Cochrane's risk of bias tool for non-randomized studies (ROBINS-I) is frequently misapplied: A methodological systematic review

Implementability of opioid deprescribing interventions at transitions of care: A scoping review

Continuation of opioids at transitions of care increases the risk of long-term opioid use and related harm. To our knowledge, no study has examined the implementability of opioid deprescribing interventions at transitions of care. Our scoping review aimed to identify the type of opioid deprescribing interventions employed at transitions of care and assess the implementability of tested interventions. Nine electronic databases were searched on 15 May 2023 for English-language studies of adults transitioning between care settings, where opioid deprescribing interventions targeting patients, clinicians or health systems were implemented. Implementability was assessed using the Cochrane Intervention Complexity Assessment Tool for Systematic Reviews to determine intervention complexity, and mapped to the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to understand the process evaluation. A total of 79 studies were identified, with 94.0% (n = 74) examining hospital-to-home transitions. Mixed interventions (combination of pharmacological and nonpharmacological) were tested in 49.0% (n = 39) of studies. Pharmacological interventions were identified in 31.0% (n = 24) of studies, and the remaining 20.0% (n = 16) applied nonpharmacological interventions. Mixed interventions comprising multiple components were the most complex and resulted in reduced opioid use across transitions of care in 28.0% (n = 22) of studies. Few studies reported on RE-AIM dimensions including implementation (5.0% of studies), reach (4.0%), adoption (4.0%) and maintenance (0%). Most opioid deprescribing interventions targeted hospital to home care transition with mixed results in opioid deprescribing. Further research should consider the implementability of interventions during transitions of care to elucidate the impact of opioid deprescribing interventions across care settings.

Methodological Challenges in Randomized Controlled Trials of mHealth Interventions: Cross-Sectional Survey Study and Consensus-Based Recommendations

BACKGROUND

Mobile health (mHealth) refers to using mobile communication devices such as smartphones to support health, health care, and public health. mHealth interventions have their own nature and characteristics that distinguish them from traditional health care interventions, including drug interventions. Thus, randomized controlled trials (RCTs) of mHealth interventions present specific methodological challenges. Identifying and overcoming those challenges is essential to determine whether mHealth interventions improve health outcomes.

OBJECTIVE

We aimed to identify specific methodological challenges in RCTs testing mHealth interventions' effects and develop consensus-based recommendations to address selected challenges.

METHODS

A 2-phase participatory research project was conducted. First, we sent a web-based survey to authors of mHealth RCTs. Survey respondents rated on a 5-point scale how challenging they found 21 methodological aspects in mHealth RCTs compared to non-mHealth RCTs. Nonsystematic searches until June 2022 informed the selection of the methodological challenges listed in the survey. Second, a subset of survey respondents participated in an online workshop to discuss recommendations to address selected methodological aspects identified in the survey. Finally, consensus-based recommendations were developed based on the workshop discussion and email interaction.

RESULTS

We contacted 1535 authors of mHealth intervention RCTs, of whom 80 (5.21%) completed the survey. Most respondents (74/80, 92%) identified at least one methodological aspect as more or much more challenging in mHealth RCTs. The aspects most frequently reported as more or much more challenging were those related to mHealth intervention integrity, that is, the degree to which the study intervention was implemented as intended, in particular managing low adherence to the mHealth intervention (43/77, 56%), defining adherence (39/79, 49%), measuring adherence (33/78, 42%), and determining which mHealth intervention components are used or received by the participant (31/75, 41%). Other challenges were also frequent, such as analyzing passive data (eg, data collected from smartphone sensors; 24/58, 41%) and verifying the participants' identity during recruitment (28/68, 41%). In total, 11 survey respondents participated in the subsequent workshop (n=8, 73% had been involved in at least 2 mHealth RCTs). We developed 17 consensus-based recommendations related to the following four categories: (1) how to measure adherence to the mHealth intervention (7 recommendations), (2) defining adequate adherence (2 recommendations), (3) dealing with low adherence rates (3 recommendations), and (4) addressing mHealth intervention components (5 recommendations).

CONCLUSIONS

RCTs of mHealth interventions have specific methodological challenges compared to those of non-mHealth interventions, particularly those related to intervention integrity. Following our recommendations for addressing these challenges can lead to more reliable assessments of the effects of mHealth interventions on health outcomes.

Efficacy of platelet-rich plasma in meniscal repair surgery: a systematic review of randomized controlled trials

PURPOSE

This study's primary objective was to evaluate the effectiveness of platelet-rich plasma (PRP) administration for meniscal injuries treated with meniscal repair procedures (sutures), using radiologic measures and clinical scales. The secondary objective was to identify potential bias-inducing elements in the analyzed studies.

METHODS

In December 2023, a systematic search was conducted in PubMed, Cochrane, Embase, and Scopus for randomized controlled trials. This review compares PRP with placebo. Three studies were finally selected. The risk of bias was assessed using Cochrane's Risk of Bias Tool 2. Radiologic evaluation of meniscal healing was measured with magnetic resonance imaging (MRI) and arthroscopic studies, while clinical evaluation was performed using four scales [Knee Injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS), International Knee Documentation Committee Subjective Knee Form (IKDC), and Western Ontario and McMaster Universities Index (WOMAC)] and by recording the incidence of complications.

RESULTS

The three selected studies included 139 patients; of these, 76 (54.7%) were randomly assigned to the intervention group (PRP injection) and 63 (45.3%) to the control group (placebo). The mean age of the intervention group was 37.4 ± 7.5 years, while the mean age of the control group was 36.5 ± 9.2 years. There were 41 female patients (29.5%). The median follow-up duration was 27.58 ± 17.3 months. MRI evaluation did not show a significant improvement in the PRP group in any of the studies (p-value = 0.41-0.54). However, when assessed by the cumulative evaluation of MRI and arthroscopy, the cumulative failure rate was significantly better in the PRP group (p-value = 0.04-0.048). One study that evaluated isolated arthroscopy also showed significant improvement in the PRP group (p = 0.003). Regarding the VAS scale, no study demonstrated a significant difference, except for one study that showed significant improvement after 6 months and in the difference between the 3rd and 6th months. The KOOS scale yielded conflicting results; one study showed no significant difference, while the other two indicated significant improvement. The IKDC and WOMAC scales were evaluated in two studies, showing opposite results. All included studies reported no complications, and one study indicated no increased risk in the treatment group.

CONCLUSIONS

The results of this review indicate the necessity for further studies to make a definitive statement about the effectiveness of PRP administration in meniscal repair processes. Level of evidence Systematic review and meta-analysis of articles of level 1.

Synthetic vs. biologic mesh for abdominal wall reconstruction in contaminated surgical fields. A meta-analysis of randomized controlled trials and observational studies

PURPOSE

Biologic meshes had been the first choice for abdominal wall reconstruction (AWR) in contaminated surgical fields. However, due to increased cost and questioned effectiveness, synthetic meshes have been also implemented. The aim of the present meta-analysis was to compare synthetic and biologic mesh in terms of recurrence and postoperative outcomes.

METHODS

The present meta-analysis was designed using the PRISMA guidelines. A search in Medline, Scopus, EMBASE, Clinicaltrials.gov, Google Scholar and Cochrane CENTRAL was conducted from inception until September 2024. Randomized clinical trials (RCTs) and observational studies which compared the use of biologic and synthetic mesh for AWR in contaminated surgical fields were included. Data were extracted by two experienced researchers in pre-defined electronic forms. Pooled odds ratios (OR) and mean differences (MD) were calculated using a random-effects model. Included RCTs were assessed using the Risk of Bias 2 (RoB2) tool and non-randomized trials with the Risk of Bias in non-Randomized Trials (RoBINS-I) tool.

RESULTS

Overall 11 studies were included which enrolled 1,945 patients. Subgroup analysis of RCTs indicated significantly lower recurrence rates for synthetic compared to biologic mesh (p < 0.0001) with a similar follow-up (p = 0.07). Nevertheless, no difference was demonstrated in surgical site infection (SSI) rates. Although synthetic mesh was associated with shorter length of stay, the other postoperative outcomes (surgical site occurrences, mesh infections, readmissions, reoperations) were similar among the two groups.

CONCLUSION

Synthetic mesh should be considered as a safe and effective option for abdominal wall reconstruction in contaminated surgical fields compared to biologic mesh. Nevertheless, future research is expected to investigate cost-effectiveness of biosynthetic meshes, as alternative option in such surgical fields.

Use of tools for assessing the methodological quality of primary research in leading neurosurgical journals: A review of reviews

Systematic reviews (SRs) and meta-analyses (MAs) require a comprehensive and reproducible strategy to assess the methodological quality of the included studies. This research-on-research study evaluated the methods used to assess research quality by SRs and MAs published in leading neurosurgical journals, and identified factors associated with the publication of a comprehensive and reproducible assessment. We systematically surveyed SRs published in the 10 leading neurosurgical journals between 01/11/2019 and 31/12/2021. PubMed was used to search the MEDLINE database, which was supplemented by individual journal searches. Included SRs were assessed using a standardised data extraction tool. Descriptive statistics were utilised to identify factors associated with methodological and reporting quality of the tool-based quality assessment. A total of 564 SRs were included in the analysis. 326 (57.80%) included MAs, 165 (29.26%) included at least one Randomized Controlled Trial (RCT) and 29 (5.14%) included only RCTs. Scales were the most commonly used tool for methodological quality assessment (32.45%), followed by domain-based tools (24.82%) and checklists (9.93%). The number of included studies was inversely associated with multiple methodological quality assessment metrics. A positive association was observed between the number of included patients and multiple methodological quality assessment metrics. We established that the methodological and reporting quality of tool-based quality assessment requires improvement. This issue is particularly pertinent for SRs limited to non-randomised studies, which account for the vast majority of neurosurgical SRs. We recommend the use of domain-based tools for methodological quality assessment as these provide a more nuanced assessment of methodological quality.

Conducting observational analyses with the target trial emulation approach: a methodological systematic review

OBJECTIVES

Target trial emulation is an approach that is increasingly used to improve transparency in observational studies and help mitigate biases. For studies declaring that they emulated a target trial, we aimed to evaluate the specification of the target trial, examine its consistency with the observational emulation and assess the risk of bias in the observational analysis.

DESIGN

Methodological systematic review reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

The database MEDLINE (Medical Literature Analysis and Retrieval System Online) was interrogated for all studies published from 1 January 2021 to 3 July 2022. We performed an additional manual search of 20 general medical and specialised journals that spanned the same period.

ELIGIBILITY CRITERIA

All studies that declared emulating a hypothetical or real randomised trial were eligible.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers performed the whole systematic review process (screening and selection of studies, data extraction and risk of bias assessment). The main outcomes were the definition of the key protocol components of the target trial and its emulation, consistency between the target trial and its emulation and risk of bias according to the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool.

RESULTS

Among the selected sample of 100 studies, 24 (24%) did not specify the target trial. Only 40 studies (40%) provided detailed information on all components of the target trial protocol. Eligibility criteria, intervention strategies and outcomes were consistent between the target trial and its emulation in 35 studies (46% of those specifying the target trial). Overall, 28 studies (28%) exhibited serious risk of bias and 41 (41%) had misalignments in the timing of eligibility assessment, treatment assignment and the start of follow-up (time-zero). As compared with studies that did not specify the target trial, those that did specify the trial less frequently seemed to have both time-zero issues (39% vs 52%) and serious risk of bias (26% vs 33%).

CONCLUSIONS

One-quarter of studies declaring that they emulated a target trial did not specify the trial. Target trials and their emulations were particularly inconsistent for studies emulating a real randomised trial. Risk of methodological issues seemed lower in observational analyses that specified versus did not specify the target trial.

Meta-analysis of visual fatigue based on visual display terminals

BACKGROUND

This study aims to explore the impact of using visual display terminal (VDT) on the visual fatigue of operators through meta-analysis.

METHODS

The terms "VDT", "visual fatigue", "eyestrain", and "viewing distance" were selected from the Wangfang, China National Knowledge Infrastructure (CNKI), Web of Science, Springer, and Science Direct online databases. The retrieval time was from the establishment of the database to the present. All clinical studies related to the analysis of the effects of VDT use on visual fatigue were available. The included studies were screened, and after quality assessment, basic data and outcome index data were extracted. The count data were represented by relative risk (RR) and 95% confidence interval (CI). The measurement data were represented by the mean value (MD), standard deviation (SD), and 95% CI. Review Manager 5.3 (RevMan5.3) was employed to analyze the included indicators. Funnel plots were drawn using RevMan5.3 to analyze potential publication bias. The incidence of visual fatigue, lens use time, blink interval, and other indicators were compared between the VDT group and the control (Ctrl) group. Meanwhile, the incidence of eye fatigue and blurred vision in the two groups was counted.

RESULT

The incidence of eye pain, fatigue, blurred vision, teary eyes, and dry eyes in the VDT group significantly exceeded that in the Ctrl group. Meanwhile, the dry eye score, as well as the scores for eye fatigue, discomfort, and blurred vision, were significantly higher in the VDT group compared to the Ctrl group.

CONCLUSIONS

The results indicate that the use of VDT has a significant impact on visual fatigue.

Effects of Perceptual-Cognitive Training on Anticipation and Decision-Making Skills in Team Sports: A Systematic Review and Meta-Analysis

Team sports require athletes' exceptional perceptual-cognitive skills, such as anticipation and decision-making. Perceptual-cognitive training in laboratories aims to enhance these abilities. However, its effectiveness in real-game performance remains controversial, necessitating a systematic review and meta-analysis to determine optimal training methods. Following the PRISMA guidelines, we searched databases (e.g., PubMed, WOS, Scopus, and EBSCO) for relevant studies published before November 2023, assessed study quality, extracted important characteristics, and conducted a meta-analysis using Stata 15.1. This study was registered in PROSPERO (CRD42023494324). A total of 22 quantitative studies involving 45 effect sizes were included. Perceptual-cognitive training positively influenced elite athletes' anticipation and decision-making. However, its transfer effect on real-game performance improvement (ES = 0.65) was inferior to laboratory performance improvement (ES = 1.51). Sub-group analyses indicated that the effects of training interventions varied based on stimulus presentation and intervention duration. Based on our findings, we concluded that while perceptual-cognitive training improved on-court performance, its transfer effects were limited. To maximize effectiveness, future interventions should use virtual reality to present training stimuli and incorporate participants' sport-specific responses to reflect real-game scenarios.

[Observational studies to evaluate robotic-assisted lung cancer surgery?]

BACKGROUND

The aim of this work is to assess the quality of observational studies and to make direct and indirect comparisons of robotic surgery with other approaches.

METHOD

We searched various databases between 2014 and 2024 for observational studies comparing robotic-assisted surgery to thoracoscopy or thoracotomy.

RESULTS

Eighteen studies were included in the meta-analysis. Risk of confounding bias was present in 90% of studies, while risk of classification bias appeared in 80%. Robotic-assisted surgery reduced the risk of conversion to thoracotomy compared with thoracoscopy with an odds ratio of 0.21 (95% confidence interval: 0.06-0.65), with high heterogeneity between studies (I2=80%). Robotic-assisted surgery did not significantly reduce postoperative complications or 30-day mortality compared with thoracotomy or thoracoscopy. For 5-year overall survival, comparisons of robotic-assisted surgery to thoracoscopy or thoracotomy were non-significant with I2 of 55%.

CONCLUSION

This work demonstrates the need for a randomized controlled trial to validate robotic surgery for the treatment of bronchial cancer.

Efficacy and safety of intraoperative injection of mitomycin C during trabeculectomy: a systematic review and meta-analysis

PURPOSE

Trabeculectomy, a primary surgical treatment for glaucoma, often employs mitomycin C (MMC) to reduce scar formation and improve surgical outcomes. However, the optimal application method of MMC, whether by injection or sponge, remains a subject of debate. This meta-analysis aims to compare injectable and sponge-based MMC application in terms of efficacy and safety, focusing on various clinical outcomes in glaucoma patients.

METHODS

A comprehensive literature search of Scopus, MEDLINE, EMBASE, Ovid, Chinese biomedical literature database, China National Knowledge Infrastructure, and Cochrane Library was done for eligible studies that report data of glaucoma patients who were administered MMC by injection or sponge application during trabeculectomy. Outcomes of interest included intraocular pressure (IOP) reduction, bleb appearance grading (height, extent, vascularity), use of anti-glaucoma medications, and rates of complete success, qualified success, and failure. Data were reported as weighted mean differences (WMD) or odds ratios (OR) with confidence intervals (CI). The random-effects inverse-variance model with DerSimonian-Laird estimate of tau2 was employed, with continuity correction applied where necessary.

RESULTS

A total of 15 studies with 1276 participants were included. The meta-analysis revealed no significant difference in IOP reduction between patients treated by MMC injection and sponge application (WMD = - 0.434). Significant differences were observed in bleb appearance grading scores for height (WMD = - 0.170) and extent (WMD = 0.174), with substantial heterogeneity. The use of anti-glaucoma medications was significantly lower in the injection group (WMD = - 0.274). However, there were no significant differences in the rates of complete success, qualified success, and failure. The study demonstrated moderate to high heterogeneity across various outcomes.

CONCLUSION

This meta-analysis indicated that while both injection and sponge methods of MMC application during trabeculectomy were equally effective for IOP reduction, they differ in their impact on bleb morphology and postoperative medication requirement. The findings highlight the need for individualized treatment approaches in glaucoma surgery, taking into account the specific needs and characteristics of each patient.

Machine learning-derived phenotypic trajectories of asthma and allergy in children and adolescents: protocol for a systematic review

INTRODUCTION

Development of asthma and allergies in childhood/adolescence commonly follows a sequential progression termed the 'atopic march'. Recent reports indicate, however, that these diseases are composed of multiple distinct phenotypes, with possibly differential trajectories. We aim to synthesise the current literature in the field of machine learning-based trajectory studies of asthma/allergies in children and adolescents, summarising the frequency, characteristics and associated risk factors and outcomes of identified trajectories and indicating potential directions for subsequent research in replicability, pathophysiology, risk stratification and personalised management. Furthermore, methodological approaches and quality will be critically appraised, highlighting trends, limitations and future perspectives.

METHODS AND ANALYSES

10 databases (CAB Direct, CINAHL, Embase, Google Scholar, PsycInfo, PubMed, Scopus, Web of Science, WHO Global Index Medicus and WorldCat Dissertations and Theses) will be searched for observational studies (including conference abstracts and grey literature) from the last 10 years (2013-2023) without restriction by language. Screening, data extraction and assessment of quality and risk of bias (using a custom-developed tool) will be performed independently in pairs. The characteristics of the derived trajectories will be narratively synthesised, tabulated and visualised in figures. Risk factors and outcomes associated with the trajectories will be summarised and pooled estimates from comparable numerical data produced through random-effects meta-analysis. Methodological approaches will be narratively synthesised and presented in tabulated form and figure to visualise trends.

ETHICS AND DISSEMINATION

Ethical approval is not warranted as no patient-level data will be used. The findings will be published in an international peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023441691.

Do educational interventions reduce the gender gap in communication skills?- a systematic review

BACKGROUND

Efficient doctor-patient communication is essential for improving patient care. The impact of educational interventions on the communication skills of male and female students has not been systematically reviewed. The aim of this review is to identify interventions used to improve communication skills in medical curricula and investigate their effectiveness in improving the communication skills of male and female medical students.

METHODS

A systematic review of the literature was conducted using the PRISMA guidelines. Inclusion criteria were as follows: used intervention strategies aiming to improve communication skills, participants were medical students, and studies were primary research studies, systematic reviews, or meta-analyses.

RESULTS

2913 articles were identified based on search terms. After title, abstract, and full-text review, 58 studies were included with interventions consisting of Training or Drama Courses, Curriculum-Integrated, Patient Learning Courses, and Community-Based Learning Courses. 69% of articles reported improved communication skills for both genders equally, 28% for women more than men, and 3% for men more than women. 16 of the 58 articles reported numerical data regarding communication skills pre-and post-intervention. Analysis revealed that post-intervention scores are significantly greater than pre-intervention scores for both male (p < 0.001) and female students (p < 0.001). While the post-test scores of male students were significantly lower than that of female students (p = 0.01), there is no significant difference between genders for the benefits, or difference between post-intervention and pre-intervention scores (p = 0.15), suggesting that both genders benefited equally.

CONCLUSION

Implementation of communication training into medical education leads to improvement in communication skills of medical students, irrespective of gender. No specific interventions benefitting male students have been identified from published literature, suggesting need of further studies to explore the phenomenon of gender gap in communication skills and how to minimize the differences between male and female students.

Lifestyle interventions with dietary strategies after breast cancer diagnosis: a systematic review

PURPOSE

Obesity can increase mortality and morbidity in breast cancer survivors. Healthy lifestyle factors such as diet can help manage weight in this population. This systematic review examined lifestyle interventions with dietary strategies for breast cancer survivors and their effect on diet and/or weight-related outcomes.

METHODS

Searches were conducted in Ovid MEDLINE® ALL (1946-February 14, 2022), Embase (Elsevier), CINAHL Complete (EBSCO), and APA PsycArticles (EBSCO), using keywords for diet, breast cancer, and intervention. The search was limited to human studies, English language, and publication processing date 2016-2023.

RESULTS

The search yielded 3427 articles. After title and abstract review, 225 full-text articles were screened, and 67 articles with 61 distinct samples and interventions met inclusion criteria. Of these 61 lifestyle interventions with dietary strategies, 43 interventions also addressed physical activity. Most studies were randomized controlled trials (n = 41) and conducted post-treatment (n = 45). Mean participant age was 54 years. Of 29 studies that reported race/ethnicity, 20 (69%) reported ≥50% White participants. Of 36 that reported dietary outcomes, 29 (81%) reported significant findings. Of 57 that reported weight-related outcomes, 51 (89%) reported significant findings.

CONCLUSION

This review demonstrated promising evidence for the efficacy of lifestyle interventions with dietary strategies in breast cancer survivors. However, culturally tailored interventions and interventions conducted before and during treatment are lacking.

Clinical outcomes of ketamine in patients with traumatic brain injury: A systematic review

The current literature provides contradictory results concerning the impact of ketamine-induced anesthesia on traumatic brain injury (TBI) outcomes. This study aimed to investigate the potential of ketamine boluses to influence the brain pathophysiology in TBI patients. Twenty-one studies (n = 886) were extracted from PubMed, Web of Science, Scopus, CINAHL, and Cochrane Library. The primary endpoints included intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The secondary endpoints were mean arterial pressure (MAP), heart rate (HR), electroencephalography (EEG), mean cerebral blood flow velocity, jugular oxygen saturation, ventilation, neurological outcomes, mortality, and overall efficacy and side-effects of ketamine-induced anesthesia. Four studies indicated a statistically significant decline in ICP in TBI patients, with ketamine sedation. Contrastingly, two studies revealed statistically significant ICP elevations, after ketamine-induced anesthesia, in TBI patients. Five studies negated any correlation between ketamine dosages and ICP changes. Three studies indicated a statistically significant increase in CPP after ketamine-induced anesthesia in TBI patients. One study revealed CPP decline after the administration of ketamine-midazolam treatment to TBI patients. Five studies revealed no noticeable influence of ketamine bolus on CPP in TBI patients. Similarly, inconsistent variations were observed in most of the secondary endpoints, including electroencephalography, neurologic outcomes, and ketamine-related side effects (all P <0.05). This systematic review emphasizes the role of ketamine-induced anesthesia in inconsistently improving or deteriorating clinical outcomes in patients with TBI. Future studies should evaluate the predominant causes (i.e., factors and attributes) of ketamine-related clinical outcomes in the TBI setting.

Survival Benefit Associated With Participation in Clinical Trials of Anticancer Drugs: A Systematic Review and Meta-Analysis

Importance

Many cancer clinical investigators view clinical trials as offering better care for patients than routine clinical care. However, definitive evidence of clinical benefit from trial participation (hereafter referred to as the participation effect) has yet to emerge.

Objective

To conduct a systematic review and meta-analysis of the evidence examining whether patient participation in cancer trials was associated with greater survival benefit compared with routine care.

Data Sources

Studies were found through PubMed and Embase (January 1, 2000, until August 31, 2022), as well as backward and forward citation searching.

Study Selection

Studies were included that compared overall survival of trial participants and routine care patients.

Data Extraction and Synthesis

Data extraction and methodological quality assessment were completed by 2 independent coders using Covidence software. Data were pooled using a random-effects model and analyzed based on the quality of the comparison between trial participants and routine care patients (ie, extent to which studies controlled for bias and confounders).

Main Outcomes and Measures

The hazard ratio (HR) for overall survival of trial participants vs routine care patients.

Results

Thirty-nine publications were included, comprising 85 comparisons of trial participants and routine care patients. The meta-analysis revealed a statistically significant overall survival benefit for trial participants (HR, 0.76 [95% CI, 0.69-0.82]) when all studies were pooled, regardless of design or quality. However, survival benefits diminished in study subsets that matched trial participants and routine care patients for eligibility criteria (HR, 0.85 [95% CI, 0.75-0.97]) and disappeared when only high-quality studies were pooled (HR, 0.91 [95% CI, 0.80-1.05]). They also disappeared when estimates were adjusted for potential publication bias (HR, 0.94 [95% CI, 0.86-1.03]).

Conclusions and Relevance

Many studies suggest a survival benefit for cancer trial participants. However, these benefits were not detected in studies using designs addressing important sources of bias and confounding. Pooled results of high-quality studies are not consistent with a beneficial effect of trial participation on its own.

Effects of Practicing Closed- vs. Open-Skill Exercises on Executive Functions in Individuals with Attention Deficit Hyperactivity Disorder (ADHD)-A Meta-Analysis and Systematic Review

(1) Background: Previous studies have identified discrepancies in improvements in executive functioning in typically developing children when comparing closed- and open-skill exercise interventions. However, there is limited research on executive functioning in attention deficit hyperactivity disorder (ADHD). This study aims to conduct a systematic review and meta-analysis to explore the impact of closed- and open-skill exercises on ADHD populations. (2) Methods: The PRISMA guidelines for systematic reviews were followed to search seven databases to evaluate and analyze studies published from 2013 to 2023. Prospero: CRD42023460452. (3) Results: A meta-analysis of 578 subjects with ADHD in 11 RCTs (Randomized control trial) and 3 NRS (Non-randomized studies) revealed that closed-skill exercise significantly improved executive function subdomains, including inhibitory control (standardized mean differences (SMD) = -1.00), cognitive flexibility (SMD = -1.33), and working memory (SMD = -0.85). Furthermore, open-skill exercise was found to have a positive effect on inhibitory control (SMD = -1.98) and cognitive flexibility (SMD = -0.97) in ADHD patients. Both types of exercise interventions demonstrated an improvement in executive function compared to controls, with open-skill exercises exhibiting superior effects (Qb = 6.26). (4) Conclusions: The review recommends a 12-week intervention cycle with exercise at least twice a week of moderate or higher intensity as suitable for ADHD individuals. This review also encourages individuals with ADHD to engage in exercises involving multiple motor skill types.

Efficacy and safety of antibody-drug conjugates in the treatment of urothelial cell carcinoma: a systematic review and meta-analysis of prospective clinical trials

Introduction: Urothelial carcinoma (UC) is a refractory disease for which achieving satisfactory outcomes remains challenging with current surgical interventions. Antibody-drug conjugates (ADCs) are a novel class of targeted therapeutics that have demonstrated encouraging results for UC. Although there is a limited number of high-quality randomized control trials (RCTs) examining the use of ADCs in patients with UC, some prospective non-randomized studies of interventions (NRSIs) provide valuable insights and pertinent information. We aim to assess the efficacy and safety of ADCs in patients with UC, particularly those with locally advanced and metastatic diseases. Methods: A systematic search was conducted across PubMed, Embase, the Cochrane Library, and Web of Science databases to identify pertinent studies. Outcomes, such as the overall response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), adverse events (AEs), and treatment-related adverse events (TRAEs), were extracted for further analyses. Results: Twelve studies involving 1,311 patients were included in this meta-analysis. In terms of tumor responses, the pooled ORR and DCR were 40% and 74%, respectively. Regarding survival analysis, the pooled median PFS and OS were 5.66 months and 12.63 months, respectively. The pooled 6-month PFS and OS were 47% and 80%, while the pooled 1-year PFS and OS were 22% and 55%, respectively. The most common TRAEs of the ADCs were alopecia (all grades: 45%, grades ≥ III: 0%), decreased appetite (all grades: 34%, grades ≥ III: 3%), dysgeusia (all grades: 40%, grades ≥ III: 0%), fatigue (all grades: 39%, grades ≥ III: 5%), nausea (all grades: 45%, grades ≥ III: 2%), peripheral sensory neuropathy (all grades: 37%, grades ≥ III: 2%), and pruritus (all grades: 32%, grades ≥ III: 1%). Conclusion: The meta-analysis in this study demonstrates that ADCs have promising efficacies and safety for patients with advanced or metastatic UC. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42023460232.

Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature

OBJECTIVE

Uterosacral ligament suspension (USLS) is one of the most frequently used operations for the restoration of apical support in women with uterovaginal prolapse. However, existing studies are inconclusive as to whether and which surgical access route is superior. The aim of the present meta-analysis is tentatively to compare the efficiency and the postoperative complications of laparoscopic USLS (L-USLS) and vaginal USLS (V-USLS), highlighting that current evidence remains inconclusive regarding the superiority of either surgical access route.

DATA SOURCES

We performed a systematic literature review of 5 major databases (Medline, Scopus, Google Scholar Cochrane Central Register of Controlled Trials and Clinicaltrials.gov) from inception till April 2023.

METHODS OF STUDY SELECTION

No language restrictions were applied. All comparative studies that compared L-USLS and V-USLS for the management of women with uterovaginal prolapse were included.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 retrospective cohort studies on 856 patients were extracted and analyzed. The methodological quality of the included studies was assessed using the risk of bias in nonrandomized studies of interventions tool and ranged between moderate to serious. The pooled results suggest that L-USLS was associated with a potentially decreased incidence of ureteral compromise (odds ratio [OR], 0.19; 95% confidence interval [CI] 0.04-0.89; p = .04) and seemingly lower objective (OR 0.47; 95% CI 0.23-0.97; p = .04) and subjective recurrence rates (OR 0.46; 95% CI 0.23-0.92; p = .03). There were no significant differences between the rates of postoperative pain from USLS sutures, postoperative pelvic hematomas, the suture exposure/granulation tissue formation, and the prolapse recurrence retreatment among the 2 groups.

CONCLUSION

The present meta-analysis indicates that L-USLS is possibly associated with significantly fewer ureteral compromise rates and decreased subjective and objective recurrences rates compared to V-USLS. Nevertheless, given the limitations in data quality and heterogeneity of the included studies, these findings should be interpreted with caution. Large-scale randomized studies are essential to more definitively determine the relative merits of the laparoscopic versus vaginal approach.

Oral regimen for high dose methotrexate urine alkalinization: a systematic review and meta-analysis

OBJECTIVE

Urine alkalinization prevents nephrotoxicity in patients receiving high-dose methotrexate (HDMTX). While the standard approach involves IV sodium bicarbonate, alternative oral bicarbonate regimens are crucial in drug shortages and outpatient settings. This study aims to review the efficacy and safety of such regimens.

METHODS

PubMed, WOS, and Scopus were systematically searched using the PRISMA protocol for relevant studies involving human subjects, including randomized clinical trials, retrospective, prospective, cohort, case reports, and case series studies. There were no restrictions on language, time, or age group. Qualified and eligible papers were used to extract data on efficacy and safety indicators, and the final relevant records were assessed for quality using the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) assessment tool.

RESULTS

12 studies with 1212 participants were included in the systematic review, with pooled data from 8 studies used for meta-analysis. No significant differences in mean differences (MDs) or odds ratio (OR) were found after the oral bicarbonate regimen, except for when urine pH fell to < 7 (MD: 0.91, 95% CI: 0.32, 1.5, P < 0.05) and the incidence of diarrhea (OR: 2.92, 95% CI: 1.69, 5.05, P < 0.05).

CONCLUSION

An oral bicarbonate regimen is a safe and effective way to alkalize HDMTX urine, providing a viable and cost-effective alternative to IV protocols. Further prospective multicenter studies are necessary. Systematic review registration identifier: CRD42023379666.

Advanced Home-Based Shoulder Rehabilitation: A Systematic Review of Remote Monitoring Devices and Their Therapeutic Efficacy

Shoulder pain represents the most frequently reported musculoskeletal disorder, often leading to significant functional impairment and pain, impacting quality of life. Home-based rehabilitation programs offer a more accessible and convenient solution for an effective shoulder disorder treatment, addressing logistical and financial constraints associated with traditional physiotherapy. The aim of this systematic review is to report the monitoring devices currently proposed and tested for shoulder rehabilitation in home settings. The research question was formulated using the PICO approach, and the PRISMA guidelines were applied to ensure a transparent methodology for the systematic review process. A comprehensive search of PubMed and Scopus was conducted, and the results were included from 2014 up to 2023. Three different tools (i.e., the Rob 2 version of the Cochrane risk-of-bias tool, the Joanna Briggs Institute (JBI) Critical Appraisal tool, and the ROBINS-I tool) were used to assess the risk of bias. Fifteen studies were included as they fulfilled the inclusion criteria. The results showed that wearable systems represent a promising solution as remote monitoring technologies, offering quantitative and clinically meaningful insights into the progress of individuals within a rehabilitation pathway. Recent trends indicate a growing use of low-cost, non-intrusive visual tracking devices, such as camera-based monitoring systems, within the domain of tele-rehabilitation. The integration of home-based monitoring devices alongside traditional rehabilitation methods is acquiring significant attention, offering broader access to high-quality care, and potentially reducing healthcare costs associated with in-person therapy.

Efficacy and safety of ibrexafungerp in the treatment of vulvovaginal candidiasis: A meta-analysis of randomized controlled trials

Background

This study aims to evaluate the efficacy and safety associated with ibrexafungerp in the treatment of vulvovaginal candidiasis infection patients.

Methods

We conducted a comprehensive search of the PubMed, Embase, Cochrane Library, and Clinical Trials databases up to December 25, 2022. The primary outcomes were clinical cure rate and mycological eradication rate, whereas the secondary outcomes were the risk of an adverse events.

Results

In total of four studies encompassing 880 patients diagnosed with vulvovaginal candidiasis (VVC) were included in the analysis. The findings demonstrated that ibrexafungerp exhibited superior clinical cure ratio (RR = 1.33 [1.07, 1.66]), mycological eradication rate (RR = 1.72 [1.00, 2.95]), and overall success ratio (RR = 1.64 [0.92, 2.92]) when compared to the fluconazole/placebo in the treatment of VVC. Furthermore, patients treated with ibrexafungerp demonstrated significantly higher clinical cure rates, mycological eradication, and overall success ratio compared to those receiving other treatments for vulvovaginal candidiasis caused by C. albicans. When ibrexafungerp was compared to fluconazole/placebo, the duration of any treatment-related treatment-emergent adverse events (TEAE), nausea, and diarrhea during therapy was significantly longer.

Conclusion

In summary, the use of ibrexafungerp was linked to superior clinical cure ratio, and mycological eradication when compared to fluconazole/placebo.

Causal Assessment of Income Inequality on Self-Rated Health and All-Cause Mortality: A Systematic Review and Meta-Analysis

Policy Points Income is thought to impact a broad range of health outcomes. However, whether income inequality (how unequal the distribution of income is in a population) has an additional impact on health is extensively debated. Studies that use multilevel data, which have recently increased in popularity, are necessary to separate the contextual effects of income inequality on health from the effects of individual income on health. Our systematic review found only small associations between income inequality and poor self-rated health and all-cause mortality. The available evidence does not suggest causality, although it remains methodologically flawed and limited, with very few studies using natural experimental approaches or examining income inequality at the national level.

CONTEXT

Whether income inequality has a direct effect on health or is only associated because of the effect of individual income has long been debated. We aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality) and assess if these relationships are likely to be causal.

METHODS

We searched Medline, ISI Web of Science, Embase, and EconLit (PROSPERO: CRD42021252791) for studies considering income inequality and SRH or mortality using multilevel data and adjusting for individual-level socioeconomic position. We calculated pooled odds ratios (ORs) for poor SRH and relative risk ratios (RRs) for mortality from random-effects meta-analyses. We critically appraised included studies using the Risk of Bias in Nonrandomized Studies - of Interventions tool. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework and causality using Bradford Hill (BH) viewpoints.

FINDINGS

The primary meta-analyses included 2,916,576 participants in 38 cross-sectional studies assessing SRH and 10,727,470 participants in 14 cohort studies of mortality. Per 0.05-unit increase in the Gini coefficient, a measure of income inequality, the ORs and RRs (95% confidence intervals) for SRH and mortality were 1.06 (1.03-1.08) and 1.02 (1.00-1.04), respectively. A total of 63.2% of SRH and 50.0% of mortality studies were at serious risk of bias (RoB), resulting in very low and low certainty ratings, respectively. For SRH and mortality, we did not identify relevant evidence to assess the specificity or, for SRH only, the experiment BH viewpoints; evidence for strength of association and dose-response gradient was inconclusive because of the high RoB; we found evidence in support of temporality and plausibility.

CONCLUSIONS

Increased income inequality is only marginally associated with SRH and mortality, but the current evidence base is too methodologically limited to support a causal relationship. To address the gaps we identified, future research should focus on income inequality measured at the national level and addressing confounding with natural experiment approaches.

Assessing risk of bias in the meta-analysis of round 1 of the Health Care Innovation Awards

BACKGROUND

Systematic reviews of observational studies can be affected by biases that lead to under- or over-estimates of true intervention effects. Several tools have been reported in the literature that attempt to characterize potential bias. Our objective in this study was to determine the extent to which study-specific bias may have influenced intervention impacts on total costs of care (TCOC) in round 1 of the Health Care Innovation Awards.

METHODS

We reviewed 82 statistical evaluations of innovation impacts on Medicare TCOC. We developed five risk-of-bias measures and assessed their influence on TCOC impacts using meta-regression.

RESULTS

The majority of evaluations used propensity score matching to create their comparison groups. One third of the non-randomized interventions were judged to have some risk of biased effects due largely to the way they recruited their treatment groups, and 35% had some degree of covariate imbalance remaining after propensity score adjustments. However, in the multivariable analysis of TCOC effects, none of the bias threats we examined (comparison group construction method, risk of bias, or degree of covariate imbalance) had a major impact on the magnitude of HCIA1 innovation effects. Evaluations using propensity score weighting produced larger but imprecise savings effects compared to propensity score matching.

DISCUSSION

Our results suggest that it is unlikely that HCIA1 TCOC effect sizes were systematically affected by the types of bias we considered. Assessing the risk of bias based on specific study design features is likely to be more useful for identifying problematic characteristics than the subjective quality ratings used by existing risk tools.

Protocol of the development of a core outcome set for stroke in multidimensional value assessment of traditional Chinese medicine

INTRODUCTION

Stroke is the most common cause of death in China. In Chinese clinical practise, traditional Chinese medicine (TCM) and integrative medicine have been widely used as adjuvant therapies for the treatment of stroke. However, their clinical effectiveness, particularly their clinical value, has been inconsistent in the literature mainly because various outcome measures have been used and reported in clinical research. Hence, obtaining a comprehensive list of outcomes for TCM value assessment is crucial for a multidimensional value assessment. Therefore, the main objective of this protocol was to develop an outcome set used in health technology assessment (HTA) decision-making for TCM treatment of stroke.

METHODS AND ANALYSIS

The outcome set will be developed in four phases: (1) we will perform a systematic literature review to identify candidate outcomes that have been previously measured in published studies; (2) we will develop a comprehensive list of outcome measures by conducting a multistakeholder semistructured interview; (3) we will conduct two-round Delphi surveys to prioritise outcomes for each HTA domain; and (4) we will finalise the outcome sets by holding a ratification meeting with multiple stakeholder groups. The developed outcome set should be measured and reported as the minimum set of outcomes for HTA assessment for the TCM treatment of acute ischaemic stroke (AIS).

ETHICS AND DISSEMINATION

This protocol was reviewed and approved by the Institutional Review Board of the Minhang Hospital of Fudan University. Our findings will be shared at academic conferences and in peer-reviewed publications.

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.

A Systematic Review and Meta-Analysis of the Outcomes of Laparoscopic Cholecystectomy Compared to the Open Procedure in Patients with Gallbladder Disease

Background  Conflicting evidence regarding the laparoscopic versus open cholecystectomy outcomes in scientific literature impacts the medical decision-making for patients with gallbladder disease. This study aimed to compare a range of primary and secondary outcomes between patients receiving laparoscopic cholecystectomy and those with open intervention. Methods  Articles published from 1993 to 2023 were explored by utilizing advanced filters of PubMed Central/Medline, Web of Science, CINAHL, JSTOR, Cochrane Library, Scopus, and EBSCO. The gallbladder disease was determined by the presence of one or more of the following conditions: 1) Gangrenous cholecystitis, 2) acute cholecystitis, 3) chronic gallbladder diseases, and 4) cholelithiasis. The primary end-point was mortality, while the secondary outcome included (1) bile leakage, 2) common bile duct injury, 3) gangrene, 4) hospital stay (days), 5) major complications, 6) median hospital stay (days), (7) pneumonia, 8) sick leaves (days), and 9) wound infection. Results  Statistically significant reductions were observed in mortality (odds ratio [OR]: 0.30, 95% confidence interval [CI]: 0.30, 0.45, p  < 0.00001), mean hospital stay duration (mean difference: -2.68, 95% CI: -3.66, -1.70, p  < 0.00001), major complications (OR: 0.35, 95% CI: 0.19, 0.64, p  = 0.0005), post/intraoperative wound infection (OR: 0.29, 95% CI: 0.16, 0.51, p  < 0.0001), and sick leaves (OR: 0.34, 95% CI: 0.14, 0.80, p  = 0.01) in patients who underwent laparoscopic cholecystectomy compared with those with the open intervention. No statistically significant differences were recorded between the study groups for bile leakage, common bile duct injury, gangrene, median hospital stay days, and pneumonia ( p  > 0.05). Conclusions  The pooled outcomes favored the use of laparoscopic cholecystectomy over the open procedure in patients with gallbladder disease. The consolidated findings indicate the higher impact of laparoscopic cholecystectomy in improving patient outcomes, including safety episodes, compared with open cholecystectomy.

Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis: An updated systematic review

BACKGROUND

Evidence-based recommendations for treatment of Lyme neuroborreliosis (LNB) should rely on the available literature. As new data emerges, close review and evaluation of the recent literature is needed to build evidence-based recommendations to inform clinical practice and management of LNB. We performed an update of a previous systematic review on treatment of LNB.

METHODS

A systematic literature search of Medline and CENTRAL was performed for published studies from 2015 to 2023 to update a previous systematic review. Randomized controlled trials (RCTs) and non-randomized studies (NRS) were evaluated. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs; NRS were assessed using the ROBINS-I-tool. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were integrated into an existing meta-analysis of the available literature.

RESULTS

After screening 1530 records, two RCTs and five NRS with new and relevant data were additionally identified. Meta-analysis showed no statistically significant difference between doxycycline and beta-lactam antibiotics regarding residual neurological symptoms after 12 months. Meta-analysis showed no benefit of extended antibiotic treatment of LNB. Three NRS show no benefit for additional steroid use in LNB with facial palsy.

DISCUSSION

Additional incorporated recent research corroborates existing guideline recommendations for treatment of LNB. New RCTs add to the certainty of previous analysis showing similar efficacy for doxycycline and beta-lactam antibiotics in LNB. Available evidence shows no benefit for extended antibiotic treatment in LNB. NRS do not suggest a role for steroids in facial palsy due to LNB.

Observational Studies

Studies can be observational or experimental. With an observational study, the investigator does not determine the assignment of subjects, and there might not be a control group. If there is a control group, assignment of the independent variable (exposure or intervention) is not under the control of the investigator. Observational studies can be rigorously conducted, but the lack of random assignment of the exposure/intervention introduces confounding and bias. Thus, the quality of evidence resulting from observational studies is lower than that of experimental randomized controlled trials (RCTs). An observational study might be performed if an RCT is unethical, impractical, or outside the control of the investigator. There are many types of prospective and retrospective observational study designs. However, an observational study design should be avoided if an experimental study is possible. Sophisticated statistical approaches can be used, but this does not elevate an observational study to the level of an RCT. Regardless of quality, an observational study cannot establish causality.

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.

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.

The absence of data on driving under the influence of alcohol in road traffic studies: a scoping review of non-randomized studies with vote counting based on the direction of effects of alcohol policies

BACKGROUND

Data on driving under the influence of alcohol (DUIA) are not always available, accurate, or reliable, making it difficult to study the effects of alcohol policies on road traffic outcomes. The objectives of our study were twofold: 1) to describe how road traffic outcomes of alcohol policies are assessed when DUIA data are missing, and 2) to explore the effects of alcohol policies when DUIA data are missing.

METHODS

We conducted a scoping review of non-randomized studies that assessed the road traffic outcomes of alcohol policies when DUIA data are missing. Until November 2021, we searched studies published between 2000 and 2021, in English or French, via MEDLINE, APA PsycInfo, CINAHL, and SocINDEX. We assessed the risk of bias in the included studies with the Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group. The selection process, data extraction, and the risk of bias assessment were conducted independently and in duplicate. We used vote counting based on the direction of the effects of alcohol policies as a synthesis method. The protocol for this review was published in PROSPERO under record number CRD42021266744.

RESULTS

Twenty-four eligible studies were included. Regarding objective 1, most studies used uncontrolled interrupted time series designs to assess road traffic fatalities resulting from night-time crashes. The reasons for missing DUIA data were generally not reported. Regarding objective 2, we found evidence for an association between alcohol policies and decreased road traffic fatalities. Subgroup analyses found no evidence for an association between methodological modifiers and positive effect directions for road traffic fatalities.

CONCLUSION

Caution is needed when interpreting road traffic outcomes associated with alcohol policies when DUIA data are missing. Greater efforts should be made to improve the reporting of outcomes assessments. Future studies must address several methodological issues (e.g., more granular data, well-defined intervention and implementation, and controlled designs). Our results should be compared to those from others reviews where DUIA data were available to confirm or recalibrate the associations found in studies where DUIA data were missing.

Weight-Related Outcomes After Revisional Bariatric Surgery in Patients with Non-response After Sleeve Gastrectomy-a Systematic Review

Weight non-response after sleeve gastrectomy is an emerging issue. This systematic review compared revisional procedures for weight-related outcomes. We searched several databases for relevant articles and included adult patients with revisional bariatric procedures after primary sleeve gastrectomy. Twelve trials with 1046 patients were included, covering five revisional procedures. There were no randomised controlled trials, and 10 studies had a critical risk of bias. Significant variations in inclusion criteria, therapy benchmarks, follow-up schemes, and outcome measurements were observed, preventing meaningful comparison of results. Evidence-based treatment strategies for weight non-response after sleeve gastrectomy cannot be deduced from the current literature. Prospective studies with well-defined indications, standardised techniques, and strict adherence to outcome measurements are needed.

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.

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.

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.

The Use of Social Media for Dissemination of Research Evidence to Health and Social Care Practitioners: Protocol for a Systematic Review

BACKGROUND

Effective dissemination of research to health and social care practitioners enhances clinical practice and evidence-based care. Social media use has potential to facilitate dissemination to busy practitioners.

OBJECTIVE

This is a protocol for a systematic review that will quantitatively synthesize evidence of the effectiveness of social media, compared with no social media, for dissemination of research evidence to health and social care practitioners. Social media platforms, formats, and sharing mechanisms used for effective dissemination of research evidence will also be identified and compared.

METHODS

Electronic database searches (MEDLINE, PsycINFO, CINAHL, ERIC, LISTA, and OpenGrey) will be conducted from January 1, 2010, to January 10, 2023, for studies published in English. Randomized, nonrandomized, pre-post study designs or case studies evaluating the effect of social media on dissemination of research evidence to postregistration health and social care practitioners will be included. Studies that do not involve social media or dissemination or those that evaluate dissemination of nonresearch information (eg, multisource educational materials) to students or members of the public only, or without quantitative data on outcomes of interest, will be excluded. Screening will be carried out by 2 independent reviewers. Data extraction and quality assessment, using either the Cochrane tool for assessing risk of bias or the Newcastle-Ottawa Scale, will be completed by 2 independent reviewers. Outcomes of interest will be reported in 4 domains (reach, engagement, dissemination, and impact). Data synthesis will include quantitative comparisons using narrative text, tables, and figures. A meta-analysis of standardized pooled effects will be undertaken, and subgroup analyses will be applied, if appropriate.

RESULTS

Searches and screening will be completed by the end of May 2023. Data extraction and analyses will be completed by the end of July 2023, after which findings will be synthesized and reported by the end of October 2023.

CONCLUSIONS

This systematic review will summarize the evidence for the effectiveness of social media for the dissemination of research evidence to health and social care practitioners. The limitations of the evidence may include multiple outcomes or methodological heterogeneity that limit meta-analyses, potential risk of bias in included studies, and potential publication bias. The limitations of the study design may include potential insensitivity of the electronic database search strategy. The findings from this review will inform the dissemination practice of health and care research.

TRIAL REGISTRATION

PROSPERO CRD42022378793; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=378793.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45684.

Guidance to best tools and practices for systematic reviews1

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.

Adherence of systematic reviews to Cochrane RoB2 guidance was frequently poor: a meta epidemiological study

OBJECTIVES

To assess whether the use of the revised Cochrane risk of bias tool for randomized trials (RoB2) in systematic reviews (SRs) adheres to RoB2 guidance.

METHODS

We searched MEDLINE, Embase, Cochrane Library from 2019 to May 2021 to identify SRs using RoB2. We analyzed methods and results sections to see whether risk of bias was assessed at outcome measure level and applied to primary outcomes of the SR as per RoB2 guidance. The relation between SR characteristics and adequacy of RoB2 use was examined by logistic regression analysis.

RESULTS

Two hundred-eight SRs were included. We could assess adherence in 137 SRs as 12 declared using RoB2 but actually used RoB1 and 59 did not report the number of primary outcomes. The tool usage was adherent in 69.3% SRs. Considering SRs with multiple primary outcomes, adherence dropped to 28.8%. We found a positive association between RoB2 guidance adherence and the methodological quality of the reviews assessed by AMSTAR2 (p-for-trend 0.007). Multivariable regression analysis suggested journal impact factor [first quartile vs. other quartiles] was associated with RoB2 adherence (OR 0.34; 95% CI: 0.16-0.72).

CONCLUSIONS

Many SRs did not adhere to RoB2 guidance as they applied the tool at the study level rather than at the outcome measure level. Lack of adherence was more likely among low and very low quality reviews.

Home-built environment interventions and inflammation biomarkers: a systematic review and meta-analysis protocol

BACKGROUND

Inflammation control is a fundamental part of chronic care in patients with a history of cancer and comorbidity. As the risk-benefit profile of anti-inflammatory drugs is unclear in survivors of cancer, GPs and patients could benefit from alternative non-pharmacological treatment options for dysregulated inflammation. There is a potential for home-built environment (H-BE) interventions to modulate inflammation; however, discrepancies exist between studies.

AIM

To evaluate the effectiveness of H-BE interventions on cancer-associated inflammation biomarkers.

DESIGN & SETTING

A systematic review and meta-analysis of randomised and non-randomised trials in community-dwelling adults.

METHOD

PubMed and MEDLINE, Embase, Web of Science, and Google Scholar will be searched for clinical trials published in January 2000 onwards. The study will include H-BE interventions modifying air quality, thermal comfort, non-ionising radiation, noise, nature, and water. No restrictions to study population will be applied to allow deriving expectations for effects of the interventions in cancer survivors from available source populations. Outcome measures will be inflammatory biomarkers clinically and physiologically relevant to cancer. The first reviewer will independently screen articles together with GPs and extract data that will be verified by a second reviewer. The quality of studies will be assessed using the Cochrane risk-of-bias tools. Depending on the clinical and methodological homogeneity of populations, interventions, and outcomes, a meta-analysis will be conducted using random-effects models.

CONCLUSION

Findings will determine the effectiveness of H-BE interventions on inflammatory parameters, guide future directions for its provision in community-dwelling survivors of cancer and support GPs with safer anti-inflammatory treatment options in high-risk patients for clinical complications.

In elite athletes with meniscal injuries, always repair the lateral, think about the medial! A systematic review

PURPOSE

This study aimed to evaluate and compare the time required to return to sports (RTS) after surgery, the rate of revision surgery and the time required for RTS after revision surgery in elite athletes undergoing meniscal repair or partial meniscectomy, particularly analysing the difference between medial and lateral menisci. It was hypothesised that both procedures would entail similar, high rates of RTS, with the lateral meniscus exhibiting higher potential healing postprocedure compared to the medial meniscus.

METHODS

A systematic review was conducted based on the PRISMA guidelines. Quality assessment of the systematic review was performed using the AMSTAR-2 checklist. The following search terms were browsed in the title, abstract and keyword fields: 'meniscus' or 'meniscal' AND 'tear,' 'injury' or 'lesion' AND 'professional,' 'elite' or 'high-level' AND 'athletes,' 'sports,' 'sportsman,' 'soccer,' 'basketball,' 'football' or 'handball'. The resulting measures extracted from the studies were the rate of RTS, level of RTS, complications, revision surgery and subsequent RTS, Tegner, International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS).

RESULTS

In this study, the cohort consisted of 421 patients [415 (98.6%) men and 6 (1.4%) women] with a mean age of 23.0 ± 3.0 years. All patients were elite athletes in wrestling, baseball, soccer, rugby or handball. While 327 (77.7%) patients received partial meniscectomy at a mean age of 23.3 ± 2.6 years, 94 (22.3%) patients received meniscal repair at a mean age of 22.1 ± 4.0 years. After partial meniscectomy, 277 patients (84.7%) returned to their competitive sports activity and 256 (78.3%) returned to their pre-injury activity levels. A total of 12 (3.7%) patients required revision surgery because of persistent pain [5 (1.5%) patients], chondrolysis [2 (0.7%) patients] or both chondrolysis and lateral instability [5 (1.5%) patients]. Ten (83.3%) of the twelve patients had involvement of the lateral meniscus, whereas the location of injury was not specified in the remaining two patients. After revision surgery, all patients (100%) resumed sports activity. However, after meniscal repair, 80 (85.1%) athletes returned to their competitive sports activity and 71 (75.5%) returned to their pre-injury activity levels. A total of 16 (17.0%) patients required partial meniscectomy in cases of persistent pain or suture failure. Of these, 4 (25%) patients involved lateral and medial menisci each and 8 (50%) patients were not specified. After revision surgery, more than 80.0% of the patients (13) resumed sports activity.

CONCLUSIONS

In elite athletes with isolated meniscal injury, partial meniscectomy and meniscal suture exhibited similar rates of RTS and return to pre-injury levels. Nonetheless, athletes required more time for RTS after meniscal repair and exhibited an increased rate of revision surgery associated with a reduced rate of RTS after the subsequent surgery. For lateral meniscus tears, meniscectomy was associated with a high rate of revision surgery and risk of chondrolysis, whereas partial medial meniscectomy allowed for rapid RTS but with the potential risk of developing knee osteoarthritis over the years. The findings of this systematic review suggested a suture on the lateral meniscus in elite athletes because of the high healing potential after the procedure, the reduced risk of developing chondrolysis and the high risk of revision surgery after partial meniscectomy. Furthermore, it is important to evaluate several factors while dealing with the medial meniscus. If rapid RTS activity is needed, a hyperselective meniscectomy is recommended; otherwise, a meniscal suture is recommended to avoid accelerated osteoarthritis.

LEVEL OF EVIDENCE

Level IV.

STUDY REGISTRATION

PROSPERO-CRD42022351979 ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351979 ).

Psychological and Emotional Effects of Digital Technology on Digitods (14-18 Years): A Systematic Review

Background

The use of smartphones and other technologies has been increasing in digitods aged 14-18 years old. To further explain this relationship and explore the gap in research, this paper will appraise the available evidence regarding the relationship digital technology use and psychological/emotional outcomes and report on the strength of the associations observed between these variables.

Methodology

To select relevant studies, five separate computerized searches of online and electronic databases were performed. These included PubMed (MEDLINE, National Library of Medicine), ScienceDirect, Cochrane, Scopus, and Web of Science to attain literature from January 2017 to April 2022. The author independently reviewed studies for eligibility as per the inclusion/exclusion criteria and extracted the data according to a priori defined criteria. Risk of bias was assessed using the Agency for Healthcare Research and Quality (AHRQ) for healthcare studies and Cochrane Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) assessment tool.

Results

Seven studies were included in this review. A positive relationship was found between excessive digital technology usage and negative psychological and emotional outcomes in digitods aged 14-18 (p ≤ 0.005). A statistically significant difference was found between girls and boys, with girls experiencing more negative outcomes than boys.

Conclusions

As the evidence in this review is distinctive, it is imperative that further research be conducted to investigate any synergistic relationships among these variables on a larger scale in order to better advise public health initiatives to specifically target heightened digital technology usage in adolescents.

PROTOCOL: The association between marital transitions and physical and mental health in late life: A systematic review

This is the protocol for a Campbell systematic review. The objectives are as follows: What is the association between marital transitions and physical health among people older than 60? What is the association between marital transitions and mental health among people older than 60? What is the role of gender, age, and education on the association between marital transitions and health among people older than 60? What is the influence of geographical region, housing, neighborhood, and social support on the association between marital transitions and health status among people older than 60?

Assessing the causal relationship between income inequality and mortality and self-rated health: protocol for systematic review and meta-analysis

BACKGROUND

Income inequality has been linked to health and mortality. While there has been extensive research exploring the relationship, the evidence for whether the relationship is causal remains disputed. We describe the methods for a systematic review that will transparently assess whether a causal relationship exists between income inequality and mortality and self-rated health.

METHODS

We will identify relevant studies using search terms relating to income inequality, mortality, and self-rated health (SRH). Four databases will be searched: MEDLINE, ISI Web of Science, EMBASE, and the National Bureau of Economic Research. The inclusion criteria have been developed to identify the study designs best suited to assess causality: multilevel studies that have conditioned upon individual income (or a comparable measure, such as socioeconomic position) and natural experiment studies. Risk of bias assessment of included studies will be conducted using ROBINS-I. Where possible, we will convert all measures of income inequality into Gini coefficients and standardize the effect estimate of income inequality on mortality/SRH. We will conduct random-effects meta-analysis to estimate pooled effect estimates when possible. We will assess causality using modified Bradford Hill viewpoints and assess certainty using GRADE.

DISCUSSION

This systematic review protocol lays out the complexity of the relationship between income inequality and individual health, as well as our approach for assessing causality. Understanding whether income inequality impacts the health of individuals within a population has major policy implications. By setting out our methods and approach as transparently as we can, we hope this systematic review can provide clarity to an important topic for public policy and public health, as well as acting as an exemplar for other "causal reviews".

Systematic review of transcriptome and microRNAome associations with gestational diabetes mellitus

PURPOSE

Gestational diabetes (GDM) is associated with increased risk for preterm birth and related complications for both the pregnant person and newborn. Changes in gene expression have the potential to characterize complex interactions between genetic and behavioral/environmental risk factors for GDM. Our goal was to summarize the state of the science about changes in gene expression and GDM.

DESIGN

The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

PubMed articles about humans, in English, from any date were included if they described mRNA transcriptome or microRNA findings from blood samples in adults with GDM compared with adults without GDM.

RESULTS

Sixteen articles were found representing 1355 adults (n=674 with GDM, n=681 controls) from 12 countries. Three studies reported transcriptome results and thirteen reported microRNA findings. Identified pathways described various aspects of diabetes pathogenesis, including glucose and insulin signaling, regulation, and transport; natural killer cell mediated cytotoxicity; and fatty acid biosynthesis and metabolism. Studies described 135 unique miRNAs that were associated with GDM, of which eight (miR-16-5p, miR-17-5p, miR-20a-5p, miR-29a-3p, miR-195-5p, miR-222-3p, miR-210-3p, and miR-342-3p) were described in 2 or more studies. Findings suggest that miRNA levels vary based on the time in pregnancy when GDM develops, the time point at which they were measured, sex assigned at birth of the offspring, and both the pre-pregnancy and gestational body mass index of the pregnant person.

CONCLUSIONS

The mRNA, miRNA, gene targets, and pathways identified in this review contribute to our understanding of GDM pathogenesis; however, further research is warranted to validate previous findings. In particular, longitudinal repeated-measures designs are needed that control for participant characteristics (e.g., weight), use standardized data collection methods and analysis tools, and are sufficiently powered to detect differences between subgroups. Findings may be used to improve early diagnosis, prevention, medication choice and/or clinical treatment of patients with GDM.