hemoglobin (HbA_{1 c}) compared with liraglutide at 26 weeks, and significantly greater reductions at 52 weeks. Changes in body weight with oral semaglutide were significantly greater compared with liraglutide after 26 and 52 weeks. Adding oral semaglutide 7 or 14 mg to insulin resulted in significant reductions in HbA_{1 c} and body weight at both 26 and 52 weeks compared with placebo, and facilitated a decrease in total daily insulin dosage. Oral semaglutide was associated with low proportions of patients experiencing severe or blood glucose-confirmed symptomatic hypoglycemia when added to oral glucose-lowering therapies, and did not increase the incidence of such events when added to insulin. The tolerability profile of oral semaglutide was consistent with that seen for injectable GLP-1RAs, with gastrointestinal side effects seen most frequently; most were transient and tended to occur during dose escalation. For patients requiring treatment intensification after oral therapy or as add-on to insulin, oral semaglutide provides effective glucose lowering and body weight loss, with low risk of hypoglycemia, thus broadening the range of therapeutic options for treatment of T2D in primary care.

Comparative efficacy and safety of drug treatment for premature ejaculation: A systemic review and Bayesian network meta-analysis

To assess the comparative efficacy and safety of drug treatments for premature ejaculation. A systemic review and Bayesian network meta-analysis were executed on randomised controlled trials of drug interventions for premature ejaculation. Intravaginal ejaculation latency time and related adverse effects were outcome measures. A total of 44 RCTs with 11,008 patients were included in our NMA. In therapy <8 weeks, the ranking of drug efficacy was topical creams >selective serotonin reuptake inhibitor (SSRI)+ phosphodiesterase 5 inhibitor (PDE5i) > PDE5i > sertraline > clomipramine > paroxetine > dapoxetine 60 milligram (mg) > dapoxetine 30 mg > fluoxetine>citalopram > duloxetine>placebo. In therapy ≥ 8 weeks, the ranking of drug efficacy was SSRI + PDE5i > topical creams > paroxetine > tramadol > PDE5i > fluoxetine > dapoxetine 60 mg > dapoxetine 30 mg > clomipramine>citalopram > placebo. For total adverse events, clomipramine, dapoxetine 30 mg, dapoxetine 60 mg, paroxetine, PDE5i, SSRI + PDE5i and tramadol had a higher risk than placebo. In conclusion, in ≥8 weeks of therapy, the drug combination of SSRI + PDE5i was the most effective PE therapy. In <8 weeks of therapy, the efficacy of local anaesthetics was best. All drug treatments were ranked better than placebo. In general, drugs with better effects had more obvious side effects.

Reading and interpreting reviews for health professionals: a practical review

Literature reviews can be directly used by clinicians and other health professionals to support many decision-making processes. This review aims to offer health professionals an essential practical guide to critically evaluate and properly understand results of review articles published in the scientific literature. An evidence-based methodological review with step-by-step theoretical concepts and practical suggestions was developed. Key steps of this guide are: to consider the topic and the research question (a), to check the review type (b), to evaluate the methodology (with a keen focus on review guidelines, search strategy and study-selection process, evaluation of the quality and certainty of included evidence, and statistical analysis) (c), and to define the real impact of review results (d). This guide offers a description of essential and easy-to-apply key steps which can help health professionals to evaluate the reliability and implications of a literature review, and to select the latest high-quality scientific evidence to keep updated with.