Estimating the mean and variance from the median, range, and the size of a sample

Transcatheter or surgical treatment of paravalvular leaks: A meta-analysis of 13 studies and 2003 patients

Background

Significant paravalvular leak is a rare but serious complication of heart valve replacement, leading to symptomatic heart failure and hemolysis. Due to the paucity of comparative data between surgical and transcatheter paravalvular leak correction, we performed a systematic review and meta-analysis of available studies.

Methods

Studies comparing transcatheter and surgical treatment of paravalvular leak were systematically identified. Short-term all-cause mortality was the primary outcome. Technical and procedural success, 30-day persistence of significant paravalvular leak, length of hospital stay and long-term mortality, persistence of symptoms and paravalvular leak were the main secondary endpoints.

Results

Thirteen studies with 2003 patients were included, treating in most of the cases a mitral prothesis. Transcatheter closure was associated with lower short-term mortality rate (30 days OR 0.28, 95 % CI 0.18-0.42, p < 0.001) compared to surgical treatment. Technical and procedural success did not differ among the two groups. 30-day and long-term rates of persistence of moderate or severe paravalvular leak were higher in the transcatheter group (OR 3.56, 95 % CI 1.49-8.49, p = 0.004 and OR 2.20, 95 % CI 1.27-3.81, p = 0.005 respectively). Long-term death and re-hospitalization events did not differ among the two treatment modalities. The mean difference in days of length of stay was significantly lower in the transcatheter group (mean difference -9.66, 95 % CI -12.37 to -6.94, p < 0.001).

Conclusion

Transcatheter closure of paravalvular leaks is associated with lower short-term mortality rates but higher persistence of moderate-severe paravalvular leak and heart failure symptoms at short and long-term follow-up compared to surgical treatment.

Effects of selected dietary supplements on migraine prophylaxis: A systematic review and dose-response meta-analysis of randomized controlled trials

BACKGROUND

The existing evidence on the effect of dietary supplements for preventing migraines has generated conflicting results.

METHODS

We assessed alterations in migraine clinical features corresponding to the intake of dietary supplements. Our main outcomes included the frequency (number of attacks), duration (in hours), the severity (intensity) and the monthly migraine days. Using a dose-response meta-analysis, we estimated the dose-dependent impact. The certainty of evidence was evaluated using the GRADE tool.

RESULTS

Finally, twenty-two trials were included in the systematic review and meta-analysis. Magnesium supplementation reduced migraine attacks (mean difference (MD) = -2.51), severity (MD = -0.88), and the monthly migraine days (MD = -1.66) compared with the control group. CoQ10 decreased the frequency (MD = -1.73), severity (MD = -1.35), and duration of migraine (MD = -1.72). Riboflavin decreased attack frequency (MD = -1.34). Alpha-lipoic acid decreased attack frequency (MD = -1.24) and severity (MD = -0.38). Probiotics decreased the frequency (MD = -1.16), severity (MD = -1.07) and the monthly migraine days (MD = -3.02). Vitamin D reduced migraine frequency (MD = -1.69) and the monthly migraine days (MD = -2.41). In adults, compared with placebo, these supplements did not significantly affect other outcomes, and omega-3 supplementation did not yield a statistically significant reduction in any of these outcomes.

CONCLUSION

The use of certain dietary supplements has resulted in a significant decrease in migraine prophylaxis. Further clinical trials of high quality appear to be beneficial.

Stylet-driven leads versus lumenless pacing leads in patients with left bundle branch area pacing: A systematic review and meta-analysis

BACKGROUND

Despite advancements in lead designs for optimum left bundle branch area pacing (LBBAP), limited data exist on the performance of stylet-driven leads (SDLs).

OBJECTIVE

This meta-analysis sought to compare the performance and safety of SDLs in comparison with lumenless leads (LLLs) following LBBAP.

METHODS

Systematic literature search was conducted using PubMed, Europe PMC, and ScienceDirect for studies that compared the outcomes of SDLs during LBBAP compared with LLLs. Study outcomes included periprocedural parameters, pacing metrics, and complications.

RESULTS

A total of 6 studies involving 3991 participants were included. LBBAP procedural success was comparable between SDLs and LLLs (90.2% and 90.5%, respectively). Compared with LLLs, SDLs appeared to result in shortened procedural (-11.50 minutes) and fluoroscopy (-2.56 minutes) times, along with increased capture threshold and reduced lead impedance at implantation. However, paced QRS, R-wave amplitude, capture threshold, and lead impedance remained comparable between both groups during follow-up. The number of lead-implantation attempts was similar between SDLs and LLLs (2.6 ± 1.0 vs 2.2 ± 0.6). Lead dislodgement and lead-related complications (except septal perforation) occurred mostly in the SDL group. No statistical differences were found in life-threatening complications.

CONCLUSION

SDLs demonstrated comparable effectiveness in achieving LBBAP, exhibiting similar success rates, mean attempts for lead placement, and pacing parameters, although they were associated with a higher overall incidence of lead-related complications. The reduced overall procedural and fluoroscopy time may be attributed to the ability of SDLs' different delivery sheath selections in identifying the optimal anatomical site, rather than being lead specific.

Effects of exercise on cognitive function and glycated hemoglobin A1c among patients with type 2 diabetes mellitus and cognitive impairment: A systematic review and meta-analysis

AIM

To evaluate the effects of exercise versus without-exercise group on global cognitive function, executive function, glycated hemoglobin A1c (HbA1c) and fasting plasma glucose in patients with type 2 diabetes mellitus and cognitive impairment.

METHODS

A systematic search of Cqvip, SinoMed, Wanfang Data, CINAHL, Cochrane, Embase, Pubmed, Lippincott, Web of Science and Scopus was carried out. Randomized control trials were selected. The risk of bias was evaluated using the Cochrane Risk of Bias tool. The random-effects model was used to obtain the pooled estimates.

RESULTS

Eight trials with 884 participants were included. Exercise could significantly improve global cognitive function (standardized mean difference 0.82, 95% CI 0.53-1.12), executive function measured by the Trail-Marking Test part B (mean difference -20.43, 95% CI -36.20, -4.66), glycated hemoglobin A1c (%; mean difference -0.58, 95% CI -0.88, -0.29) and fasting plasma glucose (mg/dL; mean difference -17.61, 95% CI -32.67, -2.54).

CONCLUSIONS

Exercise can improve cognitive function, glycated hemoglobin A1c and fasting plasma glucose among type 2 diabetes mellitus patients with cognitive impairment. Additional studies with higher methodological quality are expected to draw more definite conclusions. This finding could provide a reference for clinical decision-making and guide future research initiatives. Geriatr Gerontol Int 2025; 25: 148-159.

Precision nutrition-based interventions for the management of obesity in children and adolescents up to the age of 19 years

BACKGROUND

Precision nutrition-based methods develop tailored interventions and/or recommendations accounting for determinants of intra- and inter-individual variation in response to the same diet, compared to current 'one-size-fits-all' population-level approaches. Determinants may include genetics, current dietary habits and eating patterns, circadian rhythms, health status, gut microbiome, socioeconomic and psychosocial characteristics, and physical activity. ​​​​In this systematic review, we examined the evidence base for the effect of interventions based on precision nutrition approaches on overweight and obesity in children and adolescents to help inform future research and global guidelines.

OBJECTIVES

To examine the impact of precision nutrition-based interventions for the management of obesity in children and adolescents in all their diversity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, CINAHL, Web of Science Core Collection, BIOSIS Previews, Global Index Medicus (all regions), IBECS, SciELO, PAHO, PAHO IRIS, WHO IRIS, WHOLIS, Bibliomap, and TRoPHI, as well as the WHO ICTRP and ClinicalTrials.gov. We last searched the databases on 23 July 2024. We did not apply any language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that evaluated precision nutrition-based interventions (accounting for 'omics' such as phenotyping, genotyping, gut microbiome; clinical data, baseline dietary intake, postprandial glucose response, etc., and/or including artificial intelligence such as machine learning methods) compared to general or one-size-fits-all interventions or no intervention in children and adolescents aged 0 to 9 years or 10 to 19 years with overweight or obesity.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study screening, data extraction, and risk of bias and GRADE assessments. We used fixed-effect analyses. Our outcomes of interest were physical and mental well-being, physical activity, health-related quality of life, obesity-associated disability, and adverse events associated with the interventions as defined or measured by trialists, and weight change (reduction, stabilisation or maintenance).

MAIN RESULTS

Two studies (3 references, 105 participants) conducted in Ukraine and Greece met our eligibility criteria. One study reported nonprofit funding sources, whilst the other did not report funding, and the certainty of evidence ranged from very low to low across outcomes (all measured at endpoint). Only one trial (65 participants) contributed data on our primary outcomes of interest. Precision nutrition-based intervention versus one-size-fits-all intervention or standard of care In children 0 to 9 years of age, evidence is very uncertain about the effect of a precision nutrition-based intervention (a computerised Decision Support Tool (DST) that incorporates a variety of participant data and provides personalised diet recommendations based on decision-tree algorithms) on body mass index (BMI) (mean difference (MD) -1.40 kg/m2, 95% confidence interval (CI) -3.48 to 0.68; 1 study, 35 participants; very low-certainty evidence) and on weight (MD -2.60 kg, 95% CI -8.42 to 3.22; 1 study, 35 participants; very low-certainty evidence) compared with a one-size-fits-all control intervention. In children and adolescents 10 to 19 years of age, evidence is very uncertain about the effect of a precision nutrition-based intervention (computerised DST) on BMI (MD 3.00 kg/m2, 95% CI -0.26 to 6.26; 1 study, 30 participants; very low-certainty evidence) and on weight (MD 11.40 kg, 95% CI -0.47 to 23.27; 1 study, 30 participants; very low-certainty evidence) compared with a one-size-fits-all control intervention.

AUTHORS' CONCLUSIONS

Based on data from two small studies with a total of 105 participants, the evidence is very uncertain about the effect of precision nutrition-based interventions on body weight or BMI. This review was limited by the number of available randomised controlled trials in this relatively nascent field. Given these limitations, the two studies do not provide sufficient evidence to adequately inform practice. Future research should report participant outcome data, including outcomes related to mental, emotional, and functional well-being, in addition to biochemical and physical measures, stratified by World Health Organization-defined age groups (children (0 to 9 years), and children and adolescents (10 to 19 years)). Future studies should also report methods related to randomisation, blinding, and compliance, as well as include prespecified analysis plans.

Effects of apple cider vinegar on glycemic control and insulin sensitivity in patients with type 2 diabetes: A GRADE-assessed systematic review and dose-response meta-analysis of controlled clinical trials

Background and aims

Diabetes mellitus (DM) is a multifactorial metabolic disorder that affects the body's ability to regulate blood sugar levels. Apple cider vinegar (ACV) could possibly improve diabetes; nevertheless, evidences provide conflicting results. This study aimed to evaluate the effects of ACV on glycemic profile in type 2 diabetes patients (T2DM) in controlled trials (CTs) by systematically reviewing and dose-response meta-analysis.

Methods

The Scopus, PubMed, and Web of Science databases were searched until November 2024 according to a systematic approach. All CTs investigating ACV's effects on glycemic factors were included. We used a random-effects model to calculate WMDs and 95% confidence intervals (CIs). The present study assessed publication bias, sensitivity analysis, meta-regression, and heterogeneity based on standard methods. We assessed the bias risk of the included studies using Cochrane quality assessments and used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) to calculate evidence certainty. We registered the study protocol at Prospero (no. CRD42023457493).

Results

Overall, we included seven studies in this meta-analysis. ACV significantly reduced fasting blood sugar (FBS) (WMD: -21.929 mg/dL, 95% CI: -29.19, -14.67, p < 0.001) and HbA1c (WMD: -1.53, 95% CI: -2.65, -0.41, p = 0.008) and increased insulin (WMD: 2.059 μu/ml, 95% CI: 0.26, 3.86, p = 0.025), while it did not affect hemostatic model assessment for insulin resistance (HOMA-IR). We observed linear and non-linear associations between ACV consumption and FBS levels (p < 0.001). Each 1 mL/day increase in ACV consumption was associated with a-1.255 mg/dL reduction in FBS. Moreover, greater effects on FBS were in dosages >10.

Conclusion

ACV had positive effects on FBS and HbA1c in T2DM patients.

Systematic Review Registration

The study protocol was registered at Prospero (no. CRD42023457493).

Peripheral blood cell counts as predictors of immune-related adverse events in cancer patients receiving immune checkpoint inhibitors: a systematic review and meta-analysis

Background

In recent years, immune checkpoint inhibitors (ICIs) have shown significant efficacy in treating various malignancies and have become a key therapeutic approach in cancer treatment. However, while ICIs activate the immune system, they can also induce immune-related adverse events (irAEs). Due to the variability in the frequency and severity of irAEs, clinical management faces a significant challenge in balancing antitumor efficacy with the risk of irAEs. Predicting and preventing irAEs during the early stages of treatment has become a critical research focus in cancer immunotherapy. This study aims to evaluate the predictive value of peripheral blood cell counts for irAEs.

Methods

Studies meeting the inclusion criteria were identified through database searches. The standardized mean difference (SMD) was used to compare continuous blood cell counts. For studies that did not provide adjusted odds ratios (ORs) and 95% confidence intervals (CIs), crude ORs for categorized blood cell counts were calculated. The study protocol was registered on PROSPERO (CRD42024592126).

Results

The meta-analysis included 60 studies involving 16,736 cancer patients treated with ICIs. Compared to patients without irAEs, those experiencing irAEs had significantly higher baseline continuous ALC (SMD = 0.12, 95% CI = 0.01-0.24), while ANC (SMD = -0.18, 95% CI = -0.28 to -0.07) and PLR (SMD = -0.32, 95% CI = -0.60 to -0.04) were significantly lower. Similarly, categorized blood cell counts indicated that higher baseline ALC (OR = 2.46, 95% CI = 1.69-3.57) and AEC (OR = 2.05, 95% CI = 1.09-3.85), along with lower baseline NLR (OR = 0.64, 95% CI = 0.50-0.81) and PLR (OR = 0.63, 95% CI = 0.48-0.82), were associated with an increased risk of irAEs. Subgroup analysis further identified cutoff values for ALC (2×10^9/L), NLR (5 or 3), and PLR (180) as better predictors of irAEs.

Conclusion

Higher baseline ALC and AEC, along with lower baseline ANC, NLR, and PLR, are associated with an increased risk of irAEs. However, further research is needed to determine the optimal cutoff values and to explore the efficacy of blood cell counts in predicting specific types of irAEs.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024592126.

Transfusion Practices in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Balancing oxygen requirements, neurologic outcomes, and systemic complications from transfusions in traumatic brain injury (TBI) patients is challenging. This review compares liberal and restrictive transfusion strategies in TBI patients.

DATA SOURCES

Electronic databases were searched from inception to October 2024.

STUDY SELECTION

We included randomized controlled trials comparing liberal and restrictive transfusion strategies in TBI patients.

DATA EXTRACTION

Data were extracted by two reviewers using predefined forms.

DATA SYNTHESIS

We included five studies with 1,533 patients: 769 (50.2%) in the liberal transfusion group and 764 (49.8%) in the restrictive group. There were no significant differences between groups favorable Glasgow Outcome Scale (risk ratio [RR], 1.16; 95% CI, 1.00-1.34), although a leave-one-out analysis demonstrated significance in this endpoint (RR, 1.24; 95% CI, 1.06-1.45). No significant difference was found regarding hospital mortality (RR, 0.98; 95% CI, 0.76-1.27), mortality at follow-up (RR, 1.03; 95% CI, 0.82-1.28), mortality in the ICU (RR, 1.00; 95% CI, 0.73-1.37), infection rates (RR, 1.08; 95% CI, 0.95-1.23), thromboembolic events (RR, 1.79; 95% CI, 0.74-4.31), hospital length of stay (LOS) (mean difference [MD], -1.45; 95% CI, -4.85 to 1.96), or ICU LOS (MD, -0.47; 95% CI, -3.84 to 2.91). The liberal transfusion strategy group had a significantly higher prevalence of acute respiratory distress syndrome (RR, 1.78; 95% CI, 1.06-2.98) and received more blood units per patient (MD, 2.62; 95% CI, 1.90-3.33).

CONCLUSIONS

Our findings suggest that a liberal transfusion strategy results in better neurologic outcomes than a restrictive approach. Future research should examine the complication profile and the effects of using a 9 g/dL threshold. We advocate for revising current guidelines to establish 9 g/dL as the standard threshold for transfusions in TBI patients.

Game-thinking; utilizing serious games and gamification in nursing education - a systematic review and meta-analysis

BACKGROUND

The digital shift in higher education is moving from teacher-focused models to active learning with digital technologies, including the integration of game-based learning strategies. We aim to identify, assess, and summarize the findings of evidence and determine the effectiveness of game-thinking on learning outcomes in nursing education.

METHODS

A comprehensive search for relevant literature was conducted between April and May 2022 Seven databases ERIC, Scopus, ProQuest Education Source, MEDLINE, CINAHL, Web of Science, and Embase were utilized to locate original, peer-reviewed papers published in English. The review was conducted and reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

RESULTS

Overall, 3302 studies were initially screened based on their titles and abstract. From this selection 281 studies were then assessed for full-text eligibility. In the end, 70 studies, consisting of 27 Randomized Controlled Trials (RCTs) and 43 Quasi-experimental studies were included in the review. These studies encompassed data from a total of 8348 participants. The results from the narrative synthesis of the results revealed consistencies across the included studies and their findings. The meta-analysis suggested that game-thinking could be beneficial in nursing education, notably improving students' academic achievement (Pooled ES = 0.99, [95%CI 0.53, 1.44]). The most significant effect of game-thinking on academic achievement was observed in the academic knowledge performance of nursing students (Pooled ES = 1.06, [95%CI 0.55, 1.57]), followed by academic skill performance (Pooled ES = 0.54, [95%CI 0.06, 1.03]).

CONCLUSIONS

The systematic review and meta-analysis provide evidence supporting the effectiveness of game-thinking in nursing education. The findings highlight the potential of game-based learning in enhancing nursing education through knowledge acquisition, albeit with a nuanced effect on skill development. As nursing education continues to adapt to the digital era, integration of game-thinking strategies could serve as a valuable method for creating engaging and effective learning experiences for nursing students.

Effects of cold-water immersion on health and wellbeing: A systematic review and meta-analysis

BACKGROUND

Cold-water immersion (CWI) has gained popularity as a health and wellbeing intervention among the general population.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the psychological, cognitive, and physiological effects of CWI in healthy adults.

METHODS

Electronic databases were searched for randomized trials involving healthy adults aged ≥ 18 years undergoing acute or long-term CWI exposure via cold shower, ice bath, or plunge with water temperature ≤15°C for at least 30 seconds. Outcomes of interest were sleep, stress, fatigue, energy, skin health, immunity, inflammation, mental wellbeing, depression, anxiety, mood, concentration, and alertness or focus. Meta-analyses were conducted using RevMan software (version 5.4), applying random effects models to calculate standardized mean differences (SMD) between pre- and post-CWI exposure outcomes. Risk of bias was assessed using the PEDro scale.

RESULTS

Eleven studies were included, comprising 3177 total participants and a mean PEDro score of 6.4 (n = 7 moderate quality, n = 4 high quality). CWI interventions were performed in baths (n = 10) or showers (n = 1) at temperatures ranging from 7°C to 15°C and durations ranging from 30 seconds to 2 hours. The meta-analysis revealed significant increases in inflammation immediately (SMD: 1.03, [95% CI: 0.37, 1.68], p <  0.01) and 1 hour post CWI (SMD: 1.26, [95% CI: 0.59, 1.94], p <  0.01), indicating an acute inflammatory response. A significant reduction in stress was observed 12 hours post-CWI (SMD: -1.00, [95% CI: -1.40, -0.61], p <  0.01), however, no significant effects on stress were detected immediately (SMD: -0.09 [95% CI: -0.45, 0.63], p >  0.05), 1 hour (SMD: -0.29 [95% CI: -0.66, 0.08], p >  0.05), 24 hours (SMD: -0.06 [95% CI: -0.50, 0.38], p >  0.05), or 48 hours (SMD: 0.09 [95% CI: -0.28, 0.46], p >  0.05) post-exposure. While meta-analysis showed no significant effects on immune function immediately (SMD: -0.16 [95% CI: -0.82, 0.51], p >  0.05) or 1 hour (SMD: -0.18 [95% CI: -1.09, 0.74], p >  0.05) post-CWI, narrative synthesis suggested longer-term benefits, including a 29% reduction in sickness absence among participants who took cold showers. Improvements were also observed in sleep quality and quality of life, but not mood.

CONCLUSIONS

This systematic review suggests that CWI delivers time-dependent effects on inflammation, stress, immunity, sleep quality, and quality of life, offering potential practical applications for health practitioners considering CWI for stress management and wellbeing support. However, the current evidence base is constrained by few RCTs, small sample sizes, and a lack of diversity in study populations. Future high-quality RCTs are needed to examine the long-term effects of CWI, its impact on diverse health outcomes, and optimal CWI protocols. PROSPERO (ID: CRD42024500591).

Virtual reality-based interventions improve balance skills in children with developmental coordination disorder: systematic review and meta-analysis

PURPOSE

Virtual reality-based interventions (VRBI) are a gamified approach to therapy that can improve balance and motor skills in children diagnosed with Developmental Coordination Disorder (DCD). The aim was to investigate the effectiveness of VRBI in improving balance and motor skills in children with DCD.

METHODS

According to PRISMA guidelines, meta-analyses were conducted by searching randomized controlled trials (RCTs) that investigated the effect of VRBI on balance and motor skills in children with DCD. The global search was carried out in PubMed, SCOPUS, WOS, CINAHL and PEDro during the period from April 1st to 24th, 2024, without publication date restrictions. Standardized mean difference (SMD) and its 95% confidence interval (95%CI) was calculated as the pooled effect measure.

RESULTS

Nine RCTs, with a moderate mean methodological quality (5.11 points in PEDro) providing data from 266 participants, were included. All studies included used non-immersive virtual reality (NIVR) devices to carry out the VRBI. Meta-analyses revealed that NIVR was effective in increasing balance (SMD = 0.4; 95%CI 0.09-0.71), as well as running and agility skills (SMD = 0.45; 95%CI 0.03-0.87). However, no statistical differences were found in improving motor skills.

CONCLUSIONS

Findings reported in this meta-analysis support that VRBI that use NIVR devices can be effective in improving balance in children with DCD.

Effect of Vitamin D Supplementation on Lipid Profile in Overweight or Obese Women: A Meta-analysis and Systematic Review of Randomized Controlled Trials

CONTEXT

Previous studies have explored the relationship between vitamin D and lipid profile in individuals with obesity or overweight women, but the results have been inconsistent.

OBJECTIVE

This meta-analysis and systematic review of randomized controlled trials (RCTs) was conducted to assess the effect of vitamin D on lipid profile in women who are overweight or obese.

DATA SOURCES

A meticulous search strategy was used across the Scopus, PubMed/Medline, Web of Science, and Embase databases up to June 2024.

DATA EXTRACTION

RCT studies administering vitamin D to overweight or obese women were extracted. A random-effects model was applied to compute the weighted mean difference (WMD) and 95% CIs of the intervention on each variable.

DATA ANALYSES

Thirteen eligible publications with 16 arms focused on low-density-lipoprotein cholesterol (LDL-C), 16 arms on high-density-lipoprotein cholesterol (HDL-C), 18 arms on total cholesterol (TC), and 18 arms on triglycerides (TG) were included in the final quantitative analysis. Vitamin D supplementation resulted in significant reductions in TG (WMD: -6.13 mg/dL; 95% CI: -8.99 to -3.28; P = .000) and TC (WMD: -4.45 mg/dL; 95% CI: -7.06 to -1.83; P = .001), as well as a significant increase in HDL-C concentrations (WMD: 1.54 mg/dL; 95% CI: 0.57 to 2.52; P = .002). Stratified analysis indicated a greater reduction in TG levels in studies with a mean baseline TG concentration ≥150 mg/dL (WMD: -23.58 mg/dL) and when vitamin D was administered for ≤26 weeks (WMD: -11.44 mg/dL).

CONCLUSION

According to our findings, vitamin D has a significant effect on hypertriglyceridemia in individuals who are overweight or obese. However, vitamin D has no significant effect on LDL-C concentrations in this population.

The Effects of Exercise Training on Body Composition and Cardiometabolic Risk Factors in Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIM

We performed a systematic review and meta-analysis to investigate the effects of exercise training on body composition and cardiometabolic health in patients with Type 1 diabetes (T1D).

METHOD

A search in three main databases including PubMed, Web of Science, and Scopus was conducted from the inception of this review until June 2024 to identify randomized control trials investigating the effects of exercise training compared to a control on body composition and cardiometabolic risk factors in patients with T1D. The data were pooled using random effects models to calculate weighted mean differences (WMDs), standardized mean differences (SMDs), and 95% confidence intervals (CIs).

RESULTS

Overall, 25 studies involving 1120 patients with T1D were included in the meta-analysis. Exercise training decreased body mass index (BMI) [WMD: -0.18 kg.m2, p = 0.02], fasting glucose [WMD: -14.97 mg/dl, p = 0.01], and HbA1c [WMD: -0.49%, p = 0.003], and increased VO2max/peak [WMD: 2.76 mL/kg/min, p = 0.001] as compared with controls. Exercise training had no effect on body fat percentage or lean body mass, lipid profiles, or blood pressure. Subgroup analysis indicated that age, exercise mode, and intervention duration were the main moderators for the beneficial effects of exercise training.

CONCLUSIONS

In patients with T1D, exercise training is effective for decreasing body weight and cardiometabolic risk factors.

Inflammatory Markers as Predictors of Diabetic Nephropathy in Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background and Objectives: Diabetic nephropathy (DN) is a major complication of diabetes mellitus and a leading cause of end-stage renal disease. Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and red cell distribution width (RDW) have been proposed as potential predictors of DN progression. This study systematically reviews and meta-analyzes the role of these markers in DN. Materials and Methods: A comprehensive literature search was conducted to identify studies evaluating NLR, PLR, SII, and RDW in type 2 diabetes patients with normoalbuminuria, microalbuminuria, and macroalbuminuria. Five databases were searched: PubMed, Scopus, Embase, Web of Science, and LILACS. The Newcastle Ottawa Scale was used to assess the risk of bias in selected articles. Results: Out of 1556 records that were identified through searches, 40 were selected for the review. Finally, 35 were included for meta-analyses, including 13,519 patients. Higher levels of NLR, PLR, SII, and RDW were observed in macro- and microalbuminuria compared to normoalbuminuria, with significantly elevated NLR in microalbuminuria. Meta-analyses showed that NLR and RDW were significantly associated with higher odds of DN (NLR: OR 1.84, p < 0.001; RDW: OR 1.9, p = 0.023). However, PLR and SII were not significantly associated with DN. A longitudinal study confirmed SII as a significant predictor of DN progression (hazard ratio: 3.24, p = 0.023). Conclusions: This study highlights the potential of NLR and RDW as predictive markers for diabetic nephropathy.

Effectiveness of Mobile Health-Based Gamification Interventions for Improving Physical Activity in Individuals With Cardiovascular Diseases: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Gamification refers to using game design elements in nongame contexts. Promoting physical activity (PA) through gamification is a novel and promising avenue for improving lifestyles and mitigating the advancement of cardiovascular diseases (CVDs). However, evidence of its effectiveness remains mixed.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the efficacy of gamification interventions in promoting PA during short-term and follow-up periods in individuals with CVDs and to explore the most effective game design elements.

METHODS

A comprehensive search of 7 electronic databases was conducted for randomized controlled trials published in English from January 1, 2010, to February 3, 2024. Eligible studies used mobile health-based gamification interventions to promote PA or reduce sedentary behavior in individuals with CVDs. In total, 2 independent reviewers screened the retrieved records, extracted data, and evaluated the risk of bias using the RoB 2 tool. Discrepancies were resolved by a third reviewer. Meta-analyses were performed using a random-effects model with the Sidik-Jonkman method adjusted by the Knapp-Hartung method. Sensitivity analysis and influence analysis examined the robustness of results, while prediction intervals indicated heterogeneity. A meta-regression using a multimodel inference approach explored the most important game design elements. Statistical analyses were conducted using R (version 4.3.2; R Foundation for Statistical Computing).

RESULTS

In total, 6 randomized controlled trials were included. Meta-analysis of 5 studies revealed a small effect of gamification interventions on short-term PA (after sensitivity analysis: Hedges g=0.32, 95% CI 0.19-0.45, 95% prediction interval [PI] 0.02-0.62). Meta-analysis of 3 studies found the maintenance effect (measured with follow-up averaging 2.5 months after the end of the intervention) was small (Hedges g=0.20, 95% CI 0.12-0.29, 95% PI -0.01 to 0.41). A meta-analysis of 3 studies found participants taking 696.96 more steps per day than the control group (95% CI 327.80 to 1066.12, 95% PI -121.39 to 1515.31). "Feedback" was the most important game design element, followed by "Avatar."

CONCLUSIONS

This meta-analysis demonstrates that gamification interventions effectively promote PA in individuals with CVD, with effects persisting beyond the intervention period, indicating they are not merely novel effects caused by the game nature of gamification. The 95% PI suggests that implementing gamification interventions in similar populations in the future will lead to actual effects in promoting PA in the vast majority of cases. However, the limited number of included studies underscores the urgent need for more high-quality research in this emerging field.

TRIAL REGISTRATION

PROSPERO CRD42024518795; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=518795.

The effects of Garcinia cambogia on glycaemic control and liver enzymes in adults: a systematic review and meta-analysis of randomised controlled trials

Previous studies have assessed how supplementing with Garcinia cambogia affects glycaemic control and liver enzyme levels; nevertheless, the results were not consistent. The study aimed to evaluate the impact of Garcinia cambogia on glycaemic control and liver enzymes through a systematic review and meta-analysis. Searches were conducted from the beginning through February 2023, using online databases (Scopus, Web of Science, PubMed, and Cochrane Library). Trials examining the impact of Garcinia cambogia on serum levels of fasting blood sugar (FBS), serum level of insulin, alanine transaminase (ALT), and aspartate transaminase (AST) in adults were included. The overall estimates and their 95% confidence intervals (CIs) were calculated using a random-effects model. This meta-analysis includes nine publications with 444 participants. The results showed that Garcinia cambogia has no significant effect on FBS (weighted mean difference (WMD): 1.02 mg/dl, 95% CI: -1.29, 3.33), insulin (WMD: -0.12 mU/L, 95% CI: -1.50, 1.25), AST (Hedges' g: -0.08, 95% CI: -0.43, 0.26), and ALT (Hedges' g: 0.27, 95% CI: -0.20, 0.73). Subgroup analysis showed that Garcinia cambogia significantly increased insulin levels in females and also increased insulin and FBS levels in those with a BMI ≥30 kg/m2. Nevertheless, the administration of Garcinia cambogia for more than 8 weeks significantly decreased insulin levels. This meta-analysis showed that supplementation with Garcinia cambogia has no significant effect on FBS, insulin, ALT, or AST levels compared with control groups; however, it seems that increasing the duration of the intervention may have a decreasing effect on insulin levels.

Gut microbiota in patients with sarcopenia: a systematic review and meta-analysis

Background

Intestinal dysbiosis was considered a pivotal pathological mechanism underlying sarcopenia. Despite the fervor surrounding research in this domain, substantial controversy persists regarding the obtained outcomes.

Objective

To systematically summarized the disparities in gut microbiota composition between the group afflicted by sarcopenia and non-sarcopenia controls.

Methods

PubMed, Medline, CINAHL, EMBASE, Scopus, Web of Science and Google Scholer, Cochrane Library and gray literature sources were systematically searched for in randomized controlled trials. Meta-analysis and random-effects meta-regression were conducted using Rev. Man 5.3. Overall effect was measured using Hedges's g and determined using Z-statistics. Cochran's Q test and I 2 were used to investigate heterogeneity. The Newcastle-Ottawa Scale was used to assess overall quality of evidence.

Results

Ten studies, including 421 cases of sarcopenia and 1,642 cases of controls, were included in the meta-analysis. Patients with sarcopenia showed significantly reduced gut microbiota in α diversity, and β diversity was significantly different in 8/9 of included studies. We also found more abundance of phylum Proteobacteria and genus Escherichia-Shigella, and less abundance of phylum Firmicutes and genus Faecalibacterium, Prevotella 9, Blautia in the sarcopenia group.

Conclusion

The gut microbiota composition in patients with sarcopenia has undergone alterations, serving as a fundamental reference for further investigation into the potential pathogenic mechanisms and treatment strategies for sarcopenia.

The impact of oleuropein, hydroxytyrosol, and tyrosol on cardiometabolic risk factors: a meta-analysis of randomized controlled trials

The so-called Mediterranean diet, with olive oil as a key component, is effective in reducing cardiometabolic disease risk. Olive oil consumption improves blood pressure, insulin levels and resistance, supporting heart health and glycemic control. Its phenolic compounds, including oleuropein (OLE), hydroxytyrosol (HT), and tyrosol (TYR) are hypothesized to likely contribute to these benefits. Thus, this meta-analysis evaluated the clinical effects of dietary supplementation with OLE, HT, and TYR on cardiometabolic outcomes. Fourteen human intervention studies with 594 participants were included. The analysis using a random-effects model showed that OLE, HT, and TYR significantly reduced total cholesterol (SMD = -0.19, CI: -0.37 to -0.01, p = 0.04, I2 = 35%), triacylglycerol (SMD = -0.32, CI: -0.60 to -0.03, p = 0.03, I2 = 73%), and insulin (SMD = -0.42, CI: -0.82 to -0.01, p = 0.04, I2 = 78%). Subgroup analysis showed that, in certain contexts, interventions may be more beneficial for BMI <30, non-Mediterranean, and cardiometabolic disease individuals, while intervention compound, type of intervention, and duration might have differential effects regarding considered outcomes. Overall, the meta-analysis suggests that supplementation with OLE, HT, and TYR may beneficially impact some cardiometabolic parameters, though further studies are needed to confirm these findings.

Reverse shock index multiplied by Glasgow coma scale (rSIG) to predict mortality in traumatic brain injury: systematic review and meta-analysis

OBJECTIVE

To determine whether the Reverse Shock Index multiplied by the Glasgow Coma Scale (rSIG) is a predictor of in-hospital mortality in patients with traumatic brain injury (TBI).

DESIGN

This is a systematic review and meta-analysis.

SETTING

A comprehensive search was conducted in five databases for studies published up to May 22, 2024, using a PECO strategy. Eight studies were identified for quantitative analysis and included in our meta-analysis.

PARTICIPANTS

The participants of the included primary studies.

INTERVENTIONS

Patients with a low rSIG as a predictor of in-hospital mortality in TBI.

MAIN VARIABLES OF INTEREST

rSIG, in-hospital mortality, TBI.

RESULTS

Our meta-analysis evaluated a total of eight observational studies encompassing 430,000 patients with TBI, observing 6,417 deaths (15%). After performing a sensitivity analysis, we found that patients with TBI and a low value of the reverse shock index multiplied by the Glasgow Coma Scale (rSIG) had a 24% higher risk of death (OR 1.24; 95% CI 1.12-1.38; I²: 96%). Furthermore, rSIG values were significantly higher in survivors compared to those who died (MD 7.72; 95% CI 1.86-13.58; I²: 99%).

Antibodies against neuronal surface antigens in acute stroke: a systematic review and meta-analysis

Background

Antibodies against neuronal surface antigens (NSA-Abs), particularly against the NMDA receptor (NMDAR-Ab), have been reported in acute stroke patients (ASP). However, their role in stroke is far from being understood.

Methods

We conducted a systematic review and meta-analysis to investigate: 1) the frequency of NSA-Abs in patients with acute stroke compared to controls; 2) the de novo appearance of NSA-Abs after stroke; and 3) their effects on the clinical outcome.

Results

We included nine studies in the qualitative analysis and seven in the quantitative analysis. Analyses were restricted to NMDAR-Abs due to the lack of data about other NSA-Abs. Considering only studies that adopted a cell-based assay, IgA-IgM NMDAR-Abs isotypes (but not the IgG) were found more frequently in patients with acute stroke (OR 2.69, 95% CI 2.00-3.62, I2 = 4%). There was no de novo NMDAR-Abs formation after stroke. There was no statistical difference in mean discharge/day-7 NIHSS (SMD 0.21, 95% CI -1.10-1.52, I2 = 84%) and 3-12-month mRS (SMD 0.38, 95% CI -0.56-1.32, I2 = 78%) between patients with stroke with and without NMDAR-Abs seropositivity.

Conclusions

Serum IgA/IgM NMDAR-Abs are more frequent in patients with stroke than controls. Due to several methodological issues, these findings should be interpreted cautiously. Additional, methodologically robust studies are needed to clarify the prevalence and significance of NMDAR-Abs in patients with stroke.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022241278#:~:text=https%3A//www.crd.york.ac.uk/prospero/display_record.php%3FID%3DCRD42022241278, identifier CRD42022241278.

Single and multilevel decompression alone in patients with multilevel lumbar spinal stenosis: a systematic review and meta-analysis

Multilevel lumbar spinal stenosis (LSS) is a prevalent degenerative condition characterized by lower back pain, intermittent claudication, and radicular leg pain. It ranks as one of the primary indications of spinal surgery in patients aged 65 and older. In this study, we aim to compare single-level and multilevel approaches for decompression alone in LSS considering the incidence of complications, reduction in pain score, and rates of surgical revisions. A systematic search was conducted on PubMed (MEDLINE), Embase, Web of Science, and Cochrane Library databases for studies directly comparing single-level and multilevel decompression in patients with LSS. A total of 1,039 patients across five studies were analyzed, with 605 (58.2%) patients who underwent single-level decompression and 434 (41.8%) patients in the multilevel decompression cohort. Despite the multilevel decompression group showing a higher incidence of complications (14% vs. 7%), there was no statistically significant difference between groups (OR 0.60; 95%CI 0.34-1.08; p = 0.087; I2 = 0%). Also, there was no statistically significant difference between the groups in terms of pain score reduction. (OR 0.70; 95%CI -0.37-1.77; p = 0.199; I2 = 96%). Ultimately, surgical revision was necessary for 33 (8%) patients in the single-level cohort and 7 (5%) patients in the multilevel group, however, there was no statistically significant difference (OR 1.81; 95% CI 0.78-4.18; p = 0.166; I2 = 0%). Decompression involving two or more levels showed comparable postoperative outcomes to single-level decompression, suggesting it could be a non-inferior procedure. Nevertheless, further research is required to solidify its efficacy and safety profile.

Pervasive Games for Sexual Health Promotion: Scoping Literature Review

BACKGROUND

Serious games play a fundamental role in promoting safe sexual behaviors. This medium has great potential for promoting healthy behaviors that prevent potential risk factors, such as sexually transmitted infections, and promote adherence to sexual health treatments, such as antiretroviral therapy. The ubiquity of mobile devices enhances access to such tools, increasing the effectiveness of video games as agents of change.

OBJECTIVE

In this scoping review, we aimed to (1) identify the extent to which pervasive games have been used in the field of sexual health, (2) determine the theories used in the design and evaluation of pervasive games for sexual health, (3) identify the methods used to evaluate pervasive games for sexual health, and (4) explore the reported benefits of using pervasive games for sexual health.

METHODS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology, we conducted a comprehensive literature search in the Web of Science, Scopus, IEEE Xplore, and ACM databases for articles published between January 1, 2000, and August 4, 2024. Included articles were published in English between 2000 and 2024 and involved the design, implementation, or evaluation of a ubiquitous video game focused on promoting safe sexual behaviors, with qualitative and/or quantitative results based on theory-based techniques and ubiquitous technologies. Review articles, conference papers, or books without available data or quantitative or qualitative results were excluded.

RESULTS

We screened 521 of 612 articles (85.1%) after removing duplicates. After the title and abstract review, 51 (9.8%) articles were assessed for eligibility, and 30 (5.8%) articles meeting the criteria were studied and evaluated in depth. The results suggested that the use of pervasive video games has a positive impact on promoting safe sexual behaviors. This is enhanced by the effectiveness of theory-based techniques and the use of mobile technologies as developmental factors that drive the gaming experience. The results indicated that this domain is a growing field that should not be ignored.

CONCLUSIONS

The literature showed that pervasive video games have been effective in promoting safe sexual behaviors. Substantial growth has been seen in scientific community interest in researching this domain; nevertheless, there is still much to work on. In this context, we advocate for the standardization of design, implementation, and experimentation as essential phases in creating video game experiences. These 3 fundamental aspects are critical in the development of video game-based studies to ensure the reproducibility of experiments.

Long-term outcomes comparison of Bentall-De Bono-versus valve-sparing aortic root replacement: An updated systematic review and reconstructed time-to-event meta-analysis

BACKGROUND

For patients with aortic root dilatation and a structurally normal aortic valve (AV) undergoing composite aortic valve-graft (Bentall-De Bono) versus valve-sparing aortic root replacement (VSARR) procedures there are conflicting data regarding early and long-term benefits. We undertook a study-level meta-analysis to compare the results of both procedures.

METHODS

Three databases were assessed, and both randomized trials and observational studies were considered eligible. Kaplan-Meier curves of long-term survival and reoperation risk were reconstructed and compared with Cox linear regression and incidence rate ratios (IRR) with 95 % confidence intervals (CI). Landmark analysis and time-varying hazard ratio (HR) were analyzed. Odds ratios (OR) were calculated for early mortality, postoperative stroke, and re-exploration for postoperative bleeding. A random effects model was used. Sensitivity analyses included leave-one-out-analysis, meta-regression and subgroups analysis.

RESULTS

1456 articles were identified, including 39 observational studies, totaling 14,651 patients (Bentall-De Bono = 9557 and VSARR = 5094). Twelve studies were adjusted. The mean weighted follow-up was 5.05 ± 3.7 years. VSARR was associated with significantly greater survival (HR = 0.50; 95 % CI, 0.45-0.57; p < 0.0001) at 15-year follow-up. The reoperation risk was higher following VSARR (HR = 1.30; 95 % CI, 1.03-1.63; p = 0.02.), although time-varying HR model and landmark analysis reported an increased risk of reoperation within 5 years after VSARR (HR = 1.57; 95 % CI, 1.23-2.01; p < 0.001), after which the difference disappeared. Subgroups analysis of studies excluding aortic dissection showed a comparable rate of late reoperation.

CONCLUSIONS

VSARR is associated with improved long-term survival compared to Bentall-De Bono. The risk of late reoperation is higher within 5 years following VSARR, after which the two procedures are comparable.

Effects of propolis consumption on blood pressure, lipid profile and glycemic parameters in adults: a GRADE-assessed systematic review and dose-response meta-analysis

Propolis, as a by-product of honey production, has shown several beneficial effects on cardiovascular risks in past randomised controlled trials, although the findings are not conclusive. In this review, we intend to evaluate the effects of propolis consumption on cardiovascular risk factors by conducting a meta-analysis. The Web of Science, Medline and Scopus databases were comprehensively searched until September 2023. Eligible studies were identified by screening, and their data were extracted. Weighted mean differences with a 95 % CI for each outcome were estimated using the random-effects model. This meta-analysis revealed that propolis consumption led to a significant decrease in the levels of TAG (weighted mean differences (WMD): -10·44 mg/dl 95 % CI: -16·58, -4·31; P = 0·001), LDL-cholesterol (WMD: -9·31 mg/dl; 95 % CI: -13·50, -5·12 mg; P < 0·001), fasting blood glucose (WMD: -7·30 mg/dl; 95 % CI: -11·58, -3·02; P = 0·001), HbA1c (WMD: -0·32 %; 95 % CI: -0·60, -0·05; P = 0·01), insulin (WMD: -1·36 μU/ml; 95 % CI: -2·36, -0·36; P = 0·007), homeostatic model assessment for insulin resistance (WMD: -0·39; 95 % CI: -0·74, -0·03; P = 0·020) and systolic blood pressure (WMD: -2·24 mmHg 95 % CI: -4·08, -0·39; P = 0·010), compared with the control groups. Furthermore, propolis consumption had a significant increasing effect on HDL-cholesterol levels (WMD: 2·03 mg/dl; 95 % CI: 0·24, 3·83; P = 0·020). In contrast, the consumption of propolis had no significant effect on total cholesterol and diastolic blood pressure levels. This systematic review and dose-response meta-analysis suggested that propolis intake may be effective in cardiometabolic improvement in adults. Further, well-designed studies are required to confirm and elucidate all aspects of these findings.

Associations of RANKL levels and polymorphisms with rheumatoid arthritis: A meta-analysis

OBJECTIVES

This study examined the correlation between circulating receptor activator for nuclear factor-κB ligand (RANKL) levels and rheumatoid arthritis (RA), and investigated the association between polymorphisms in the RANKL gene and susceptibility to RA.

METHOD

We searched the Medline, Embase, and Cochrane databases for relevant publications up to September 2024. A meta-analysis was conducted to assess serum/plasma RANKL levels in patients with RA and controls, and to explore the relationship between RANKL rs9533156 and rs2277438 polymorphisms and RA susceptibility.

RESULTS

Ten studies encompassing 1,682 RA patients and 1,288 controls were analyzed. RANKL levels were significantly higher in RA patients compared to controls (SMD = 0.665, 95% CI = 0.290-1.040, P = 0.001). Subgroup analysis affirmed these findings' consistency across different sample sizes and publication years. RANKL levels were positively associated with rheumatoid factor (RF) and Disease Activity Score-28 (DAS28) (RF correlation coefficient = 0.157, 95% CI = 0.028-0.282, P = 0.018; DAS28 correlation coefficient = 0.151, 95% CI = 0.125-0.370, P < 0.001). Additionally, the meta-analysis revealed significant associations between the susceptibility to RA and the RANKL rs9533156 C allele (OR = 0.609, 95% CI = 0.520-0.714, P < 0.010) as well as the rs2277438 G allele (OR = 1.206, 95% CI = 1.003-1.451, P = 0.047). These associations were consistent across homozygote comparisons and different genetic models.

CONCLUSIONS

This meta-analysis underscores the elevated circulating RANKL levels in RA patients and their significant correlation with RF and DAS28. Additionally, the RANKL rs9533156 and rs2277438 polymorphisms were significantly associated with RA susceptibility.

Impact of Obesity on Short-Term Outcomes in Patients Undergoing Retroperitoneal Laparoscopic/Retroperitoneoscopic Adrenalectomy for Benign or Malignant Adrenal Diseases: A Meta-Analysis

Background and Objectives: Retroperitoneal laparoscopic adrenalectomy (RLA) is one of two laparoscopic procedures used to treat benign and malignant adrenal diseases. Obesity in patients undergoing minimally invasive adrenal surgery is a frequently discussed topic. Our meta-analysis aimed to provide updated evidence by comparing intraoperative and perioperative outcomes on non-obese (NOb) and obese (Ob) patients who underwent RLA due to benign or malignant disease. Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, Scopus, Web of Science (Science and Social Science Citation Index), and Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL)) databases were used to identify articles of interest. The meta-analysis was performed using RevMan [Computer program] Version 5.4. Results: The four included comparative studies (809 patients: 552 NOb versus 257 Ob) covered an approximately 15-year-study period (2007-2022). All the included studies were observational in nature. By comparing the Ob and NOb groups, shorter operative time and lower overall postoperative complication rates in the NOb population were recorded through the meta-analysis. Considering the subgroup analysis (BMI ≥ 30 kg/m2), just the operative time maintained statistical significance. Conclusions: Obesity did not appear to impact RLA safety and effectiveness. Due to important biases (small overall sample size and few analyzed events), the interpretation of our results must be a careful one. Later randomized and multi-center trials may help the confirmation of our results.

Effect of del Nido cardioplegia in patients with reduced left ventricular ejection fraction: A meta-analysis

PURPOSE

Research on the safety and efficacy of del Nido cardioplegia in adult patients with reduced left ventricular ejection fraction (LVEF) is limited. We evaluated the effect of del Nido cardioplegia on early outcomes of cardiac surgery in this cohort.

METHODS

PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched through August 2024 to conduct a meta-analysis comparing del Nido to other cardioplegia in adult patients with reduced LVEF (≤50%). Primary endpoint was early mortality, and secondary endpoints included morbidities, aortic cross-clamp time and postoperative LVEF before discharge. A random-effect model was used to estimate the pooled effect size.

RESULTS

Seven studies met our eligibility criteria, including three propensity score-matched studies with a total of 1160 patients. Conventional blood cardioplegia was used exclusively as a control solution in the included studies. The incidence of early mortality was similar between the del Nido and control groups, with a pooled odds ratio of 0.94 [95% confidence interval: 0.52; 1.71] (p = .822). Postoperative stroke (p = .680), renal failure (p = .832), atrial fibrillation (p = .412), and aortic cross-clamp time (p = .153) were also comparable between the two groups. Postoperative LVEF was significantly higher in the del Nido group compared to the control group, with a standardized mean difference of 0.52 [95% confidence interval: 0.07; 0.96] (p = .034).

CONCLUSIONS

In adult patients with reduced LVEF undergoing cardiac surgery, del Nido cardioplegia provides comparable mortality and morbidity rates compared to conventional blood cardioplegic solutions, with the potential to offer protective effects on myocardial function.

A comprehensive systemic review and meta-analysis of the association between lipid profile and hidradenitis suppurativa

BACKGROUND

While several studies have suggested a connection between Metabolic Syndrome (MetS) and Hidradenitis Suppurativa (HS), a definitive analysis confirming the association between lipid abnormalities and HS based on actual lipid values is lacking. Previous research, using odds ratios from ICD codes, indicates links between elevated triglycerides and low high-density lipoprotein levels with HS. However, these findings may not fully represent real-life situations, as no comprehensive analysis using actual lipid measurements has been performed.

OBJECTIVES

To examine the relationship between lipid profile values-total cholesterol, triglycerides (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL)-and HS.

METHODS

A comprehensive search of PubMed, Cochrane Library, and Embase was conducted to identify studies reporting lipid profiles in HS patients. A meta-analysis using standardized mean differences (SMDs) was performed to assess the association between lipid abnormalities and HS.

RESULTS

The meta-analysis found that HS patients had significantly higher TG levels (SMD = 0.28, 95% CI: 0.09-0.47, P = 0.004) and lower HDL levels (95% CI: -0.53 to -0.16, P < 0.001) compared to healthy controls. No significant differences were observed in total cholesterol (SMD = 0.01, 95% CI: -0.19-0.21, P = 0.93) and LDL levels (SMD = 0.04, 95% CI: -0.10-0.17, P = 0.61). These results corroborate earlier studies linking HS with dyslipidemia, particularly hypertriglyceridemia and hypo-HDL cholesterolemia, with the added strength of using actual lipid values.

CONCLUSIONS

This study confirms the association between hypertriglyceridemia and low HDL cholesterol in HS patients, highlighting the broader systemic association of the condition. Dermatologists should monitor lipid profiles in HS patients to mitigate potential cardiovascular risks through early detection and management.

Comparison of Intubating Conditions Between Direct Laryngoscopy and C-MAC Video-laryngoscopy in Patients With Simulated Cervical Spine Immobilization: A Systematic Review and Meta-analysis

Intubation of patients requiring cervical spine immobilization can be challenging. Recently, the use of C-MAC video laryngoscopes (VL) has increased in popularity over direct laryngoscopy (DL). We aimed to conduct a systematic review and meta-analysis to evaluate the efficacy of C-MAC VL as compared with DL for intubation in C-spine immobilized patients. A systematic search of electronic databases, including PubMed, Cochrane Library, Embase, and Web of Science was performed. Time taken to intubate was the primary outcome whereas the use of optimization maneuvers, laryngoscopy view, first-pass success rates, and difficulty of intubation were secondary outcomes. Seven trials involving 490 patients were included in the analysis. There was no significant difference between the 2 groups in terms of time taken to intubate, standardized mean difference 0.65 (95% CI, -2.55, 3.86). The certainty of evidence for the primary outcome, time taken to intubate, was low, with high heterogeneity (I2=97%). The C-MAC VL group had higher first-pass success rates (odds ratio 2.92 [95% CI, 1.14, 7.49]) and a lower incidence of a poor laryngoscopy view (odds ratio 0.21 [95% CI, 0.07, 0.66]). There was no difference in terms of the difficulty of intubation and the use of optimization maneuvers. Overall, C-MAC VL did not reduce the time taken to intubate, although the strength of this finding is limited by wide confidence intervals. C-MAC VL significantly improved laryngoscopy views and first-pass success rate as compared with DL.

Pulmonary function among flour mill workers: a systematic review and meta-analysis

BACKGROUND

Flour dust, with an inherent allergic nature, increases vulnerability to various respiratory ailments. We systemically reviewed and compared literature-reported pulmonary function parameters to quantify pulmonary dysfunction among individuals with high flour dust exposure (among flour mill workers) and relatively un-exposed groups.

METHODS

Studies that compared pulmonary function parameters for flour dust exposed and unexposed control groups were systemically searched in PubMed, Scopus and Embase from inception to June 2024. The Newcastle Ottawa scale was used to assess the risk of bias among included studies. With the random effect model, we pooled (along with 95% CI) the mean difference for forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), the ratio of FEV1 & FVC, mid-expiratory flow (FEF25-75%), peak expiratory flow rate (PEFR) and other pulmonary function parameters. Cochran-Q test and I2 statistics were applied to determine heterogeneity.

RESULTS

This quantitative synthesis included twenty-two studies involving 2,482 flour dust exposed and 1,925 control participants. The pooled mean difference for FEV1, FVC, FEV1/FVC, PEFR and FEF25 - 75% were - 0.43 L (-0.57, -0.29; I2 = 88.7), -0.49 L (-0.64, -0.33; I2 = 89.3), -3.5% (-6.49, -0.5; I2 = 89.7), -1.36 L/s (-1.70, -1.03; I2 = 90.4) and - 0.34 L/s (-0.63, -0.06; I2 = 77.3). The pooled odds ratio for obstructive [12.9 (3.41, 49.2); I2 = 82.4)] and restrictive changes [5.11 (0.55, 47.4); I2 = 81.6] were significantly higher among the exposed than controls. As per the bias assessment majority of studies rated with moderate to severe risk of bias.

CONCLUSION

Study observed pulmonary function deficits associated with exposure to flour dust. However, considering the quality of primary studies and higher heterogeneity, high-quality larger studies with longitudinal design are required to affirm the effects of flour dust on lung function.

Efficacy of intermittent fasting on improving liver function in individuals with metabolic disorders: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting (IF) can be an effective dietary therapy for weight loss and improving cardiometabolic health. However, there is scant evidence regarding the role of IF on indicators of liver function, particularly in adults with metabolic disorders. Therefore, we performed a systematic review and meta-analysis to investigate the effects of IF on liver function in adults with metabolic disorders.

METHODS

Three primary electronic databases including PubMed, Web of Science, and Scopus, were searched from inception to September 2024 to identify original studies that used IF interventions with or without control groups in adults with metabolic disorders. Inclusion criteria were (1) studies of human participants with metabolic diseases, (2) interventions that evaluated the effects of IF, (3) with or without a control group, and (4) measured liver fat, liver steatosis, liver fibrosis, or liver enzymes, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as primary outcomes. Standardized mean differences (SMD) and 95% confidence intervals were calculated using random effects models. Heterogeneity was assessed using the Cochran's Q statistic and I-squared statistic (I2). Publication bias was assessed using the visual inspection of funnel plots and Egger's tests. The risk of bias was assessed using the PEDro scale and the NIH quality assessment tool.

RESULTS

A total 21 studies involving 1,226 participants with metabolic disorders were included in the meta-analysis. Overall, IF effectively decreased liver fat with a large effect size [SMD: -1.22 (95% CI: -1.63 to -0.80), p = 0.001], liver steatosis with a medium effect size [SMD: -0.73 (95% CI: -1.12 to -0.35), p = 0.001], ALT with a small effect size [SMD: -0.44 (95% CI: -0.58 to -0.30), p = 0.001], and AST with a small effect size [SMD: -0.30 (95% CI: -0.49 to -0.11), p = 0.001], but not liver fibrosis [SMD: -0.28 (95% CI: -0.59 to 0.02), p = 0.07]. Subgroup analyses showed that IF decreased liver fat and ALT significantly, independent of IF mode, participant age, health status, weight status, and intervention duration. IF significantly decreased liver fibrosis in those with obesity; and decreased AST following 5:2 diets, in middle-aged adults, adults with obesity, and regardless of health status or intervention duration.

CONCLUSIONS

IF seems to be an effective dietary therapy for improving liver function in adults with metabolic disorders, and many of liver function-related benefits occur regardless of IF mode, intervention duration, or participant health status.

LIMITATIONS

Significant heterogeneity, small numbers of studies and inclusion of non-randomized trials or single-group pre-post trials were the main limitation of our meta-analysis. Further randomized clinical trials are needed to elucidate the effects of IF on liver function in adults with metabolic disorders.

Robotic Versus Laparoscopic Adrenalectomy for Adrenal Tumors: An Up-to-Date Meta-Analysis on Perioperative Outcomes

Background: Minimally invasive surgery (MIS) for adrenal glands is becoming increasingly developed worldwide and robotic surgery has advanced significantly. Although there are still concerns about the generalization of outcomes and the cost burden, the robotic platform shows several advantages in overcoming some laparoscopic shortcomings. Materials and Methods: A systematic review and meta-analysis were conducted using the PubMed, MEDLINE and Cochrane library databases of published articles comparing RA and LA up to January 2024. The evaluated endpoints were technical and post-operative outcomes. Dichotomous data were calculated using the odds ratio (OR), while continuous data were analyzed usingmean difference (MD) with a 95% confidence interval (95% CI). A random-effects model (REM) was applied. Results: By the inclusion of 28 studies, the meta-analysis revealed no statistically significant difference in the rates of intraoperative RBC transfusion, 30-day mortality, intraoperative and overall postoperative complications, re-admission, R1 resection margin and operating time in the RA group compared with the LA. However, the overall cost of hospitalization was significantly higher in the RA group than in the LA group, [MD USD 4101.32, (95% CI 3894.85, 4307.79) p < 0.00001]. With respect to the mean intraoperative blood loss, conversion to open surgery rate, time to first flatus and length of hospital stay, the RA group showed slightly statistically significant lower rates than the laparoscopic approach. Conclusions: To our knowledge, this is the largest and most recent meta-analysis that makes these comparisons. RA can be considered safe, feasible and comparable to LA in terms of the intraoperative and post-operative outcomes. In the near future, RA could represent a promising complementary approachto LA for benign and small malignant adrenal masses, particularly in high-volume referral centers specializing in robotic surgery. However, further studies are needed to confirm these findings.

The Effects of Apple Cider Vinegar on Cardiometabolic Risk Factors: A Systematic Review and Meta-analysis of Clinical Trials

BACKGROUND

Cardiometabolic syndrome (CMS) is a set of metabolic abnormalities that are risk factors for cardiovascular disease (CVD). Apple cider vinegar (ACV) has been used in several studies as a natural agent to improve CMS risk factors. The present study aimed to perform a systematic review and meta-analysis of the effects of ACV consumption on lipid and glycemic parameters.

METHODS

PubMed, Scopus, and ISI Web of Science databases were systematically searched to find clinical trials evaluating the effects of ACV consumption on CMS risk factors.

RESULTS

Overall, 25 clinical trials (33 arms) comprising 1320 adults were entered in this study. ACV consumption could significantly improve the levels of FBG (-21.20 mg/dl; 95% CI: -32.31 to -2.21; I2: 95.8%), HbA1c (-0.91mg/dl; 95% CI: -1.62 to -0.21; I2: 98.9%), and TC (-6.72 mg/dl; 95% CI: -12.91 to -0.53; I2:50.8%). No significant results were observed for BMI, HOMA-IR, serum insulin, TG, LDL-C, and HDL-C. Subgroup analysis showed a significant decrease in FBG, HbA1c, TC, and TG in diabetic patients. In this type of analysis, ACV consumption significantly reduced FBG levels when administered for both duration subgroups (≥12 and <12 weeks). Moreover, in the subgroup analysis based on duration, TG concentration was significantly decreased following ACV consumption for ≥ 12 weeks.

CONCLUSION

This meta-analysis showed that consumption of ACV has a favorable effect in decreasing some CMS risk factors including FBG, HbA1c, and TC.

CXCR4-Targeted PET Imaging in Hematologic Malignancies: A Systematic Review and Meta-analysis

PURPOSE

The aims of this study were to perform a comprehensive review and meta-analyses and to report pooled diagnostic results on CXCR4-targeted PET, particularly considering detection, visualization, and prognostication.

PATIENTS AND METHODS

This study followed PRISMA-DTA. A systematic search was conducted on major medical literature databases up to March 1, 2024. The search strategy was designed to include CXCR4 PET studies in hematologic malignancies. A random-effects model combined sensitivity values derived from 2-by-2 contingency tables. Pooled means for SUV max were computed. Analyses were performed by R software.

RESULTS

The initial search resulted in a total of 1428 studies. Ultimately, 18 were eligible for systematic review and meta-analytic calculations. Twelve studies (320 patients) included B-cell lymphoma. The pooled detection rate of CXCR4 PET was 99.4% (95% confidence interval [CI]: 88.3%-100%). Marginal zone lymphoma was investigated in 5 studies (209 patients), with a pooled sensitivity of 97.6% (95% CI: 79.7%-99.8%). In studies on central nervous system lymphoma, CXCR4 PET demonstrated 100% accuracy at both patient and lesion levels. Also, it demonstrated a significantly higher tumor-to-background ratio than 18 F-FDG PET. For multiple myeloma, 5 studies (116 patients) showed a patient-level pooled sensitivity of 77.8% (95% CI: 64.4%-87.2%), whereas 18 F-FDG PET had 65.0% (95% CI: 55.2%-73.7%). The pooled SUV max for CXCR4 PET was 13.6 (95% CI: 9.3-17.8) versus 9.0 (95% CI: 6.3-11.7) for 18 F-FDG PET. Additionally, CXCR4 PET-derived parameters were significant predictors of survival in multiple myeloma.

CONCLUSIONS

CXCR4 PET can be a helpful imaging tool for evaluating hematologic malignancies, particularly in B-cell lymphoma and multiple myeloma patients. In specific clinical scenarios, it appears to be superior compared with the current standard-of-care imaging.

Histopathological outcomes of transanal, robotic, open, and laparoscopic surgery for rectal cancer resection. A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed.

RESULTS

The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I2:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I2:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I2:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I2:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved.

CONCLUSION

When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.

Statins and Portal Hypertension: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Statins are primarily used to decrease elevated LDL-cholesterol and thus prevent atherosclerotic cardiovascular disease. Portal hypertension is one of the most important complications of chronic liver disease. Several studies indicated that statins might be beneficial for portal hypertension as well but there is still no clear answer whether this is true or not.

METHODS

A literature search of the major databases was performed to find eligible randomized controlled trials (RCTs) analyzing the effect of statins on portal hypertension from inception to February 5th, 2021. Six RCTs with 442 patients who received statin or statin plus carvedilol were finally included. Meta-analysis was performed using the Comprehensive Meta-Analysis V2 software.

RESULTS

Reduction of portal hypertension after statin treatment was not significant (WMD: -0.494, 95% CI: -1.239, 0.252, p=0.194; I2:0%). The reduction of portal hypertension was robust in the leave-one-out sensitivity analysis.

CONCLUSION

Treatment with statins did not decrease significantly portal hypertension.

Electrogastrography in Adult Gastroparesis: A Systematic Review and Meta-Analysis

BACKGROUND

Gastroparesis is a delay in gastric emptying without mechanical obstruction, lacking a clear pathophysiological mechanism, but with multiple histological abnormalities including loss of interstitial cells of Cajal, which may alter slow waves. We can assess slow waves with electrogastrography.

OBJECTIVES

To determine the prevalence and range of abnormalities in gastric slow waves in adults with gastroparesis using electrogastrography.

METHODS

We systematically searched Medline, Embase, LILACS, Web of Science, and Cochrane Register of Controlled Trials. We included studies with patients older than 18 years with gastroparesis, assessed using electrogastrography. We evaluated the percentage of duration of the recording in which the dominant power was in normogastria, tachygastria, and bradygastria; dominant frequency; power ratio; change in post-stimulus dominant power; and dominant frequency instability coefficient. Methodological quality was assessed using the Joanna Briggs Institute tool. Data were synthesized using narrative summary and meta-analysis.

RESULTS

A total of 3730 articles were reviewed, including 31 articles with 1545 patients and 340 controls. Compared to controls, gastroparetics patients had less normogastria (fasting: 50.3% versus 65.8%) (post-stimulus: 54.3% versus 66.5%), more bradygastria (fasting: 37.7% versus 13%) (post-stimulus: 31.9% versus 16.3%), and more tachygastria (fasting: 16.1% versus 4.6%) (post-stimulus: 18.3% versus 5.2%). Gastroparetics had less change in post-stimulus dominant power (1.45 dB versus 5.03 dB) and less power ratio (1.4 versus 5.26).

CONCLUSIONS

Gastroparetic patients present abnormalities in the frequency and changes in the post-stimulus power of slow waves, possibly secondary to a reduced number of interstitial cells of Cajal, as described in these patients.

All-Polyethylene Tibias Equal to Metal-Backed Tibias in Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

We sought to conduct a systematic review of the literature and a meta-analysis of post-operative outcomes following TKA with an all-polyethylene tibial (APT) or a metal-backed tibial component (MBT). A systematic review of the literature was conducted to identify all studies comparing APT and MBT for TKA based upon rates of complications, revisions, reoperation, and patient-reported outcomes. Data was pooled and relative risk of each outcome measure at short (< 5 year), mid (5-10 year), and long (> 10 year) follow-up was calculated. Thirty-eight studies met criteria and were included for analysis, totaling 113,413 primary TKAs performed in 106,490 patients. Of these, 21,752 were performed with an APT and 91,661 with an MBT. APT had a statistically significant decrease in the relative risk of revisions, reoperations, total complications, septic complications, and aseptic complications at one-to-five-year follow-up. There was no statistically significant difference in the relative risk of these metrics between APT and MBT beyond 5 years. This study demonstrates that patients with APT components, compared to the MBT tibial components, had significantly lower rates of complications and revisions at 1-to-5-year follow-up, and no difference in these metrics beyond five years. Further prospective studies are warranted for better external validity of results found in this study.

Radical cystectomy with stentless urinary diversion: A systematic review and meta-analysis of comparative studies

PURPOSE

To systematically compare the evidence about surgical outcomes, postoperative complications, and sequelae of Radical cystectomy with urinary diversion with or without stent placement.

MATERIAL AND METHODS

A literature search was performed through PubMed, Scopus®, and Web of Science up to December 2023 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. The study protocol was registered in PROSPERO (CRD 42023492384), and the research question was formulated according to the PICOs model. Three comparative studies were identified, 2 randomized and 1 prospective coming from a randomized cohort.

RESULTS

The stent group showed higher odds of postoperative major complications (OR 3.00 - 95%CI 1.06; 8.52; P = 0.04) than the stentless group. There was no statistically significant difference between the 2 groups regarding 30-day readmission (P = 0.06), postoperative uretero-ileal anastomotis stricture (UIAS) (P = 0.09), postoperative uretero-ileal anastomotis leak (UIAL) (P = 0.20), postoperative urinary tract infections (UTIs) (P = 0.08), and postoperative ureteral obstruction (P = 0.35). No statistically significant difference between the 2 groups was found regarding UIAS management in terms of ureteral reimplantation (P = 0.28) or dilatation (P = 0.36).

CONCLUSIONS

Our pooled data analysis shows no statistically significant difference between stentless and stented urinary diversion after radical cystectomy. Stentless could be a reasonable choice when performing diversion during radical cystectomy.

The Impact of Metabolic and Bariatric Surgery on Diabetic Kidney Disease in Patients with Type 2 Diabetes: A Systematic Review and Meta-analysis

We aimed to determine the effect of metabolic and bariatric surgery (MBS) on the improvement of diabetic nephropathy (DN) in patients with obesity and type 2 diabetes (T2DM). A systematic search was performed in the PubMed, Embase, Scopus, and Web of Science databases. Meta-analysis of 31 studies with 2594 patients showed that urine albumin-to-creatinine ratio (UACR) was significantly reduced with a mean difference of - 28.19 mg/g (95% CI - 41.17, - 15.21, P-value < 0.001). In addition, subgroup analysis of studies showed a significant decrease after Roux-en-Y gastric bypass (RYGB) but not after sleeve gastrectomy (SG). These results suggest that MBS may lead to better kidney function and improvement in DN.

Complications after knee derotational osteotomies in patients with anterior knee pain and/or patellofemoral instability: a systematic review with meta-analysis

Purpose

Investigate intra- and post-operative complications and revisions following distal femoral and/or high tibial derotational osteotomies to correct rotational malalignments of the lower limb in patients with anterior knee pain (AKP) and/or patellofemoral instability (PFI).

Methods

A literature search was conducted on PubMed, EMBASE and Web of Science (until 30 September 2023), including studies reporting complications, reinterventions and revisions following knee derotational osteotomies. Incidence rates were collected for each level of derotational osteotomy (distal femur, high tibia or double-level). A meta-analysis using the Freeman-Tukey double arcsine transformation was conducted to estimate the pooled proportions with their 95% confidence intervals (CIs).

Results

Twenty-one studies involving 564 osteotomies (n = 484) were included, with a mean follow-up of 45.6 ± 15.7 months. The overall complication proportion was 7.5% (95% CI: 3.9-11.8%). Postoperative residual AKP was seen in a pooled proportion of 7.6% (95% CI: 0.7-18.8%), and persistent PFI was not common (0.1%; 95% CI: 0.0-1.7%). Intraoperative complications occurred in a pooled proportion of 3.8% (95% CI: 2.4-6.0%), with peroneal nerve injury being the most common (1.3%) after derotational high tibial osteotomy. Reintervention was needed in a pooled proportion of 13.0% (95% CI: 2.9-27.2%), primarily for hardware removal (n = 158; 28.3%). There was a pooled proportion of knees requiring revision procedures of 12.3% (95% CI: 2.6-26.1%).

Conclusions

Distal femur and high tibial derotational osteotomies exhibit a considerable incidence of intra- and post-operative complications. Peroneal nerve injury, although infrequent, is a significant complication, underscoring the importance of implementing intraoperative preventive measures during derotational high tibial osteotomy.

Association between Intraoperative Electroencephalogram Burst Suppression and Postoperative Delirium: A Systematic Review and Meta-analysis

BACKGROUND

Electroencephalogram burst suppression can be associated with postoperative delirium; however, the results of relevant studies are discrepant. This systematic review and meta-analysis aimed to assess the association between intraoperative burst suppression and postoperative delirium in adult surgical patients.

METHODS

PubMed, MEDLINE, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials were systematically searched and updated in May 2023. The authors included cohort studies, case-control studies, and randomized controlled studies reporting on postoperative delirium incidence with documented intraoperative burst suppression in adults receiving general anesthesia for any surgery. The primary outcome was the pooled odds ratio for postoperative delirium in cases with intraoperative burst suppression compared to those without burst suppression, calculated using a random-effects model. Two independent investigators extracted the data. The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (registration No. CRD42022326479); the results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

RESULTS

Fourteen studies (6,435 patients) were included in the analysis. The overall incidence of postoperative delirium was 21.1% (1,358 of 6,435). Patients with intraoperative burst suppression had a higher incidence of postoperative delirium than those without burst suppression (pooled odds ratio, 1.492; 95% CI, 1.022 to 2.178; I2 = 44%; 95% CI, 0 to 75%; τ2 = 0.110). The intraoperative duration of burst suppression was significantly longer in patients who developed postoperative delirium (standardized mean difference, 0.462; 95% CI, 0.293 to 0.632; I2 = 63%; 95% CI, 16 to 84%; τ2 = 0.027). The burst suppression ratio was significantly higher in the delirium group (standardized mean difference, 0.150; 95% CI, 0.055 to 0.245; I2 = 0%; 95% CI, 0 to 85%; τ2 = 0.00).

CONCLUSIONS

The meta-analysis suggests an association between intraoperative burst suppression and postoperative delirium; however, the quality of evidence was very low. The limited number of studies and substantial heterogeneity across them emphasize the need for further high-quality studies to establish a more robust conclusion.

EDITOR’S PERSPECTIVE

Management of children with heterozygous familial hypercholesterolaemia worldwide: a meta-analysis

Aims

Heterozygous familial hypercholesterolaemia (HeFH) is one of the most frequent monogenic disorders in the world, leading to premature atherosclerotic cardiovascular diseases. The aim of this meta-analysis was to evaluate the efficacy and safety of lipid-lowering therapy (LLT) and achievement of low density lipoprotein cholesterol (LDL-C) goal in children with HeFH.

Methods and results

The main endpoint was efficacy of goal achievement for LDL-C and other lipid parameters: total cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL-C), apolipoprotein B, and lipoprotein(a), and the LLT safety [adverse events (AEs), including endocrine function, and growth indices]. The secondary endpoint was an effect of LLT on attainment of LDL-C goal treatment (<3.5 mmol/L/130 mg/dL). A total of 41 studies with 4667 paediatric patients at mean age 12.08 ± 2.4 years were included. Seventeen reported the efficacy and safety of LLT therapy compared to control, while the remaining assessed LLT through pre- and post-treatment. At median follow-up of 18.8 months, the group on LLT had significantly higher mean reductions of TC, LDL-C, TG, and increased HDL-C compared to control [-1.75 mmol/L (-67.7 mg/dL), -1.84 mmol/L (-71.2 mg/dL), -0.11 mmol/L (-9.74 mg/dL), 0.08 mmol/L (3.1 mg/dL), respectively, P < 0.001 for all]. In the subgroup analysis according to different types of LLT, we observed a significantly higher mean reduction of LDL-C by statin combined with ezetimibe treatment, followed by statins in monotherapy, PCSK9 inhibitors, and monotherapy with ezetimibe [-2.48 mmol/L (-95.9 mg/dL), -2.16 mmol/L (-83.5 mg/dL), -2.03 mmol/L (-78.5 mg/dL), and -1.50 mmol/L (-58 mg/dL), respectively, test for overall effect: P < 0.001]. The pooled LDL-C was reduced by 33.44% [-2.14 mmol/L (-82.8 mg/dL), P < 0.001] and failed to reach the goal treatment (<3.5 mmol/L) by 12.6% (95% CI, 12.4-12.9%). A total of 38.7% of children achieved the LDL-C goal, 23.9% fell short by up to 10%, 10.7% experienced moderate failure (were over the LDL-C target between >10% and 20%), and 26.7% failed by more than 20% to reach the LDL-C target. When comparing different regions, only Sweden and Greece achieved the LDL-C goal < 3.5 mmol/L in the follow-up. Netherlands, Norway, Poland, USA, UK, France, Spain, Belgium, and Austria required 2.2%, 3.4%, 3.5%, 8.9%, 10.2%, 11.2%, 11.2%, 15%, and 19.4% additional reduction in LDL-C respectively to achieve the LDL-C goal of < 3.5 mmol/L. All other countries required over 20% additional reduction in LDL-C to achieve the LDL-C goal. For other investigated countries, over 20% mean LDL-C reduction was required. All parameters related to endocrine function and demographic indices were unaffected by LLT therapy (P > 0.05). The AEs were not reported significantly higher when compared to the control, and the prevalence of therapy discontinuation was only 0.8%.

Conclusion

Despite the efficacy of LLT in children with HeFH and the low occurrence of discontinuation-related adverse events, achieving LDL-C treatment goals was relatively rare, with large differences between the investigated countries. These results underscore the importance of considering early combination therapy of statins and ezetimibe, and PCSK9 inhibitors (if available) to attain LDL-C goals effectively.

Comparative efficacy of intravenous treatments for perioperative shivering in patients undergoing caesarean delivery under neuraxial anaesthesia: A systematic review and Bayesian network meta-analysis of randomised-controlled trials

INTRODUCTION

Shivering affects 52 % of patients undergoing caesarean delivery under neuraxial anaesthesia. Despite extensive research focused on its prevention, there is still no consensus regarding optimal pharmacological treatment. This systematic review and network meta-analysis aims to compare available intravenous treatments of perioperative shivering in patients undergoing caesarean delivery under neuraxial anaesthesia.

METHODS

We searched seven databases (PubMed MEDLINE, Scopus, Web of Science, Embase, LILACS, Cochrane CRCT and clinicaltrials.gov) for randomised controlled trials comparing intravenous treatments of perioperative shivering during caesarean delivery and performed a Bayesian model network meta-analysis. We assessed study quality using the Cochrane risk of bias assessment tool. The primary outcome evaluated in this meta-analysis was shivering control (cessation or significant reduction in intensity), and secondary outcomes included time to shivering control, shivering recurrence, and incidence of maternal nausea.

RESULTS

Twenty randomised controlled trials, with a total of 1983 patients, were included in this analysis. Network estimates of odds ratios (OR [95 % Credible Interval]) of effective treatment of shivering compared with saline were: dexmedetomidine (38.1 [14.2 to 111.5]), tramadol (33.6 [15.1 to 81.8]), nalbuphine (26.2 [10.8 to 80.2]), meperidine (20.9 [6.2 to 73.1]), ondansetron (6.6 [2.2 to 23.2]), and clonidine (3.2 [0.6 to 14.9]). The rank order of interventions by surface area under the cumulative ranking curve scores (in parenthesis) for shivering control was dexmedetomidine (0.87) > tramadol (0.85) > nalbuphine (0.74) > meperidine (0.66) > ondansetron (0.41) > clonidine (0.3) > amitriptyline (0.03). Dexmedetomidine was also the top-ranked intervention for time to shivering control, shivering recurrence and maternal nausea. We judged the certainty in the evidence to be moderate for dexmedetomidine and nalbuphine, and low for all other interventions.

CONCLUSION

This network meta-analysis identified four effective intravenous treatments for shivering in patients undergoing caesarean delivery under neuraxial anaesthesia: dexmedetomidine, tramadol, nalbuphine and meperidine. Dexmedetomidine was the top-ranked intervention for all outcomes.

The Effects of Testosterone Replacement Therapy in Adult Men With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Systematic Review and Meta-analysis

INTRODUCTION

Sex steroids modulate metabolic dysfunction-associated steatotic liver disease (MASLD) pathobiology. We hypothesized that testosterone treatment (TT) modulates progression of MASLD and performed a systematic review to evaluate the efficacy of TT on liver steatosis and fibrosis.

METHODS

We searched PubMed and Embase from inception until November 2023. We screened 1,489 studies and identified 9 eligible studies. We assessed risk of bias for randomized trials using RoB-2 "Cochrane risk of bias tool for randomized trials," nonrandomized studies using ROBINS-I tool "Risk of Bias In Nonrandomized Studies-of Interventions," and Murad's tool for single-arm studies. We pooled estimates using RevMan 5.

RESULTS

Three randomized controlled trials|, 4 nonrandomized studies, and 2 single-arm studies were identified. The population of interest comprised men with MASLD. TT was administered at varying doses, routes, and frequencies, with follow-up ranging from 12 weeks to 8 years. Liver fibrosis and steatosis were assessed using liver biopsy in 3 studies, CT/MRI in 5, and serum scores in 2. All studies provided evidence of reduction in liver steatosis with TT compared with no TT. In addition, the LiFT (randomized controlled trials) trial demonstrated a resolution of MASLD/ metabolic dysfunction-associated steatohepatitis and a regression in liver fibrosis. TT led to decrease in liver enzymes. Studies were heterogenous in terms of population characteristics, treatment modalities, endpoints, and follow-up. Adverse events were comparable between the 2 groups.

DISCUSSION

TT is a promising treatment option for men with MASLD and low testosterone. It may improve liver steatosis and reduce liver fibrosis. Large, double-blinded randomized placebo-controlled trials are needed.

Effect of carotenoid supplementation on blood pressure in adults: a GRADE-assessed systematic review and dose-response meta-analysis of randomized controlled trials

CONTEXT

Hypertension (HTN) is regarded as a serious public health issue throughout the world. High blood pressure (BP) may be improved by carotenoid supplementation; however, randomized controlled trials (RCTs) provide conflicting evidence.

OBJECTIVE

The aim of this study was to evaluate the effects of carotenoid supplementation on BP in RCTs by systematically review and meta-analysis.

DATA SOURCES

A comprehensive literature search was performed in the Scopus, PubMed, and Web of Science databases until October 2023, with no limitation on the date or language of publication.

DATA EXTRACTION

Studies that evaluated the net effects of carotenoids in the form of supplements on BP in adults were selected. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated on the basis of a fixed or random-effects model. Sensitivity analysis, meta-regression, publication bias, and heterogeneity were assessed using standard methods. Cochrane quality assessments were used to evaluate the included studies' bias risks. Evidence certainty was calculated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework).

DATA ANALYSIS

Reports on a total of 19 RCTs involving 1151 participants were included in this review. Carotenoid supplementation significantly reduced the systolic BP (SBP) (WMD, -2.492 mmHg; 95%CI, -4.52, -0.47; P = 0.016) and diastolic BP (DBP) (WMD, -1.60 mmHg; 95%CI, -2.73, -0.47; P = 0.005). Greater effects were observed in Asian participants, those aged >50 years, nonhealthy participants, and participants with a baseline SBP ≥130 mmHg and DBP ≥80 mmHg, at dose >10 mg. Dose-response analysis showed that carotenoid supplementation decreased SBP and DBP levels at doses of, respectively, 0-25 and 0-20 mg/d. Evidence for all SBP, DBP, and heart rate values was high quality.

CONCLUSIONS

Carotenoid supplementation had a beneficial effect on BP parameters, especially in nonhealthy study participants with high BP baseline levels.

PROSPERO REGISTRATION NO

CRD42023402740.

Role of Preoperative Embolization in Surgical Management of Carotid Body Tumors: A Systematic Review and Meta-Analysis

The objective of this study is to evaluate the effect of preoperative embolization on carotid body tumor resection. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, Scopus, and Web of Science were screened for studies published between 2010 and 2022. Primary outcomes investigated were intraoperative blood loss, operative time, length of hospital stay, and perioperative complications such as transient ischemic attack (TIA)/stroke, vascular injury, and cranial nerve injury (CNI). A random effects model was used in cases where study heterogeneity was high. Overall, 25 studies were included in the systematic review, involving 1649 patients: 23 studies were eligible for meta-analysis. The incidence of vascular injury was significantly less in the preoperative embolization group (odds ratio (OR) = 0.60; 95% CI: 0.42-0.84; P = .003). There was no statistically significant difference between the two groups regarding intraoperative blood loss, operative time, length of hospital stay, incidence of TIA/stroke, and CNI. Subgroup analyses did not demonstrate significant difference between Shamblin I, II, and III subgroups regarding operative time. This meta-analysis found preoperative embolization to be significantly beneficial in reducing incidence of vascular injury.

Associations between circulating interleukin-18 levels and adult-onset Still's disease: a meta-analysis

Objective

This study aimed to investigate the link between circulating interleukin-18 (IL-18) levels and adult-onset Still's disease (AOSD).

Methods

A thorough search was performed on MEDLINE, Embase, and Web of Science to find relevant articles. A meta-analysis was conducted to compare serum/plasma IL-18 levels in AOSD patients to those in control subjects.

Results

The meta-analysis included 13 studies with a total of 562 AOSD patients and 790 controls. The results showed a significant increase in IL-18 levels in the AOSD group compared to the control group (standard mean difference [SMD]=1.899, 95% confidence interval [CI]=1.078~2.720, p<0.001). When stratified by ethnicity, higher IL-18 levels were found in both Asian and European populations with AOSD. Subgroup analysis, regardless of variable adjustments, consistently indicated significantly higher IL-18 levels in the AOSD group. Significant elevations in IL-18 levels were observed in both small (n<50) and large groups (n>50), as well as in original and imputed data groups after data type stratification. Free IL-18 levels were significantly higher in the active group compared to the inactive group (SMD=0.900, 95% CI=0.532~1.268, p<0.001). The meta-analysis showed a positive correlation between IL-18 levels and ferritin (correlation coefficient=0.542, 95% CI=0.431~0.637, p<0.001) and C-reactive protein.

Conclusion

This meta-analysis demonstrated a significant increase in circulating IL-18 levels and a positive correlation between IL-18 levels and ferritin and C-reactive protein levels in patients with AOSD.

Lateral extra-articular procedures combined with ACL reconstructions lead to a higher return to pre-injury level of sport: A systematic review and meta-analysis

Purpose

To compare postoperative activity levels between patients who received an anterior cruciate ligament reconstruction (ACLR) with- and without a lateral extra-articular procedure (LEAP).

Objectives

The primary objective is to examine whether patients treated with an ALCR and LEAP have a greater chance to return to sport (RTS) and return to their pre-injury level of sport (RTPS). The re-rupture rates between the two groups will also be analysed as this is of great influence on the RTS and RTPS.

Methods

A thorough search according to PRISMA guidelines was conducted through the PubMed and Embase databases in May 2024. Randomised controlled trials (RCT) and retrospective cohort studies on patients who underwent primary ACLR with- or without a LEAP were included. Postoperative Tegner score, RTS, RTPS and re-rupture rate were evaluated. All articles were revised according to Cochrane risk of bias tools (RoB 2.0 and ROBINS-I).

Results

Twenty-four studies were included after examining 966 titles, abstracts and manuscripts. A total of 33,527 patients were included in this review with a weighted mean age of 24.9 years. Pooled data demonstrates that the ACLR + LEAP group shows significantly higher postoperative Tegner scores (MD, 0.43 [95% confidence interval, 0.21-0.65]; p < 0.01). 62% of patients who underwent ACLR + LEA returned to their pre-injury level of sport compared to 40% in ACLR group (reported in nine studies).

Conclusion

This meta-analysis demonstrates that patients undergoing a LEAP procedure in addition to ACLR return to higher postoperative activity levels and are more likely to return to their pre-injury level of sport. These results -in addition to further research- may help dictate when to add a LEAP, and whether LEAP in addition to ACLR should become the golden standard.

Level of Evidence

Level III, retrospective cohort studies have been analysed, alongside RCT's, and thus this is the level of evidence.

Crocin Supplementation on Inflammation and Oxidative Stress: A Systematic Review and Meta-Analysis

Saffron is the dried stigma of Crocus sativus L. flowers. The yellow-orange color of saffron comes from crocin, a water-soluble carotenoid that can be ingested. Crocin is known for its anti-inflammatory and antioxidant potential. It is believed to affect inflammation and oxidative stress, making it a promising therapeutic option. However, research on its impact is inconclusive. This meta-analysis aimed to assess the benefits of crocin supplementation and its specific effects on inflammation and oxidative stress markers. A comprehensive search of the literature was conducted up to February 2024 in PubMed/Medline, Scopus, and Web of Science to find suitable randomized clinical trials (RCTs). All participants were adults who were supplemented with crocin as part of the study intervention. The selected trials were subjected to heterogeneity tests using the I 2 statistic. Random effects models were examined based on the heterogeneity tests, and the pooled data were calculated as weighted mean differences (WMD) with a 95% confidence interval (CI). Of the 519 papers that remain after duplications were removed, 13 eligible RCTs were included in the present meta-analysis. Our findings indicated that crocin supplementation significantly reduced c-reactive protein (CRP) levels (SMD: -0.50; 95%CI: -0.86 to -0.13; p = 0.008), tumor necrosis factor-α (TNF-α) (SMD: -1.96; 95%CI: -2.72 to -1.19; p < 0.001), and interleukin-6 (IL-6) (SMD: -3.52; 95%CI: -6.84 to -0.20; p = 0.03). Also, crocin supplementation led to a significant increase in total antioxidant capacity (TAC) (SMD: 1.48; 95%CI: 0.52 to 2.43; p = 0.002). Overall effect size showed that crocin intake failed to change the erythrocyte sedimentation rate (ESR) and malondialdehyde (MDA) levels significantly. Crocin reduces inflammatory markers and increases TAC. The effect of crocin on inflammatory markers was greater in a dose ≥ 30 mg/day and an intervention duration ≥ 12 weeks. However, more studies are needed for definitive conclusions.