Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children with ADHD find it difficult to pay attention, they are hyperactive and impulsive.Methylphenidate is the drug most often prescribed to treat children and adolescents with ADHD but, despite its widespread use, this is the first comprehensive systematic review of its benefits and harms.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

In February 2015 we searched six databases (CENTRAL, Ovid MEDLINE, EMBASE, CINAHL, PsycINFO, Conference Proceedings Citations Index), and two trials registers. We checked for additional trials in the reference lists of relevant reviews and included trials. We contacted the pharmaceutical companies that manufacture methylphenidate to request published and unpublished data.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. At least 75% of participants needed to have an intellectual quotient of at least 70 (i.e. normal intellectual functioning). Outcomes assessed included ADHD symptoms, serious adverse events, non-serious adverse events, general behaviour and quality of life.

DATA COLLECTION AND ANALYSIS

Seventeen review authors participated in data extraction and risk of bias assessment, and two review authors independently performed all tasks. We used standard methodological procedures expected within Cochrane. Data from parallel-group trials and first period data from cross-over trials formed the basis of our primary analyses; separate analyses were undertaken using post-cross-over data from cross-over trials. We used Trial Sequential Analyses to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach for high risk of bias, imprecision, indirectness, heterogeneity and publication bias.

MAIN RESULTS

The studies.We included 38 parallel-group trials (5111 participants randomised) and 147 cross-over trials (7134 participants randomised). Participants included individuals of both sexes, at a boys-to-girls ratio of 5:1, and participants' ages ranged from 3 to 18 years across most studies (in two studies ages ranged from 3 to 21 years). The average age across all studies was 9.7 years. Most participants were from high-income countries.The duration of methylphenidate treatment ranged from 1 to 425 days, with an average duration of 75 days. Methylphenidate was compared to placebo (175 trials) or no intervention (10 trials). Risk of Bias.All 185 trials were assessed to be at high risk of bias. Primary outcomes. Methylphenidate may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.77, 95% confidence interval (CI) -0.90 to -0.64; 19 trials, 1698 participants; very low-quality evidence). This corresponds to a mean difference (MD) of -9.6 points (95% CI -13.75 to -6.38) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points; DuPaul 1991a). A change of 6.6 points on the ADHD-RS is considered clinically to represent the minimal relevant difference. There was no evidence that methylphenidate was associated with an increase in serious (e.g. life threatening) adverse events (risk ratio (RR) 0.98, 95% CI 0.44 to 2.22; 9 trials, 1532 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 0.91 (CI 0.02 to 33.2).

SECONDARY OUTCOMES

Among those prescribed methylphenidate, 526 per 1000 (range 448 to 615) experienced non-serious adverse events, compared with 408 per 1000 in the control group. This equates to a 29% increase in the overall risk of any non-serious adverse events (RR 1.29, 95% CI 1.10 to 1.51; 21 trials, 3132 participants; very low-quality evidence). The Trial Sequential Analysis-adjusted intervention effect was RR 1.29 (CI 1.06 to 1.56). The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems (RR 1.60, 95% CI 1.15 to 2.23; 13 trials, 2416 participants), and 266% greater risk for decreased appetite (RR 3.66, 95% CI 2.56 to 5.23; 16 trials, 2962 participants) than children in the control group.Teacher-rated general behaviour seemed to improve with methylphenidate (SMD -0.87, 95% CI -1.04 to -0.71; 5 trials, 668 participants; very low-quality evidence).A change of seven points on the Child Health Questionnaire (CHQ; range 0 to 100 points; Landgraf 1998) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a MD of 8.0 points (95% CI 5.49 to 10.46) on the CHQ, which suggests that methylphenidate may improve parent-reported quality of life (SMD 0.61, 95% CI 0.42 to 0.80; 3 trials, 514 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

The results of meta-analyses suggest that methylphenidate may improve teacher-reported ADHD symptoms, teacher-reported general behaviour, and parent-reported quality of life among children and adolescents diagnosed with ADHD. However, the low quality of the underpinning evidence means that we cannot be certain of the magnitude of the effects. Within the short follow-up periods typical of the included trials, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases risk of serious adverse events.Better designed trials are needed to assess the benefits of methylphenidate. Given the frequency of non-serious adverse events associated with methylphenidate, the particular difficulties for blinding of participants and outcome assessors point to the advantage of large, 'nocebo tablet' controlled trials. These use a placebo-like substance that causes adverse events in the control arm that are comparable to those associated with methylphenidate. However, for ethical reasons, such trials should first be conducted with adults, who can give their informed consent.Future trials should publish depersonalised individual participant data and report all outcomes, including adverse events. This will enable researchers conducting systematic reviews to assess differences between intervention effects according to age, sex, comorbidity, type of ADHD and dose. Finally, the findings highlight the urgent need for large RCTs of non-pharmacological treatments.

Repurposed therapeutic agents targeting the Ebola virus: a protocol for a systematic review

BACKGROUND

The recent Ebola epidemic in western Africa developed into an acute public health emergency of unprecedented level in modern times. The treatment provided in most cases has been limited to supportive care, as no approved therapies are available to date. Several established, licenced drugs have been suggested as potential repurposed therapeutic agents for Ebola. However, scientific data on their efficacy in treating Ebola is limited. The purpose of this review is to systematically assess scientific evidence on potential drugs targeting Ebola. In specific, we aim to (1) identify drug library screens involving therapeutic agents targeting the Ebola virus, (2) list potential approved drugs identified from drug screens and review their mechanism of action against the Ebola virus and (3) summarise the outcome of preclinical and clinical trials investigating approved drugs targeting the Ebola virus.

METHODS/DESIGN

We will develop comprehensive systematic search strategies and will perform a systematic literature search in MEDLINE, Embase and Cochrane Central Register of Controlled Trials (CENTRAL). Two authors will independently screen the titles, abstracts and the references of all selected articles on the basis of inclusion criteria. These include any available drug screening, preclinical studies and clinical studies examining the efficacy of approved therapeutic agents targeting the Ebola virus. There will be no restrictions on the type of participants, the type of comparator, time or setting. Data extraction and quality assessment will be undertaken by two review authors working independently.

DISCUSSION

This systematic review will provide systematic knowledge on potential repurposed therapeutic agents targeting Ebola. It aims to help guide future investigations on repurposed drugs and avoid repetitive studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024349.

Changes in health-related quality of life (HRQoL) after discharge from intensive care unit: a protocol for a systematic review

INTRODUCTION

Treatment on an intensive care unit (ICU) imposes a high treatment burden on patients, as well as an economic burden for the healthcare provider. Many studies have recorded health-related quality of life (HRQoL) in patients after treatment on an ICU. We propose a systematic review of these studies.

METHODS

We will search the National Library of Medicine's PubMed electronic database (PubMed), the Cochrane database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Open Grey to identify papers reporting quality of life after discharge from ICU. We will include papers including validated quality of life measures. We will examine three categories: populations of patients treated on general ICUs, patients with severe infections and patients with respiratory dysfunction. We will extract HRQoL data. We will assess papers for risk of bias using the QUADAS-2 tool. The strength of our conclusions will depend on the quality and number of papers showing uniform results.

ETHICS AND DISSEMINATION

This review will use published literature and contains no primary data; so we do not need ethical approval. We will submit the outcome of the systematic review to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015024700.

Protocol for a Systematic Review of Telehealth Privacy and Security Research to Identify Best Practices

Healthcare professionals engaged in telehealth are faced with complex US federal regulations (e.g., HIPAA/HITECH) and could benefit from the guidance provided by best practices in Privacy and Security (P&S). This article describes a systematic review protocol to address this need. The protocol described herein uses the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The PRISMA-P contains 17 items that are considered essential, as well as minimum components to include in systematic reviews. PICOS (participants, interventions, comparisons, outcome(s) and study design of the systematic review) are also relevant to the development of best practices in P&S in telehealth systems. A systematic process can best determine what information should be included and how this information should be retrieved, condensed, analyzed, organized, and disseminated.

Mesh fixation methods in open inguinal hernia repair: a protocol for network meta-analysis and trial sequential analysis of randomised controlled trials

INTRODUCTION

Randomised clinical trials (RCTs) have been used to compare and evaluate different types of mesh fixation usually employed to repair open inguinal hernia. However, there is no consensus among surgeons on the best type of mesh fixation method to obtain optimal results. The choice often depends on surgeons' personal preference. This study aims to compare different types of mesh fixation methods to repair open inguinal hernias and their role in the incidences of chronic groin pain, risk of hernia recurrence, complications, operative time, length of hospital stay and postoperative pain, using Bayesian network meta-analysis and trial sequential analysis of RCTs.

METHODS AND ANALYSIS

A systematic search will be performed using PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Chinese Biomedical Literature Database (CBM) and Chinese Journal Full-text Database, to include RCTs of different mesh fixation methods (or fixation vs no fixation) during open inguinal hernia repair. The risk of bias in included RCTs will be evaluated according to the Cochrane Handbook V.5.1.0. Standard pairwise meta-analysis, trial sequential analysis and Bayesian network meta-analysis will be performed to compare the efficacy of different mesh fixation methods.

ETHICS AND DISSEMINATION

Ethical approval and patient consent are not required since this study is a meta-analysis based on published studies. The results of this network meta-analysis and trial sequential analysis will be submitted to a peer-reviewed journal for publication.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42015023758.

The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review

BACKGROUND

Head injury represents an extremely common presentation to emergency departments (ED), but not all patients present immediately after injury. There is evidence that clinical deterioration following head injury will usually occur within 24 h. It is unclear whether this means that head injury patients that present in a delayed manner, especially after 24 h, have a lower prevalence of significant traumatic injuries including intra-cranial haemorrhages.

METHODS

A systematic review protocol was designed with the aim of systematically identifying and evaluating studies in delayed ED presentation head injury populations in order to establish whether the prevalence of significant intra-cranial injury was affected by delay in presentation. Two independent researchers assessed retrieved studies for inclusion against pre-determined inclusion criteria. Studies had to be conducted in ED head injury populations presenting in a delayed manner, and report a measure of prevalence of traumatic CT abnormality as an outcome.

RESULTS

Three studies were eligible for inclusion. They were all of poor methodological quality, and heterogeneity prevented meta-analysis. The reported prevalence of traumatic intra-cranial injury on CT was between 2.2 and 6.3%. This is generally lower than reported in the literature for non-delayed presentation head injury populations.

CONCLUSIONS

Available evidence suggests that head injury patients who present in a delayed fashion to the ED may have lower rates of intra-cranial injury compared to non-delayed head injury patients. However, the evidence is sparse and it is of too low quality to guide clinical practice. Further research is required to help the clinical risk assessment of this group.

TRIAL REGISTRATION

PROSPERO

CRD42015016135.

Systematic review and meta-analysis: Multi-strain probiotics as adjunct therapy for Helicobacter pylori eradication and prevention of adverse events

BACKGROUND

Eradication rates with triple therapy for Helicobacter pylori infections have currently declined to unacceptable levels worldwide. Newer quadruple therapies are burdened with a high rate of adverse events. Whether multi-strain probiotics can improve eradication rates or diminish adverse events remains uncertain.

METHODS

Relevant publications in which patients with H. pylori infections were randomized to a multi-strain probiotic or control were identified in PubMed, Cochrane Databases, and other sources from 1 January 1960-3 June 2015. Primary outcomes included eradication rates, incidence of any adverse event and the incidence of antibiotic-associated diarrhea. As probiotic efficacy is strain-specific, pooled relative risks and 95% confidence intervals were calculated using meta-analysis stratified by similar multi-strain probiotic mixtures.

RESULTS

A total of 19 randomized controlled trials (20 treatment arms, n = 2730) assessing one of six mixtures of strains of probiotics were included. Four multi-strain probiotics significantly improved H. pylori eradication rates, five significantly prevented any adverse reactions and three significantly reduced antibiotic-associated diarrhea. Only two probiotic mixtures (Lactobacillus acidophilus/Bifidobacterium animalis and an eight-strain mixture) had significant efficacy for all three outcomes.

CONCLUSIONS

Our meta-analysis found adjunctive use of some multi-strain probiotics may improve H. pylori eradication rates and prevent the development of adverse events and antibiotic-associated diarrhea, but not all mixtures were effective.

Fluid strategies and outcomes in patients with acute respiratory distress syndrome, systemic inflammatory response syndrome and sepsis: a protocol for a systematic review and meta-analysis

BACKGROUND

Fluid administration to critically ill patients remains the subject of considerable controversy. While intravenous fluid given for resuscitation may be life-saving, a positive fluid balance over time is associated with worse outcomes in critical illness. The aim of this systematic review is to summarise the existing evidence regarding the relationship between fluid administration or balance and clinically important patient outcomes in critical illness.

METHODS

We will search Medline, EMBASE, the Cochrane Central Register of Controlled Trials from 1980 to the present and key conference proceedings from 2009 to the present. We will include studies of critically ill adults and children with acute respiratory distress syndrome (ARDS), sepsis and systemic inflammatory response syndrome (SIRS). We will include randomised controlled trials comparing two or more fluid regimens of different volumes of fluid and observational studies reporting the relationship between volume of fluid administered or fluid balance and outcomes including mortality, lengths of intensive care unit and hospital stay and organ dysfunction. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. We will conduct a narrative and/or meta-analysis as appropriate.

DISCUSSION

While fluid management has been extensively studied and discussed in the critical care literature, no systematic review has attempted to summarise the evidence for post-resuscitation fluid strategies in critical illness. Results of the proposed systematic review will inform practice and the design of future clinical trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005608. ( http://www.crd.york.ac.uk/PROSPERO/ ).

Current-reported outcome domains in studies of adults with a focus on the treatment of tinnitus: protocol for a systematic review

INTRODUCTION

In Europe alone, over 70 million people experience tinnitus. Despite its considerable socioeconomic relevance, progress in developing successful treatments has been limited. Clinical effectiveness is judged according to change in primary outcome measures, but because tinnitus is a subjective condition, the definition of outcomes is challenging and it remains unclear which distinct aspects of tinnitus (ie, 'domains') are most relevant for assessment. The development of a minimum outcome reporting standard would go a long way towards addressing these problems. In 2006, a consensus meeting recommended using 1 of 4 questionnaires for tinnitus severity as an outcome in clinical trials, in part because of availability in different language translations. Our initiative takes an approach motivated by clinimetrics, first by determining what to measure before seeking to determine how to measure it. Agreeing on the domains that contribute to tinnitus severity (ie, 'what') is the first step towards achieving a minimum outcome reporting standard for tinnitus that has been reached via a methodologically rigorous and transparent process.

METHODS AND ANALYSIS

Deciding what should be the core set of outcomes requires a great deal of discussion and so lends itself well to international effort. This protocol lays out the first-step methodology in defining a Core Domain Set for clinical trials of tinnitus by establishing existing knowledge and practice with respect to which outcome domains have been measured and which instruments used in recent registered and published clinical trials.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Findings will be reported at national and international ear, nose and throat (ENT) and audiology conferences and in a peer-reviewed journal, using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines.

TRIAL REGISTRATION NUMBER

The systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): CRD42015017525.

Predictors of Third Molar Impaction

The objective of this meta-analysis was to evaluate the prevalence of third molar (M3) impaction worldwide in individuals ≥17 y, from either sex, who had undergone oral radiography and presented with no orofacial syndromes or defects. We performed a literature search using PubMed, ISI Web of Science, and Google Scholar and retrieved English and non-English articles from any period for review. We included studies reporting M3 impaction prevalence based on radiographic examination. Risk of bias was assessed regarding individuals with craniofacial syndromes, prior extraction of permanent teeth, multiple effect size estimates, and studies conflating lack of eruption with impaction. Our search yielded 49 studies involving 83,484 individuals. Worldwide M3 impaction prevalence was found to be 24.40% (95% confidence interval [95% CI]: 18.97% to 30.80%). The odds of M3 impaction in the mandible were 57.58% (95% CI: 43.3% to 68.3%, P < 0.0001) higher than in the maxilla, but we did not detect any difference in the odds of impaction between men and women (18.62%, 95% CI: –4.9% to 48.0%, P = 0.12). Mesioangular impaction was most common (41.17%, 95% CI: 33.8% to 49.0%), followed by vertical (25.55%, 95% CI: 20.0% to 32.0%), distoangular (12.17%, 95% CI: 9.1% to 16.0%), and horizontal (11.06%, 95% CI: 8.3% to 14.6%). Impaction of 1 (42.71%, 95% CI: 30.0% to 56.5%) or 2 (29.64%, 95% CI: 19.5% to 42.3%) M3s was much more common than 3 (12.04%, 95% CI: 7.2% to 19.3%) or 4 (8.74%, 95% CI: 5.2% to 14.5%). There were small differences among impaction prevalence depending on geographic region ( F test, P = 0.049). Selection bias was evident because individuals had to undergo radiographic examination to be included in the analysis. The subgroup analysis by sex was underpowered. Worldwide M3 impaction prevalence is lower than previously reported. The percentage of individuals with impacted M3s is much smaller than the percentage that undergoes clinical treatment for M3 problems.

Index-based dietary patterns and colorectal cancer risk: a systematic review

Colorectal cancer (CRC) is the third most common cancer in both men and women in the United States. Various a priori dietary patterns that take into account diet complexity have been associated with CRC risk. This systematic review augments the evidence for an association between CRC risk and the Mediterranean Diet Score (MDS) and the Healthy Eating Index (HEI), and provides new evidence for a novel Dietary Inflammatory Index (DII). Human studies published in English after 31 December 2008 were reviewed. Five case-control studies and 7 prospective cohort studies conducted in the United States and Europe were identified. Five of the studies examined the MDS, 4 examined the HEI, and 4 examined the DII. Comparing highest to lowest score groups, higher MDSs were associated with an 8-54% lower CRC risk, and higher HEI scores were associated with a 20-56% lower CRC risk. More proinflammatory diet scores were associated with a 12-65% higher CRC risk compared with more anti-inflammatory diets in studies that used the DII. The results reported by sex suggested similar associations for men and women. This review builds upon the evidence supporting the association between higher overall diet quality and lower risk of CRC. Increasing scores of MDS and HEI and anti-inflammatory DII scores are characterized by high intake of plant-based foods and low intake of animal products. Future studies in more diverse populations and with consistent scoring calculations are recommended.

Key components in models of community-based interventions coordinating care in dementia: a mixed studies systematic review protocol

BACKGROUND

Current health and social care systems are providing suboptimal and fragmented care to the growing dementia population. Interventions aiming to coordinate care services for individuals with dementia and their families are already widely used; however, the structure and implementation of these interventions vary. This mixed studies review aims to investigate the key components of effective community-based interventions that focus on coordinating care in dementia.

METHODS

We will search MEDLINE, Cochrane Library, Embase and PsycINFO databases for studies of any design that look at community-based interventions that aim to coordinate dementia care through the allocation of a specified professional responsible for provision of care. Health Management Information Consortium (HMIC), Social Policy and Practice (SPP), ProQuest and International Clinical Trials Registry Platform (ICTRP) databases will be searched for grey literature. Outcomes of interest are health outcome measures that relate to the individual with dementia and/or informal caregiver, measures of resource use or process measures. Two independent reviewers will screen identified papers and extract data from eligible studies. Evidence synthesis will take place in three stages, and methods will be largely dependent on the data available. A sequential review design will be used where the qualitative evidence will be synthesised first, focusing on stakeholder's subjective views of key components. This will drive forward the quantitative stage which will identify key components of effective interventions. The final stage of the review will merge the two strands of evidence through a narrative synthesis.

DISCUSSION

The results from this review will be used to develop a model for a community-based intervention coordinating care in dementia. Furthermore, the findings will help guide future work on intervention development of health and social care services for dementia.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024618.

Identifying the content of home-based health behaviour change interventions for frail older people: a systematic review protocol

BACKGROUND

Meeting the needs of the growing number of older people is a challenge for health and social care services. Home-based interventions aiming to modify health-related behaviours of frail older people have the potential to improve functioning and well-being. Previous reviews have focused on whether such interventions are effective, rather than what might make them effective. Recent advances in behavioural science make possible the identification of potential 'active ingredients' of effective interventions, such as component behaviour change techniques (BCTs), and intended intervention functions (IFs; e.g. to educate, to impart skills). This paper reports a protocol for a systematic review that seeks to (a) identify health behaviour change interventions for older frail people, (b) describe the content of these interventions, and (c) explore links between intervention content and effectiveness. The protocol is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 guidelines.

METHODS/DESIGN

Studies will be identified through a systematic search of 15 electronic databases, supplemented by citation tracking. Studies will be retained for review where they report randomised controlled trials focusing on home-based health promotion delivered by a health professional for frail older people in community settings, written in English, and either published from 1980 onwards, or, for registered trials only, unpublished but completed with results obtainable from authors. Interventions will be coded for their content (BCTs, IFs) and for evidence of effectiveness (outcome data relating to behavioural and health outcomes). Analyses will describe characteristics of all interventions. Interventions for which effectiveness data are available will be categorised into those showing evidence of effectiveness versus those showing no such evidence. The potential for each intervention characteristic to contribute to change in behaviour or health outcomes will be estimated by calculating the percentage of all interventions featuring those characteristics that have shown effectiveness.

DISCUSSION

Results will reveal the strategies that have been drawn on within home-based interventions to modify the health behaviours of frail older people, and highlight those more associated with positive changes in behaviour and health. Findings from this review will provide a useful basis for understanding, developing, and implementing behaviour change interventions in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010370.

Community-based interventions to prevent fatal overdose from illegal drugs: a systematic review protocol

INTRODUCTION

Drug overdose is the most frequent cause of death among people who misuse illegal drugs. People who inject these drugs are 14-17 times more likely to die than their non-drug using peers. Various strategies to reduce drug-related deaths have failed to meet target reductions. Research into community-based interventions for preventing drug overdose deaths is promising. This review seeks to identify published studies describing community-based interventions and to evaluate their effectiveness at reducing drug overdose deaths.

METHODS AND ANALYSIS

We will systematically search key electronic databases using a search strategy which groups terms into four facets: (1) Overdose event, (2) Drug classification, (3) Intervention and (4) Setting. Searches will be limited where possible to international literature published in English between 1998 and 2014. Data will be extracted by two independent reviewers using a predefined table adapted from the Cochrane Collaboration handbook. The quality of included studies will be evaluated using the Cochrane Collaboration's tool for assessing risk of bias. We will conduct a meta-analysis for variables which can be compared across studies, using statistical methods to control for heterogeneity where appropriate. Where clinical or statistical heterogeneity prevents a valid numerical synthesis, we will employ a narrative synthesis to describe community-based interventions, their delivery and use and how effectively they prevent fatal overdoses.

ETHICS AND DISSEMINATION

We will publish findings from this systematic review in a peer-reviewed scientific journal and present results at national and international conferences. It will be disseminated electronically and in print.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42015017833.

The effectiveness of interventions to improve uptake and retention of HIV-infected pregnant and breastfeeding women and their infants in prevention of mother-to-child transmission care programs in low- and middle-income countries: protocol for a systematic review and meta-analysis

BACKGROUND

Despite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs.

METHODS/DESIGN

We will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological Abstracts, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity.

DISCUSSION

Our findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020829.

Optimal strategies to consider when peer reviewing a systematic review and meta-analysis

Systematic reviews are popular. A recent estimate indicates that 11 new systematic reviews are published daily. Nevertheless, evidence indicates that the quality of reporting of systematic reviews is not optimal. One likely reason is that the authors' reports have received inadequate peer review. There are now many different types of systematic reviews and peer reviewing them can be enhanced by using a reporting guideline to supplement whatever template the journal editors have asked you, as a peer reviewer, to use. Additionally, keeping up with the current literature, whether as a content expert or being aware of advances in systematic review methods is likely be make for a more comprehensive and effective peer review. Providing a brief summary of what the systematic review has reported is an important first step in the peer review process (and not performed frequently enough). At its core, it provides the authors with some sense of what the peer reviewer believes was performed (Methods) and found (Results). Importantly, it also provides clarity regarding any potential problems in the methods, including statistical approaches for meta-analysis, results, and interpretation of the systematic review, for which the peer reviewer can seek explanations from the authors; these clarifications are best presented as questions to the authors.

Incidence of sexually transmitted hepatitis C virus infection in HIV-positive men who have sex with men

OBJECTIVE

The epidemiology of the incidence of sexually transmitted hepatitis C virus (HCV) infection in HIV-positive men who have sex with men (MSM) is only partially understood. In the presence of HIV, HCV infection is more likely to become chronic and liver fibrosis progression is accelerated.

DESIGN

A systematic review and meta-analysis was used to synthesize data characterizing sexually transmitted HCV in HIV-positive MSM.

METHODS

Electronic and other searches of medical literature (including unpublished reports) were conducted. Eligible studies reported on HCV seroconversion or on reinfection postsuccessful HCV treatment in HIV-positive MSM who were not injecting drugs. Pooled incidence rates were calculated using random-effects meta-analysis, and meta-regression was used to assess study-level moderators. Attributable risk measures were calculated from statistically significant associations between exposures and HCV seroconversion.

RESULTS

More than 13 000 HIV-positive MSM in 17 studies were followed for more than 91 000 person-years between 1984 and 2012; the pooled seroconversion rate was 0.53/100 person-years. Calendar time was a significant moderator of HCV seroconversion, increasing from an estimated rate of 0.42/100 person-years in 1991 to 1.09/100 person-years in 2010, and 1.34/100 person-years in 2012. Reinfection postsuccessful HCV treatment (n = 2 studies) was 20 times higher than initial seroconversion rates. Among the seroconverters, a large proportion of infections were attributable to high-risk behaviours including mucosally traumatic sex and sex while high on methamphetamine.

CONCLUSION

The high reinfection rates and the attributable risk analysis suggest the existence of a subset of HIV-positive MSM with recurring sexual exposure to HCV. Approaches to HCV control in this population will need to consider the changing epidemiology of HCV infection in MSM.

Efficacy and safety of stenting for elderly patients with severe and symptomatic carotid artery stenosis: a critical meta-analysis of randomized controlled trials

OBJECTIVE

To investigate both short-term and long-term therapeutic efficacy and safety of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for elderly patients with severe and symptomatic carotid artery stenosis.

METHODS

PubMed, EMBASE, Cochrane Library, Clinical Trials Register Centers, and Google Scholar were comprehensively searched. After identifying relevant randomized controlled trials, methodological quality was assessed by using Cochrane tools of bias assessment. Meta-analysis was performed by RevMan software, and subgroup analyses according to different follow-up periods were also conducted.

RESULTS

Sixteen articles of nine randomized controlled trials containing 6,984 patients were included. Compared with CEA, CAS was associated with high risks of stroke during periprocedural 30 days (risk ratio [RR]=1.47, 95% confidence interval [CI]: 1.15-1.88), 48 months (RR=1.37, 95% CI: 1.11-1.70), and >48 months (RR=1.76, 95% CI: 1.34-2.31). There was no significant difference in the aspects of death, disabling stroke, or death at any time between the groups. For other periprocedural complications, CAS decreased the risk of myocardial infarction (RR=0.44, 95% CI: 0.26-0.75), cranial nerve palsy (RR=0.09, 95% CI: 0.04-0.22) and hematoma (RR=0.31, 95% CI: 0.14-0.68) compared with CEA, while it increased the risk of bradycardia or hypotension (RR=8.45, 95% CI 2.91-24.58).

CONCLUSION

Compared with CEA, CAS reduced hematoma, periprocedural myocardial infarction, and cranial nerve palsy, while it was associated with higher risks of both short-term and long-term nondisabling stroke. And they seemed to be equivalent in other outcome measures. As regards to its minimal invasion, it should be applied only in specific patients.

Identifying low-value clinical practices in critical care medicine: protocol for a scoping review

INTRODUCTION

Reducing unnecessary, low-value clinical practice (ie, de-adoption) is key to improving value for money in healthcare, especially among patients admitted to intensive care units (ICUs) where resource consumption exceeds other medical and surgical populations. Research suggests that low-value clinical practices are common in medicine, however systematically and objectively identifying them is a widely cited barrier to de-adoption. We will conduct a scoping review to identify low-value clinical practices in adult critical care medicine that are candidates for de-adoption.

METHODS AND ANALYSIS

We will systematically search the literature to identify all randomised controlled trials or systematic reviews that focus on diagnostic or therapeutic interventions in adult patients admitted to medical, surgical or specialty ICUs, and are published in 3 general medical journals with the highest impact factor (New England Journal of Medicine, The Lancet, Journal of the American Medical Association). 2 investigators will independently screen abstracts and full-text articles against inclusion criteria, and extract data from included citations. Included citations will be classified according to whether or not they represent a repeat examination of the given research question (ie, replication research), and whether the results are similar or contradictory to the original study. Studies with contradictory results will determine clinical practices that are candidates for de-adoption.

ETHICS AND DISSEMINATION

Our scoping review will use robust methodology to systematically identify a list of clinical practices in adult critical care medicine with evidence supporting their de-adoption. In addition to adding to advancing the study of de-adoption, this review may also serve as the launching point for clinicians and researchers in critical care to begin reducing the number of low-value clinical practices. Dissemination of these results to relevant stakeholders will include tailored presentations at local, national and international meetings, and publication of a manuscript. Ethical approval is not required for this study.

Systematic Review and Meta-Analysis of Studies Evaluating Diagnostic Test Accuracy: A Practical Review for Clinical Researchers-Part I. General Guidance and Tips

In the field of diagnostic test accuracy (DTA), the use of systematic review and meta-analyses is steadily increasing. By means of objective evaluation of all available primary studies, these two processes generate an evidence-based systematic summary regarding a specific research topic. The methodology for systematic review and meta-analysis in DTA studies differs from that in therapeutic/interventional studies, and its content is still evolving. Here we review the overall process from a practical standpoint, which may serve as a reference for those who implement these methods.

Comparative effectiveness of inhaled corticosteroids for paediatric asthma: protocol for a systematic review and Bayesian network meta-analysis

INTRODUCTION

Use of inhaled corticosteroid (ICS) is the mainstream maintenance therapy for paediatric asthma. Several forms of ICS are available, but the relative effectiveness among ICS has not been well investigated in published, randomised, controlled trials. The paucity of direct comparisons between ICS may have resulted in insufficient estimation in former systematic reviews/meta-analyses. To supplement the information on the comparative effectiveness of ICS for paediatric asthma, we plan to conduct a network meta-analysis that will enable summary of direct and indirect evidence.

METHODS AND ANALYSIS

We will retrieve randomised, controlled trials that examined the effectiveness of ICS for paediatric asthma from the PubMed and Cochrane Central Register of Controlled Trials. After one author scans the title and abstract for eligible studies, two authors will independently review study data and assess the quality of the study. Studies of children (≤18 years old) with chronic asthma or recurrent wheezing episodes will be included if they used ICS for ≥4 weeks. We will define a priori core outcomes and supplemental outcomes of paediatric asthma, including exacerbation, healthcare use and pulmonary function. Studies reporting a minimum of one core outcome will be entered into the systematic review. After the systematic review is performed, extracted data of relevant studies will be synthesised in the Bayesian framework using a random-effects model.

ETHICS AND DISSEMINATION

The results will be disseminated through peer-reviewed publications and conference presentations.

PROTOCOL REGISTRATION NUMBER

UMIN (000016724) and PROSPERO (CRD42015025889).

Multimorbidity and functional decline in community-dwelling adults: a systematic review

BACKGROUND

Multimorbidity affects up to one quarter of primary care populations. It is associated with reduced quality of life, an increased risk of mental health difficulties and increased healthcare utilisation. Functional decline is defined as developing difficulties with activities of daily living and is independently associated with poorer health outcomes. The aim of this systematic review was to examine the association between multimorbidity and functional decline and to what extent multimorbidity predicts future functional decline.

METHODS

A systematic literature search (1990-2014) and narrative analysis was conducted.

INCLUSION CRITERIA

Population; Community-dwelling adults (≥18 years), Risk; Multimorbidity defined as the presence of ≥2 chronic medical conditions in an individual, Primary outcome; Physical functional decline measured using a validated instrument, Study design; cross-sectional or cohort studies. The following databases were included: PubMed, EMBASE, CINAHL, the Cochrane Library and the International Research Community on Multimorbidity (IRCMo) publication list. Methodological quality assessment of included studies was conducted with a suitable risk of bias tool.

RESULTS

A total of 37 studies were eligible for inclusion (28 cross-sectional studies and 9 cohort studies). The majority of cross-sectional studies (n = 24/28) demonstrated a consistent association between multimorbidity and functional decline. Twelve of these studies reported that increasing numbers of chronic condition counts were associated with worsening functional decline. Nine cohort studies included 14,133 study participants with follow-up periods ranging from one to six years. The majority (n = 5) found that multimorbidity predicted functional decline. Of the five studies that reported the impact of increasing numbers of conditions, all reported greater functional decline with increasing numbers of conditions. One study examined disease severity and found that this also predicted greater functional decline. Overall, cohort studies were of good methodological quality but were mixed in terms of participants, multimorbidity definitions, follow-up duration, and outcome measures.

CONCLUSIONS

The available evidence indicates that multimorbidity predicts future functional decline, with greater decline in patients with higher numbers of conditions and greater disease severity. This review highlights the importance of considering physical functioning when designing interventions and systems of care for patients with multimorbidity, particularly for patients with higher numbers of conditions and greater disease severity.

Multimorbidity and functional decline in community-dwelling adults: a systematic review

BACKGROUND

Multimorbidity affects up to one quarter of primary care populations. It is associated with reduced quality of life, an increased risk of mental health difficulties and increased healthcare utilisation. Functional decline is defined as developing difficulties with activities of daily living and is independently associated with poorer health outcomes. The aim of this systematic review was to examine the association between multimorbidity and functional decline and to what extent multimorbidity predicts future functional decline.

METHODS

A systematic literature search (1990-2014) and narrative analysis was conducted.

INCLUSION CRITERIA

Population; Community-dwelling adults (≥18 years), Risk; Multimorbidity defined as the presence of ≥2 chronic medical conditions in an individual, Primary outcome; Physical functional decline measured using a validated instrument, Study design; cross-sectional or cohort studies. The following databases were included: PubMed, EMBASE, CINAHL, the Cochrane Library and the International Research Community on Multimorbidity (IRCMo) publication list. Methodological quality assessment of included studies was conducted with a suitable risk of bias tool.

RESULTS

A total of 37 studies were eligible for inclusion (28 cross-sectional studies and 9 cohort studies). The majority of cross-sectional studies (n = 24/28) demonstrated a consistent association between multimorbidity and functional decline. Twelve of these studies reported that increasing numbers of chronic condition counts were associated with worsening functional decline. Nine cohort studies included 14,133 study participants with follow-up periods ranging from one to six years. The majority (n = 5) found that multimorbidity predicted functional decline. Of the five studies that reported the impact of increasing numbers of conditions, all reported greater functional decline with increasing numbers of conditions. One study examined disease severity and found that this also predicted greater functional decline. Overall, cohort studies were of good methodological quality but were mixed in terms of participants, multimorbidity definitions, follow-up duration, and outcome measures.

CONCLUSIONS

The available evidence indicates that multimorbidity predicts future functional decline, with greater decline in patients with higher numbers of conditions and greater disease severity. This review highlights the importance of considering physical functioning when designing interventions and systems of care for patients with multimorbidity, particularly for patients with higher numbers of conditions and greater disease severity.

The association of circulating 25-hydroxyvitamin D concentration with peripheral arterial disease: A meta-analysis of observational studies

BACKGROUND AND AIMS

The association of vitamin D deficiency with cardiovascular disease is controversial. The present meta-analysis was performed to examine if circulating levels of 25-hydroxyvitamin D [25(OH)D] were lower in patients with peripheral artery disease (PAD) when compared to non-PAD controls.

METHODS

A comprehensive database search was conducted in Web of science, Scopus, PubMed, EMBASE and The Cochrane Library to identify observational studies reporting 25(OH)D concentrations in PAD patients and non-PAD participants. Data extraction and study quality assessments were conducted independently. A random-effects model was used to meta-analyse extracted data and generate standardized mean differences (SMDs) in circulating 25(OH)D levels between PAD patients and non-PAD controls. Subgroup analyses were conducted focussing on patients presenting with intermittent claudication (IC) and critical limb ischaemia (CLI).

RESULTS

Six case-control studies assessing 6418 individuals fulfilled the inclusion criteria. Two studies were considered to be of moderate methodological quality and four were considered to be of high quality. A meta-analysis of data from 1217 PAD patients and 5201 non-PAD participants showed that circulating 25(OH)D concentrations were lower in PAD patients compared with non-PAD participants (SMD = -0.32, 95% CI: -0.58, -0.05; P = 0.02). Subgroup analyses showed that 25(OH)D levels were significantly lower among PAD patients with CLI, but not IC, when compared to non-PAD controls (SMD = -1.29, 95% CI: -1.66, -0.91; P < 0.001 and SMD = -0.01, 95% CI: -0.15, 0.13; P=0.88, respectively).

CONCLUSIONS

This meta-analysis suggests that low levels of circulating 25(OH)D are associated with PAD presence, particularly in patients presenting with CLI. These data suggest the possibility that vitamin D insufficiency may contribute to the development of more advanced PAD although this remains to be confirmed.

Economic evaluations of follow-up strategies for cancer survivors: a systematic review and quality appraisal of the literature

The aim of this study was to review and critically assess the health economics literature on post-treatment follow-up for adult cancer survivors. A systematic search was performed using PubMed, EMBASE and the Cochrane Library. The Consolidated Health Economic Evaluation Reporting Standards checklist was adopted to assess the quality of the included studies. Thirty-nine articles met the eligibility criteria. Around two thirds of the studies addressed the most common cancers (i.e., breast, colorectal, cervical and lung); 21 were based on a single clinical study, while the rest were modeling papers. All types of economic evaluations were represented other than cost-benefit analysis. The overall quality was generally high with an average proportion of 74% of checklist criteria fulfilled. The cost-effectiveness results supported the current trend towards less intensive, primary care-based and risk-adapted follow-up schemes.

Radiofrequency Ablation Turbinoplasty versus Microdebrider-Assisted Turbinoplasty: A Systematic Review and Meta-analysis

OBJECTIVE

To critically review published literature for treatment-related outcomes for bilateral inferior turbinate reduction (IFTR) via either microdebrider-assisted turbinoplasty (MAT) or radiofrequency turbinoplasty. The primary outcomes were relief of nasal obstruction according to visual analog scale and nasal airflow, volume, and resistance measures based on acoustic rhinomanometry.

DATA SOURCES

MEDLINE, EMBASE, The Cochrane Catalog, and CINAHL.

REVIEW METHODS

The databases were searched with the terms "turbinoplasty" and "turbinate reduction." Inclusion criteria were English language, human subjects, and studies specifically relating to IFTR with radiofrequency turbinoplasty or MAT. Exclusion criteria were pediatric patients and concurrent nasal procedures. Results were tabulated, and the data were analyzed per random effects modeling. Subgroup analysis and quality assessment were also performed.

RESULTS

A total of 976 articles were initially identified, with 26 meeting the inclusion/exclusion criteria. Random effects modeling demonstrated a significant improvement after IFTR, as measured with the visual analog scale (4.26-point improvement, 95% confidence interval [95% CI] = 3.32-5.20, P < .001, k = 21 studies, I(2) = 99%) and with acoustic rhinomanometry measurements of volume (2.43-cm(3) improvement, 95% CI = 0.48-4.38, P = .015, k = 6 studies, I(2) = 99%), flow (203-mL/s improvement, 95% CI = 131-276, P < .001, k = 4 studies, I(2) = 99%), and resistance change (2.78-Pa/cm(3) improvement, 95% CI = 0.433-5.13, P = .020, k = 5 studies, I(2) = 99%). There was no difference in outcome by technique, allergic rhinitis, or quality score. The 2 highest-quality papers favored MAT. The median follow-up was 6 months.

CONCLUSIONS

IFTR produces a significant subjective and objective improvement in nasal airflow in the short term. This change does not appear to be related to the technique used for IFTR.

Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature

OBJECT Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation. RESULTS Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation. CONCLUSIONS While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have acceptable complication profiles. LLIF had higher rates of sensory as well as temporary and permanent neurological symptoms, although rates of intraoperative and wound complications were less than MI-TLIF. Larger, prospective comparative studies are needed to confirm these findings as the current literature is of relative poor quality.

Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol

BACKGROUND

Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery.

METHODS/DESIGN

This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool.

DISCUSSION

We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015001068.

Community-onset sepsis and its public health burden: protocol of a systematic review

BACKGROUND

Sepsis is a life-threatening condition and major contributor of public health and economic burden in the industrialised world. The heterogeneity, absence of more specific definition, and difficulties in accurate diagnosis lead to great variability in the estimates of sepsis incidence. There has been uncertainty regarding the incidence and risk factors attributable to community-onset as opposed to hospital-acquired sepsis. Community-onset sepsis has distinct host characteristics, risk factors, pathogens, and prognosis. A systematic assessment of recent evidence is warranted in light of secular changes in epidemiology, pathogens, and the uncertainties around the incidence and risk factors of community-onset sepsis. This protocol describes a systematic review which aims to synthesise the recent empirical evidence on the incidence and risk factors of community-onset sepsis, severe sepsis, and septic shock in high-income countries.

METHODS/DESIGN

English-language publications of cohort and case-control studies reporting incidence and risk factors of community-onset sepsis will be eligible for inclusion. MEDLINE and Embase databases will be searched from 2002 and onwards. References of relevant publications will be hand-searched. Two reviewers will independently screen titles/abstracts and full texts as well as extract data and appraise the risk of bias of included studies. The data extractions and risk of bias assessments will be cross-checked. Any disagreements will be resolved via consensus. The data on incidence and risk factors of sepsis will be organised and synthesised in text, tables, and forest plots. The evidence will be pooled given sufficient data and degree of similarity across study populations, exposures, and outcomes. The heterogeneity will be assessed through visual inspection of forest plots, Chi-square-based p value, and I (2) statistic. The sources of heterogeneity will be explored via subgroup analysis.

DISCUSSION

Timeliness and accuracy of diagnosis of sepsis are both crucial aspects for improving the patient's outcome. The findings of this review will be discussed with a view to better inform future recommendations on improving public-facing campaigns, timely presentation, and diagnosis of sepsis in the community. The review will also discuss gaps in evidence and highlight future research and policy-making avenues for improving public health planning.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015023484.

Smoking, Suicidality and Psychosis: A Systematic Meta-Analysis

The aim of this study is to systematically review the literature that explored the association between smoking and suicidal risk among those with serious mental illness and to estimate the risk of suicidal behaviors attributable to smoking among this patient group. Multiple databases (CINAHL, PsycINFO, EMBASE, Informit Health Collection and the Cochrane Library databases) were searched from 1 January 1975 through 15 January 2014, along with references from relevant articles for observational studies that ascertained the association between smoking and suicidal behaviors among patients with psychotic disorders conducted in adult patients. Thirteen studies involving 6813 patients with severe mental illness were included. We found that smoking was significantly associated with suicidality in psychosis with an Odds Ratio of 2.12 (95% CI 1.67–2.7). Smoking is associated with suicidal risk amongst individuals with a severe mental illness; however, it is still unclear whether this represents a true risk factor or a confounder or a mediator via mechanisms, hitherto unknown, needs to be studied further.

Disparities in the completion of steps to kidney transplantation: protocol for a systematic review

INTRODUCTION

Disparities in access to transplantation have been well documented. The extant literature, however, focuses largely on disparities and related barriers for African-American patients and none has used the steps to transplantation as a guiding framework. This review will catalogue disparities in the steps to transplantation as well as the barriers and facilitators to completion of each step identified in the extant literature. The results of the review will be used to generate recommendations for future research to improve equity in access to kidney transplantation.

METHODS AND ANALYSIS

Standard procedures will be used in the conduct of the review. Searches will be performed using the following electronic databases: PubMed/Medline, PsycINFO, CINHAL, EMBASE, Cochrane library and Web of Science. Reports of original research will be eligible for inclusion if they are published from 2005 to present, written or available in English language, performed in the USA, enrol adult participants (18 years of age or more), and employ descriptive or observational designs. Two authors will independently screen retrieved articles for inclusion. MaxQDA will be used for data analysis and management. All included reports will be coded for article characteristics; disparities identified; barriers and motivators of completion of steps to transplantation; and proposed solutions to disparities and barriers. Each report will be coded independently by two authors and discrepancies resolved by discussion among the full team. A qualitative approach to data analysis is planned. Risk of bias will be assessed using standard procedures.

ETHICS AND DISSEMINATION

The findings will provide crucial information on the current status of disparities in access to transplantation. PRISMA guidelines will be followed in reporting the results of the review. It is anticipated that these results will inform research which seeks to increase parity in access to transplantation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014015027.

Risk of All-Cause Mortality in Alcohol-Dependent Individuals: A Systematic Literature Review and Meta-Analysis

Background

Alcohol dependence (AD) carries a high mortality burden, which may be mitigated by reduced alcohol consumption. We conducted a systematic literature review and meta-analysis investigating the risk of all-cause mortality in alcohol-dependent subjects.

Methods

MEDLINE, MEDLINE In-Process, Embase and PsycINFO were searched from database conception through 26th June 2014. Eligible studies reported all-cause mortality in both alcohol-dependent subjects and a comparator population of interest. Two individuals independently reviewed studies. Of 4540 records identified, 39 observational studies were included in meta-analyses.

Findings

We identified a significant increase in mortality for alcohol-dependent subjects compared with the general population (27 studies; relative risk [RR] = 3.45; 95% CI [2.96, 4.02]; p < 0.0001). The mortality increase was also significant compared to subjects qualifying for a diagnosis of alcohol abuse or subjects without alcohol use disorders (AUDs). Alcohol-dependent subjects continuing to drink heavily had significantly greater mortality than alcohol-dependent subjects who reduced alcohol intake, even if abstainers were excluded (p < 0.05).

Interpretation

AD was found to significantly increase an individual's risk of all-cause mortality. While abstinence in alcohol-dependent subjects led to greater mortality reduction than non-abstinence, this study suggests that alcohol-dependent subjects can significantly reduce their mortality risk by reducing alcohol consumption.

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A systematic review and meta-analysis were performed to investigate mortality risk in alcohol-dependent individuals.

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Alcohol dependence was associated with significantly higher mortality risk vs the general population, and vs alcohol abuse.

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Alcohol-dependent people with reduced alcohol consumption lowered their mortality risk, even if abstinence was not reached.

Individuals with alcohol dependence have a high risk of disease, disability or death. Treatment has traditionally focused on promoting abstinence, although some alcohol-dependent individuals would prefer to continue drinking in a controlled manner. By statistically combining results from previously published studies identified in a systematic literature review, we have shown that mortality among alcohol-dependent individuals is three to four times higher than in the general population. We have also found that individuals with alcohol dependence can reduce their risk of death by reducing alcohol consumption, even if they do not achieve abstinence.

Resilience in Vulnerable Populations With Type 2 Diabetes Mellitus and Hypertension: A Systematic Review and Meta-analysis

BACKGROUND

Patients with chronic conditions and limited access to health care experience stressful challenges resulting from the burden of managing both their conditions and their daily life demands. Resilience provides a mechanism of adapting to stressful experiences. We conducted a systematic review and meta-analysis to synthesize the evidence about interventions to enhance resiliency in managing hypertension or type 2 diabetes in vulnerable populations and to assess the efficacy of these interventions on clinical outcomes.

METHODS

We searched multiple databases from early inception through February 2015 including randomized controlled trials that enrolled patients with type 2 diabetes or hypertension. All interventions that targeted resilience in vulnerable populations were included. Data were synthesized to describe the characteristics and efficacy of resiliency interventions. We pooled the total effects by calculating standardized mean difference using the random-effects model.

RESULTS

The final search yielded 17 studies. All studies were conducted in the United States and generally targeted minority participants. Resiliency interventions used diverse strategies; discussion groups or workshops were the most common approach.

CONCLUSIONS

Interventions aimed at enhancing the resiliency of patients from vulnerable groups are diverse. Outcomes were not fully conclusive. There was some evidence that resiliency interventions had a positive effect on hemoglobin A1C levels but not blood pressure. The incorporation of resiliency-oriented interventions into the arsenal of preventing and managing chronic conditions appears to be an opportunity that remains to be better investigated and exploited, and there is need to pursue further understanding of the core components of any intervention that claims to enhance resilience.

Reminiscence Therapy Improves Cognitive Functions and Reduces Depressive Symptoms in Elderly People With Dementia: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Cognitive function impairments and depressive symptoms are common in elderly people with dementia. Previous meta-analyses of outdated and small-scale studies have reported inconsistent results regarding the effects of reminiscence therapy on cognitive functions and depressive symptoms; therefore, we conducted a meta-analysis by including more recent randomized controlled trials (RCTs) with large sample sizes to investigate the immediate and long-term (6-10 months) effects of reminiscence therapy on cognitive functions and depressive symptoms in elderly people with dementia.

REVIEW METHODS

Electronic databases, including PubMed, Medline, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, ProQuest, Google Scholar, and Chinese databases were searched to select eligible articles. Primary outcome measures included the scores of cognitive functions and depressive symptoms. In total, 12 RCT studies investigating the effects of reminiscence therapy on cognitive functions and depressive symptoms in elderly people with dementia were included. Two reviewers independently extracted data. All analyses were performed using a random-effects model.

RESULTS

Reminiscence therapy had a small-size effect on cognitive functions (g = 0.18, 95% confidence interval [CI] 0.05-0.30) and a moderate-size effect on depressive symptoms (g = -0.49, 95% CI -0.70 to -0.28) in elderly people with dementia. Long-term effects of reminiscence therapy on cognitive functions and depressive symptoms were not confirmed. Moderator analysis revealed that institutionalized elderly people with dementia exhibited greater improvement in depressive symptoms than community-dwelling people with dementia did (g = -0.59 vs. -0.16, P = .003).

CONCLUSIONS

This meta-analysis confirms that reminiscence therapy is effective in improving cognitive functions and depressive symptoms in elderly people with dementia. Our findings suggest that regular reminiscence therapy should be considered for inclusion as routine care for the improvement of cognitive functions and depressive symptoms in elderly people with dementia, particularly in institutionalized residents with dementia.

Four Proposals to Help Improve the Medical Research Literature

David Moher and Douglas Altman outline four potential interventions that may improve the quality of peer-reviewed medical research publications.

Predictors of exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure: A meta-regression analysis

BACKGROUND

The aim of this study was to undertake a comprehensive assessment of the patient, intervention and trial-level factors that may predict exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure.

DESIGN

Meta-analysis and meta-regression analysis.

METHODS

Randomized controlled trials of exercise-based rehabilitation were identified from three published systematic reviews. Exercise capacity was pooled across trials using random effects meta-analysis, and meta-regression used to examine the association between exercise capacity and a range of patient (e.g. age), intervention (e.g. exercise frequency) and trial (e.g. risk of bias) factors.

RESULTS

55 trials (61 exercise-control comparisons, 7553 patients) were included. Following exercise-based rehabilitation compared to control, overall exercise capacity was on average 0.95 (95% CI: 0.76-1.41) standard deviation units higher, and in trials reporting maximum oxygen uptake (VO2max) was 3.3 ml/kg.min(-1) (95% CI: 2.6-4.0) higher. There was evidence of a high level of statistical heterogeneity across trials (I(2) statistic > 50%). In multivariable meta-regression analysis, only exercise intervention intensity was found to be significantly associated with VO2max (P = 0.04); those trials with the highest average exercise intensity had the largest mean post-rehabilitation VO2max compared to control.

CONCLUSIONS

We found considerable heterogeneity across randomized controlled trials in the magnitude of improvement in exercise capacity following exercise-based rehabilitation compared to control among patients with coronary heart disease or heart failure. Whilst higher exercise intensities were associated with a greater level of post-rehabilitation exercise capacity, there was no strong evidence to support other intervention, patient or trial factors to be predictive.

Reporting Quality of Systematic Reviews and Meta-Analyses of Otorhinolaryngologic Articles Based on the PRISMA Statement

Background

Systematic reviews (SRs) and meta-analyses (MAs) provide the highest possible level of evidence. However, poor conduct or reporting of SRs and MAs may reduce their utility. The PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses) was developed to help authors report their SRs and MAs adequately.

Objectives

Our objectives were to (1) evaluate the quality of reporting of SRs and MAs and their abstracts in otorhinolaryngologic literature using the PRISMA and PRISMA for Abstracts checklists, respectively, (2) compare the quality of reporting of SRs and MAs published in Ear Nose Throat (ENT) journals to the quality of SRs and MAs published in the ‘gold standard’ Cochrane Database of Systematic Reviews (CDSR), and (3) formulate recommendations to improve reporting of SRs and MAs in ENT journals.

Methods

On September 3, 2014, we searched the Pubmed database using a combination of filters to retrieve SRs and MAs on otorhinolaryngologic topics published in 2012 and 2013 in the top 5 ENT journals (ISI Web of Knowledge 2013) or CDSR and relevant articles were selected. We assessed how many, and which, PRISMA (for Abstracts) items were reported adequately per journal type.

Results

We identified large differences in the reporting of individual items between the two journal types with room for improvement. In general, SRs and MAs published in ENT journals (n = 31) reported a median of 54.4% of the PRISMA items adequately, whereas the 49 articles published in the CDSR reported a median of 100.0 adequately (difference statistically significant, p < 0.001). For abstracts, medians of 41.7% for ENT journals and 75.0% for the CDSR were found (p < 0.001).

Conclusion

The reporting of SRs and MAs in ENT journals leaves room for improvement and would benefit if the PRISMA Statement were endorsed by these journals.

Prevalence of group A streptococcal disease in North and Sub-Saharan Africa: a systematic review protocol

INTRODUCTION

The true burden of group A streptococcal (GAS) disease in Africa is not known. GAS is a significant cause of mortality and morbidity on the global scale and in developing countries. According to Carapetis et al, the prevalence of severe GAS disease is at least 18.1 million cases with an incidence of at least 1.78 million cases per year.

METHODS AND ANALYSES

We aim to provide a systematic review of studies measuring the prevalence of GAS infection among people in North and Sub-Saharan African countries. A comprehensive literature search of a number of databases will be undertaken, using an African search filter, to identify GAS prevalence studies that have been published. Full copies of articles will be identified by a defined search strategy and will be considered for inclusion against predefined criteria. Statistical analysis will include two steps: (1) identification of data sources and documenting of estimates, and (2) the application of the random-effects and fixed-effects meta-analysis model to aggregate prevalence estimates, and to account for between study variability in calculating the overall pooled estimates and 95% CI for GAS prevalence. Heterogeneity will be evaluated using the I(2) statistic to determine the extent of variation in effect estimates that is due to heterogeneity rather than chance. This systematic review protocol was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) 2015 Statement. This review will provide updated evidence of a review published in 2009. Our data will have implications for the development of a GAS vaccine.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study given that this is a protocol for a systematic review of published studies. The results of this study will be disseminated through a peer-reviewed publication and conference presentation.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD4201401290 0. (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012900).

Application of meta-analysis to specific research fields: Lessons learned

Scientific research is challenged to translate findings from multiple, often conflicting, clinical trials into a simple answer of whether a treatment works or not. The public and healthcare providers alike frequently voice their frustrations when the media reports a treatment working on one day, but seemingly the next day reports a study refuting the previous one. Meta-analyses are being used more commonly by researchers to convey an understandable summary of scientific studies to the general public and healthcare providers. As time goes by, we have learned how to improve meta-analytic techniques to reflect more valid results and when it is appropriate to pool or not to pool results from different studies. Retrospective reviews often don’t acknowledge this learning curve and may fail to recommend the most current valid guidelines. This editorial presents an example of how the current use of meta-analysis has shifted in one field (the therapeutic effects of probiotics) and recommendations on how to correctly interpret the results of such an analysis.

Effective components of exercise and physical activity-related behaviour-change interventions for chronic non-communicable diseases in Africa: protocol for a systematic mixed studies review with meta-analysis

INTRODUCTION

Chronic non-communicable diseases (NCDs) account for a high burden of mortality and morbidity in Africa. Evidence-based clinical guidelines recommend exercise training and promotion of physical activity behaviour changes to control NCDs. Developing such interventions in Africa requires an understanding of the essential components that make them effective in this context. This is a protocol for a systematic mixed studies review that aims to determine the effective components of exercise and physical activity-related behaviour-change interventions for chronic diseases in Africa, by combining quantitative and qualitative research evidence from studies published until July 2015.

METHODS AND ANALYSIS

We will conduct a detailed search to identify all published and unpublished studies that assessed the effects of exercise and physical activity-related interventions or the experiences/perspectives of patients to these interventions for NCDs from bibliographic databases and the grey literature. Bibliographic databases include MEDLINE, EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), PsycINFO, CINAHL and Web of Science. We will include the following African regional databases: African Index Medicus (AIM) and AFROLIB, which is the WHO's regional office database for Africa. The databases will be searched from inception until 18 July 2015. Appraisal of study quality will be performed after results synthesis. Data synthesis will be performed independently for quantitative and qualitative data using a mixed methods sequential explanatory synthesis for systematic mixed studies reviews. Meta-analysis will be conducted for the quantitative studies, and thematic synthesis for qualitative studies and qualitative results from the non-controlled observational studies. The primary outcome will include exercise adherence and physical activity behaviour changes. This review protocol is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analysis protocols (PRISMA-P) 2015 guidelines.

ETHICS AND DISSEMINATION

There is no ethical requirement for this study, as it utilises published data. This review is expected to inform the development of exercise and physical activity-related behaviour-change interventions in Africa, and will be presented at conferences, and published in peer reviewed journals and a PhD thesis at King's College London.

PROTOCOL REGISTRATION NUMBER

This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 22 January 2015 (registration number: PROSPERO 2015: CRD42015016084).

Determining the number of stimuli required to reliably assess corticomotor excitability and primary motor cortical representations using transcranial magnetic stimulation (TMS): a protocol for a systematic review and meta-analysis

BACKGROUND

Transcranial magnetic stimulation (TMS) is a technique that can be used to assess corticospinal plasticity. Current TMS practices involve the administration of multiple stimuli over target areas of the participant's scalp. However, these procedures require 1 to 2 h per assessment. Decreasing the number of stimuli delivered during TMS assessments would improve time efficiency and decrease participant demand. Thus, the aim of this review is to determine the number of TMS stimuli required to reliably measure (1) corticomotor excitability to a target muscle at a single cranial site and (2) the topography of the primary motor cortical representation for a target muscle across multiple cranial sites (termed 'mapping').

METHODS/DESIGN

A systematic review and meta-analysis will be conducted. Electronic databases will be searched using pre-determined search terms to identify relevant studies and evaluate the studies for inclusion and risks of bias. Two independent reviewers will extract the data. Any disagreements will be resolved by a third reviewer. Studies employing single-pulse TMS to measure (1) corticomotor excitability at a single cranial site or (2) the topographic cortical organisation of a target muscle across a number of cranial sites, published before May 2015, will be included if they meet the eligibility criteria. Outcomes will include motor-evoked potential amplitude, map volume, number of active map sites, location of the map centre of gravity, and distance between the centres of gravity of the target muscle and one or more neighbouring muscles.

DISCUSSION

To our knowledge, this review will be the first to systematically explore the number of TMS stimuli required to reliably measure both corticomotor excitability and the topography of primary motor cortical representations. This research has the capacity to improve the efficiency of TMS, decrease participant demand, and facilitate the use of TMS as an outcome measurement tool in clinical populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024579.

Percutaneous versus surgical strategy for tracheostomy: protocol for a systematic review and meta-analysis of perioperative and postoperative complications

BACKGROUND

Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches to form a tracheostoma are the open surgical tracheotomy (ST) and the interventional strategy of percutaneous dilatational tracheotomy (PDT). It is particularly important to the critically ill patients that both procedures are performed with high success rates and low complication frequencies. Therefore, the aim of this systematic review is to summarize and analyze existing and relevant evidence for peri- and postoperative parameters of safety.

METHODS/DESIGN

A systematic literature search will be conducted in The Cochrane Library, MEDLINE, LILACS, and Embase to identify all randomized controlled trials (RCTs) comparing peri- and postoperative complications between the two strategies and to define the strategy with the lower risk of potentially life-threatening events. A priori defined data will be extracted from included studies, and methodological quality will be assessed according to the recommendations of the Cochrane Collaboration.

DISCUSSION

The findings of this systematic review with proportional meta-analysis will help to identify the strategy with the lowest frequency of potentially life-threatening events. This may influence daily practice, and the data may be implemented in treatment guidelines or serve as the basis for planning further randomized controlled trials. Considering the critical health of these patients, they will particularly benefit from evidence-based treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015021967.

Parent/caregiver health literacy among children with special health care needs: a systematic review of the literature

Background

Children with special health care needs (CSHCN) are children with medical or behavioral diagnoses that require services beyond those generally needed by pediatric populations. They account for a significant portion of pediatric health care expenditures and often have complicated treatment regiments. Health literacy has recently been recognized as a key indicator of quality chronic disease self-management and parental/caregiver health literacy of CSHCN is an understudied area. The purpose of this systematic review was to assess the available evidence of studies investigating parent/caregiver health literacy of CSHCN.

Methods

Databases were searched to retrieve relevant articles for inclusion (dating from 1998 to 2014). Only studies that assessed the relationship between parent/caregiver health literacy on outcomes pertinent to CSHCN were included. Because of the limited number of studies, there were no restrictions placed on type of outcome.

Results

Thirteen studies were included in the final review with a range of health literacy assessments and outcome ascertainment. The majority of studies; (1) focused on the relationship between parental/caregiver health literacy and asthma outcomes, (2) were cross-sectional study designs, and (3) included samples recruited from pediatric clinics in academic medical settings.

Conclusions

There were several gaps in the literature where future research is needed including; (1) direct assessment of child/adolescent health literacy, (2) inclusion of children with co-morbid conditions, (3) further assessment of the relationship between health literacy and health care utilization and cost, and (4) assessment of parental/caregiver health literacy in the inpatient care setting.

Minimally invasive versus standard percutaneous nephrolithotomy: a meta-analysis

The aim of the study was to objectively analyze the outcomes for minimally invasive percutaneous nephrolithotomy (MPCNL) vs standard percutaneous nephrolithotomy (PCNL) by systematic review and meta-analysis of published data. A systematic literature review was performed in November 2014 using the PUBMED, EMBASE and Cochrane Library databases to identify relevant studies. Only comparative studies investigating MPCNL vs PCNL were included. Effect sizes were estimated by pooled odds ratio (ORs) and mean differences (MDs). The analyzed outcomes were stone-free rate (SFR), blood loss, pain assessment, operative time, hospital stay and complications. We identified 8 trials with a total 749 patients. 353 patients were treated with MPCNL and 396 with PCNL. Meta-analysis of the data showed that there was no difference in SFR between MPCNL and PCNL (OR 1.06, 95% CI 0.71-1.58). Patients in the MPCNL group experienced less drop in hemoglobin (MD: -4.67 g/L, 95% CI -7.29 to -2.04), a lower incidence of blood transfusion (OR 0.18, 95% CI 0.06-0.54), less pain (visual analog score) (MD: -0.53, 95% CI -0.94 to -0.13) and shorter hospitalization (MD: -1.32 days, 95% CI -2.15 to -0.50). Operative time was longer in the MPCNL group (MD: 15.54 min, 95% CI 4.25-26.83). Postoperative fever and pyelocalyceal perforation did not differ between the groups (p = 0.38 and 0.44, respectively). Current evidence suggested that MPCNL was a safe and effective procedure with an SFR comparable to that of PCNL. MPCNL resulted in less bleeding, fewer transfusion, less pain and shorter hospitalization. Well-designed multicentric/international randomized, controlled trials are still needed.