GRADE guidelines: 21 part 2. Test accuracy: inconsistency, imprecision, publication bias, and other domains for rating the certainty of evidence and presenting it in evidence profiles and summary of findings tables

Performance of Manchester Acute Coronary Syndromes decision rules in acute coronary syndrome: a systematic review and meta-analysis

Multiple decision-aiding models are available to help physicians identify acute coronary syndrome (ACS) and accelerate the decision-making process in emergency departments (EDs). This study evaluated the diagnostic performance of the Manchester Acute Coronary Syndrome (MACS) rule and its derivations, enhancing the evidence for their clinical use. A systematic review and meta-analysis was performed. Medline, Embase, Scopus, and Web of Science were searched from inception until October 2023 for studies including adult ED patients with suspected cardiac chest pain and inconclusive findings requiring ACS risk-stratification. The predictive value of MACS, Troponin-only MACS (T-MACS), or History and Electrocardiogram-only MACS (HE-MACS) decision aids for diagnosing acute myocardial infarction (AMI) and 30-day major adverse cardiac outcomes (MACEs) among patients admitted to ED with chest pain suspected of ACS. Overall sensitivity and specificity were synthesized using the 'Diagma' package in STATA statistical software. Applicability and risk of bias assessment were performed using the QUADAS-2 tool. For AMI detection, MACS has a sensitivity of 99% [confidence interval (CI): 97-100], specificity of 19% (CI: 10-32), and AUC of 0.816 (CI: 0.720-0.885). T-MACS shows a sensitivity of 98% (CI: 98-99), specificity of 35% (CI: 29-42), and AUC of 0.859 (CI: 0.824-0.887). HE-MACS exhibits a sensitivity of 99% (CI: 98-100), specificity of 9% (CI: 3-21), and AUC of 0.787 (CI: 0.647-0.882). For MACE detection, MACS demonstrates a sensitivity of 98% (CI: 94-100), specificity of 22% (CI: 10-42), and AUC of 0.804 (CI: 0.659-0.897). T-MACS displays a sensitivity of 96% (CI: 94-98), specificity of 36% (CI: 30-43), and AUC of 0.792 (CI: 0.748-0.830). HE-MACS maintains a sensitivity of 99% (CI: 97-99), specificity of 10% (CI 6-16), and AUC of 0.713 (CI: 0.625-0.787). Of all the MACS models, T-MACS displayed the highest overall accuracy due to its high sensitivity and significantly superior specificity. T-MACS exhibits very good diagnostic performance in predicting both AMI and MACE. This makes it a highly promising tool for managing patients with acute chest pain.

The Accuracy of Artificial Intelligence Models in Hand/Wrist Fracture and Dislocation Diagnosis: A Systematic Review and Meta-Analysis

BACKGROUND

Early and accurate diagnosis is critical to preserve function and reduce healthcare costs in patients with hand and wrist injury. As such, artificial intelligence (AI) models have been developed for the purpose of diagnosing fractures through imaging. The purpose of this systematic review and meta-analysis was to determine the accuracy of AI models in identifying hand and wrist fractures and dislocations.

METHODS

Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Diagnostic Test Accuracy guidelines, Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to October 10, 2023. Studies were included if they utilized an AI model (index test) for detecting hand and wrist fractures and dislocations in pediatric (<18 years) or adult (>18 years) patients through any radiologic imaging, with the reference standard established through image review by a medical expert. Results were synthesized through bivariate analysis. Risk of bias was assessed using the QUADAS-2 tool. This study was registered with PROSPERO (CRD42023486475). Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

A systematic review identified 36 studies. Most studies assessed wrist fractures (27.90%) through radiograph imaging (94.44%), with radiologists serving as the reference standard (66.67%). AI models demonstrated area under the curve (0.946), positive likelihood ratio (7.690; 95% confidence interval, 6.400-9.190), and negative likelihood ratio (0.112; 0.0848-0.145) in diagnosing hand and wrist fractures and dislocations. Examining only studies characterized by a low risk of bias, sensitivity analysis did not reveal any difference from the overall results. Overall certainty of evidence was moderate.

CONCLUSION

In demonstrating the accuracy of AI models in hand and wrist fracture and dislocation diagnosis, we have demonstrated that the potential use of AI in diagnosing hand and wrist fractures is promising.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Population-based screening strategies for biliary atresia in the newborn: A systematic review and meta-analysis

BACKGROUND

Newborn screening for biliary atresia (BA) may facilitate earlier diagnosis and intervention for improved clinical outcomes.

METHODS

We systematically reviewed the accuracy of population-based screening strategies for BA in the newborn using PRISMA-DTA guidelines. We included cohort or cross-sectional studies. The screening (index) tests included stool color card (SCC) and direct/conjugated bilirubin (DB/CB) and the reference standard was intraoperative cholangiogram. Meta-analysis was performed using random-effects logistic regression models.

RESULTS

We included 15 studies (1,816,722 participants) that assessed 5 different population-based screening strategies. QUADAS-2 assessment revealed high risk of bias for patient selection in one study and uncertain risks for reference standard in multiple studies. High certainty evidence suggests that DB/CB assessed after birth had a summary sensitivity of 100% (95% CI 100,100) and specificity of 98.8% (98.8,98.9) (5 studies, 662141 participants). Moderate certainty evidence suggests that SCC screening at a month of age had summary sensitivity of 79.6% (95% CI 70.6, 86.4) and specificity of 99.9% (95% CI 99.9, 99.9) (7 studies, 996262 participants).

CONCLUSIONS

DB/CB in the first few days of life has the best diagnostic accuracy for population screening for biliary atresia in the newborn. Future research should focus on cost-effectiveness and combinations of screening strategies.

The quality of paediatric asthma guidelines: evidence underpinning diagnostic test recommendations from a meta-epidemiological study

BACKGROUND

Asthma is one of the most frequent reasons children visit a general practitioner (GP). The diagnosis of childhood asthma is challenging, and a variety of diagnostic tests for asthma exist. GPs may refer to clinical practice guidelines when deciding which tests, if any, are appropriate, but the quality of these guidelines is unknown.

OBJECTIVES

To determine (i) the methodological quality and reporting of paediatric guidelines for the diagnosis of childhood asthma in primary care, and (ii) the strength of evidence supporting diagnostic test recommendations.

DESIGN

Meta-epidemiological study of English-language guidelines from the United Kingdom and other high-income countries with comparable primary care systems including diagnostic testing recommendations for childhood asthma in primary care. The AGREE-II tool was used to assess the quality and reporting of the guidelines. The quality of the evidence was assessed using GRADE.

RESULTS

Eleven guidelines met the eligibility criteria. The methodology and reporting quality varied across the AGREE II domains (median score 4.5 out of 7, range 2-6). The quality of evidence supporting diagnostic recommendations was generally of very low quality. All guidelines recommended the use of spirometry and reversibility testing for children aged ≥5 years, however, the recommended spirometry thresholds for diagnosis differed across guidelines. There were disagreements in testing recommendations for 3 of the 7 included tests.

CONCLUSIONS

The variable quality of guidelines, lack of good quality evidence, and inconsistent recommendations for diagnostic tests may contribute to poor clinician adherence to guidelines and variation in testing for diagnosing childhood asthma.

Accuracy of routine laboratory tests to predict mortality and deterioration to severe or critical COVID-19 in people with SARS-CoV-2

BACKGROUND

Identifying patients with COVID-19 disease who will deteriorate can be useful to assess whether they should receive intensive care, or whether they can be treated in a less intensive way or through outpatient care. In clinical care, routine laboratory markers, such as C-reactive protein, are used to assess a person's health status.

OBJECTIVES

To assess the accuracy of routine blood-based laboratory tests to predict mortality and deterioration to severe or critical (from mild or moderate) COVID-19 in people with SARS-CoV-2.

SEARCH METHODS

On 25 August 2022, we searched the Cochrane COVID-19 Study Register, encompassing searches of various databases such as MEDLINE via PubMed, CENTRAL, Embase, medRxiv, and ClinicalTrials.gov. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs that produced estimates of prognostic accuracy in participants who presented to outpatient services, or were admitted to general hospital wards with confirmed SARS-CoV-2 infection, and studies that were based on serum banks of samples from people. All routine blood-based laboratory tests performed during the first encounter were included. We included any reference standard used to define deterioration to severe or critical disease that was provided by the authors.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from each included study, and independently assessed the methodological quality using the Quality Assessment of Prognostic Accuracy Studies tool. As studies reported different thresholds for the same test, we used the Hierarchical Summary Receiver Operator Curve model for meta-analyses to estimate summary curves in SAS 9.4. We estimated the sensitivity at points on the SROC curves that corresponded to the median and interquartile range boundaries of specificities in the included studies. Direct and indirect comparisons were exclusively conducted for biomarkers with an estimated sensitivity and 95% CI of ≥ 50% at a specificity of ≥ 50%. The relative diagnostic odds ratio was calculated as a summary of the relative accuracy of these biomarkers.

MAIN RESULTS

We identified a total of 64 studies, including 71,170 participants, of which 8169 participants died, and 4031 participants deteriorated to severe/critical condition. The studies assessed 53 different laboratory tests. For some tests, both increases and decreases relative to the normal range were included. There was important heterogeneity between tests and their cut-off values. None of the included studies had a low risk of bias or low concern for applicability for all domains. None of the tests included in this review demonstrated high sensitivity or specificity, or both. The five tests with summary sensitivity and specificity above 50% were: C-reactive protein increase, neutrophil-to-lymphocyte ratio increase, lymphocyte count decrease, d-dimer increase, and lactate dehydrogenase increase. Inflammation For mortality, summary sensitivity of a C-reactive protein increase was 76% (95% CI 73% to 79%) at median specificity, 59% (low-certainty evidence). For deterioration, summary sensitivity was 78% (95% CI 67% to 86%) at median specificity, 72% (very low-certainty evidence). For the combined outcome of mortality or deterioration, or both, summary sensitivity was 70% (95% CI 49% to 85%) at median specificity, 60% (very low-certainty evidence). For mortality, summary sensitivity of an increase in neutrophil-to-lymphocyte ratio was 69% (95% CI 66% to 72%) at median specificity, 63% (very low-certainty evidence). For deterioration, summary sensitivity was 75% (95% CI 59% to 87%) at median specificity, 71% (very low-certainty evidence). For mortality, summary sensitivity of a decrease in lymphocyte count was 67% (95% CI 56% to 77%) at median specificity, 61% (very low-certainty evidence). For deterioration, summary sensitivity of a decrease in lymphocyte count was 69% (95% CI 60% to 76%) at median specificity, 67% (very low-certainty evidence). For the combined outcome, summary sensitivity was 83% (95% CI 67% to 92%) at median specificity, 29% (very low-certainty evidence). For mortality, summary sensitivity of a lactate dehydrogenase increase was 82% (95% CI 66% to 91%) at median specificity, 60% (very low-certainty evidence). For deterioration, summary sensitivity of a lactate dehydrogenase increase was 79% (95% CI 76% to 82%) at median specificity, 66% (low-certainty evidence). For the combined outcome, summary sensitivity was 69% (95% CI 51% to 82%) at median specificity, 62% (very low-certainty evidence). Hypercoagulability For mortality, summary sensitivity of a d-dimer increase was 70% (95% CI 64% to 76%) at median specificity of 56% (very low-certainty evidence). For deterioration, summary sensitivity was 65% (95% CI 56% to 74%) at median specificity of 63% (very low-certainty evidence). For the combined outcome, summary sensitivity was 65% (95% CI 52% to 76%) at median specificity of 54% (very low-certainty evidence). To predict mortality, neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR (diagnostic Odds Ratio) 2.05, 95% CI 1.30 to 3.24), C-reactive protein increase (RDOR 2.64, 95% CI 2.09 to 3.33), and lymphocyte count decrease (RDOR 2.63, 95% CI 1.55 to 4.46). D-dimer increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.49, 95% CI 1.23 to 1.80), C-reactive protein increase (RDOR 1.31, 95% CI 1.03 to 1.65), and lactate dehydrogenase increase (RDOR 1.42, 95% CI 1.05 to 1.90). Additionally, lactate dehydrogenase increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.30, 95% CI 1.13 to 1.49). To predict deterioration to severe disease, C-reactive protein increase had higher accuracy compared to d-dimer increase (RDOR 1.76, 95% CI 1.25 to 2.50). The neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR 2.77, 95% CI 1.58 to 4.84). Lastly, lymphocyte count decrease had higher accuracy compared to d-dimer increase (RDOR 2.10, 95% CI 1.44 to 3.07) and lactate dehydrogenase increase (RDOR 2.22, 95% CI 1.52 to 3.26).

AUTHORS' CONCLUSIONS

Laboratory tests, associated with hypercoagulability and hyperinflammatory response, were better at predicting severe disease and mortality in patients with SARS-CoV-2 compared to other laboratory tests. However, to safely rule out severe disease, tests should have high sensitivity (> 90%), and none of the identified laboratory tests met this criterion. In clinical practice, a more comprehensive assessment of a patient's health status is usually required by, for example, incorporating these laboratory tests into clinical prediction rules together with clinical symptoms, radiological findings, and patient's characteristics.

Methodological Considerations in Evaluating Breast Cancer Screening Studies

In evidence-based medicine frameworks, the highest level of evidence is derived from quantitative synthesis of double-masked, high-quality, randomly assigned controlled trials. Meta-analyses of randomly assigned controlled trials have demonstrated that screening mammography reduces breast cancer deaths. In the United States, every major guideline-producing organization has recommended screening mammography in average-risk women; however, there are controversies about age and frequency. Carefully controlled observational research studies and statistical modeling studies can address evidence gaps and inform evidence-based, contemporary screening practices. As breast imaging radiologists develop and evaluate existing and new screening tests and technologies, they will need to understand the key methodological considerations and scientific criteria used by policy makers and health service researchers to support dissemination and implementation of evidence-based screening tests. The Wilson and Jungner principles and the U.S. Preventive Services Task Force general analytic framework provide structured evaluations of the effectiveness of screening tests. Key considerations in both frameworks include public health significance, natural history of disease, cost-effectiveness, and characteristics of screening tests and treatments. Rigorous evaluation of screening tests using analytic frameworks can maximize the benefits of screening tests while reducing potential harms. The purpose of this article is to review key methodological considerations and analytic frameworks used to evaluate screening studies and develop evidence-based recommendations.

Predictive Accuracy of Infant Clinical Sign Algorithms for Mortality in Young Infants Aged 0 to 59 Days: A Systematic Review

CONTEXT

Clinical sign algorithms are a key strategy to identify young infants at risk of mortality.

OBJECTIVE

Synthesize the evidence on the accuracy of clinical sign algorithms to predict all-cause mortality in young infants 0-59 days.

DATA SOURCES

MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials.

STUDY SELECTION

Studies evaluating the accuracy of infant clinical sign algorithms to predict mortality.

DATA EXTRACTION

We used Cochrane methods for study screening, data extraction, and risk of bias assessment. We determined certainty of evidence using Grading of Recommendations Assessment Development and Evaluation.

RESULTS

We included 11 studies examining 26 algorithms. Three studies from non-hospital/community settings examined sign-based checklists (n = 13). Eight hospital-based studies validated regression models (n = 13), which were administered as weighted scores (n = 8), regression formulas (n = 4), and a nomogram (n = 1). One checklist from India had a sensitivity of 98% (95% CI: 88%-100%) and specificity of 94% (93%-95%) for predicting sepsis-related deaths. However, external validation in Bangladesh showed very low sensitivity of 3% (0%-10%) with specificity of 99% (99%-99%) for all-cause mortality (ages 0-9 days). For hospital-based prediction models, area under the curve (AUC) ranged from 0.76-0.93 (n = 13). The Score for Essential Neonatal Symptoms and Signs had an AUC of 0.89 (0.84-0.93) in the derivation cohort for mortality, and external validation showed an AUC of 0.83 (0.83-0.84).

LIMITATIONS

Heterogeneity of algorithms and lack of external validation limited the evidence.

CONCLUSIONS

Clinical sign algorithms may help identify at-risk young infants, particularly in hospital settings; however, overall certainty of evidence is low with limited external validation.

Diagnostic Accuracy of Clinical Sign Algorithms to Identify Sepsis in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis

CONTEXT

Accurate identification of possible sepsis in young infants is needed to effectively manage and reduce sepsis-related morbidity and mortality.

OBJECTIVE

Synthesize evidence on the diagnostic accuracy of clinical sign algorithms to identify young infants (aged 0-59 days) with suspected sepsis.

DATA SOURCES

MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials.

STUDY SELECTION

Studies reporting diagnostic accuracy measures of algorithms including infant clinical signs to identify young infants with suspected sepsis.

DATA EXTRACTION

We used Cochrane methods for study screening, data extraction, risk of bias assessment, and determining certainty of evidence using Grading of Recommendations Assessment Development and Evaluation.

RESULTS

We included 19 studies (12 Integrated Management of Childhood Illness [IMCI] and 7 non-IMCI studies). The current World Health Organization (WHO) 7-sign IMCI algorithm had a sensitivity of 79% (95% CI 77%-82%) and specificity of 77% (95% CI 76%-78%) for identifying sick infants aged 0-59 days requiring hospitalization/antibiotics (1 study, N = 8889). Any IMCI algorithm had a pooled sensitivity of 84% (95% CI 75%-90%) and specificity of 80% (95% CI 64%-90%) for identifying suspected sepsis (11 studies, N = 15523). When restricting the reference standard to laboratory-supported sepsis, any IMCI algorithm had a pooled sensitivity of 86% (95% CI 82%-90%) and lower specificity of 61% (95% CI 49%-72%) (6 studies, N = 14278).

LIMITATIONS

Heterogeneity of algorithms and reference standards limited the evidence.

CONCLUSIONS

IMCI algorithms had acceptable sensitivity for identifying young infants with suspected sepsis. Specificity was lower using a reference standard of laboratory-supported sepsis diagnosis.

The effectiveness of non-pharmacological interventions on reducing pain in patients undergoing bone marrow aspiration and biopsy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients often consider bone marrow aspiration and biopsy to be one of the most painful medical procedures. The effectiveness of non-pharmacological interventions to reduce pain during bone marrow aspiration and biopsy remains unclear.

AIM

To synthesize existing evidence regarding the effectiveness of non-pharmacological interventions in mitigating procedural pain among patients undergoing bone marrow aspiration and biopsy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Six electronic databases, including PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Library and Web of Science were searched from inception to July 15, 2023. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 2.0. Meta-analysis was conducted using STATA 16. The certainty of the evidence was assessed by the GRADE approach.

RESULTS

This meta-analysis included 18 studies derived from 17 articles involving a total of 1017 participants. The pooled results revealed statistically significant pain reduction effects using distraction (SMD: -.845, 95% CI: -1.344 to -.346, p < .001), powered bone marrow biopsy system (SMD: -.266, 95% CI: -.529 to -.003, p = .048), and acupoint stimulation (SMD: -1.016, 95% CI: -1.995 to -.037, p = .042) among patients undergoing bone marrow aspiration and biopsy. However, the pooled results on hypnosis (SMD: -1.228, 95% CI: -4.091 to 1.515, p = .368) showed no significant impact on pain reduction. Additionally, the pooled results for distraction did not demonstrate a significant effect on operative anxiety (MD: -2.942, 95% CI: -7.650 to 1.767, p = .221).

CONCLUSIONS

Distraction, powered bone marrow biopsy system and acupoint stimulation are effective in reducing pain among patients undergoing bone marrow aspiration and biopsy.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

RELEVANCE TO CLINICAL PRACTICE

This meta-analysis highlights the effectiveness of distraction, powered bone marrow biopsy system and acupoint stimulation for reducing pain in patients undergoing bone marrow biopsy. Healthcare professionals should consider integrating these interventions into pain management practices for these patients.

REGISTRATION

(PROSPERO): CRD42023422854.

Diagnostic accuracy of salivary active matrix metalloproteinase (aMMP)-8 point-of-care test for detecting periodontitis in adults: A systematic review and meta-analysis

OBJECTIVE

To determine the accuracy of salivary active matrix metalloproteinase (aMMP)-8 point-of-care test (POCT) for detecting periodontitis in adults, through meta-analysis.

MATERIALS AND METHODS

Diagnostic studies evaluating the accuracy of salivary/oral rinse aMMP-8 POCT for detecting periodontitis in adults, when compared with clinical examination, were considered eligible. A comprehensive search was performed up to 31 August 2023 through five databases. Quality Assessment of Diagnostic Accuracy Studies 2 was utilized to evaluate the methodological quality of the included articles. Meta-analysis was performed using Bayesian bivariate hierarchical model and subgroup analysis.

RESULTS

From 368 screened studies, 6 studies (4 cross-sectional and 2 longitudinal studies) were included in the meta-analysis. Overall, the pooled sensitivity and specificity of salivary aMMP-8-POCT for detecting periodontitis were 0.63 (95% CI: 0.41-0.82) and 0.84 (95% CI: 0.65-0.95), respectively. Subgroup analyses revealed that the 95% CI for oral fluid types, predefined diagnostic thresholds and the POCT systems largely overlapped, indicating that the differences between them may not be significant.

CONCLUSION

Salivary aMMP-8 POCT shows fair accuracy for detecting periodontitis. The diagnostic accuracy cannot be significantly influenced by the types of oral fluids, predefined diagnostic thresholds or the specific POCT systems used. More research is needed to confirm the clinical utility and implementation of aMMP-8 POCT in the diagnosis of periodontitis.

Ultrasonography for confirmation of gastric tube placement

BACKGROUND

Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access.

OBJECTIVES

To assess the diagnostic accuracy of ultrasound alone or in combination with other methods for gastric tube placement confirmation in children and adults.

SEARCH METHODS

This systematic review is an update of a previously published Cochrane review. For this update, we searched the Cochrane Library (2021, Issue 6), MEDLINE (to April 2023), Embase (to April 2023), five other databases (to July 2021), and reference lists of articles, and contacted study authors.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies and case-control studies. We excluded case series or case reports. We excluded studies if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. There were sparse data for specificity. Therefore, we performed a meta-analysis of only sensitivity using a univariate random-effects logistic regression model to combine data from studies that used the same method and echo window.

MAIN RESULTS

We identified 12 new studies in addition to 10 studies included in the earlier version of this review, totalling 1939 participants and 1944 tube insertions. Overall, we judged the risk of bias in the included studies as low or unclear. No study was at low risk of bias or low concern for applicability in every QUADAS-2 domain. There were limited data (152 participants) for misplacement detection (specificity) due to the low incidence of misplacement. The summary sensitivity of ultrasound on neck and abdomen echo windows were 0.96 (95% confidence interval (CI) 0.92 to 0.98; moderate-certainty evidence) for air injection and 0.98 (95% CI 0.83 to 1.00; moderate-certainty evidence) for saline injection. The summary sensitivity of ultrasound on abdomen echo window was 0.96 (95% CI 0.65 to 1.00; very low-certainty evidence) for air injection and 0.97 (95% CI 0.95 to 0.99; moderate-certainty evidence) for procedures without injection. The certainty of evidence for specificity across all methods was very low due to the very small sample size. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (8 studies, 552 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide CIs. For studies of ultrasound alone (9 studies, 782 participants), sensitivity estimates ranged from 0.77 to 0.98 and specificity estimates were 1.00 with wide CIs or not estimable due to no occurrence of misplacement.

AUTHORS' CONCLUSIONS

Of 22 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Is trofinetide a future treatment for Rett syndrome? A comprehensive systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Rett syndrome (RTT) is a rare, life-threatening, genetic neurodevelopmental disorder. Treatment in RTT encounters many challenges. Trofinetide, a modified amino-terminal tripeptide of insulin-like growth factor 1, has demonstrated clinically promising results in RTT. In this study, trofinetide efficacy and safety in RTT are systematically reviewed and meta-analyzed.

METHODS

A systematic search of five electronic databases was conducted until January 2024. Review Manager 5.4 software was used for the analysis. The analysis was based on a weighted mean difference and standard error with a confidence interval (CI) of 95%, and a statistically significant P-value was considered if it was < 0.05. The study was registered on PROSPERO with registration number CRD42024499849. Quality of evidence was assessed using GRADE.

RESULTS

Three randomized controlled trials (RCTs) with 276 patients were included in the analysis. Trofinetide improved both caregiver outcomes and clinical scales by improving the Rett Syndrome Behavior Questionnaire (RSBQ) (mean difference (MD): - 3.46 points, 95% CI: - 5.63 to - 1.27, P = 0.0002) and Clinical Global Impression Scale-Improvement (CGI-I) (MD: - 0.35, 95% CI: - 0.51 to - 0.18, P < 0.0001), respectively. However, trofinetide neither improved the Caregiver Top 3 Concerns Visual Analog Scale nor the Rett Motor Behavioral Assessment. Regarding safety, trofinetide was significantly associated with vomiting compared to placebo (odds ratio (OR): 3.17, 95% CI: 1.57 to 6.43, P = 0.001). After solving heterogeneity, results showed a statistically significant incidence of diarrhea in the trofinetide (200 mg) group compared to placebo (OR: 18.51, 95% CI: 9.30 to 36.84, P ≤ 0.00001).

CONCLUSIONS

Trofinetide demonstrated statistically significant improvements in CGI-I and RSBQ in pediatrics and adult patients with Rett. Side effects are limited to vomiting and diarrhea. Although diarrhea yielded an insignificant result in our analysis, it emerged as a cause for treatment discontinuation in the participating trials, and a statistically significant risk for diarrhea emerged when excluding the study using a lower dose of the drug, hence causing heterogeneity, in the meta-analysis. Given the diverse genetic landscape of RTT, future RCTs investigating correlations between RTT genotype and phenotypic improvements by trofinetide will be beneficial. RCTs encompassing male patients with larger and longer cohorts are recommended.

Architectural design of national evidence based medicine information system based on electronic health record

BACKGROUND

The global implementation of Electronic Health Records has significantly enhanced the quality of medical care and the overall delivery of public health services. The incorporation of Evidence-Based Medicine offers numerous benefits and enhances the efficacy of decision-making in areas such as prevention, prognosis, diagnosis, and therapeutic approaches.

OBJECTIVE

The objective of this paper is to propose an architectural design of an Evidence-Based Medicine information system based on the Electronic Health Record, taking into account the existing and future level of interoperability of health information systems in Greece.

METHODS

A study of the suggested evidence-based medicine architectures found in the existing literature was conducted. Moreover, the interoperability architecture of health information systems in Greece was analyzed. The architecture design reviewed by specialized personnel and their recommendations were incorporated into the final design of the proposed architecture.

RESULTS

The proposed integrated architecture of an Evidence-Based Medicine system based on the Electronic Health Record integrates and utilizes citizens' health data while leveraging the existing knowledge available in the literature.

CONCLUSIONS

Taking into consideration the recently established National Interoperability Framework, which aligns with the European Interoperability Framework, the proposed realistic architectural approach contributes to improving the quality of healthcare provided through the ability to make safe, timely and accurate decisions by physicians.

Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis

BACKGROUND

Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM.

OBJECTIVE

This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.

RESULTS

Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).

CONCLUSIONS

Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.

The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Molecular Diagnostic Testing (December 2023)

Accurate molecular diagnostic tests are necessary for confirming a diagnosis of coronavirus disease 2019 (COVID-19) and for identifying asymptomatic carriage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The number of available SARS-CoV-2 nucleic acid detection tests continues to increase as does the COVID-19 diagnostic literature. Thus, the Infectious Diseases Society of America (IDSA) developed an evidence-based diagnostic guideline to assist clinicians, clinical laboratorians, patients, and policymakers in decisions related to the optimal use of SARS-CoV-2 nucleic acid amplification tests. In addition, we provide a conceptual framework for understanding molecular diagnostic test performance, discuss nuances of test result interpretation in a variety of practice settings, and highlight important unmet research needs related to COVID-19 diagnostic testing. IDSA convened a multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review to identify and prioritize clinical questions and outcomes related to the use of SARS-CoV-2 molecular diagnostics. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel agreed on 12 diagnostic recommendations. Access to accurate SARS-CoV-2 nucleic acid testing is critical for patient care, hospital infection prevention, and the public health response to COVID-19 infection. Information on the clinical performance of available tests continues to grow, but the quality of evidence of the current literature to support this updated molecular diagnostic guideline remains moderate to very low. Recognizing these limitations, the IDSA panel weighed available diagnostic evidence and recommends nucleic acid testing for all symptomatic individuals suspected of having COVID-19. In addition, testing is suggested for asymptomatic individuals with known or suspected contact with a COVID-19 case when the results will impact isolation/quarantine/personal protective equipment (PPE) usage decisions. Evidence in support of rapid testing and testing of upper respiratory specimens other than nasopharyngeal swabs, which offer logistical advantages, is sufficient to warrant conditional recommendations in favor of these approaches.

The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19: Antigen Testing (January 2023)

Immunoassays designed to detect SARS-CoV-2 protein antigens (Ag) are commonly used to diagnose COVID-19. The most widely used tests are lateral flow assays that generate results in approximately 15 minutes for diagnosis at the point-of-care. Higher throughput, laboratory-based SARS-CoV-2 Ag assays have also been developed. The number of commercially available SARS-CoV-2 Ag detection tests has increased rapidly, as has the COVID-19 diagnostic literature. The Infectious Diseases Society of America (IDSA) convened an expert panel to perform a systematic review of the literature and develop best-practice guidance related to SARS-CoV-2 Ag testing. This guideline is an update to the third in a series of frequently updated COVID-19 diagnostic guidelines developed by the IDSA. IDSA's goal was to develop evidence-based recommendations or suggestions that assist clinicians, clinical laboratories, patients, public health authorities, administrators, and policymakers in decisions related to the optimal use of SARS-CoV-2 Ag tests in both medical and nonmedical settings. A multidisciplinary panel of infectious diseases clinicians, clinical microbiologists, and experts in systematic literature review identified and prioritized clinical questions related to the use of SARS-CoV-2 Ag tests. A review of relevant, peer-reviewed published literature was conducted through 1 April 2022. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make testing recommendations. The panel made 10 diagnostic recommendations that address Ag testing in symptomatic and asymptomatic individuals and assess single versus repeat testing strategies. US Food and Drug Administration (FDA) SARS-CoV-2 Ag tests with Emergency Use Authorization (EUA) have high specificity and low to moderate sensitivity compared with nucleic acid amplification testing (NAAT). Ag test sensitivity is dependent on the presence or absence of symptoms and, in symptomatic patients, on timing of testing after symptom onset. In most cases, positive Ag results can be acted upon without confirmation. Results of point-of-care testing are comparable to those of laboratory-based testing, and observed or unobserved self-collection of specimens for testing yields similar results. Modeling suggests that repeat Ag testing increases sensitivity compared with testing once, but no empirical data were available to inform this question. Based on these observations, rapid RT-PCR or laboratory-based NAAT remain the testing methods of choice for diagnosing SARS-CoV-2 infection. However, when timely molecular testing is not readily available or is logistically infeasible, Ag testing helps identify individuals with SARS-CoV-2 infection. Data were insufficient to make a recommendation about the utility of Ag testing to guide release of patients with COVID-19 from isolation. The overall quality of available evidence supporting use of Ag testing was graded as very low to moderate.

A brief step-by-step guide on conducting a systematic review and meta-analysis of prognostic model studies

Prognostic models provide an avenue to predict the risk of individual patients and support shared-decision making. Many prognostic models are published annually, and systematic reviews provide an avenue to collate the existing evidence behind prognostic models to determine whether a model demonstrates adequate predictive performance and is ready for real-world use. This article provides a brief step-by-step guide on how to conduct a systematic review and meta-analysis of prognostic model studies and how these reviews differ from systematic reviews of therapy and diagnosis.

Accuracy of skeletal scintigraphy for the evaluation of mandibular growth disorders: a systematic review

Bone scans, reflecting blood flow and metabolic activity in a region of interest, are frequently used to evaluate mandibular growth disorders. Increased uptake is a non-specific finding and can occur as a result of multiple causes. The correlation between radioactive tracer uptake and growth activity has not been consistently demonstrated. The aim of this study was to assess the accuracy of planar skeletal scintigraphy (SS), single-photon emission computed tomography (SPECT), and SPECT with computed tomography (CT) images (SPECT/CT) in detecting abnormal mandibular growth activity compared to clinical and radiographic/tomographic methods (reference standard) and histologic findings. A systematic review was conducted following the PRISMA guidelines. Sensitivity, specificity, and accuracy were calculated for planar SS, SPECT, and SPECT/CT. Compared to the reference standard, SPECT/CT had the best diagnostic accuracy (76.5% sensitivity, 90.4% specificity, 83.2% accuracy), followed by planar SS (81.8% sensitivity, 84.5% specificity, 83.0% accuracy) and SPECT (77.7% sensitivity, 72.4% specificity, 74.5% accuracy). The results of this study indicate that SPECT/CT has the best clinical correlation, but the certainty of the evidence is low. The differences in sensitivity and specificity between the three index tests were not clinically significant. The three tests can be useful, with only a small difference in their diagnostic value. Histopathology was found not to be satisfactory as a reference standard.

Comprehensive evaluation framework for intervention on health effects of ambient temperature

Despite the existence of many interventions to mitigate or adapt to the health effects of climate change, their effectiveness remains unclear. Here, we introduce the Comprehensive Evaluation Framework for Intervention on Health Effects of Ambient Temperature to evaluate study designs and effects of intervention studies. The framework comprises three types of interventions: proactive, indirect, and direct, and four categories of indicators: classification, methods, scope, and effects. We trialed the framework by an evaluation of existing intervention studies. The evaluation revealed that each intervention has its own applicable characteristics in terms of effectiveness, feasibility, and generalizability scores. We expanded the framework's potential by offering a list of intervention recommendations in different scenarios. Future applications are then explored to establish models of the relationship between study designs and intervention effects, facilitating effective interventions to address the health effects of ambient temperature under climate change.

Diagnostic Accuracy of Transthoracic Echocardiography for Acute Type A Aortic Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND

Transthoracic echocardiography (TTE) is currently recognized as the potential first-line imaging test for patients with suspected acute type A aortic syndrome (AAAS). Direct TTE sign for detecting AAAS is positive if there is an intimal flap separating two aortic lumens or aortic wall thickening seen in the ascending aorta. Indirect TTE sign indicates high-risk features of AAAS, such as aortic root dilatation, pericardial effusion, and aortic regurgitation. Our aim is to summarize the existing clinical evidence regarding the diagnostic accuracy of TTE and to evaluate its potential role in the management of patients with suspected AAAS.

METHODS

We included prospective or retrospective diagnostic cohort studies, written in any language, that specifically focused on using TTE to diagnose AAAS from databases such as PubMed, EMBASE, MEDLINE, and the Cochrane Library. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio [1], and hierarchical summary receiver-operating characteristic (HSROC) curve were calculated for TTE in diagnosing AAAS. We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria.

RESULTS

Ten studies (2886 patients) were included in the meta-analysis. The pooled sensitivity and specificity of direct TTE signs were 58% (95% CI, 38-76%) and 94% (95% CI, 89-97%). For any TTE signs, the pooled sensitivity and specificity were 91% (95% CI, 85-94%) and 74% (95% CI, 61-84%). The diagnostic accuracy of direct TTE signs was significantly higher than that of any TTE signs, as measured by the area under the HSROC curve [0.95 (95% CI, 0.92-0.96) vs. 0.87 (95% CI, 0.84-0.90)] in four studies.

CONCLUSIONS

Our study suggests that TTE could serve as the initial imaging test for patients with suspected AAAS. Given its high specificity, the presence of direct TTE signs may indicate AAAS, whereas the absence of any TTE signs, combined with low clinical suspicion, could suggest a lower likelihood of AAAS.

Prognostic nutritional index as a predictive marker for acute kidney injury in adult critical illness population: a systematic review and diagnostic test accuracy meta-analysis

BACKGROUND

The prognostic nutritional index (PNI), integrating nutrition and inflammation markers, has been increasingly recognized as a prognostic predictor in diverse patient cohorts. Recently, its effectiveness as a predictive marker for acute kidney injury (AKI) in various clinical settings has gained attention. This study aims to assess the predictive accuracy of the PNI for AKI in critically ill populations through systematic review and meta-analysis.

METHODS

A systematic review was conducted using the databases MEDLINE, EMBASE, PubMed, and China National Knowledge Infrastructure up to August 2023. The included trials reported the PNI assessment in adult population with critical illness and its predictive capacity for AKI. Data on study characteristics, subgroup covariates, and diagnostic performance of PNI, including sensitivity, specificity, and event rates, were extracted. A diagnostic test accuracy meta-analysis was performed. Subgroup analyses and meta-regression were utilized to investigate the sources of heterogeneity. The GRADE framework evaluated the confidence in the meta-analysis's evidence.

RESULTS

The analysis encompassed 16 studies with 17 separate cohorts, totaling 21,239 patients. The pooled sensitivity and specificity of PNI for AKI prediction were 0.67 (95% CI 0.58-0.74) and 0.74 (95% CI 0.67-0.80), respectively. The pooled positive likelihood ratio was 2.49 (95% CI 1.99-3.11; low certainty), and the negative likelihood ratio was 0.46 (95% CI 0.37-0.56; low certainty). The pooled diagnostic odds ratio was 5.54 (95% CI 3.80-8.07), with an area under curve of summary receiver operating characteristics of 0.76. Subgroup analysis showed that PNI's sensitivity was higher in medical populations than in surgical populations (0.72 vs. 0.55; p < 0.05) and in studies excluding patients with chronic kidney disease (CKD) than in those including them (0.75 vs. 0.56; p < 0.01). Overall, diagnostic performance was superior in the non-chronic kidney disease group.

CONCLUSION

Our study demonstrated that PNI has practical accuracy for predicting the development of AKI in critically ill populations, with superior diagnostic performance observed in medical and non-CKD populations. However, the diagnostic efficacy of the PNI has significant heterogeneity with different cutoff value, indicating the need for further research.

Comparison of safety and efficacy of different positions in percutaneous nephrolithotomy: a network meta-analysis

OBJECTIVES

Various new positions for percutaneous nephrolithotomy (PCNL) were proposed to reduce the limitations of the traditional position. This study was aimed to evaluate the efficacy and safety of the different PCNL positions.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) up to 18 April 2023. The authors collected five common surgical positions used for PCNL: oblique supine position (OSP), supine position (SP), flank position (FP), split-leg oblique supine/flank position (SLP), and prone position (PP). Paired and network meta-analysis were conducted to compare relevant outcomes, including complications, operative time, stone-free rates, hospital stay, and hemoglobin loss among these different positions.

RESULTS

The study included 17 RCTs with a total of 1841 patients. The result demonstrated that SLP significantly outperformed in terms of decreasing operation time (FP vs SLP MD- MD-41.65; OSP vs SLP MD 28.97; PP vs SLP MD 34.94), hospital stay, and hemoglobin loss. Ranking probabilities showed SLP had highest stone-free rate. Prone position was more likely to occur complications than others. Based on SMAA model, the benefit-risk analysis suggested the SLP was the optimal position in PCNL.

CONCLUSIONS

For PCNL, the split-leg, flank, supine, and OSPs are as secure as the prone position. Further RCTs are necessary to confirm the outstanding safety and efficacy of split-leg position. Besides, the position should be selected regard for the patient's demands, the surgeon's preference and learning curve.

Diagnostic accuracy of interleukin-6 in multiple diseases: An umbrella review of meta-analyses

Objective

This review aims to conduct a comprehensive study of the diagnostic accuracy of interleukin-6 (IL-6) for multiple diseases by utilizing existing systematic reviews and meta-analyses.

Methods

We performed a thorough search of Embase, Web of Science, PubMed, and Cochrane Database of Systematic Reviews up to April 2023 to gather meta-analyses that investigate the diagnostic accuracy of IL-6. To assess the methodological quality of the studies, we employed the Assessing the Methodological Quality of Systematic Reviews-2 and Grading of Recommendations, Assessment, Development and Evaluation criteria.

Results

We included 34 meta-analyses out of the 3024 articles retrieved from the search. These meta-analyses covered 9 categories of diseases of the International Classification of Diseases-11. Studies rated as "Critically Low" or "Very Low" in the quality assessment process were excluded, resulting in a total of 6 meta-analyses that encompassed sepsis, colorectal cancer, tuberculous pleural effusion (TPE), endometriosis, among others. Among these diseases, IL-6 demonstrated a relatively high diagnostic potential in accurately identifying TPE and endometriosis.

Conclusions

IL-6 exhibited favorable diagnostic accuracy across multiple diseases, suggesting its potential as a reliable diagnostic biomarker in the near future. Substantial evidence supported its high diagnostic accuracy, particularly in the cases of TPE and endometriosis.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

The diagnostic accuracy of cardiac ultrasound for acute myocardial ischemia in the emergency department: a systematic review and meta-analysis

BACKGROUND

Chest pain is responsible for millions of visits to the emergency department (ED) annually. Cardiac ultrasound can detect ischemic changes, but varying accuracy estimates have been reported in previous studies. We synthetized the available evidence to yield more precise estimates of the accuracy of cardiac ultrasound for acute myocardial ischemia in patients with chest pain in the ED and to assess the effect of different clinical characteristics on test accuracy.

METHODS

A systematic search for studies assessing the diagnostic accuracy of cardiac ultrasound for myocardial ischemia in the ED was conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Web of Science, two trial registries and supplementary methods, from inception to December 6th, 2022. Prospective cohort, cross-sectional, case-control studies and randomized controlled trials (RCTs) that included data on diagnostic accuracy were included. Risk of bias was assessed with the QUADAS-2 tool and a bivariate hierarchical model was used for meta-analysis with paired Forest and SROC plots used to present the results. Subgroup analyses was conducted on clinically relevant factors.

RESULTS

Twenty-nine studies were included, with 5043 patients. The overall summary sensitivity was 79.3% (95%CI 69.0-86.8%) and specificity was 87.3% (95%CI 79.9-92.2%), with substantial heterogeneity. Subgroup analyses showed increased sensitivity in studies where ultrasound was conducted at ED admission and increased specificity in studies that excluded patients with previous heart disease, when the target condition was acute coronary syndrome, or when final chart review was used as the reference standard. There was very low certainty in the results based on serious risk of bias and indirectness in most studies.

CONCLUSIONS

Cardiac ultrasound may have a potential role in the diagnostic pathway of myocardial ischemia in the ED; however, a pooled accuracy must be interpreted cautiously given substantial heterogeneity and that important patient and test characteristics affect its diagnostic performance.

PROTOCOL REGISTRATION

PROSPERO (CRD42023392058).

Implementing GRADE in systematic reviews that adhere to JBI methodological conduct

GRADE is a methodological approach used to establish certainty in a body of evidence and is now widely adopted among the evidence synthesis and guideline development community. JBI is an international evidence-based health care organization that provides guidance for a range of evidence synthesis approaches. The GRADE approach is currently endorsed for use in a subset of JBI systematic reviews; however, there is some uncertainty regarding when (and how) GRADE may be implemented in reviews that follow JBI methodology.

Effectiveness of glutamine for the treatment of radiodermatitis in cancer patients: a meta-analysis of randomized controlled trials

BACKGROUND

After receiving radiation therapy, 60%-95% of patients with cancer develop radiodermatitis, which causes pain, wound infection, and poor quality of life. Glutamine is a popular nutritional supplement for patients with cancer. Several studies examined the usefulness of glutamine for reducing radiodermatitis. However, there is still no consolidated evidence for clinical use.

METHODS

We searched PubMed, Embase, Cochrane Library, CINAHL PLUS, and the China Knowledge Resource Integrated Database for the relevant literature published up to March 2023, without language restrictions. Two reviewers screened, filtered, and appraised these articles independently, and their data were pooled using a random-effects model.

RESULTS

Five randomized controlled trials (RCTs) with 218 participants were analyzed. The incidence of radiodermatitis in the glutamine group (89/110) was significantly lower than in the placebo group (99/108; risk ratio [RR], 0.90; 95% CI, 0.81-1.00; p = 0.05; I2 = 7%). The incidence of moderate to severe radiodermatitis was significantly lower in the glutamine group than in the placebo group (RR, 0.49; 95% CI, 0.32-0.76; p = 0.001; I2 = 52%). Moreover, subgroup analysis demonstrated heterogeneity (I2 = 52%) for moderate to severe radiodermatitis, the risk of which might be significantly reduced by a glutamine dose of 20-30 g/day (RR, 0.60; 95% CI, 0.41-0.87; I2 = 0%).

CONCLUSION

The meta-analysis indicate that glutamine might lead to a lower incidence of radiodermatitis, and that a glutamine dose of 20-30 g/day might decrease the incidence of moderate to severe dermatitis. Thus, the serious impact of radiodermatitis on treatment follow-up makes the clinical use of glutamine even more important. PROSPERO number: CRD42021254394.

Identification of depression and anxiety during pregnancy: A systematic review and meta-analysis of test accuracy

INTRODUCTION

Depression and anxiety are significant contributors to maternal perinatal morbidity and a range of negative child outcomes. This systematic review and meta-analysis aimed to review and assess the diagnostic test accuracy of selected screening tools (Edinburgh Postnatal Depression Scale [EPDS], EPDS-3A, Patient Health Questionnaire [PHQ-9]-, PHQ-2, Matthey Generic Mood Question [MGMQ], Generalized Anxiety Disorder scale [GAD-7], GAD-2, and the Whooley questions) used to identify women with antenatal depression or anxiety in Western countries.

MATERIAL AND METHODS

On January 16, 2023, we searched 10 databases (CINAHL, Cochrane Library, CRD Database, Embase, Epistemonikos, International HTA Database, KSR Evidence, Ovid MEDLINE, PROSPERO and PsycINFO); the references of included studies were also screened. We included studies of any design that compared case-identification with a relevant screening tool to the outcome of a diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders, fourth or fifth edition (DSM-IV or DSM-5), or the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Diagnoses of interest were major depressive disorder and anxiety disorders. Two authors independently screened abstracts and full-texts for relevance and evaluated the risk of bias using QUADAS-2. Data extraction was performed by one person and checked by another team member for accuracy. For synthesis, a bivariate model was used. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

REGISTRATION

PROSPERO CRD42021236333.

RESULTS

We screened 8276 records for eligibility and included 16 original articles reporting on diagnostic test accuracy: 12 for the EPDS, one article each for the GAD-2, MGMQ, PHQ-9, PHQ-2, and Whooley questions, and no articles for the EPDS-3A or GAD-7. Most of the studies had moderate to high risk of bias. Ten of the EPDS articles provided data for synthesis at cutoffs ≥10 to ≥14 for diagnosing major depressive disorder. Cutoff ≥10 gave the optimal combined sensitivity (0.84, 95% confidence interval [CI]: 0.75-0.90) and specificity (0.87, 95% CI: 0.79-0.92).

CONCLUSIONS

Findings from the meta-analysis suggest that the EPDS alone is not perfectly suitable for detection of major depressive disorder during pregnancy. Few studies have evaluated the other instruments, therefore, their usefulness for identification of women with depression and anxiety during pregnancy remains very uncertain. At present, case-identification with any tool may best serve as a complement to a broader dialogue between healthcare professionals and their patients.

Performance Characteristics of Basophil Activation Tests for Diagnosing Penicillin Allergy: A Meta-Analysis

BACKGROUND

Approximately 10% of the global population identify themselves as penicillin allergic, yet 90% are not truly allergic and could safely tolerate penicillin. There is no simple way to identify these people. Current in vitro diagnostics include specific immunoglobulin E (with a sensitivity of 19% and specificity of 97%) and a basophil activation test (BAT) with undefined sensitivity and specificity.

OBJECTIVE

To define the sensitivity and specificity of BAT in the diagnosis of penicillin allergy METHODS: We searched PubMed and EMBASE from inception to April 2, 2023, for original studies evaluating the performance characteristics of BAT for penicillin allergy in adults. Study selection, data extraction, risk of bias, assessment with QUADAS-2 tool, certainty assessment with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology were performed independently, in duplicate. Meta-analysis was performed using Reitsma methodology.

RESULTS

Twenty-two studies fulfilled the inclusion criteria. Twelve used the same positive threshold giving a summary point sensitivity 51% (95% confidence interval [95% CI]46%-56%) and specificity 89% (95% CI 85%-93%). Significant risk of bias was identified owing to patient selection. GRADE certainty of evidence rated sensitivity very low due to imprecision and specificity as low. There was great heterogeneity in methods used. Use of 1,000 basophils per test did not improve performance above 500 basophils.

CONCLUSIONS

BAT sensitivity is highly variable across studies and remains too low to be considered as a routine element of clinical practice. BAT specificity is not as good as specific immunoglobulin E in penicillin allergy diagnosis. Significant further work is required in this field before clinical application of BAT in routine practice.

Diagnostic performance of clinical prediction rules to detect group A beta-haemolytic streptococci in people with acute pharyngitis: a systematic review

OBJECTIVE

To assess and compare the diagnostic performance of Clinical Prediction Rules (CPRs) developed to detect group A Beta-haemolytic streptococci in people with acute pharyngitis (or sore throat).

STUDY DESIGN

A systematic review.

METHODS

We searched PubMed, Embase and Web of Science (inception-September 2022) for studies deriving and/or validating CPRs comprised of ≥2 predictors from an individual's history or physical examination. Two authors independently screened articles, extracted data and assessed risk of bias in included studies. A meta-analysis was not possible due to heterogeneity. Instead we compared the performance of CPRs when they were validated in the same study population (head-to-head comparisons). We used a modified grading of recommendations, assessment, development, and evaluations (GRADE) approach to assess certainty of the evidence.

RESULTS

We included 63 studies, all judged at high risk of bias. Of 24 derived CPRs, 7 were externally validated (in 46 external validations). Five validation studies provided data for head-to-head comparison of four pairs of CPRs. Very low certainty evidence favoured the Centor CPR over the McIsaac (2 studies) and FeverPain CPRs (1 study) and found the Centor CPR was equivalent to the Walsh CPR (1 study). The AbuReesh and Steinhoff 2005 CPRs had a similar poor discriminative ability (1 study). Within and between study comparisons suggested the performance of the Centor CPR may be better in adults (>18 years).

CONCLUSION

Very low certainty evidence suggests a better performance of the Centor CPR. When deciding about antibiotic prescribing for pharyngitis patients, involving patients in a shared decision making discussion about the likely benefits and harms, including antibiotic resistance, is recommended. Further research of higher rigour, which compares CPRs across multiple settings, is needed.

Postoperative pain after single-visit root canal treatment or vital pulp therapy: A systematic review and meta-analysis

BACKGROUND

This systematic review aimed to investigate whether vital pulp therapy and root canal treatment (RCT) promote different postoperative pain.

STUDIES REVIEWED

The authors searched PubMed, Cochrane Library, Embase, and Latin American and Caribbean Health Sciences Literature databases for studies published through June 30, 2022. The authors included randomized clinical trials if they reported on the assessment of postoperative pain after direct pulp capping, partial pulpotomy, pulpotomy, or single-visit RCT. The authors assessed the frequency of no, mild, moderate, and severe postoperative pain. They conducted meta-analyses to compare postoperative pain after full pulpotomy (PULP) and RCT.

RESULTS

The qualitative synthesis included 57 studies, and the authors conducted meta-analysis of 3. PULP leads to more asymptomatic cases (relative risk [RR], 1.06; 95% CI, 1.01 to 1.11; P < .01; I2 = 67%) and to a lower occurrence of mild (RR, 0.89; 95% CI, 0.79 to 0.99; P < .04; I2 = 37%) and moderate (RR, 0.70; 95% CI, 0.51 to 0.95; P < .02; I2 = 57%) postoperative pain than RCT. The frequency of severe pain was very low for both vital pulp therapy and RCT. Moderate to severe postoperative pain was more common at 48 hours through 72 hours after RCT and up to 36 hours after PULP. Pain intensity after PULP was higher using calcium-enriched material compared with using mineral trioxide aggregate at 12, 18, and 36 hours (P < .001).

PRACTICAL IMPLICATIONS

PULP showed a significantly higher incidence of no pain and a lower incidence of mild and moderate pain than single-visit RCT. Clinical decisions for RCT or PULP should not be based on differences in postoperative pain. When analgesia is indicated, it probably should be limited to a short time after PULP.

Effectiveness of Community-Based Rehabilitation (CBR) Centers for Improving Physical Fitness for Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

To synthesise the best available evidence for the effectiveness of interventions delivered in community-based rehabilitation (CBR) centers on physical fitness, for community-dwelling older adults living in Asian countries. This study is a systematic review and meta-analysis. Seven English and two Chinese electronic databases were searched for randomised controlled trials (RCTs) and quasi-experimental studies that were conducted by centers providing CBR. Independent reviewers screened, quality-appraised and extracted data. The primary outcome was physical fitness measured by validated assessment tools, including the Timed Up and Go Test (TUG), gait speed, hand grip strength, Functional Reach Test (FRT), and one-leg standing test. Assessments of activity of daily living and quality of life using tools including the Barthel Index, Short Form (SF)-12, and SF-36 were secondary outcomes. After screening 5,272 studies, 29 studies were included (16 RCTs, 13 quasi-experimental studies) from four countries. Meta-analyses found that CBR programs significantly decreased TUG time (mean difference [MD], -1.89 seconds; 95% confidence interval [95% CI], -2.84 to -0.94; I2=0%; Z=3.90, p<0.0001), improved gait speed (MD, 0.10 m/s; 95% CI, 0.01-0.18; I2=0%; Z=2.26, p=0.02), and increased one-leg standing time (MD, 2.81 seconds; 95% CI, 0.41-5.22; I2=0%; Z=2.29, p=0.02). Handgrip strength and FRT showed no statistically significant improvement in the meta-analyses. CBR may improve aspects of physical fitness for older adults in Asian countries. However, variability in intervention components and measurement tools reduced the ability to pool individual studies. Further trials are required with robust designs including standardised measures of physical fitness.

Accuracy of the 10 μg desmopressin test for differential diagnosis of Cushing syndrome: a systematic review and meta-analysis

We evaluated the accuracy of the 10 μg desmopressin test in differentiating Cushing disease (CD) from non-neoplastic hypercortisolism (NNH) and ectopic ACTH syndrome (EAS). A systematic review of studies on diagnostic test accuracy in patients with CD, NNH, or EAS subjected to the desmopressin test obtained from LILACS, PubMed, EMBASE, and CENTRAL databases was performed. Two reviewers independently selected the studies, assessed the risk of bias, and extracted the data. Hierarchical and bivariate models on Stata software were used for meta-analytical summaries. The certainty of evidence was measured using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation Working Group) approach. In total, 14 studies were included: 3 studies on differentiated CD versus NNH and 11 studies on differentiated CD versus EAS. Considering ΔACTH in 8 studies involving 429 patients, the pooled sensitivity for distinguishing CD from EAS was 0.85 (95% confidence interval [CI]: 0.80-0.89, I2 = 17.6%) and specificity was 0.64 (95% CI: 0.49-0.76, I2 = 9.46%). Regarding Δcortisol in 6 studies involving 233 participants, the sensitivity for distinguishing CD from EAS was 0.81 (95% CI: 0.74-0.87, I2 = 7.98%) and specificity was 0.80 (95% CI: 0.61-0.91, I2 = 12.89%). The sensitivity and specificity of the combination of ΔACTH > 35% and Δcortisol > 20% in 5 studies involving 511 participants were 0.88 (95% CI: 0.79-0.93, I2 = 35%) and 0.74 (95% CI: 0.55-0.87, I2 = 27%), respectively. The pooled sensitivity for distinguishing CD from NNH in 3 studies involving 170 participants was 0.88 (95% CI: 0.79-0.93) and the specificity was 0.94 (95% CI: 0.86-0.97). Based on the desmopressin test for differentiating CD from EAS, considering ΔACTH, Δcortisol, or both percent increments, 15%, 19%, or 20% of patients with CD, respectively, would be incorrectly classified as having EAS. For CD versus NNH, 11% of patients with CD would be falsely diagnosed as having NNH, whereas 7% of patients with NNH would be falsely diagnosed as having CD. However, in all hierarchical plots, the prediction intervals were considerably wider than the confidence intervals. This indicates low confidence in the estimated accuracy, and the true accuracy is likely to be different.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85634, identifier CRD42018085634; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=68317, identifier CRD42017068317.

Efficacy of CDK4/6 inhibitors combined with endocrine therapy in HR+/HER2- breast cancer: an umbrella review

BACKGROUND

The use of Cyclin-Dependent kinase 4 and 6 (CDK4/6) inhibitors has profoundly changed the challenge of endocrine therapy (ET) resistance in hormone receptor-positive (HR+)/HER2-negative (HER2-) breast cancer. However, there is currently no comprehensive evaluation of the evidence for the efficacy of CDK4/6 inhibitors. We conducted an umbrella review to explore the impact of CDK4/6 inhibitor combined with ET on breast cancer by summarizing and assessing the meta-analysis (MA) and systematic review (SR) evidence.

METHODS

Cochrane, PubMed, Embase, and Web of Science databases were searched from inception to August 1st, 2022. Eligible studies were assessed for methodological quality, report quality, and evidence quality using the AMSTAR-2 scale, PRISMA 2020, and GRADE grading systems, respectively. We summarized all efficacy outcomes of CDK4/6 inhibitors for breast cancer and reported them in narrative form.

RESULTS

Our study included 24 MAs and SRs. The strongest evidence demonstrated that CDK4/6 inhibitor combined with ET significantly improved progression-free survival (PFS), overall survival (OS) in advanced breast cancer (ABC). A large body of moderate to high evidence showed a significant association between combination therapy and objective response rate (ORR), and clinical benefit response (CBR) benefit in ABC. Low evidence suggested some degree of benefit from combination therapy in second progression-free survival (PFS2) and time to subsequent chemotherapy (TTC) outcomes in ABC and invasive disease-free survival (IDFS) outcomes in early breast cancer.

CONCLUSIONS

Based on current evidence, CDK4/6 inhibitors combined with ET have great confidence in improving PFS, OS, ORR, and CBR outcomes in patients with ABC, which provides more rational and valid evidence-based medicine for CDK4/6 inhibitor promotion and clinical decision support.

The adverse events of CDK4/6 inhibitors for HR+/ HER2- breast cancer: an umbrella review of meta-analyses of randomized controlled trials

Background: The clinical selection of three CDK4/6 inhibitors presents a challenging issue, owing to the absence of distinct clinical case characteristics, biomarkers, and their comparable clinical benefits in progression-free survival and overall survival To inform clinical treatment decisions, we conducted a comprehensive evaluation of the adverse events associated with CDK4/6 inhibitors in combination with endocrine therapy for hazard ratio+/HER2-breast cancer. Methods: We searched Cochrane, PubMed, Embase, and Web of Science databases from their inception until 1 August 2022. The results were summarized narratively, and we assessed the methodological quality, reporting quality, and evidence quality of AEs by AMSTAR-2, PRISMA, and GRADE. Results: Our analysis included 24 meta-analyses systematic reviews that evaluated the quality of AEs in 13 cases of early breast cancer (EBC) and 158 cases of advanced breast cancer The addition of CDK4/6 inhibitors was found to significantly increase AEs of any grade and AEs of grade 3 or higher in early breast cancer, along with a significant increase in the risk of treatment discontinuation. In advanced breast cancer, high and moderate-quality evidence indicated that CDK4/6 inhibitors significantly increased AEs across all grades, including grade 3/4 AEs, leucopenia, grade 3/4 leucopenia, neutropenia, grade 3/4 neutropenia, anemia, grade 3/4 anemia, nausea, grade 3/4 constipation, fatigue, pyrexia, venous thromboembolism abdominal pain, and cough. However, they did not significantly elevate the incidence of grade 3/4 diarrhea. Subgroup analysis revealed that palbociclib primarily increased hematologic toxicity, particularly grade 3/4 neutropenia, anemia, and thrombocytopenia. Ribociclib was mainly associated with grade 3/4 neutropenia, prolonged QT interval, and alopecia. Abemaciclib was closely linked with diarrhea and elevated blood creatinine levels. Conclusion: The AEs associated with CDK4/6 inhibitors vary, necessitating individualized and precise clinical selection for optimal management. This approach should be based on the patient's medical history and the distinct characteristics of different CDK4/6 inhibitors to improve the patient's quality of life. Systematic Review Registration: [https://systematicreview.gov/], identifier [CRD42022350167].

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy. A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work. Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

GRADE guidance 37: rating imprecision in a body of evidence on test accuracy

OBJECTIVES

To provide guidance on rating imprecision in a body of evidence assessing the accuracy of a single test. This guide will clarify when Grading of Recommendations Assessment, Development and Evaluation (GRADE) users should consider rating down the certainty of evidence by one or more levels for imprecision in test accuracy.

STUDY DESIGN AND SETTING

A project group within the GRADE working group conducted iterative discussions and presentations at GRADE working group meetings to produce this guidance.

RESULTS

Before rating the certainty of evidence, GRADE users should define the target of their certainty rating. GRADE recommends setting judgment thresholds defining what they consider a very accurate, accurate, inaccurate, and very inaccurate test. These thresholds should be set after considering consequences of testing and effects on people-important outcomes. GRADE's primary criterion for judging imprecision in test accuracy evidence is considering confidence intervals (i.e., CI approach) of absolute test accuracy results (true and false, positive, and negative results in a cohort of people). Based on the CI approach, when a CI appreciably crosses the predefined judgment threshold(s), one should consider rating down certainty of evidence by one or more levels, depending on the number of thresholds crossed. When the CI does not cross judgment threshold(s), GRADE suggests considering the sample size for an adequately powered test accuracy review (optimal or review information size [optimal information size (OIS)/review information size (RIS)]) in rating imprecision. If the combined sample size of the included studies in the review is smaller than the required OIS/RIS, one should consider rating down by one or more levels for imprecision.

CONCLUSION

This paper extends previous GRADE guidance for rating imprecision in single test accuracy systematic reviews and guidelines, with a focus on the circumstances in which one should consider rating down one or more levels for imprecision.

CTA and CTP for Detecting Distal Medium Vessel Occlusions: A Systematic Review and Meta-analysis

BACKGROUND

The optimal imaging method for detecting distal medium vessel occlusions (DMVOs) remains undefined.

PURPOSE

The objective of this study is to compare the diagnostic performance of CTA with CTP in detecting DMVOs.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials up to March 31, 2023 (PROSPERO: CRD42022344006).

STUDY SELECTION

A total of 12 studies reporting accuracy values of CTA and/or CTP were included, comprising 2607 patients with 479 cases (18.3%) of DMVOs.

DATA ANALYSIS

Pooled sensitivity and specificity of both imaging methods were compared using a random-effects model. Subgroup analyses were performed based on the technique used in CTA (multi or single-phase) and the subtype of DMVOs (M2-only vs. M2 and other DMVOs). We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria.

DATA SYNTHESIS

CTA demonstrated significantly lower sensitivity compared to CTP in detecting DMVOs [0.74, 95%CI (0.63-0.82) vs. 0.89, 95% CI (0.82-0.93), P < 0.01]. When subgrouped into single-phase and multi-phase CTA, multi-phase CTA exhibited higher sensitivity for DMVO detection than single-phase CTA [0.91, 95%CI (0.85-0.94) vs. 0.64, 95%CI (0.56-0.71), P < .01], while reaching similar levels to CTP. The sensitivity of single-phase CTA substantially decreased when extending from M2 to other non-M2 DMVOs [0.74, 95%CI (0.63-0.83) vs. 0.61, 0.95%CI (0.53-0.68), P = .02].

LIMITATIONS

We identified an overall high risk of bias and low quality of evidence, attributable to the design and reference standards of most studies.

CONCLUSIONS

Our findings highlight a significantly lower sensitivity of single-phase CTA compared to multi-phase CTA and CTP in diagnosing DMVOs.

Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome

BACKGROUND

Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function.

OBJECTIVES

To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022.

SELECTION CRITERIA

We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome.

MAIN RESULTS

We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard.

AUTHORS' CONCLUSIONS

The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.

Sweat conductivity diagnostic accuracy for cystic fibrosis: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis of diagnostic test accuracy studies to summarise the properties of sweat conductivity (SC) to rule in/out cystic fibrosis (CF).

DATA SOURCE

We searched PubMed, Embase, Web of Science, Google Scholar, SciELO and LILACS up to 13 March 2023.

STUDY SELECTION

We selected prospective and retrospective diagnostic test accuracy studies which compared SC, measured through two well-established and commercially available devices, that is, Nanoduct or Sweat-Chek Analyser, to quantitative measurement of sweat chloride.

MAIN OUTCOME MEASURES

Pooled sensitivity, specificity, positive likelihood ratio (+LR) and negative likelihood ratio (-LR), and their corresponding 95% CIs.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines were followed. Data were extracted by one reviewer and checked by another. The hierarchical summary receiver operating characteristics model was used to estimate diagnostic test accuracy.

RESULTS

Ten studies involving 8286 participants were included. The pooled estimates of sensitivity, specificity, +LR and -LR were 0.97 (95% CI 0.94 to 0.98), 0.99 (95% CI 0.98 to 0.99), 171 (95% CI 58 to 500) and 0.02 (95% CI 0.01 to 0.05), respectively. Sensitivity analyses did not reveal a substantial impact of study-level factors on the results, such as study quality, cut-off values for a positive test, study sample size and participant age group. The quality of evidence was considered moderate.

CONCLUSION

SC demonstrated excellent diagnostic performance. In addition, its accuracy parameters suggest its role as an alternative to the sweat test for CF diagnosis.

PROSPERO REGISTRATION NUMBER

CRD42022284504.

Diagnostic Accuracy of Urinary N Terminal pro-B Type Natriuretic Peptides for Hemodynamically Significant-Patent Ductus Arteriosus in Preterm Infants

BACKGROUND

Echocardiography is the gold standard for the diagnosis hemodynamically significant-patent ductus arteriosus (hs-PDA). It requires trained personnel and is not readily available. Urinary biomarkers can be used as an adjunct.

OBJECTIVE

The objective of this study was to systematically review the diagnostic accuracy of urinary N terminal pro-B type natriuretic peptides (NT-proBNP) for hs-PDA in preterm neonates.

METHODS

We included studies that evaluated urinary NT-proBNP and urinary NT-proBNP/creatinine ratio (index tests) in preterm neonates with hs-PDA (participants) in comparison with echocardiogram (reference standard). Methodological quality and certainty of evidence were assessed using Quality Assessment of Diagnostic-Accuracy Studies (QUADAS-2) and Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively.

RESULTS

Low quality of evidence suggests that urinary NT-proBNP has modest sensitivity and specificity for the diagnosis of a hs-PDA, with variation in accuracy based on assay and patient characteristics.

CONCLUSION

Urinary NT-proBNP assays must be locally validated for specific patient populations and further studies to support its use must be performed.

The effect of mind-body exercise in lung cancer patients: a meta-analysis of RCTs

PURPOSE

This study aimed to evaluate the impact of mind-body exercise (yoga, tai chi, qigong, etc.) on lung cancer.

METHODS

We performed a literature search of the electronic databases PubMed, Web of Science, Cochrane Library, Embase, CNKI, CBM, WanFang Data, and VIP from their inception to 16 May 2023. The primary outcome was the 6-min walk test (6MWT), while the secondary outcomes were anxiety levels and quality of life (QoL). Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Cochrane risk of bias (ROB) tool for randomized controlled trials, with differences agreed by consensus. Meta-analysis was performed using RevMan 5.4 and Stata 15 software to analyze the extracted data.

RESULTS

This meta-analysis included a total of 11 studies involving 897 patients. The results indicated that compared to the usual care group, lung cancer patients in the mind-body exercise group could increase the 6-min walk distance (5 studies, 346 participants, WMD: 18.83, 95% CI (7.55, 30.10) P = 0.001), reduce anxiety levels (4 studies, 362 participants, SMD: - 1.51, 95% CI (- 1.74, - 1.27), P < 0.05), and enhance the overall quality of life (6 studies, 594 participants, SMD: 0.71, 95% CI (0.10, 1.31), P = 0.02). The overall certainty of the evidence for all outcomes was low; seven studies were judged to be at low risk of bias, and four studies were judged to be at moderate risk of bias.

CONCLUSION

Mind-body exercise could improve exercise capacity in lung cancer survivors, reduce anxiety, and positively affect overall quality of life.

PROSPERO REGISTRATION NUMBER

CRD42023426800.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy. A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work. Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Unsupervised home spirometry versus supervised clinic spirometry for respiratory disease: a systematic methodology review and meta-analysis

BACKGROUND

The number of patients completing unsupervised home spirometry has recently increased due to more widely available portable technology and the COVID-19 pandemic, despite a lack of solid evidence to support it. This systematic methodology review and meta-analysis explores quantitative differences in unsupervised spirometry compared with spirometry completed under professional supervision.

METHODS

We searched four databases to find studies that directly compared unsupervised home spirometry with supervised clinic spirometry using a quantitative comparison (e.g. Bland-Altman). There were no restrictions on clinical condition. The primary outcome was measurement differences in common lung function parameters (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)), which were pooled to calculate overall mean differences with associated limits of agreement (LoA) and confidence intervals (CI). We used the I2 statistic to assess heterogeneity, the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence certainty for the meta-analyses. The review has been registered with PROSPERO (CRD42021272816).

RESULTS

3607 records were identified and screened, with 155 full texts assessed for eligibility. We included 28 studies that quantitatively compared spirometry measurements, 17 of which reported a Bland-Altman analysis for FEV1 and FVC. Overall, unsupervised spirometry produced lower values than supervised spirometry for both FEV1 with wide variability (mean difference -107 mL; LoA= -509, 296; I2=95.8%; p<0.001; very low certainty) and FVC (mean difference -184 mL, LoA= -1028, 660; I2=96%; p<0.001; very low certainty).

CONCLUSIONS

Analysis under the conditions of the included studies indicated that unsupervised spirometry is not interchangeable with supervised spirometry for individual patients owing to variability and underestimation.

Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis

OBJECTIVE

To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes.

SETTING

Any setting in any country listed as very high on the human development index.

PARTICIPANTS

People with a diagnosis of any tendinopathy of any severity or duration.

INTERVENTIONS

Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion.

MAIN OUTCOME MEASURES

Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC).

RESULTS

From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset.

CONCLUSION

Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Diagnostic accuracy of the upper limb neurodynamic test with median bias (ULNT1) for cervical radiculopathy: a systematic review and meta-analysis

BACKGROUND

The upper limb neurodynamic test for median nerve (ULNT1) is commonly applied for assessment of cervical radiculopathy (CR). However, the diagnostic accuracy of ULNT1 in diagnosing CR remains unclear.

OBJECTIVE

This study aimed to examine the diagnostic accuracy of the ULNT1 for the CR.

DATA SOURCES

Four databases were searched for relevant studies published up to April 30, 2023.

STUDY SELECTION

Cross-sectional or cohort studies that assessed the diagnostic accuracy of ULNT1 for CR were included.

DATA SYNTHESIS

The methodological quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist. A bivariate random-effects regression model was used for the data synthesis. The overall quality of evidence was evaluated using the GRADE approach.

RESULTS

A total of 592 references were identified, and five studies with 465 patients met the inclusion criteria. The overall quality of the body of evidence was very low across studies. Heterogeneity of studies was high. The pooled sensitivity and specificity of the ULNT1 were 0.69 (95% CI 0.50-0.83) and 0.54 (95% CI 0.36-0.71), respectively. The summary receiver operating characteristic curve area was 0.65 (95% CI 0.61-0.69).

CONCLUSION

There is low certainty of evidence that the ULNT1 has only fair accuracy in diagnosing CR. The ULNT1 was recommended as an add-on test after the existing diagnostic pathway to enhance diagnostic accuracy further. High-quality studies which follow the Standards for Reporting of Diagnostic Accuracy and the QUADAS-2; a revised tool for the quality assessment of diagnostic accuracy, are needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO: CRD42021255686 CONTRIBUTION OF THE PAPER.

Performance of smartphone application to accurately quantify hyperbilirubinemia in neonates: a systematic review with meta-analysis

Neonatal jaundice is a common clinical condition that can progress to severe hyperbilirubinemia if identification and intervention are delayed. In this study, we aimed to analyze the current evidence on the accurate performance of smartphone applications to quantify bilirubin levels. PubMed, Embase, Emcare, MEDLINE, the Cochrane Library, and Google Scholar were searched from inception until July 2022. Grey literature was searched on "OpenGrey" and "MedNar" databases. We included prospective and retrospective cohort studies that recruited infants with a gestation of ≥ 35 weeks and reported paired total serum bilirubin (TSB) and smartphone app-based bilirubin (ABB) levels. We conducted the review using the guidelines of the Cochrane Collaboration Diagnostic Test Accuracy Working Group and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-diagnostic test accuracy (PRISMA-DTA) statement. The data were pooled using the random effects model. The outcome of interest was agreement between ABB and TSB measurements, provided as correlation coefficient, mean difference, and standard deviation. Certainty of evidence (COE) was assessed based on GRADE guidelines. Fourteen studies were included in the meta-analysis. The number of infants in individual studies ranged between 35 and 530. The pooled correlation coefficient (r) between ABB and TSB was 0.77 (95% CI 0.69 to 0.83; p < 0.01). Reported sensitivities for predicting a TSB of 250 µmol/L in individual studies ranged between 75 and 100% and specificities ranged from 61 to 100%. Similarly, a sensitivity of 83 to 100% and a specificity of 19.5 to 76% were reported for predicting a TSB of 205 μmol/L. Overall COE was considered moderate.    Conclusion: Smartphone app-based bilirubin estimation showed a reasonable correlation to TSB levels. Well-designed studies are required to determine its utility as a screening tool for various TSB cut-off levels. What is Known: • Neonatal jaundice is a common clinical condition. Timely screening and intervention are necessary to prevent neurological morbidities • Transcutaneous bilirubinometer is a widely used non-invasive screening device but is mostly available in hospital settings and has cost limitations. Researchers have recently explored the utility of smartphone applications to estimate bilirubin levels in neonates. What is New: • This is the first systematic review and meta-analysis conducted to assess the performance of smartphone applications to detect neonatal hyperbilirubinemia. • Bilirubin estimates of newborn infants obtained through smartphone applications had a reasonable correlation with serum bilirubin levels.

Acupressure can reduce preoperative anxiety in adults with elective surgery: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Preoperative anxiety is prevalent amongst adults with elective surgery and is associated with multiple detrimental perioperative physiological effects. Increasing studies support the effectiveness of acupressure in managing preoperative anxiety. However, the magnitude of acupressure's positive association with preoperative anxiety is still unclear due to a lack of rigorous evidence synthesis.

OBJECTIVE

To estimate the efficacy of acupressure on preoperative anxiety and physiological parameters amongst adults scheduled for elective surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Search terms were combined for acupressure and preoperative anxiety in PubMed, Cochrane Library, EMBASE, CINAHL, China National Knowledge Infrastructure, and WanFang Data Knowledge Service Platform to search for eligible randomised controlled trials from the inception of each database through September 2022.

METHODS

Pairs of researchers independently screened and extracted data from included studies. The risk of bias was assessed using the Cochrane risk of bias tool Version 2.0. Meanwhile, random-effects meta-analysis of overall effects and prespecified subgroup (i.e., surgery types, intervention providers, and acupressure stimulation tools) was conducted using Review Manager Software 5.4.1. Meta-regression was performed to explore study-level variables that may contribute to heterogeneity using STATA 16.

RESULTS

Of 24 eligible randomised controlled trials, there were a total of 2537 participants from 5 countries contributed to this synthesis. When comparing acupressure with usual care or placebo, acupressure showed a large effect size for preoperative anxiety (SMD = -1.30; 95%CI = -1.54 to -1.06; p < 0.001; I2 = 86%). The significant mean reduction of heart rate, and systolic and diastolic blood pressure was -4.58 BPM (95%CI = -6.70 to -2.46; I2 = 89%), -6.05 mmHg (95%CI = -8.73 to -3.37; p < 0.001; I2 = 88%), and -3.18 mmHg (95%CI = -5.09 to -1.27; p = 0.001; I2 = 78%), respectively. Exploratory subgroup analyses showed significant differences in surgery types and acupressure stimulation tools, whilst the intervention providers (i.e., healthcare professionals and self-administered) showed no statistically significant difference for acupressure therapy. None of the predefined participants and study-level characteristics moderated preoperative anxiety through meta-regression.

CONCLUSION

Acupressure appears efficacious as a therapy for improving preoperative anxiety and physiological parameters amongst adults with elective surgery. Self-administered acupressure, which is effective with a large effect, may be considered as an evidence-based approach to managing preoperative anxiety. Hence, this review aids in the development of acupressure in different types of elective surgeries and the improvement of the rigour of acupressure therapy.