Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies

Effects of short-chain fatty acids on blood glucose and lipid levels in mouse models of diabetes mellitus: A systematic review and network meta-analysis

Short-chain fatty acids (SCFAs), the main metabolites of gut microbiota, have been associated with lower blood glucose and lipid levels in diabetic mice. However, a comprehensive summary and comparison of the effects of different SCFA interventions on blood glucose and lipid levels in diabetic mice is currently unavailable. This study aims to compare and rank the effects of different types of SCFAs on blood glucose and lipid levels by collecting relevant animal research. A systematic search through PubMed, Embase, Cochrane Library, and Web of Science database was conducted to identify relevant studies from inception to March 17, 2023. Both pairwise meta-analysis and Bayesian network meta-analysis were used for statistical analyses. In total, 18 relevant studies involving 5 interventions were included after screening 3793 citations and 53 full-text articles. Notably, butyrate therapy (mean difference [MD] = -4.52, 95% confidence interval [-6.29, -2.75]), acetate therapy (MD = -3.12, 95% confidence interval [-5.79, -0.46]), and propionate therapy (MD = -2.96, 95% confidence interval [-5.66, -0.26]) significantly reduced the fasting blood glucose levels compared to the control group; butyrate therapy was probably the most effective intervention, with a surface under the cumulative ranking curve (SUCRA) value of 85.5%. Additionally, acetate plus propionate therapy was probably the most effective intervention for reducing total cholesterol (SUCRA = 85.8%) or triglyceride levels (SUCRA = 88.1%). These findings underscore the potential therapeutic implications of SCFAs for addressing metabolic disorders, particularly in type 2 diabetes mellitus.

The Efficacy and Safety of Regimens for Helicobacter pylori Eradication Treatment in China: A Systemic Review and Network Meta-Analysis

BACKGROUND

With Helicobacter pylori's increasing antibiotic resistance, evidence of more effective treatments is lacking in China, where H. pylori prevalence is nearly 50%. Thus, we performed a network meta-analysis to compare therapeutic regimens.

METHODS

Data extracted from eligible randomized controlled trials from January 2000 to September 2021 were entered into a Bayesian hierarchical random-effects model to evaluate the efficacy and safety of H. pylori eradication regimens.

RESULTS

This study included 101 trials involving 21,745 patients. Vonoprazan-bismuth-containing quadruple therapy (VBQT) ranked the highest [surfaces under cumulative ranking curve (SUCRA), 83.64%], followed by high-dose amoxicillin dual therapy (HDDT) [SUCRA, 79.70%, odds ratio (OR)=1.31, 95% credible interval (CrI) (0.36, 4.72)] and proton pump inhibitor-based bismuth-containing quadruple therapy (BQT) [SUCRA, 63.59%, OR=1.59, 95% CrI (0.48, 5.24)]. HDDT [OR=2.47, 95% CrI (1.51, 4.06)], BQT [OR=2.04, 95% CrI (1.69, 2.47)], concomitant quadruple nonbismuth therapy (CT) [OR=1.93, 95% CrI (1.19, 3.15)], and sequential therapy (ST) [OR=1.86, 95% CrI (1.50, 2.32)] had higher eradication rates than standard triple therapy (TT). ST (SUCRA, 82.52%) and VBQT (SUCRA, 83.89%) had the highest eradication rate before and after 2010 in the effectiveness ranking, respectively. Furthermore, the H. pylori eradication rate of patients receiving 14-day BQT treatment was higher than that of 10-day BQT regimen [OR=2.55, 95% CI (1.84, 3.53)] and 7-day BQT regimen [OR=3.64, 95% CI (2.64, 5.01)].

CONCLUSIONS

The TT regimen was not an optimal choice in China for H. pylori eradication; VBQT, HDDT, and BQT showed better efficacy. After 2010, there is a trend toward significance that VBQT provided a higher H. pylori eradication rate in China, but with only 1 randomized controlled trial. Thus, more supportive real-world data are needed to confirm its effectiveness.

Oral analgesic for musculoskeletal injuries in children: A systematic review and network meta-analysis

OBJECTIVE

Pain in pediatric musculoskeletal (MSK) injuries can lead to increased anxiety, fear, and avoidance of medical care, making analgesic management critical. Therefore, we evaluated analgesic efficacy and adverse effects to select the optimal analgesic agent in pediatric patients with MSK injuries.

METHODS

Four databases were searched from inception to March 2023 for peer-reviewed, open randomized controlled trials (RCTs). Inclusion criteria were: (1) trials with RCT design, (2) children aged 1 month-18 years with MSK injury, (3) outpatient setting, (4) interventions and control, (5) primary outcome of pain score at 60 and 120 min and secondary outcome of adverse effects, and (6) full-text and peer-reviewed articles. Two reviewers screened, extracted data, and assessed the risk of bias. A frequentist random-effects network meta-analysis (NMA) was performed. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach.

RESULTS

We included eight trials comprising 1645 children. Ibuprofen was significantly associated with pain reduction at 120 min, compared with acetaminophen (SMD 0.31 [95% CI 0.11-0.51]; moderate certainty) and opioids (SMD 0.34 [95% CI 0.20-0.48]; moderate certainty). Compared with opioids alone, ibuprofen-opioid combination was significantly associated with pain reduction at 120 min (SMD 0.19 [95% CI 0.03-0.35]). No significant differences were found in pain interventions at 60 min. Ibuprofen had statistically fewer adverse events than opioids (RR, 0.54 [95% CI 0.33-0.90]; moderate certainty) and ibuprofen with opioids (RR 0.47 [95% CI 0.25-0.89]; moderate certainty). In terms of limitations, the eight RCTs included had relatively small sample sizes; only two were high-quality RCTs.

CONCLUSIONS

Our NMA found ibuprofen to be the most effective and least adverse analgesic in pediatric patients with MSK injuries.

Exploring the Effectiveness of Self-Management Interventions in Type 2 Diabetes: A Systematic Review and Network Meta-Analysis

BACKGROUND

Chronic diseases are a leading cause of global morbidity and mortality. In response to this challenge, self-management interventions (SMIs) have emerged as an essential tool in improving patient outcomes. However, the diverse and complex nature of SMIs pose significant challenges in measuring their effectiveness. This work aims to investigate the comparative effectiveness of SMIs on Type 2 diabetes mellitus (T2DM) outcomes.

METHODS

A rigorous analytical framework was employed to assess the relative effectiveness of different SMIs, encompassing both pairwise and network meta-analysis (NMA), as well as component network meta-analysis (CNMA). Various outcomes were considered, including glycated hemoglobin (HbA1c) control, body mass index (BMI) reduction and low-density lipoprotein (LDL) cholesterol. Visualization tools were also utilized to enhance the interpretation of results.

RESULTS

SMIs were found promising in improving clinical outcomes and patient-reported measures. However, considerable heterogeneity and inconsistency across studies challenged the validity of NMA results. CNMA along with various visualization tools offered insights into the contributions of individual SMI components, highlighting the complexity of these interventions.

DISCUSSION/CONCLUSIONS

SMIs represent a valuable approach to managing chronic conditions, but their effectiveness is context-dependent. Further research is needed to elucidate the contextual factors influencing SMI outcomes. This work contributes to a comprehensive understanding of SMIs' role in T2DM management, aiming to aid decision-makers, clinicians, and patients in selecting tailored interventions.

Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials

OBJECTIVE

We explored the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD).

DESIGN

Systematic review and network meta-analysis of randomised clinical trials (RCTs).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, CENTRAL, and SCOPUS were searched to May 2021, and again in January 2023.

STUDY SELECTION

Interventional RCTs that enrolled patients presenting with chronic pain associated with TMD.

DATA EXTRACTION AND SYNTHESIS

Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We captured all reported patient-important outcomes, including pain relief, physical functioning, emotional functioning, role functioning, social functioning, sleep quality, and adverse events. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence and categorise interventions from most to least beneficial.

RESULTS

233 trials proved eligible for review, of which 153-enrolling 8713 participants and exploring 59 interventions or combinations of interventions-were included in network meta-analyses. All subsequent effects refer to comparisons with placebo or sham procedures. Effects on pain for eight interventions were supported by high to moderate certainty evidence. The three therapies probably most effective for pain relief were cognitive behavioural therapy (CBT) augmented with biofeedback or relaxation therapy (risk difference (RD) for achieving the minimally important difference (MID) in pain relief of 1 cm on a 10 cm visual analogue scale: 36% (95% CI 33 to 39)), therapist-assisted jaw mobilisation (RD 36% (95% CI 31 to 40)), and manual trigger point therapy (RD 32% (29 to 34)). Five interventions were less effective, yet more effective than placebo, showing RDs ranging between 23% and 30%: CBT, supervised postural exercise, supervised jaw exercise and stretching, supervised jaw exercise and stretching with manual trigger point therapy, and usual care (such as home exercises, self stretching, reassurance).Moderate certainty evidence showed four interventions probably improved physical functioning: supervised jaw exercise and stretching (RD for achieving the MID of 5 points on the short form-36 physical component summary score: 43% (95% CI 33 to 51)), manipulation (RD 43% (25 to 56)), acupuncture (RD 42% (33 to 50)), and supervised jaw exercise and mobilisation (RD 36% (19 to 51)). The evidence for pain relief or physical functioning among other interventions, and all evidence for adverse events, was low or very low certainty.

CONCLUSION

When restricted to moderate or high certainty evidence, interventions that promote coping and encourage movement and activity were found to be most effective for reducing chronic TMD pain.

REGISTRATION

PROSPERO (CRD42021258567).

Comparing the efficacies of transcranial magnetic stimulation treatments using different targeting methods in major depressive disorder: protocol for a network meta-analysis

INTRODUCTION

Transcranial magnetic stimulation (TMS) over the left dorsolateral prefrontal cortex (lDLPFC) has been widely used as a treatment for major depressive disorder (MDD) in the past two decades. Different methods for localising the lDLPFC target include the '5 cm' method, the F3 method and the neuro-navigational method. However, whether TMS efficacies differ between the three targeting methods remains unclear. We present a protocol for a systematic review and network meta-analysis (NMA) to compare the efficacies of TMS treatments using these three targeting methods in MDD.

METHODS AND ANALYSIS

Relevant studies reported in English or Chinese and published up to May 2023 will be identified from searches of the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, China National Knowledge Infrastructure, Wan Fang Database, Chinese BioMedical Literature Database, and China Science and Technology Journal Database. We will include all randomised controlled trials assessing the efficacy of an active TMS treatment using any one of the three targeting methods compared with sham TMS treatment or comparing efficacies between active TMS treatments using different targeting methods. Interventions must include a minimum of 10 sessions of high-frequency TMS over the lDLPFC. The primary outcome is the reduction score of the 17-item Hamilton Depression Rating Scale, 24-item Hamilton Depression Rating Scale or Montgomery-Asberg Depression Rating Scale. The dropout rate is a secondary outcome representing the TMS treatment's acceptability. Pairwise meta-analyses and a random-effects NMA will be conducted using Stata. We will use the surface under the cumulative ranking curve to rank the different targeting methods in terms of efficacy and acceptability.

ETHICS AND DISSEMINATION

This systematic review and NMA does not require ethics approval. The results will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023410273.

Ginger (Zingiber officinale Roscoe) preparations for prophylaxis of postoperative nausea and vomiting: A Bayesian network meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Ginger has been proposed for prevention of postoperative nausea and vomiting (PONV), however it remains equivocal whether ginger can be an alternative option and which certain preparation is optimal for PONV prophylaxis.

AIM OF THE STUDY

We conducted a network meta-analysis (NMA) to compare and rank relative efficacy for PONV control among all available ginger preparations collected in the databases.

METHODS

Eligible records were identified by retrieving Medline (via Pubmed), Embase, Web of Science, CENTRAL, CNKI, WHO ICTRP and ClinicalTrials.gov for randomized controlled trials that investigated the efficacy of ginger therapies for the prophylaxis of PONV. A bayesian NMA within random-effects models was implemented. Certainty of evidence for estimates was investigated following GRADE framework. We prospectively registered the protocol (CRD 42021246073) in PROSPERO.

RESULTS

Eighteen publications comprising 2199 participants with PONV were identified. Ginger oil (RR [95%CI], 0.39 [0.16, 0.96]) appeared to have the highest probability of being ranked best to decrease the incidence of postoperative vomiting (POV), with statistical significance compared with placebo, based on high to moderate confidence in estimates. With regard to reducing postoperative nausea (PON), statistically superiority was not observed in ginger regimens compared with placebo based on moderate to low certainty of evidence. Reduction in antemetic use and nausea intensity were noticed in ginger powder and oil. Ginger was significantly associated with better efficacy for Asian, older age, higher dosage, preoperative administration, hepatobiliary and gastrointestinal surgery.

CONCLUSIONS

Ginger oil appeared to be superior to other ginger treatments for the prophylaxis of POV. With regard to reducing PON, ginger preparations indicated no obvious advantages.

Efficacy and safety of different dual antiplatelet strategies in patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

Background

Dual antiplatelet therapy (DAPT) is key for preventing ischaemic events post-percutaneous coronary intervention (PCI). Various DAPT modifications like the shortened duration or P2Y12 inhibitor (P2Y12i) de-escalation are implemented to reduce bleeding risk. However, these strategies lack direct comparative studies. This study aimed to assess the efficacy and safety of such DAPT strategies, including de-escalated and short DAPT, in patients undergoing PCI.

Methods

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for relevant randomized controlled trials (RCTs). We performed a network meta-analysis (NMA) to estimate risk ratios (RRs) and 95% confidence intervals (CIs). The primary efficacy endpoint was major adverse cardiac events (MACEs), and the primary safety endpoint was major bleeding. Secondary endpoints included individual components of MACEs and net adverse clinical events (NACEs).

Results

A total of 17 RCTs comprising 53,156 patients (median age, 62.0 years, 24.8% female) were included. NMA suggested that de-escalation DAPT was associated with a significantly lower risk of MACEs (risk ratio [RR] = 0.79, 95% confidence interval [CI] = 0.64-0.98), bleeding (RR = 0.63, 95% CI = 0.49-0.82), and NACEs (RR = 0.69, 95% CI = 0.60-0.79) compared with standard DAPT. Short DAPT followed by P2Y12i monotherapy exhibited a significantly decreased risk of major bleeding (RR = 0.63, 95% CI = 0.46-0.86) compared with standard DAPT.

Conclusions

De-escalation DAPT was the most effective strategy for preventing the risk of MACEs without increasing bleeding events, while short DAPT followed by P2Y12i monotherapy was the most effective strategy for reducing the risk of bleeding among patients undergoing PCI.

Effective luting agents for glass-fiber posts: A network meta-analysis

OBJECTIVES

The aims of this study were to systematically review the literature and compare the relative effects of various luting agents on bonding between glass-fiber posts and root canal dentin in short- and long-term aging conditions.

DATA/SOURCES

The literature was electronically searched in PubMed, Embase, and Scopus. A manual search was performed by scanning the reference lists of the included studies.

STUDY SELECTION

Two reviewers independently conducted the selection of studies, data extraction, and risk of bias assessment. Pairwise meta-analyses were based on random effect models. Network meta-analyses were conducted within a frequentist framework with a multivariable random effects approach. The standardized mean difference and 95% confidence interval was calculated.

RESULTS

One hundred and eighteen studies were included and assessed the effects of five luting agents. For pairwise meta-analyses, in short-term aging conditions, a significantly higher bond strength of self-adhesive resin cement (SARC) compared to etch-and-rinse adhesive composite resin core material (ERCM) in the total, coronal, and middle regions. In long-term aging conditions, a significantly higher bond strength of ERCM compared to etch-and-rinse adhesive resin cement (ERRC) in all regions. Furthermore, SARC showed a significantly higher bond strength compared to self-etch adhesive composite resin core material (SECM) in the total, middle, and apical regions. For network meta-analyses, in the apical region, a significantly higher bond strength of SARC compared to ERRC in both aging conditions.

CONCLUSIONS

The SARC tended to be the most effective luting agent in bonding between glass-fiber posts and root canal dentin in short- and long-term aging conditions.

Comparative efficacy of glucose-lowering drugs on liver steatosis as assessed by means of magnetic resonance imaging in patients with type 2 diabetes mellitus: systematic review and network meta-analysis

PURPOSE

To assess the comparative efficacy of glucose-lowering drugs on liver steatosis as assessed by means of magnetic resonance imaging (MRI) in patients with T2D.

METHODS

We searched several databases and grey literature sources. Eligible trials had at least 12 weeks of intervention, included patients with T2D, and assessed the efficacy of glucose-lowering drugs as monotherapies. The primary outcome of interest was absolute reduction in liver fat content (LFC), assessed by means of MRI. Secondary efficacy outcomes were reduction in visceral and subcutaneous adipose tissue. We performed random effects frequentist network meta-analyses to estimate mean differences (MDs) with 95% confidence intervals (CIs). We ranked treatments based on P-scores.

RESULTS

We included 29 trials with 1906 patients. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors (P-score 0.84) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) (0.71) were the most efficacious in terms of liver fat content reduction. Among individual agents, empagliflozin was the most efficacious (0.86) and superior to pioglitazone (MD -5.7, 95% CI -11.2 to -0.3) (very low confidence). GLP-1 RAs had also the most favorable effects on visceral and subcutaneous adipose tissue.

CONCLUSIONS

GLP-1 RAs and SGLT-2 inhibitors seem to be the most efficacious glucose-lowering drugs for liver steatosis in patients with T2D. Assessment of their efficacy on NAFLD in patients irrespective of presence of T2D is encouraged.

Comparative efficacy on outcomes of C-CABG, OPCAB, and ONBEAT in coronary heart disease: a systematic review and network meta-analysis of randomized controlled trials

IMPORTANCE

Coronary artery bypass grafting (CABG) remains the gold standard for the treatment of multivessel and left main coronary heart disease. However, the current evidence about the optimal surgical revascularization strategy is inconsistent and is not sufficient to allow for definite conclusions. Thus, this topic needs to be extensively discussed.

OBJECTIVE

The aim of this present study was to compare the clinical outcomes of off-pump CABG (OPCAB), conventional on-pump CABG (C-CABG), and on-pump beating heart (ONBEAT) CABG via an updated systematic review and network meta-analysis of randomized controlled trials.

DATA SOURCES

PubMed, Web of Science, and the Cochrane Central Registry were searched for relevant randomized controlled trials that were published in English before 1 December 2021.

STUDY SELECTION

Published trials that included patients who received OPCAB, C-CABG, and ONBEAT CABG were selected.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened the search results, assessed the full texts to identify eligible studies and the risk of bias of the included studies, and extracted data. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data.

MAIN OUTCOMES AND MEASURES

The primary outcome was postoperative mortality in patients who underwent C-CABG, OPCAB, or ONBEAT CABG. The secondary outcomes were postoperative myocardial infarction, stroke, and renal impairment in the three groups. The time point for analysis of outcomes was all time periods during the postoperative follow-up.

RESULTS

A total of 39 385 patients (83 496.2 person-years) in 65 studies who fulfilled the prespecified criteria were included. In the network meta-analysis, OPCAB was associated with an increase of 12% in the risk of all-cause mortality when compared with C-CABG [odds ratio (OR): 1.12; 95% CI: 1.04-1.21], a reduction of 49% in the risk of myocardial infarction when compared with ONBEAT (OR: 0.51; 95% CI: 0.26-0.99), a reduction of 16% in the risk of stroke when compared with C-CABG (OR: 0.84; 95% CI: 0.72-0.99) and a similar risk of renal impairment when compared with C-CABG and ONBEAT.

CONCLUSIONS AND RELEVANCE

OPCAB was associated with higher all-cause mortality but lower postoperative stroke compared with C-CABG. OPCAB was associated with a lower postoperative myocardial infarction than that of ONBEAT. Early mortality was comparable among OPCAB, ONBEAT, and C-CABG.

Effectiveness of Interventions Aimed at Changing Movement Patterns in People With Patellofemoral Pain: A Systematic Review With Network Meta-analysis

OBJECTIVE: To summarize the effectiveness of interventions for changing movement during weight-bearing functional tasks in people with patellofemoral pain (PFP). DESIGN: Systematic review with network meta-analysis (NMA). LITERATURE SEARCH: Medline, Embase, CINAHL, SPORTDiscus, and Cochrane Library were searched from inception up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials involving people with PFP and nonsurgical, nonpharmacological interventions on task kinematics were included. DATA SYNTHESIS: NMA was conducted for frontal knee movement data, and pairwise meta-analysis was used to pool data when NMA was not possible. Reduced movements were those changes that indicated movements occurring with less amplitude. The GRADE approach was used to grade the certainty of the evidence. RESULTS: Thirty-seven trials were included (n = 1235 participants). Combining knee/hip exercises with internal feedback had the strongest effect on reducing frontal knee movements (standardized mean difference [SMD] from NMA = -2.66; GRADE: moderate evidence). On pairwise comparisons, the same combination of interventions reduced frontal hip movements (SMD = -0.47; GRADE: moderate evidence) and increased sagittal knee movements (SMD = 1.03; GRADE: moderate evidence), with no effects on sagittal hip movements (GRADE: very low evidence), compared to knee/hip exercises alone. There was no effect for single applications of braces on the frontal knee movement (GRADE: very low evidence) and taping on movements of the knee, hip, and ankle (GRADE: very low to low evidence) compared to no intervention. CONCLUSION: Knee/hip exercises combined with internal feedback techniques may change knee and hip movements in people with PFP. The combination of these interventions can reduce frontal knee and hip movements, and can increase sagittal knee movements. J Orthop Sports Phys Ther 2023;53(12):1-13. Epub 14 September 2023. doi:10.2519/jospt.2023.11956.

Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This study aimed to conduct a comprehensive and updated systematic review with network meta-analysis (NMA) to assess the outcome benefits of various blood purification modalities for adult patients with severe infection or sepsis.

DATA SOURCES

We conducted a search of PubMed, MEDLINE, clinical trial registries, Cochrane Library, and Embase databases with no language restrictions.

STUDY SELECTION

Only randomized controlled trials (RCTs) were selected.

DATA EXTRACTION

The primary outcome was overall mortality. The secondary outcomes were the length of mechanical ventilation (MV) days and ICU stay, incidence of acute kidney injury (AKI), and kidney replacement therapy requirement.

DATA SYNTHESIS

We included a total of 60 RCTs with 4,595 participants, comparing 16 blood purification modalities with 17 interventions. Polymyxin-B hemoperfusion (relative risk [RR]: 0.70; 95% CI, 0.57-0.86) and plasma exchange (RR: 0.61; 95% CI, 0.42-0.91) were associated with low mortality (very low and low certainty of evidence, respectively). Because of the presence of high clinical heterogeneity and intransitivity, the potential benefit of polymyxin-B hemoperfusion remained inconclusive. The analysis of secondary outcomes was limited by the scarcity of available studies. HA330 with high-volume continuous venovenous hemofiltration (CVVH), HA330, and standard-volume CVVH were associated with shorter ICU stay. HA330 with high-volume CVVH, HA330, and standard-volume CVVH were beneficial in reducing MV days. None of the interventions showed a significant reduction in the incidence of AKI or the need for kidney replacement therapy.

CONCLUSIONS

Our NMA suggests that plasma exchange and polymyxin-B hemoperfusion may provide potential benefits for adult patients with severe infection or sepsis/septic shock when compared with standard care alone, but most comparisons were based on low or very low certainty evidence. The therapeutic effect of polymyxin-B hemoperfusion remains uncertain. Further RCTs are required to identify the specific patient population that may benefit from extracorporeal blood purification.

Bayesian or frequentist: there is no question when comparing single-inhaler triple therapies via network meta-analysis. Focus on fluticasone furoate/umeclidinium/vilanterol fixed-dose combination in chronic obstructive pulmonary disease

OBJECTIVES

Single-inhaler triple therapies (SITTs) have never been directly compared in randomized controlled trials (RCTs) in chronic obstructive pulmonary disease (COPD). Cochrane recommends the Bayesian approach for indirect comparisons but a frequentist network meta-analysis (NMA) reported superiority of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) over other SITT. We assessed the most appropriate inference method for NMA characterized by between-study heterogeneity on SITT in COPD.

METHODS

Bayesian and frequentist NMA were performed on RCTs investigating the effect of SITT on exacerbations and trough forced expiratory volume in the 1st second (FEV1) in COPD.

RESULTS

The included RCTs (ETHOS, FULFIL, IMPACT, KRONOS 200812) reported significant between-study heterogeneity (I2 > 99%, p < 0.001). The Bayesian random-effect NMA provided unbiased evidence that FF/UMEC/VI was not superior to other SITT on exacerbations and trough FEV1. The frequentist fixed-effect NMA indicated that FF/UMEC/VI was significantly (p < 0.05) more effective than other SITT, although results were affected by dispersion, asymmetry, and significant risk of bias. Frequentist random-effect NMA provided effect estimates rather similar but not equal to those of Bayesian approach.

CONCLUSION

Indirect comparison should be performed via Bayesian approach instead of frequentist inference with a fixed-effect model. Claiming the superiority of a specific medication over other therapies should be confirmed by findings originating from well-designed RCTs.

A new approach to evaluating loop inconsistency in network meta-analysis

In network meta-analysis, studies evaluating multiple treatment comparisons are modeled simultaneously, and estimation is informed by a combination of direct and indirect evidence. Network meta-analysis relies on an assumption of consistency, meaning that direct and indirect evidence should agree for each treatment comparison. Here we propose new local and global tests for inconsistency and demonstrate their application to three example networks. Because inconsistency is a property of a loop of treatments in the network meta-analysis, we locate the local test in a loop. We define a model with one inconsistency parameter that can be interpreted as loop inconsistency. The model builds on the existing ideas of node-splitting and side-splitting in network meta-analysis. To provide a global test for inconsistency, we extend the model across multiple independent loops with one degree of freedom per loop. We develop a new algorithm for identifying independent loops within a network meta-analysis. Our proposed models handle treatments symmetrically, locate inconsistency in loops rather than in nodes or treatment comparisons, and are invariant to choice of reference treatment, making the results less dependent on model parameterization. For testing global inconsistency in network meta-analysis, our global model uses fewer degrees of freedom than the existing design-by-treatment interaction approach and has the potential to increase power. To illustrate our methods, we fit the models to three network meta-analyses varying in size and complexity. Local and global tests for inconsistency are performed and we demonstrate that the global model is invariant to choice of independent loops.

Is moderate resistance training adequate for older adults with sarcopenia? A systematic review and network meta-analysis of RCTs

BACKGROUND

Resistance training (RT) and nutritional supplementation are recommended for the management of sarcopenia in older adults. However, optimal RT intensity for the treatment of sarcopenia has not been well investigated.

METHODS

This network meta-analysis aims to determine the comparative effectiveness of interventions for sarcopenia, taking RT intensity into consideration. RT intensity was classified into light-to-moderate intensity RT(LMRT), moderate intensity RT(MRT), and moderate-to-vigorous intensity RT(MVRT) based on percentage of one repetition maximum (%1RM) and/or rating of perceived exertion.

RESULTS

A total of 50 RCTs (N = 4,085) were included after screening 3,485 articles. The results confirmed that RT with or without nutrition was positively associated with improved measures of muscle strength and physical performance. Regarding RT intensity, LMRT only demonstrated positive effects on hand grip (aerobic training + LMRT + nutrition: mean difference [MD] = 2.88; 95% credential intervals [CrI] = 0.43,5.32). MRT provided benefits on improvement in the 30-s chair stand test (repetitions) (MRT: MD = 2.98, 95% CrI = 0.35,5.59), timed up and go test (MRT: MD = -1.74, 95% CrI: = -3.34,-0.56), hand grip (MRT: MD = 2.44; 95% CrI = 0.03,5.70), and leg press (MRT: MD = 8.36; 95% CrI = 1.87,13.4). MVRT also improved chair stand test repetitions (MVRT: MD = 5.64, 95% CrI = 0.14,11.4), gait speed (MVRT + nutrition: MD = 0.21, 95% CrI = 0.003,0.48), appendicular skeletal muscle index (MVRT + nutrition: MD = 0.25, 95% CrI = 0.01,0.5), and leg press (MVRT: MD = 14.7, 95% CrI: 5.96,22.4; MVRT + nutrition: MD = 17.8, 95% CrI: 7.55,28.6).

CONCLUSION

MVRT had greater benefits on muscle mass, lower extremity strength, and physical performance compared to MRT. Increasing RT intensity may be recommended for sarcopenic older adults.

Inconsistency identification in network meta-analysis via stochastic search variable selection

The reliability of the results of network meta-analysis (NMA) lies in the plausibility of the key assumption of transitivity. This assumption implies that the effect modifiers' distribution is similar across treatment comparisons. Transitivity is statistically manifested through the consistency assumption which suggests that direct and indirect evidence are in agreement. Several methods have been suggested to evaluate consistency. A popular approach suggests adding inconsistency factors to the NMA model. We follow a different direction by describing each inconsistency factor with a candidate covariate whose choice relies on variable selection techniques. Our proposed method, stochastic search inconsistency factor selection (SSIFS), evaluates the consistency assumption both locally and globally, by applying the stochastic search variable selection method to determine whether the inconsistency factors should be included in the model. The posterior inclusion probability of each inconsistency factor quantifies how likely is a specific comparison to be inconsistent. We use posterior model odds or the median probability model to decide on the importance of inconsistency factors. Differences between direct and indirect evidence can be incorporated into the inconsistency detection process. A key point of our proposed approach is the construction of a reasonable "informative" prior concerning network consistency. The prior is based on the elicitation of information derived historical data from 201 published network meta-analyses. The performance of our proposed method is evaluated in two published network meta-analyses. The proposed methodology is publicly available in an R package called ssifs, published on CRAN and developed and maintained by the authors of this work.

Systematic review and network meta-analysis of efficacy and safety of interventions for preventing anti-tuberculosis drug induced liver injury

Anti-tuberculosis drug induced liver injury (Anti-TB DILI) is the most common adverse events (AEs) necessitating therapy interruption but there is no preventing regimen. This study aimed to examine the efficacy and safety of herbs/alternative medicines for preventing anti-TB DILI. Relevant articles were identified through a systematic search in 5 international databases from inception till March 2022. All randomized controlled trials (RCT) assessing the effects of herbal or alternative medicines against anti-TB DILI were included. The network meta-analysis (NMA) was used to synthesize the evidence for preventing hepatotoxicity using a random-effects model. A total of 3423 patients from 14 RCTs were included. The NMA indicated that supplementation of Turmeric plus Tinospora cordifolia (RR 0.07; 95% CI 0.02 to 0.28), and N-acetyl cysteine (NAC) (RR 0.09; 95% CI 0.01 to 0.75) significantly reduced the incidence of anti-TB DILI compared with placebo. In addition, poly herbal product significantly reduced alkaline phosphatase (ALP) (MD - 21.80; 95% CI - 33.80 to - 9.80) and total bilirubin (Tbil) compared with placebo (MD - 0.51; 95% CI - 0.76 to - 0.26). There was no statistically significant difference in the occurrence of AEs in any intervention. In conclusion, Turmeric plus Tinospora cordifolia, NAC and poly-herbal product may provide benefit for preventing anti-TB DILI in TB patients. However, these findings are based on a small number of studies. Additional studies are warranted to confirm the findings.

Treatment of diabetic kidney disease. A network meta-analysis

BACKGROUND

Diabetic kidney disease (DKD) is a health burden of rising importance. Slowing progression to end stage kidney disease is the main goal of drug treatment. The aim of this analysis is to compare drug treatments of DKD by means of a systemic review and a network meta-analysis.

METHODS

We searched Medline, CENTRAL and clinicaltrials.gov for randomized, controlled studies including adults with DKD treated with the following drugs of interest: single angiotensin-converting-enzyme-inhibitor or angiotensin-receptor-blocker (single ACEi/ARB), angiotensin-converting-enzyme-inhibitor and angiotensin-receptor-blocker combination (ACEi+ARB combination), aldosterone antagonists, direct renin inhibitors, non-steroidal mineralocorticoid-receptor-antagonists (nsMRA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i). As primary endpoints, we defined: overall mortality and end-stage kidney disease, as secondary endpoints: renal composite outcome and albuminuria and as safety endpoints: acute kidney injury, hyperkalemia and hypotension. Under the use of a random effects model, we computed the overall effect estimates using the statistic program R4.1 and the corresponding package "netmeta". Risk of bias was assessed using the RoB 2 tool and the quality of evidence of each pairwise comparison was rated according to GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

Of initial 3489 publications, 38 clinical trials were found eligible, in total including 42346 patients. Concerning the primary endpoints overall mortality and end stage kidney disease, SGLT2i on top of single ACEi/ARB compared to single ACEi/ARB was the only intervention significantly reducing the odds of mortality (OR 0.81, 95%CI 0.70-0.95) and end-stage kidney disease (OR 0.69, 95%CI 0.54-0.88). The indirect comparison of nsMRA vs SGLT2i in our composite endpoint suggests a superiority of SGLT2i (OR 0.60, 95%CI 0.47-0.76). Concerning safety endpoints, nsMRA and SGLT2i showed benefits compared to the others.

CONCLUSIONS

As the only drug class, SGLT2i showed in our analysis beneficial effects on top of ACEi/ARB treatment regarding mortality and end stage kidney disease and by that reconfirmed its position as treatment option for diabetic kidney disease. nsMRA reduced the odds for a combined renal endpoint and did not raise any safety concerns, justifying its application.

The effect of balance and gait training on specific balance abilities of survivors with stroke: a systematic review and network meta-analysis

Background

Stroke, which is a common clinical cerebrovascular disease, causes approximately 83% of survivors to suffer from balance impairments. Balance and gait training (BGT) is widely used to restore balance in patients with stroke. However, its wide variety presents clinicians with a dilemma when selecting interventions. This study aimed to compare and rank BGT interventions by quantifying information based on randomized controlled trials (RCTs).

Methods

We conducted a network meta-analysis (NMA) of non-gait-trained controls and head-to-head RCTs and compared the effects of 12 BGT interventions. A total of nine literature databases, including Medline, Embase, Cochrane Library, Web of Science, Scopus, SPORTDiscus, ClinicalTrials.gov, CNKI, and Chinese biomedical literature databases, were searched from their database inception to August 2023. Two authors independently selected studies and extracted data. The difference in outcomes, which were expressed as standardized mean differences and confidence intervals (CIs) of 95%, were explored in this meta-analysis.

Results

A total of 66 studies with 1,933 participants were included. Effect size estimates showed that not all BGT interventions were more effective than controls, with treadmill training as the least effective for balance test batteries (SMD = -0.41, 95% CI [-1.09, 0.27]) and proactive balance (SMD = -0.50, 95% CI [-1.14, 0.14]). Body-weight-supported treadmill training with external stimulation was most effective for proactive balance and dynamic steady-state balance (SMD = 1.57, 95% CI [-0.03, 3.16]); SMD = 1.18, 95% CI [0.67, 1.68]. Virtual reality gait training (SMD = 1.37, 95% CI [0.62, 2.11]) had the best effect on improving balance test batteries, while dual-task BGT (SMD = 1.64, 95% CI [0.50, 2.78]) had the best effect on static steady-state balance. After analyses for possible impact covariates, the findings through the outcomes did not change substantially. Confidence in the evidence was generally low or very low.

Conclusion

This NMA suggested that virtual reality gait training was the most effective BGT modality for improving balance test batteries. Body-weight support treadmill training with external stimulation was the most effective for improving active and dynamic balance. In addition, dual-task BGT was the best choice for improving static balance. However, balance is a multidimensional concept, and patients' different needs should be considered when selecting BGT.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022316057, ID: CRD42022316057.

Effectiveness of conduction system pacing for cardiac resynchronization therapy: A systematic review and network meta-analysis

INTRODUCTION

Cardiac resynchronization therapy (CRT) with biventricular pacing (BiV-CRT) is ineffective in approximately one-third of patients. CRT with Conduction system pacing (CSP-CRT) may achieve greater synchronization. We aimed to assess the effectiveness of CRT with His pacing (His-CRT) or left bundle branch pacing (LBB-CRT) in lieu of biventricular CRT.

METHODS AND RESULTS

The PubMed, Embase, Web of Science, Scopus, and the Cochrane Library were systematically searched until August 19, 2023, for original studies including patients with reduced left ventricular ejection fraction (LVEF) who received His- or LBB-CRT, that reported either CSP-CRT success, LVEF, QRS duration (QRSd), or New York Heart Association (NYHA) classification. Effect measures were compared with frequentist network meta-analysis. Thirty-seven publications, including 20 comparative studies, were included. Success rates were 73.5% (95% CI: 61.2-83.0) for His-CRT and 91.5% (95% CI: 88.0-94.1) for LBB-CRT. Compared to BiV-CRT, greater improvements were observed for LVEF (mean difference [MD] for His-CRT +3.4%; 95% CI [1.0; 5.7], and LBB-CRT: +4.4%; [2.5; 6.2]), LV end-systolic volume (His-CRT:17.2mL [29.7; 4.8]; LBB-CRT:15.3mL [28.3; 2.2]), QRSd (His-CRT: -17.1ms [-25.0; -9.2]; LBB-CRT: -17.4ms [-23.2; -11.6]), and NYHA (Standardized MD [SMD]: His-CRT:0.4 [0.8; 0.1]; LBB-CRT:0.4 [-0.7; -0.2]). Pacing thresholds at baseline and follow-up were significantly lower with LBB-CRT versus both His-CRT and BiV-CRT. CSP-CRT was associated with reduced mortality (R = 0.75 [0.61-0.91]) and hospitalizations risk (RR = 0.63 [0.42-0.96]).

CONCLUSION

This study found that CSP-CRT is associated with greater improvements in QRSd, echocardiographic, and clinical response. LBB-CRT was associated with lower pacing thresholds. Future randomized trials are needed to determine CSP-CRT efficacy.

Effects of different mind-body exercises on glucose and lipid metabolism in patients with type 2 diabetes: A network meta-analysis

BACKGROUND

This study aims to compare the relative effectiveness of different forms of mind-body exercise in improving glycolipid metabolism in patients with T2DM using a network meta-analysis.

METHODS

The relevant literature was systematically searched in Cochrane Library, Embase, PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang database and VIP Chinese Science. A network meta-analysis was conducted using a random-effects model within a frequentist framework.

RESULTS

A total of 52 studies with 6 modalities of mind-body exercise involving 4024 patients were included. Compared with controls, all exercise modalities except Yijinjing significantly improved patients' fasting blood glucose (MDs ranged from -0.72(95% CI: -1.20,-0.25) in dance to -2.06(95% CI: -2.59,-1.54) in yoga), glycated hemoglobin (MDs ranged from -0.62 (95% CI: -0.96) in taijiquan to -0.27,-0.27) in Pilates to -1.18(95% CI: 1.80,-0.57)), total cholesterol (MDs ranged from -0.73(95% CI: -1.29,-0.17) in Pilates to -0.41(95% CI: -0.62,-0.19) in Tai Chi), triglycerides (MDs ranged from -0.56 in Pilates (95% CI: -1.07,-0.04) for Pilates to -0.38 (95% CI: -0.67,-0.10)) for dance; only Tai Chi Chuan (MD:0.12 95% CI:0.04,0.20) and Baduanjin (MD:0.14 95% CI:0.06,0.22) significantly increased high-density lipoprotein cholesterol levels in patients; only yoga(MD: 0.78 95%CI: 1.20,-0.37) and Tai Chi Chuan(MD: 0.32 95%CI: 0.60,-0.04) significantly decreased high-density lipoprotein cholesterol levels in patients.

CONCLUSION

All mind-body exercises help to improve blood glucose and lipid levels in T2DM patients, but the ranking of relative effectiveness needs to be rationalized. Our study suggests that T2DM patients should choose appropriate mind-body exercises according to their conditions and stick to them for a long time under their healthcare professionals' guidance to achieve effective diabetes control.

Efficacy and safety of novel biologics in the treatment of lupus nephritis based on registered clinical trials: a systematic review and network meta-analysis

To compare the clinical effectiveness and safety of novel biologics for the treatment of lupus nephritis based on a reticulated meta-analysis approach. Registered clinical trials in 4 major databases (PubMed, Embase, Web of Science, The Cochrane Register of Clinical Trials) and ClinicalTrials.gov were systematically searched with a search time frame of build to June 2022. And we screened registered randomized controlled clinical trials of biologics for the treatment of lupus nephritis according to the protocol's nadir criteria. Trials were evaluated for quality using the Cochrane Risk of Bias Assessment Tool, and data were statistically analyzed using Stata 16.0 and Review Manager 5.3 software to compare and rank differences in effectiveness and safety between the biologics. A total of 10 registered randomized controlled clinical trials involving 2148 subjects were included in this study. The interventions were ranked from best to worst in terms of the primary outcome indicator of effectiveness, renal complete remission: belimumab > anifrolumab (900 + 300) mg > obinutuzumab > ocrelizumab 400 mg > abatacept 30/10 mg/kg > belimumab + rituximab > abatacept 10/10 mg/kg > abatacept (30/10 + 10/10) mg/kg > placeo > ocrelizumab 1000 mg > rituximab > anifrolumab 300 mg, belimumab was superior to placebo [OR = 1.75, 95% CI (1.13, 2.70)] and anifrolumab 300 mg [OR = 3.27, 95% CI (1.05, 10.14)], anifrolumab (900 + 300) mg was superior to anifrolumab 300 mg [OR = 3.56, 95% CI (1.30, 9.76)], and all were statistically significant. The ranking of each intervention in terms of overall renal remission for secondary outcome indicators from best to worst was: obinutuzumab > belimumab + rituximab > anifrolumab (900 + 300) mg > ocrelizumab 1000 mg > ocrelizumab 400 mg > belimumab > rituximab 1000 mg > abatacept 30/10 mg/kg > abatacept (30/10 + 10/10) mg/kg > placeo > abatacept 10/10 mg/kg > anifrolumab 300 mg, obinutuzumab was superior to placebo [OR = 2.27, 95% CI (1.11, 4.67)] and belimumab was also superior to placebo [OR = 1.56, 95% CI (1.07, 2.27)], and all were statistically significant. In terms of safety, with a focus on serious adverse events and serious infections, the results were: Serious adverse events at 1 year of monitoring occurred better with ocrelizumab 1000 mg than ocrelizumab 400 mg [OR = 0.51, 95% CI (0.29, 0.89)] and were statistically different; serious adverse events at 2 years of monitoring infection adverse events occurred better with obinutuzumab than with abatacept (30/10 + 10/10) mg/kg [OR = 0.24, 95% CI (0.07, 0.81)] and were statistically different. The safety of the new biologics in combination with conventional standard therapies is generally good, but it is belimumab and obinutuzumab that are most effective in achieving complete and overall remission in the kidney. This study protocol has been registered with PROSPERO, with a registration number of CRD42021262498.

Efficacy and Profitability of Fungicides for Managing Frogeye Leaf Spot on Soybean in the United States: A 10-Year Quantitative Summary

Frogeye leaf spot (FLS), caused by Cercospora sojina, is an economically important disease of soybean in the United States. Data from 66 uniform fungicide trials (UFTs) conducted from 2012 to 2021 across eight states (Alabama, Arkansas, Illinois, Iowa, Kentucky, Louisiana, Mississippi, and Tennessee) were gathered and analyzed to determine the efficacy and profitability of the following fungicides applied at the beginning pod developmental stage (R3): azoxystrobin + difenoconazole (AZOX + DIFE), difenoconazole + pydiflumetofen (DIFE + PYDI), pyraclostrobin (PYRA), pyraclostrobin + fluxapyroxad + propiconazole (PYRA + FLUX + PROP), tetraconazole (TTRA), thiophanate-methyl (TMET), thiophanate-methyl + tebuconazole (TMET + TEBU), and trifloxystrobin + prothioconazole (TFLX + PROT). A network meta-analytic model was fitted to the log of the means of FLS severity data and to the nontransformed mean yield for each treatment, including the nontreated. The percent reduction in disease severity (%) and the yield response (kg/ha) relative to the nontreated was the lowest for PYRA (11%; 136 kg/ha) and the greatest for DIFE + PYDI (57%; 441 kg/ha). A significant decline in efficacy over time was detected for PYRA (18 percentage points [p.p.]), TTRA (27 p.p.), AZOX + DIFE (18 p.p.), and TMET + TEBU (19 p.p.) by using year as a continuous covariate in the model. Finally, probabilities of breaking even were the greatest (>65%) for the most effective fungicide DIFE + PYDI and the lowest (<55%) for PYRA. Results of this meta-analysis may be useful to support decisions when planning fungicide programs.

Network meta-analysis of comparative efficacy and safety of intubation devices in children

To evaluate the comparative efficacy and safety of different intubation devices on intubation outcomes in pediatric intubation. We identified relevant studies from previous meta-analyses and literature retrieval in PubMed, EMBASE, and Cochrane Library. The primary outcome was the first-pass success (FPS), and the secondary outcome included the time to intubation (TTI) and the risk of local complications (LC). Network meta-analysis was performed using STATA 14.0. Twenty-three randomized comparative trials (RCTs) including 12 devices were included. Compared with Macintosh, Airtraq (odds ratio [OR] = 13.05, 95% confidence interval [CI] = 4.68 to 36.38), Miller (OR = 4.77, 95%CI = 1.32 to 17.22), Glidescope (OR = 2.76, 95%CrI = 1.60 to 4.75) and McGrath (OR = 4.61, 95%CI = 1.18 to 17.99) obtained higher PFS. Meanwhile, Airtraq was superior to Glidescope (OR = 0.21, 95%CI = 0.07 to 0.65) for PFS. For TTI, Canada was superior to other intubation devices, as well as CMAC was superior to TruViewEVO2, Glidescope, and StorzDCI. Airtraq lowered the risk of LC compared with Macintosh and Pentax but there was no statistical difference between Airtraq and KingVision. Airtraq may be the optimal option for FPS, Canada for TTI, and KingVision for LC in pediatric intubation.

Comparative efficacy and safety of adjunctive drugs to levodopa for fluctuating Parkinson's disease - network meta-analysis

It remains unclear which adjunctive drug for Parkinson's disease (PD) in combination with levodopa is more effective, tolerable, and safe. We aimed to compare the efficacy, tolerability, and safety among anti-PD drugs from several classes in patients with fluctuating PD who received levodopa through network meta-analysis (NMA). Twelve anti-PD drugs belonging to 4 different drug classes (dopamine agonists, monoamine oxidase type B inhibitors, catechol-O-methyl transferase inhibitors, and an adenosine A2A receptor antagonist) were selected. We systematically searched PubMed, Embase, and the Cochrane Library for eligible randomized controlled trials (RCTs) comparing placebo with anti-PD drug or among anti-PD drugs in patients with PD who experienced motor fluctuations or wearing-off and received levodopa. We included 54 RCTs in the analysis. The NMA was performed under a frequentist framework using a random-effects model. The efficacy outcome was change in daily off-time, and the tolerability outcome was discontinuation due to all causes. Safety outcomes included discontinuation due to adverse events (AEs) and the incidence of AEs, dyskinesia, hallucination, and orthostatic hypotension. According to the surface under the cumulative ranking curve (SUCRA) in the NMA, ropinirole transdermal patch (SUCRA, 0.861) ranked the highest in efficacy, followed by pramipexole (0.762), ropinirole extended release (ER) (0.750), and safinamide (0.691). In terms of tolerability, ropinirole (0.954) ranked the highest, followed by pramipexole (0.857), safinamide (0.717), and ropinirole ER (0.708). Each anti-PD drug had different SUCRA ranking profiles for the safety outcomes. These findings suggest that ropinirole, pramipexole, and safinamide are well-balanced anti-PD drugs that satisfy both efficacy and tolerability outcomes.

Dose-response relationship between acupuncture time parameters and the effects on chronic non-specific low back pain: a systematic review and Bayesian model-based network meta-analysis protocol

INTRODUCTION

Low back pain (LBP) is a major global public health problem and the majority (nearly 90%) of patients with LBP suffer from non-specific LBP (NSLBP). Acupuncture has been widely used for relieving pain and is recommended as a first-line treatment in LBP guidelines. However, the guidelines do not recommend a specific acupuncture temporal dosage. A Bayesian model-based network meta-analysis (MBNMA) will be conducted to optimise the dosages of time parameters (session, frequency and duration).

METHODS AND ANALYSIS

The following databases will be searched from their inception until 1 July 2023: MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, Cumulative Index to Nursing & Allied Health Literature (CINAHL), alternative health research database (Alt HealthWatch), China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database for Chinese Technical Periodicals, ClinicalTrials.gov, the WHO's International Clinical Trial and Chinese Clinical Registry. RCTs assessing the effects of acupuncture on chronic NSLBP will be selected. The primary outcome measure will be the improvement in pain intensity at different acupuncture time points. The MBNMA will be performed using R V.4.2.1 with related R packages. Risk of Bias V.2.0 and Confidence in Network Meta-Analysis will be used to assess the evidence quality.

ETHICS AND DISSEMINATION

Ethical approval is not required for literature-based studies. The results will be published in peer-reviewed journals or conferences.

PROSPERO REGISTRATION NUMBER

CRD42022336056.

Pharmacological intervention for irritability, aggression, and self-injury in autism spectrum disorder (ASD)

BACKGROUND

Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self-injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs).

OBJECTIVES

To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self-injury in ASD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies.

SELECTION CRITERIA

We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait-list control.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self-injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome.

MAIN RESULTS

We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short-term follow-up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) -0.90, 95% confidence interval (CI) -1.25 to -0.55, 12 studies, 973 participants; moderate-certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD -0.44, 95% CI -0.89 to 0.01; 1 study, 77 participants; very low-certainty evidence). Atypical antipsychotics may also reduce self-injury (SMD -1.43, 95% CI -2.24 to -0.61; 1 study, 30 participants; low-certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low-certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low-certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short-term follow-up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD -0.18, 95% CI -0.37 to -0.00; 8 studies; 466 participants; very low-certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self -injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low- and very low-certainty evidence). Attention-deficit hyperactivity disorder (ADHD)-related medications versus placebo At short-term follow-up, ADHD-related medications may reduce irritability slightly (SMD -0.20, 95% CI -0.40 to -0.01; 10 studies, 400 participants; low-certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD-related medications have an effect on self-injury (SMD -0.62, 95% CI -1.63 to 0.39; 1 study, 16 participants; very low-certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low-certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low-certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short-term follow-up, there was no clear evidence that antidepressants have an effect on irritability (SMD -0.06, 95% CI -0.30 to 0.18; 3 studies, 267 participants; low-certainty evidence). No data for aggression or self-injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low-certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low-certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low-certainty evidence), nor between groups in musculoskeletal AEs (very low-certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias.

AUTHORS' CONCLUSIONS

Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD-related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self-injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self-injury between ADHD-related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self-injury, although the evidence is uncertain. No data were reported (or could be used) for self-injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD-related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD-related medications. The other drug classes had minimal or no associated AEs.

Relative effectiveness and safety of interleukin-6 and Janus kinase inhibitors versus adalimumab in patients with rheumatoid arthritis: a network meta-analysis

OBJECTIVE

The relative efficacy and tolerability of interleukin‑6 (IL-6) and Janus kinase (JAK) inhibitor therapies were compared with those of adalimumab in patients with rheumatoid arthritis (RA) and inadequate responses to methotrexate (MTX).

METHODS

We performed a Bayesian network meta-analysis to combine direct and indirect evidence from randomized controlled trials (RCTs) to examine the efficacy and safety of IL‑6 inhibitors, JAK inhibitors, and adalimumab in patients with RA and inadequate responses to MTX.

RESULTS

Seven RCTs, which included 4428 patients (1066 for IL‑6 inhibitors and 3362 for JAK inhibitors), met the inclusion criteria. IL‑6 inhibitors were placed at the top left of the league table diagonal (Odds ratio, OR 1.43; 95% CrI 1.12-1.82) as these were correlated with the most beneficial ACR20 response rate. Conversely, the placebo was placed at the bottom right of the league table diagonal as it was correlated with the least desirable effects. IL‑6 and JAK inhibitors produced a substantial ACR20 response relative to adalimumab. The surface under the cumulative ranking curve (SUCRA) revealed that treatment with IL‑6 inhibitors had the greatest ability to reach the ACR20 response rate (SUCRA = 0.826), followed by treatment with JAK inhibitors (SUCRA = 0.672) and adalimumab (SUCRA = 0.001). The ACR50 and ACR70 rates displayed patterns similar to the ACR20 response rate. With regard to serious adverse events (SAEs), the SUCRA rating likelihood showed that adalimumab was likely to be the best intervention, followed by JAK and IL‑6 inhibitors.

CONCLUSION

Both IL‑6 and JAK inhibitors are more effective than adalimumab and have similar effects in patients with RA and an inadequate response to MTX. Adalimumab is likely to be safer than JAK and IL‑6 inhibitors.

Optimal dose and type of physical activity to improve functional capacity and minimise adverse events in acutely hospitalised older adults: a systematic review with dose-response network meta-analysis of randomised controlled trials

OBJECTIVE

To identify the optimal dose and type of physical activity to improve functional capacity and reduce adverse events in acutely hospitalised older adults.

DESIGN

Systematic review and Bayesian model-based network meta-analysis.

DATA SOURCES

Four databases were searched from inception to 20 June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that assessed the effectiveness of a physical activity-based intervention on at least one functional outcome in people aged ≥50 years hospitalised due to an acute medical condition were included. Pooled effect estimates (ie, standardised mean differences for functional capacity and the ratio of means for adverse events) were calculated using random treatment effects network meta-analysis models.

RESULTS

Nineteen studies (3842 participants) met the inclusion criteria. Approximately 100 Metabolic Equivalents of Task per day (METs-min/day) (~40 min/day of light effort or ~25 min/day of moderate effort activities) was the minimal dose to improve the functional capacity of acute hospitalised older adults (standardised mean difference (SMD)=0.28, 95% credible interval (CrI) 0.01 to 0.55). The optimal dose was estimated at 159 METs-min/day (~70 min/day of light effort or ~40 min/day of moderate effort activities; SMD=0.41, 95% CrI 0.08 to 0.72). Ambulation was deemed the most efficient intervention, and the optimal dose was reached at 143 METs-min/day (~50 min/day of slow-paced walking; SMD=0.76, 95% CrI 0.35 to 1.16), showing a high evidential power (87.68%). The minimal effective ambulation dose was estimated at 74 METs-min/day (~25 min/day of slow-paced walking; SMD=0.25, 95% CrI 0.01 to 0.41). Physical activity interventions resulted in a decrease in the rate of adverse events compared with usual care at discharge (ratio of means=0.96, 95% CrI 0.95 to 0.97; median time 7 days).

CONCLUSIONS

This meta-analysis yielded low to moderate evidence supporting the use of in-hospital supervised physical activity programmes in acutely hospitalised older adults. As little as ~25 min/day of slow-paced walking is sufficient to improve functional capacity and minimise adverse events in this population.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42021271999.

Comparative effectiveness of various noninvasive local treatments in patients with epistaxis: A systematic review and network meta-analysis

BACKGROUND

The best initial strategy for managing epistaxis is unclear. We performed a systematic review and network meta-analysis (NMA) to compare the effectiveness of various noninvasive treatments for patients with epistaxis.

METHODS

We searched PubMed, Embase, and the Cochrane Library from inception to September 2022 without language restrictions. Randomized controlled trials (RCTs) assessing immediate hemostasis, 2-day and 7-day rebleeding outcomes, as well as the use of noninvasive interventions for the treatment of epistaxis were selected. Frequentist NMA was performed.

RESULTS

The systematic review included 20 RCTs (2994 participants) involving 12 different interventions. The NMA demonstrated that topical treatment with tranexamic acid (TXA) significantly reduced the odds of 2-day rebleeding compared with the control conservative treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61) and traditional anterior nasal packing (OR 0.45, 95% CI 0.26-0.76). The sensitivity analysis yielded robust results, and the overall evidence was high. Topical TXA significantly reduced the odds of 7-day rebleeding compared with traditional nasal packing (OR 0.33, 95% CI 0.15-0.70), with moderate evidence owing to the heterogeneous results. Despite the significant effects of topical TXA on achieving immediate hemostasis and Rapid Rhino nasal packing on preventing 2-day rebleeding compared to the control and traditional nasal packing, the evidence is low to very low due to heterogeneity, inconsistency, and within-study bias.

CONCLUSIONS

In the treatment of epistaxis, topical TXA may be superior to conservative treatment or traditional nasal packing, particularly in preventing 2-day rebleeding.

Glucometabolic outcomes of GLP-1 receptor agonist-based therapies in patients with type 2 diabetes: a systematic review and network meta-analysis

Background

Innovative GLP-1 receptor agonist (GLP-1RA)-based treatment strategies-such as tirzepatide, GLP-1RA plus basal insulin fixed-ratio combinations [FRC], GLP-1RA plus sodium glucose cotransporter-2 inhibitors [SGLT-2i] combinations, and high-dose GLP-1RA-have been listed among the most efficacious options for type 2 diabetes management. However, differences in their glucometabolic effects have not been assessed in dedicated head-to-head trials. In the absence of such trials, we aimed to provide a useful comparison among these treatment strategies to guide clinical practice.

Methods

In this network meta-analysis, we searched PubMed, MEDLINE, and Web of Science (from database inception to June 24, 2023) for randomised controlled studies, published in English, that enrolled individuals with type 2 diabetes treated with tirzepatide, iGlarLixi, iDegLira, GLP-1RA plus SGLT-2i combination, or high-dose GLP-1RA (dulaglutide 3 mg and 4.5 mg, semaglutide 2 mg) compared with placebo or active comparators. Eligible studies reported change from baseline in HbA1c as an outcome, which was the primary outcome of this analysis. Secondary outcomes were changes in fasting and post-prandial glucose, bodyweight, LDL-cholesterol, blood pressure and risk of hypoglycaemia. We assessed risk of bias through the Cochrane Collaboration's tool (RoB2 tool), publication bias through visual inspection of funnel plots and Egger's test, and heterogeneity by comparing the magnitude of the common between-study variance (τ2) for each outcome with empirical distributions of heterogeneity variances. This network meta-analysis was registered in PROSPERO (CRD42022329878).

Findings

40 trials were included. Tirzepatide 15 mg ranked first in terms of HbA1c reduction compared to other GLP-1RA-based strategies, even those including insulin (vs. iDegLira MD -0.40%, 95% CI [-0.66; -0.14], low certainty; vs. iGlarLixi MD -0.48%, 95% CI [-0.75; -0.21], low certainty), without increasing the risk of hypoglycaemia (vs. iDegLira OR 0.35, 95% CI [0.16; 0.79], high certainty; vs. iGlarLixi OR 0.31, 95% CI [0.20; 0.48], high certainty). Tirzepatide 15 mg was also the most efficacious on weight lowering, even compared to high-dose GLP-1RA (eg, semaglutide 2 mg MD -6.56 kg, 95% CI [-7.38; -5.73], low certainty) and GLP-1RA plus SGLT-2i combination (MD -4.61 kg, 95% CI [-5.29; -3.93], low certainty). Risk of bias and publication bias were generally low throughout studies, while high levels of heterogeneity were detected for most outcomes.

Interpretation

Aiming to support clinicians in tailoring treatment to patients' needs, we suggest that a hierarchy among treatment strategies be devised considering the best options for type 2 diabetes. Tirzepatide, followed by GLP-1RA plus basal insulin FRC and GLP-1RA plus SGLT-2i combination, was associated with greater benefit on HbA1c than high-dose GLP-1RA.

Funding

Fondazione per la Ricerca Biomedica "Saverio e Isabella Cianciola" and Next Generation EU, in the context of the National Recovery and Resilience Plan, Investment PE8-Project Age-It: Ageing Well in an Ageing Society.

Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis

OBJECTIVE

To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies.

METHODS

A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558.

RESULTS

From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT.

LIMITATIONS

Uneven quality of literature, simple network, and subjective judgment.

CONCLUSION

Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Non-invasive Brain Stimulation Techniques for the Improvement of Upper Limb Motor Function and Performance in Activities of Daily Living After Stroke: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the efficacy of non-invasive brain stimulation (NiBS) such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation (TBS), and transcutaneous vagus nerve stimulation (taVNS) in upper limb stroke rehabilitation.

DATA SOURCES

PubMed, Web of Science, and Cochrane databases were searched from January 2010 to June 2022.

DATA SELECTION

Randomized controlled trials (RCTs) assessing the effects of "tDCS", "rTMS", "TBS", or "taVNS" on upper limb motor function and performance in activities of daily livings (ADLs) after stroke.

DATA EXTRACTION

Data were extracted by 2 independent reviewers. Risk of bias was evaluated with the Cochrane Risk of Bias tool.

DATA SYNTHESIS

87 RCTs with 3750 participants were included. Pairwise meta-analysis showed that all NiBS except continuous TBS (cTBS) and cathodal tDCS were significantly more efficacious than sham stimulation for motor function (standardized mean difference [SMD] range 0.42-1.20), whereas taVNS, anodal tDCS, and both low and high frequency rTMS were significantly more efficacious than sham stimulation for ADLs (SMD range 0.54-0.99). NMA showed that taVNS was more effective than cTBS (SMD:1.00; 95% CI (0.02-2.02)), cathodal tDCS (SMD:1.07; 95% CI (0.21-1.92)), and Physical rehabilitation alone (SMD:1.46; 95% CI (0.59-2.33)) for improving motor function. P-score found that taVNS is best ranked treatment in improving motor function (SMD: 1.20; 95% CI (0.46-1.95)) and ADLs (SMD:1.20; 95% CI (0.45-1.94)) after stroke. After taVNS, excitatory stimulation protocols (intermittent TBS, anodal tDCS, and HF-rTMS) are most effective in improving motor function and ADLs after acute/sub-acute (SMD range 0.53-1.63) and chronic stroke (SMD range 0.39-1.16).

CONCLUSIONS

Evidence suggests that excitatory stimulation protocols are the most promising intervention in improving upper limb motor function and performance in ADLs. taVNS appeared to be a promising intervention for stroke patients, but further large RCTs are required to confirm its relative superiority.

Comparative safety of anaplastic lymphoma kinase tyrosine kinase inhibitors in advanced anaplastic lymphoma kinase-mutated non-small cell lung cancer: Systematic review and network meta-analysis

OBJECTIVE

Anaplastic lymphoma kinase-tyrosine kinase inhibitors (ALK-TKIs) are new treatment for advanced non-small cell lung cancer. Here, we quantified the toxicity profiles of different ALK-TKIs to guide clinical decision making.

MATERIALS AND METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Data were analyzed using random effects and consistency models under the frequency framework.

RESULTS

Of 865 relevant studies, 13 RCTs (encompassing 3,353 patients) were finally included. A network meta-analysis of all-grade AEs, fatal AEs, and treatment discontinuation due to AEs revealed no significant differences among the six ALK-TKIs. The rates of grade 3-4 AEs were: alectinib (16.2%), crizotinib (46.4%), brigatinib (63.7%), ensartinib (75.6%), ceritinib (78.3%), and lorlatinib (91.6%). The toxicity spectra of ALK-TKIs were different. The most frequent AEs associated with crizotinib were gastrointestinal reactions, visual disorders, neutropenia, edema, fatigue, and elevated alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels, while those in the alectinib group were anemia and constipation. Diarrhea, hepatotoxicity, and increased serum creatinine were most common with ceritinib. The most frequent AEs in the brigatinib group were gastrointestinal reactions, hypertension, cough, headache, and elevated ALT or AST levels. The most significant toxicities of ensartinib were skin disorders, including pruritus and rash. Changes in lipid levels were the most frequent AEs associated with lorlatinib; weight gain, cognitive effects, and mood effects were lorlatinib-specific AEs.

CONCLUSIONS

The toxicity spectra of ALK-TKIs differed. Alectinib might be the safest ALK-TKI drug according to the combined evidence of grades 3-4 AEs and the combined incidence.

Pharmacologic interventions for the therapy of postanesthetic shivering in adults: a systematic review and network meta-analysis

INTRODUCTION

Shivering is a common side effect after general anesthesia. Risk factors are hypothermia, young age and postoperative pain. Severe complications of shivering are rare but can occur due to increased oxygen consumption. Previous systematic reviews are outdated and have summarized the evidence on the topic using only pairwise comparisons. The objective of this manuscript was a quantitative synthesis of evidence on pharmacological interventions to treat postanesthetic shivering.

EVIDENCE ACQUSITION

Systematic review and frequentist network meta-analysis using the R package netmeta. Endpoints were the risk ratio (RR) of persistent shivering at one, five and 10 minutes after treatment with saline/placebo as the comparator. Data were retrieved from Medline, Embase, Central and Web of Science up to January 2022. Eligibility criteria were: randomized, controlled, and blinded trials comparing pharmacological interventions to treat shivering after general anesthesia. Studies on shivering during or after any type of regional anesthesia were excluded as well as sedated patients after cardiac surgery.

EVIDENCE SYNTHESIS

Thirty-two trials were eligible for data synthesis, including 28 pharmacological interventions. The largest network included 1431 patients. The network geometry was two-centered with most comparisons linked to saline/placebo or pethidine. The best interventions were after one minute: doxapram 2 mg/kg, tramadol 2 mg/kg and nefopam 10 mg, after 5 minutes: tramadol 2 mg/kg, nefopam 10 mg and clonidine 150 µg and after 10 minutes: nefopam 10 mg, methylphenidate 20 mg and tramadol 1 mg/kg, all reaching statistical significance. Pethidine 25 mg and clonidine 75 µg also performed well and with statistical significance in all networks.

CONCLUSIONS

Nefopam, tramadol, pethidine and clonidine are the most effective treatments to stop postanesthetic shivering. The efficacy of doxapram is uncertain since different doses showed contradictory effects and the evidence for methylphenidate is based on a single comparison in only one network. Furthermore, both lack data on side effects. Further studies are needed to clarify the efficacy of dexmedetomidine to treat postanesthetic shivering.

Efficacy and Safety of Minimally Invasive Thyroid Surgery: A Network Meta-Analysis

OBJECTIVES

Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods.

DATA SOURCES

The PubMed, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar.

REVIEW METHODS

The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed.

RESULTS

EO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding.

CONCLUSION

It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470-2479, 2023.

Combinatorial Effect of Prophylactic Interventions for Post-ERCP Pancreatitis among Patients with Risk Factors: A Network Meta-Analysis

Background/Aims

The combinatorial effects of prophylactic methods for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients with risk factors remain unclear. In this network meta-analysis, we compared the efficacy of various prophylactic strategies to decrease the risk of PEP among patients with risk factors.

Methods

A systematic review was performed to identify randomized controlled trials from PubMed, Embase, and the Cochrane Library through July 2021. We used frequentist network meta-analysis to compare the rates of PEP among patients who received prophylactic treatments as follows: class A, rectal nonsteroidal anti-inflammatory drugs; class B, prophylactic pancreatic stent; class C, aggressive hydration; or control, no prophylaxis or active control. We selected those studies that included patients with risk factors for PEP.

Results

We identified 19 trials, comprising 4,328 participants. Class ABC (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.03 to 0.24), class AC (OR, 0.10; 95% CI, 0.02 to 0.47), class AB (OR, 0.12; 95% CI, 0.05 to 0.26), class BC (OR, 0.13; 95% CI, 0.04 to 0.41), class A (OR, 0.16; 95% CI, 0.05 to 0.50), and class B (OR, 0.26; 95% CI, 0.14 to 0.46), were associated with a reduced risk of PEP as compared to that of the control. The most effective prophylaxis was ABC (0.87), followed by AC (0.68), AB (0.65), BC (0.56), A (0.49), and B (0.24) according to P-score.

Conclusions

The results of this network meta-analysis suggest that the more prophylactic methods are employed, the better the outcomes. It appears that for patients with risk factors, we need to prevent PEP through the use of these well proven combination strategies.

Indirect Treatment Comparison of First-Line CDK4/6-Inhibitors in Post-Menopausal Patients with HR+/HER2- Metastatic Breast Cancer

Background: CDK4/6-inhibitors have demonstrated similar efficacy and are considered an effective first-line endocrine treatment of patients with hormone-receptor positive (HR+)/human-epidermal-growth-factor-receptor-2 negative (HER2-) metastatic breast cancer (MBC) in the endpoint of progression-free survival (PFS). Amongst these, palbociclib was first to achieve regulatory approval, followed subsequently by ribociclib and abemaciclib. However, recent updates of overall survival (OS) showed inconsistencies in the OS benefit for palbociclib compared with the other two CDK4/6-inhibitors. With the lack of head-to-head comparison studies, our study sought to compare indirect survival outcomes between CDK4/6-inhibitors in this setting using a novel reconstructive algorithm. Methods: Phase III randomized trials comparing first-line aromatase inhibitor with/without a CDK4/6-inhibitor in post-menopausal patients with HR+/HER2- MBC were identified through systemic review and literature search of online archives of published manuscripts and conference proceedings. A graphical reconstructive algorithm was utilized to retrieve time-to-event data from reported Kaplan-Meier OS and PFS plots to allow for comparison of survival outcomes. Survival analyses were conducted with Cox proportional-hazards model with a shared-frailty term. Results: Three randomized phase III trials-PALOMA-2, MONALEESA-2 and MONARCH-3-comprising 1827 patients were included. Indirect pairwise comparisons of all CDK4/6-inhibitors showed no significant PFS differences (all p > 0.05). Likewise, indirect treatment comparison between ribociclib vs. palbociclib (one-stage: HR = 0.903, 95%-CI: 0.746-1.094, p = 0.297), abemaciclib vs. palbociclib (one-stage: HR = 0.843, 95%-CI: 0.690-1.030, p = 0.094) and abemaciclib vs. ribociclib (one-stage: HR = 0.933, 95%-CI: 0.753-1.157, p = 0.528) failed to demonstrate a significant OS difference. Conclusions: Findings from this indirect treatment comparison suggest no significant PFS or OS differences between CDK4/6-inhibitors in post-menopausal patients with HR+/HER2- MBC.

Optimal type and dose of hypoxic training for improving maximal aerobic capacity in athletes: a systematic review and Bayesian model-based network meta-analysis

Objective: This study aimed to compare and rank the effect of hypoxic practices on maximum oxygen consumption (VO2max) in athletes and determine the hypoxic dose-response correlation using network meta-analysis. Methods: The Web of Science, PubMed, EMBASE, and EBSCO databases were systematically search for randomized controlled trials on the effect of hypoxc interventions on the VO2max of athletes published from inception until 21 February 2023. Studies that used live-high train-high (LHTH), live-high train-low (LHTL), live-high, train-high/low (HHL), intermittent hypoxic training (IHT), and intermittent hypoxic exposure (IHE) interventions were primarily included. LHTL was further defined according to the type of hypoxic environment (natural and simulated) and the altitude of the training site (low altitude and sea level). A meta-analysis was conducted to determine the standardized mean difference between the effects of various hypoxic interventions on VO2max and dose-response correlation. Furthermore, the hypoxic dosage of the different interventions were coordinated using the "kilometer hour" model. Results: From 2,072 originally identified titles, 59 studies were finally included in this study. After data pooling, LHTL, LHTH, and IHT outperformed normoxic training in improving the VO2max of athletes. According to the P-scores, LHTL combined with low altitude training was the most effective intervention for improving VO2max (natural: 0.92 and simulated: 0.86) and was better than LHTL combined with sea level training (0.56). A reasonable hypoxic dose range for LHTH (470-1,130 kmh) and HL (500-1,415 kmh) was reported with an inverted U-shaped curve relationship. Conclusion: Different types of hypoxic training compared with normoxic training serve as significant approaches for improving aerobic capacity in athletes. Regardless of the type of hypoxic training and the residential condition, LHTL with low altitude training was the most effective intervention. The characteristics of the dose-effect correlation of LHTH and LHTL may be associated with the negative effects of chronic hypoxia.

Outcome-Specific Efficacy of Different Probiotic Strains and Mixtures in Irritable Bowel Syndrome: A Systematic Review and Network Meta-Analysis

Irritable bowel syndrome (IBS) is a common gastrointestinal disease. The efficacy of different probiotics in treating IBS remains controversial. This network meta-analysis aimed to compare and rank the outcome-specific efficacy of different probiotic strains or combinations in adults with IBS. We searched the literature up to June 2023. Randomized controlled trials (RCTs) that evaluated the efficacy of probiotics in IBS were included. A frequentist framework was used to perform this study. In total, 9253 participants from 81 RCTs were included in the study. Four probiotic strains and five mixtures were significantly superior to placebo in improving IBS Symptom Severity Scale, among which Lactobacillus acidophilus DDS-1 ranked first (surface under the cumulative ranking, SUCRA, 92.9%). A mixture containing five probiotics (SUCRA, 100%) ranked first in improving the IBS-Quality of life. Bacillus coagulans MTCC 5856 (SUCRA, 96.9%) and Bacillus coagulans Unique IS2 (SUCRA, 92.6%) were among the most effective probiotics for improving abdominal pain. Three probiotic strains and two mixtures were effective in alleviating abdominal bloating. Four probiotic strains and a mixture were significantly superior to placebo in reducing the bowel movement frequency in diarrhea-predominant IBS (IBS-D). Bacillus coagulans MTCC 5856 (SUCRA, 99.6%) and Saccharomyces cerevisiae CNCM I-3856 (SUCRA, 89.7%) were among the most effective probiotics for improving the Bristol stool form scale of IBS-D. Only some probiotics are effective for particular outcomes in IBS patients. This study provided the first ranking of outcome-specific efficacy of different probiotic strains and combinations in IBS. Further studies are needed to confirm these results.

Survival benefit of perioperative locoregional adjuvant treatment for hepatocellular carcinoma with portal vein tumor thrombosis: A systematic review and Bayesian network meta-analysis

BACKGROUND

To identify the optimal strategy for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) by comparing the oncological prognosis of different perioperative locoregional adjuvant treatments.

METHODS

Electronic database were searched for relevant studies. Overall survival (OS) and recurrence-free survival (RFS) were pooled by pairwise and network meta-analysis.

RESULTS

Fourteen eligible trials with 1927 patients and covering four adjuvant treatments were included. All adjuvant therapies in combination with surgery were shown to be superior to surgery alone. Adjuvant therapy with radiotherapy had the lowest hazard ratio (HR) for both OS (HR: 0.38, 95% CrI: 0.25-0.57) and RFS (HR: 0.27, 95% CrI: 0.11-0.65) compared with other combination treatments, with estimated surface under the cumulative ranking of 93.2% and 82.7%, respectively.

CONCLUSIONS

Perioperative locoregional adjuvant therapy provides OS benefits and reduces the risk of recurrence for patients suffering from HCC with PVTT. Radiotherapy is likely to be the most effective adjuvant regimen.

The effect of adjuvants added to local anaesthetics for single-injection upper extremity peripheral regional anaesthesia: A systematic review with network meta-analysis of randomised trials

BACKGROUND

Peripheral regional anaesthesia is frequently used for upper extremity surgery. To prolong the duration of analgesia, adjuvants can be added to single-injection local anaesthetics. Despite attempts to compare several adjuvants in pairwise meta-analyses, a comprehensive comparison is still missing.

OBJECTIVE

The objective of this network meta-analysis was to determine the effectiveness of adjuvants in upper extremity peripheral nerve blocks.

DESIGN

A systematic review of randomised controlled trials with network meta-analyses.

DATA SOURCES

A literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.

ELIGIBILITY CRITERIA

Randomised trials comparing different adjuvants injected perineurally in peripheral upper extremity nerve blocks were eligible. Frequentist network meta-analysis was conducted using a random effects model with physiological saline as the comparator. The primary endpoint was the ratio of means (ROM) of the duration of analgesia.

RESULTS

The review included 242 randomised controlled trials with a total of 17 391 patients. Twenty-eight adjuvants were compared in the largest networks. Most network estimations consisted of a high proportion of direct evidence. Fourteen adjuvants increased the duration of analgesia significantly by the following factors, ROM [95% confidence interval (CI)]: dexamethasone 1.95 (1.79 to 2.13), buprenorphine 1.83 (1.51 to 2.24), butorphanol 1.84 (1.41 to 2.39), potassium chloride 1.89 (1.15 to 3.11), dexmedetomidine 1.70 (1.59 to 1.81), sufentanil 1.70 (1.27 to 2.29), ketorolac 1.68 (1.24 to 2.27), midazolam 1.55 (1.24 to 1.94), tramadol 1.52 (1.32 to 1.75), nalbuphine 1.50 (1.30 to 1.72), morphine 1.43 (1.09 to 1.88), magnesium sulfate 1.42 (1.20 to 1.67), clonidine 1.36 (1.24 to 1.50) and fentanyl 1.23 (1.08 to 1.40). Inconsistency in network meta-analysis was substantial. Overall side effect rates were low with all adjuvants.

CONCLUSION

The best interventions to prolong the duration of analgesia were dexamethasone, followed by dexmedetomidine, opioids, electrolytes, ketorolac and midazolam. There are general concerns about the quality of underlying studies and the risk of publication bias.

TRIAL REGISTRATION

PROSPERO 2018 CRD42018115722.

Management of cognitive frailty: A network meta-analysis of randomized controlled trials

OBJECTIVES

We aimed to compare the effectiveness of interventions in cognitive function and frailty status and rank these interventions.

METHODS

Data Sources-We searched PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane Library, Central Register of Controlled Trials (CENTRAL), CNKI, Wanfang, VIP and Google scholar. Data synthesis-The risk of bias was assessed using the Cochrane risk bias assessment tool. Statistical heterogeneity was assessed using the Chi-square test and quantified by I2 . The results were pooled using the standardized mean difference (SMD). The rank probability for each intervention was calculated using the surface under the cumulative ranking curve (SUCRA). Additionally, the quality of the evidence was evaluated using the GRADE approach.

RESULTS

A total of 10 randomized controlled trials (RCTs) involving 1110 patients were included in our analysis. The network map of cognitive function comprised 9 RCTs with 1347 participants, examining eight different interventions. Nutritional support (SUCRA = 99.9%, SMD = 3.02, 95% CI: 2.53, 3.51) may be the most effective intervention to improve cognitive function. The network map of frailty (including 9 RCTs with 1017 participants and 9 interventions) suggested that multicomponent exercises (SUCRA = 96.4%, SMD = -5.10, 95% CI: -5.96, -4.23) tended to have a greater effect.

CONCLUSIONS

Community-based multicomponent exercises have shown significant benefits for improving cognitive function and frailty status in older adults, with moderate certainty. For hospitalized older patients with Cognitive frailty (CF), current evidence suggests that nutritional support yields the most improvement. Additionally, aerobic exercise and dual-task training have proven effective in managing CF. Further studies are needed to validate these preliminary findings and exploring more accessible and effective physical and cognitive interventions to prevent CF in aging.

A network meta-analysis of randomized controlled trials comparing the effectiveness and safety of voclosporin or tacrolimus plus mycophenolate mofetil as induction treatment for lupus nephritis

AIM

This study aimed to compare the effectiveness and safety of voclosporin + mycophenolate mofetil (MMF), tacrolimus + MMF, and monotherapy with MMF or cyclophosphamide as induction treatment for lupus nephritis.

METHODS

The study included randomized controlled trials (RCTs) that evaluated the effectiveness and safety of voclosporin + MMF, tacrolimus + MMF, and monotherapy for induction treatment in patients with lupus nephritis. To incorporate direct and indirect evidence from RCTs, we used a Bayesian network meta-analysis.

RESULTS

Four RCTs, including 936 participants, met the inclusion criteria. Tacrolimus + MMF substantially increased the incidence of complete remission relative to that following monotherapy (odds ratio [OR] 2.85; 95% credible interval [CrI] 1.87-4.39). Tacrolimus + MMF was also more effective than voclosporin + MMF (OR 1.43; 95% CrI 0.80-2.57). Tacrolimus + MMF showed the greatest chance of being the optimal treatment for overall response (surface under the cumulative ranking curve [SUCRA] = 0.942), followed by voclosporin + MMF (SUCRA = 0.558) and monotherapy (SUCRA = 0.001). In terms of safety based on severe event rates, monotherapy had the greatest chance of being the safest treatment (SUCRA = 0.903), followed by voclosporin + MMF (SUCRA = 0.517) and tacrolimus + MMF (SUCRA = 0.081).

CONCLUSION

Tacrolimus + MMF and voclosporin + MMF were more effective than monotherapy, and tacrolimus + MMF was the most effective induction treatment for lupus nephritis patients. However, tacrolimus + MMF did pose a greater risk of serious adverse events than monotherapy.

Clinical interventions with various agents to prevent early childhood caries: A systematic review with network meta-analysis

BACKGROUND

Dental caries is one of the most prevalent chronic diseases among preschool children globally. Different preventive agents and combinations have been studied. However, the rank of the effectiveness of clinical interventions is equivocal.

AIM

To summarize and rank the effectiveness of clinical interventions using different agents for primary prevention of early childhood caries (ECC).

DESIGN

Two reviewers independently searched PubMed, Embase, and Cochrane Library to identify randomized controlled trials with at least 12-month follow-up. The network meta-analysis (NMA) on different agents was based on a random-effects model and frequentist approach. Standardized mean differences (SMD) with 95% CI of the caries increment were calculated in terms of either dmft or dmfs and used in the NMA. Caries incidences at the child level were compared using odds ratios (ORs) with 95% CI. The effectiveness of the agents was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

After screening 3807 publications and selection, the NMA finally included 33 trials. These trials used either a single or combination of agents such as fluorides, chlorhexidine, casein phosphopeptide-amorphous calcium phosphate, probiotics, xylitol, and triclosan. Compared with control, fluoride foam (FF; SMD -0.69, 95% CI: -1.06, -0.32) and fluoride salt (F salt; SMD -0.66, 95% CI: -1.20, -0.13) were effective in preventing caries increment. Probiotic milk plus low fluoride toothpaste (PMLFTP; OR 0.34, 95% CI: 0.15, 0.77), FF (OR 0.48, 95% CI: 0.37, 0.63), fluoride varnish (FV; OR 0.63, 95% CI: 0.48, 0.81), and fluoride varnish plus high fluoride toothpaste (FVHFTP; OR 0.73, 95% CI: 0.57, 0.93) were effectively preventing caries incidence. According to the SUCRA, FF ranked first in preventing caries increment, whereas PMLFTP ranked first in preventing caries incidence.

CONCLUSION

Fluoride foam, F salt, PMLFTP, FV, and FVHFTP all effectively reduce caries increment or caries incidence in preschool children, but the evidence indicates low degree of certainty. Considering the relatively small number of studies, confidence in the findings, and limitations in the study, clinical practitioners and readers should exercise caution when interpreting the NMA results.

Comparative Efficacy of Clinical Interventions for Sacroiliac Joint Pain: Systematic Review and Network Meta-analysis With Preliminary Design of Treatment Algorithm

OBJECTIVE

We aimed to identify the most effective clinical treatment method for sacroiliac joint (SIJ)-related pain based on the systematic review and network meta-analysis (NMA) to evaluate the comparative efficacy of clinical interventions for sacroiliac joint pain by pooling the randomized controlled trials (RCTs).

METHODS

Our team conducted a systematic review and NMA of RCTs to determine the most effective clinical treatment for SIJ-related pain. We searched the PubMed (MEDLINE), Web of Science, Cochrane Library, and Scopus databases for RCTs until February 2023. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed. Pairwise and network meta-analyses were conducted using a random effects model.

RESULTS

Based on the search strategy and inclusion criteria, our systematic review and NMA included 9 randomized studies with 652 participants. Research has mainly focused on various radiofrequency sources, but their number is still low. In the network analysis, according to the NMA and mean ranking probabilities for the improvement of pain intensity (PI) and quality of life (QoL), sacroiliac joint fusion and cooled radiofrequency were associated with high treatment rank for improving PI and QoL in patients with sacroiliac joint pain.

CONCLUSION

This NMA suggest that SIJ fusion and cooled radiofrequency could be potential options for improving the QoL and relieving pain in patients with SIJ-related pain. Comparison studies of outcomes between these 2 procedures with solid methodology and a low risk of bias would be very beneficial to identify the optimal treatment option for this challenging disease.

Pharmacological interventions for antipsychotic-related sialorrhea: a systematic review and network meta-analysis of randomized trials

Antipsychotic-induced sialorrhea carries a significant burden, but evidence-based treatment guidance is incomplete, warranting network meta-analysis (NMA) of pharmacological interventions for antipsychotic-related sialorrhea. PubMed Central/PsycInfo/Cochrane Central database/Clinicaltrials.gov/WHO-ICTRP and the Chinese Electronic Journal Database (Qikan.cqvip.com) were searched for published/unpublished RCTs of antipsychotic-induced sialorrhea (any definition) in adults, up to 06/12/2023. We assessed global/local inconsistencies, publication bias, risk of bias (RoB2), and confidence in the evidence, conducting subgroup/sensitivity analyses. Co-primary efficacy outcomes were changes in saliva production (standardized mean difference/SMD) and study-defined response (risk ratios/RRs). The acceptability outcome was all-cause discontinuation (RR). Primary nodes were molecules; the mechanism of action (MoA) was secondary. Thirty-four RCTs entered a systematic review, 33 NMA (n = 1958). All interventions were for clozapine-induced sialorrhea in subjects with mental disorders. Regarding individual agents and response, metoclopramide (RR = 3.11, 95% C.I. = 1.39-6.98), cyproheptadine, (RR = 2.76, 95% C.I. = 2.00-3.82), sulpiride (RR = 2.49, 95% C.I. = 1.65-3.77), propantheline (RR = 2.39, 95% C.I. = 1.97-2.90), diphenhydramine (RR = 2.32, 95% C.I. = 1.88-2.86), benzhexol (RR = 2.32, 95% C.I. = 1.59-3.38), doxepin (RR = 2.30, 95% C.I. = 1.85-2.88), amisulpride (RR = 2.23, 95% C.I. = 1.30-3.81), chlorpheniramine (RR = 2.20, 95% C.I. = 1.67-2.89), amitriptyline (RR = 2.09, 95% C.I. = 1.34-3.26), atropine, (RR = 2.03, 95% C.I. = 1.22-3.38), and astemizole, (RR = 1.70, 95% C.I. = 1.28-2.26) outperformed placebo, but not glycopyrrolate or ipratropium. Across secondary nodes (k = 28, n = 1821), antimuscarinics (RR = 2.26, 95% C.I. = 1.91-2.68), benzamides (RR = 2.23, 95% C.I. = 1.75-3.10), TCAs (RR = 2.23, 95% C.I. = 1.83-2.72), and antihistamines (RR = 2.18, 95% C.I. = 1.83-2.59) outperformed placebo. In head-to-head comparisons, astemizole and ipratropium were outperformed by several interventions. All secondary nodes, except benzamides, outperformed the placebo on the continuous efficacy outcome. For nocturnal sialorrhea, neither benzamides nor atropine outperformed the placebo. Active interventions did not differ significantly from placebo regarding constipation or sleepiness/drowsiness. Low-confidence findings prompt caution in the interpretation of the results. Considering primary nodes' co-primary efficacy outcomes and head-to-head comparisons, efficacy for sialorrhea is most consistent for the following agents, decreasing from metoclopramide through cyproheptadine, sulpiride, propantheline, diphenhydramine, benzhexol, doxepin, amisulpride, chlorpheniramine, to amitriptyline, and atropine (the latter not for nocturnal sialorrhea). Shared decision-making with the patient should guide treatment decisions regarding clozapine-related sialorrhea.

Comparison of external, internal flat-to-flat, and conical implant abutment connections for implant-supported prostheses: A systematic review and network meta-analysis of randomized clinical trials

STATEMENT OF PROBLEM

The implant abutment connection interface has been considered one of the major factors affecting the outcome of implant therapy. However, drawbacks of traditional meta-analyses are the inability to compare more than 2 treatments at a time, which complicates the decision-making process for dental clinicians, and the lack of a network meta-analysis.

PURPOSE

The purpose of this network meta-analysis was to assess whether the implant abutment connection influences the outcome of implant-supported prostheses.

MATERIAL AND METHODS

An electronic search was undertaken to identify all randomized clinical trials comparing the effect of at least 2 different implant abutment connection designs published from 2009 up to May 2020. Outcome variables were implant survival rate, peri-implant marginal bone loss, and biologic and prosthetic complication rates at 12 months after prosthetic loading. Relevant information was extracted, and quality and risk of bias assessed. Pairwise meta-analyses and network meta-analyses based on a multivariate random-effects meta-regression were performed to assess the comparisons (α=.05 for all analyses).

RESULTS

For peri-implant marginal bone loss and prosthetic complications, conical interfaces were determined to be the most effective, with significant differences when compared with external hexagonal connections (P=.011 and P=.038, respectively). No significant differences were found among the implant abutment connections in terms of survival and biologic complications (P>.05 in all direct, indirect, and mixed comparisons).

CONCLUSIONS

After 1 year of loading, conical connections showed lower marginal bone loss and fewer prosthetic complications than external hexagonal connections. However, the implant abutment connection design had no influence on the implant survival and biologic complication rates.