A generalized pairwise modelling framework for network meta-analysis

Comparation of fixed-ratio (IDegLira and iGlarLixi) versus free combination of basal insulin and glucagon-like peptide-1 receptor agonist for uncontrolled type 2 diabetes: A systematic review and network meta-analysis

OBJECTIVE

This study aimed to evaluate the safety and efficacy of the fixed-ratio combination (FRC) and free combination of basal insulin and glucagon-like peptide-1 receptor agonist (GLP-1RA) in patients with type 2 diabetes mellitus (T2DM).

METHODS

PubMed, Web of Science, Embase, The Cochrane Library, and four Chinese databases were searched for relevant studies from inception to April 13, 2023. Phase III clinical trials involving FRC or free combination in patients with uncontrolled T2DM were included. A network meta-analysis (NMA) was used to evaluate the effects of FRC and free combination. The Cochrane Collaboration's tool was used to evaluate the risk-of-bias. The primary outcomes were changes in hemoglobin A1c (HbA1c), body weight, and incident hypoglycemia. Secondary outcomes included changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP). This study was registered with PROSPERO (CRD42023409585).

RESULTS

Forty-two trials with 23,619 patients were included in the NMA, and treatments were categorized as FRC, free combination and NOINSGLP (neither FRC nor free combination). The forest plots revealed comparable HbA1c control (mean difference (MD) = 0.07%, 95% confidence interval (CI): -0.17 to -0.30) between free combination and FRC. However, there were significant differences in the body weight (MD = -2.06 kg; 95% CI: -3.34 to -0.77), SBP (MD = -1.22 mmHg; 95% CI: -2.41 to -0.04), and DBP (MD = -1.09 mmHg; 95% CI: -1.94 to -0.24) between the two groups.

CONCLUSIONS

In patients with uncontrolled T2DM, the safety and efficacy of FRC and free combination therapy were comparable. The use of FRC is justifiable in patients requiring free combination.

Topical Preparations for Reducing Cutibacterium acnes Infections in Shoulder Surgery: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

Cutibacterium acnes (C acnes) is a commensal skin bacterium, primarily found in sebaceous glands and hair follicles, with a high prevalence in the shoulder region. It is the most common pathogenic organism in prosthetic joint infections after shoulder arthroplasty. Because of its low virulence, its diagnosis remains difficult.

PURPOSE

To evaluate the relative effects of topical preparations in reducing C acnes in shoulder surgery.

STUDY DESIGN

Meta-analysis; Level of evidence, 1.

METHODS

We searched the MEDLINE, Embase, PsychINFO, and Cochrane Library databases in March 2022. Randomized controlled trials (RCTs) comparing any form of topical preparation in arthroscopic or open shoulder surgery were included. The primary outcome was a reduction in the number of positive C acnes cultures. Secondary outcomes were adverse events related to the application of topical preparations. We performed a network meta-analysis to facilitate simultaneous comparisons between multiple preparations across studies. We calculated differences between preparations using odds ratios and their 95% CIs. The risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

The search yielded 17 RCTs (1350 patients), of which 9 were suitable for the network meta-analysis (775 patients). Overall, 2 RCTs were deemed as having a low risk of bias, and 15 raised "some concerns" of bias. Preparations included benzoyl peroxide (BPO), BPO combined with clindamycin, chlorhexidine gluconate, hydrogen peroxide, povidone-iodine, and water with soap. Only BPO resulted in significantly lower odds of a positive C acnes culture compared with placebo or soap and water (odds ratio, 0.12 [95% CI, 0.04-0.36]). There was no statistically significant difference with all other topical preparations. The only adverse events were skin irritation from BPO and chlorhexidine gluconate in a small number of reported cases.

CONCLUSION

BPO was the most effective topical agent in reducing the prevalence of C acnes in shoulder surgery. These results were limited by a combination of indirect and direct data. Future studies should focus on establishing the optimal frequency and duration of preoperative BPO to further reduce the burden of C acnes.

REGISTRATION

CRD42022310312 (PROSPERO).

Effect of Needle Gauge Size on Pain During Intravitreal Anti-VEGF Injection: A Systematic Review and Network Meta-Analysis

INTRODUCTION

Concerns related to pain from intravitreal injections are one of the key factors mentioned by patients when asked about therapy. In this systematic review and network meta-analysis, we evaluate the literature of comparative clinical trials on the relationship between needle gauge size and pain experience during intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy.

METHODS

We searched 12 literature databases on 14 October 2023 for comparative studies of gauge sizes for intravitreal anti-VEGF injections. The primary outcome of interest was the reported pain experience immediately after the injection. All outcomes of pain were transformed into standardized effect sizes using Cohen's d. Using a network meta-analysis approach, we were able to compare all gauge sizes and rank them according to the reported pain experience.

RESULTS

We identified nine eligible studies with data on a total of 998 patients and 1004 eyes. Needle sizes studied were 26-gauge, 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge. A complete network was present, which allowed for a network meta-analysis. We used the thickest (26-gauge) needle as the reference group and observed a clear trend of lower pain experience with thinner gauge sizes (d: -0.4, d: -2.7, d: -3.8, d: -4.8, d: -4.5, and d: -5.3; respectively, for 27-gauge, 29-gauge, 30-gauge, 32-gauge, 33-gauge, and 34-gauge).

CONCLUSION

A gauge size of 30 or thinner may minimize patient discomfort related to intravitreal anti-VEGF therapy.

Treatment of acute-onset hypertension in pregnancy: A network meta-analysis of randomized controlled trials comparing anti-hypertensives and route of administration

BACKGROUND

Consensus on the relative efficacy of available antihypertensive agents used in pregnancy is lacking.

OBJECTIVE

To compare treatment success with antihypertensives and categorize by route of administration.

SEARCH STRATEGY

MEDLINE, Embase, PubMed, Web of Science, Scopus, CINAHL, and clinicaltrials.gov were searched without date restriction.

DATA COLLECTION

Peer-reviewed randomized controlled trials (RCTs) comparing pharmacologic agents used to treat hypertension in parturients were included. Evaluated treatment groups included IV-labetalol (BBIV), IV-hydralazine (DIV), oral-nifedipine (CCBPO), sublingual nifedipine (CCBSL), IV-calcium channel blocker (nonspecific)(CCBIV), IV-nitroglycerine (NTG), epoprostenol infusion (PRO), IV-ketanserin (5HT2B), IV-diazoxide (BZO), oral-nifedipine + methyldopa (CCBAG), oral-methyl-dopa (AAG), and oral prazosin (ABPO).

ANALYSIS

Seventy-four studies (8324 patients) were eligible post PRISMA guidelines screening. Results were pooled using a Bayesian-approach for success of treatment (study defined target blood pressure), time to achieve target pressure, and neonatal intensive-care admissions.

RESULTS

Treatment success (primary outcome, 55 trials with 5518 patients) was analyzed. Surface under the cumulative ranking curve (SUCRA) was categorized for 13 drugs, CCBPO (0.84) followed by CCBSL (0.78) were most likely to be effective in achieving target blood pressure. After sub-grouping by presence/absence of preeclampsia, CCB-PO ranked highest for both [(0.82) vs. (0.77), respectively]. Serotonin antagonists (0.99) and nitroglycerin (0.88) ranked highest for time to target pressure. NICU admissions were lowest for alpha-2 agonists (0.89), followed by BB PO (0.82) and hydralazine IV (0.49).

CONCLUSION

Oral calcium-channel blockers ranked highest for treatment success. Ketanserin achieved target blood pressure fastest, warranting additional research. The results should be interpreted with caution as SUCRA values may not indicate whether the differences between interventions have clinically meaningful effect sizes.

Comparative efficacy and safety of PD-1/PD-L1 inhibitors in triple negative breast cancer: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Triple-Negative Breast Cancer (TNBC) is a lethal subtype of breast cancer with limited treatment options. The purpose of this Network Meta-Analysis (NMA) is to compare the efficacy and safety of inhibitors of programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) in treating TNBC.

METHODS

Our search strategy was used in six databases: PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature database, Embase, Scopus, and Web of Science up to November 2nd, 2022, as well as a thorough search in the most used trial registries. We included phase II and III randomized controlled trials that looked at the efficacy of PD-1/PD-L1 inhibitors in the treatment of TNBC and reported either Overall Survival (OS), Progression-Free Survival (PFS), or pathological Complete Response (pCR). The risk of bias was assessed utilizing Cochrane's risk of bias 2 tool, and the statistical analysis was performed using a frequentist contrast-based method for NMA by employing standard pairwise meta-analysis applying random effects model.

RESULTS

12 trials (5324 patients) were included in our NMA including seven phase III trials. Pembrolizumab in a neoadjuvant setting achieved a pooled OS of 0.82 (95% Confidence Interval (CI) 0.65 to 1.03), a PFS of 0.82 (95% CI 0.71 to 0.94) and a pCR 2.79 (95% CI 1.07 to 7.24) compared to Atezolizumab's OS of 0.92 (95% CI 0.74 to 1.15), PFS of 0.82 (95% CI 0.69 to 0.97), and pCR of 1.94 (95% CI 0.86 to 4.37). Atezolizumab had less grade ≥ 3 adverse events (OR 1.48, 95% CI 0.90 to 2.42) than Pembrolizumab (OR 1.90, 95% CI 1.08 to 3.33) in the neoadjuvant setting.

CONCLUSIONS

PD-1/PD-L1 inhibitors exhibited varying efficacy in terms of OS, PFS, and pCR. They were associated with an increase in immune-related adverse effects. When used early in the course of TNBC, PD-1/PD-L1 inhibitors exert their maximum benefit. Durvalumab as a maintenance treatment instead of chemotherapy has shown promising outcomes. Future studies should focus on PD-L1 expression status and TNBC subtypes, since these factors may contribute to the design of individualized TNBC therapy regimens. Systematic review registration PROSPERO Identifier: CRD42022380712.

Comparative efficacy of treatments for chronic central serous chorioretinopathy: A systematic review with network meta-analyses

Treatment of chronic central serous chorioretinopathy (cCSC) remains a topic of controversy. As cCSC is a disease that can wax and wane, treatment efficacy is difficult to assess especially when trials compare active treatments without any placebo/control group. In this study, we systematically reviewed short-term efficacies of any cCSC treatment tested in randomized controlled trials (RCT) and employed network meta-analyses to compare to non-treatment controls. We searched 11 literature databases on 20 March 2022 for RCTs of treatment of cCSC. We identified 17 RCTs including a total of 1172 eyes. Treatments included conventional laser (44 eyes), half-dose or half-fluence photodynamic therapy (PDT) (298 eyes), ranibizumab (16 eyes), antioxidants (50 eyes), mineralocorticoid receptor antagonists (187 eyes), rifampicin (91 eyes), selective retina therapy (SRT) (67 eyes) and subthreshold micropulse laser (192 eyes). Compared with controls, significant benefit on complete subretinal fluid resolution was only obtained from half-dose or half-fluence PDT (OR: 20.6; 95% CI: 6.3-66.7; p < 0.0001) and conventional laser (OR: 36.4; 95% CI: 2.0-655.7; p = 0.015), and at an order of magnitude lower degree from SRT (OR: 3.4; 95% CI: 1.7-6.8; p = 0.00075). Compared with controls and after sensitivity analyses, significant benefit in the change in best-corrected visual acuity was only obtained by half-dose/-fluence PDT (-0.13 logMAR; 95% CI: -0.20 to -0.06 logMAR; p = 0.00021). In conclusion, three treatment options provide significant improvement over no treatment: half-dose/-fluence PDT, conventional laser and to a much lesser degree SRT. Considering that conventional laser can only be applied for extrafoveal leaks, and the long-term data available for PDT-based treatments finding persisting treatment results, half-dose or half-fluence PDT is the only viable treatment option for patients with cCSC. Shortage issues with verteporfin should not lead to employment of ineffective treatment modalities, as they put patients at unnecessary risk of adverse events.

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.

Surgical treatment options for plantar fasciitis and their effectiveness: a systematic review and network meta-analysis

BACKGROUND

To date, there are no systematic reviews on the utility of surgical management for plantar fasciitis to guide best practice. This review aimed to evaluate the operative options for plantar fasciitis and their effectiveness.

METHODS

A systematic review and network meta-analysis were carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool.

RESULTS

17 studies involving 865 patients were included. Surgical options considered were open and endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy and dry needling. All interventions resulted in improvement in VAS and AOFAS scores. No major complications were seen from any treatment modality.

CONCLUSIONS

Surgical interventions are effective in providing short- to medium-term symptomatic relief for plantar fasciitis refractory to non-operative management. Current evidence is equivocal regarding treatment choice. Further large randomised studies are required to establish long-term outcomes and a management algorithm.

LEVEL OF EVIDENCE

Level III.

Efficacy and safety of hypoglycemic agents on gestational diabetes mellitus in women: A Bayesian network analysis of randomized controlled trials

Objective

To compare the efficacy and safety of metformin, glyburide, and insulin for GDM, we conducted a subgroup analysis of outcomes for women with GDM according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria.

Methods

We searched the NCBI, Embase, and Web of Science databases from inception to March 2022. Randomized controlled trials (RCTs) that compared the outcomes of hypoglycemic agents in women with GDM were included. Bayesian network analysis was employed.

Results

A total of 29 RCTs were included. Metformin was estimated to lead to a slight improvement in total gestational weight gain (WMD - 1.24 kg, 95% CI -2.38, -0.09), a risk of unmet treatment target in the sensitivity analysis (OR 34.50, 95% CI 1.18-791.37) than insulin. The estimated effect of metformin showed improvements in birth weight than insulin (WMD - 102.58 g, 95% CI -180.45 to -25.49) and glyburide (WMD - 137.84 g, 95% CI -255.31 to -25.45), for hypoglycemia within 1 h of birth than insulin (OR 0.65, 95% CI 0.47 to 0.84). The improvement in the estimated effect of metformin for hypoglycemia within 1 h of birth still existed when compared with glyburide (OR 0.41, 95% CI 0.26 to 0.66), whether in the IADPSG group (OR 0.33, 95% CI 0.12 to 0.92) or not (OR 0.43, 95% CI 0.20 to 0.98).

Conclusion

Metformin is beneficial for GDM women to control total GWG compared with insulin, regulate fetal birth weight more than insulin and glyburide, and increase the risk of unmet treatment targets compared with insulin. Compared to metformin, glyburide is associated with neonatal hypoglycemia.

Effects of preoperative carbohydrate loading on recovery after elective surgery: A systematic review and Bayesian network meta-analysis of randomized controlled trials

Background

Preoperative carbohydrate loading is an important element of the enhanced recovery after surgery (ERAS) paradigm in adult patients undergoing elective surgery. However, preoperative carbohydrate loading remains controversial in terms of improvement in postoperative outcomes and safety. We conducted a Bayesian network meta-analysis to evaluate the effects and safety of different doses of preoperative carbohydrates administrated in adult patients after elective surgery.

Methods

MEDLINE (PubMed), Web of Science, EMBASE, EBSCO, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure (CNKI) were searched to identify eligible trials until 16 September 2022. Outcomes included postoperative insulin resistance, residual gastric volume (RGV) during the surgery, insulin sensitivity, fasting plasma glucose (FPG), fasting serum insulin (Fin) level, the serum levels of C-reactive protein (CRP), postoperative scores of pain, patients' satisfaction, thirst, hunger, anxiety, nausea and vomit, fatigue, and weakness within the first 24 h after surgery and the occurrences of postoperative infection. The effect sizes were estimated using posterior mean difference (continuous variables) or odds ratios (dichotomous variables) and 95 credible intervals (CrIs) with the change from baseline in a Bayesian network meta-analysis with random effect.

Results

Fifty-eight articles (N = 4936 patients) fulfilled the eligibility criteria and were included in the meta-analysis. Both preoperative oral low-dose carbohydrate loading (MD: -3.25, 95% CrI: -5.27 to -1.24) and oral high-dose carbohydrate loading (MD: -2.57, 95% CrI: -4.33 to -0.78) were associated with postoperative insulin resistance compared to placebo/water. When trials at high risk of bias were excluded, association with insulin resistance was found for oral low-dose carbohydrate loading compared with placebo/water (MD: -1.29, 95%CrI: -2.26 to -0.27) and overnight fasting (MD: -1.17, 95%CrI: -1.88 to -0.43). So, there was large uncertainty for all estimates vs. control groups. In terms of safety, oral low-dose carbohydrate administration was associated with the occurrences of postoperative infection compared with fasting by 0.42 (95%Crl: 0.20-0.81). In the other outcomes, there was no significant difference between the carbohydrate and control groups.

Conclusion

Although preoperative carbohydrate loading was associated with postoperative insulin resistance and the occurrences of postoperative infection, there is no evidence that preoperative carbohydrate administration alleviates patients' discomfort.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022312944].

Short-term efficacy and adverse effects of collagenase clostridium histolyticum injections, percutaneous needle fasciotomy and limited fasciectomy in the treatment of Dupuytren’s contracture: a network meta-analysis of randomized controlled trials

Aims

Dupuytren’s contracture (DC) is a chronic debilitating fibroproliferative disorder.

Common treatment options include collagenase clostridium histolyticum injections (CI), percutaneous needle fasciotomy (NF) and limited fasciectomy (LF). Superiority of one specific treatment remains controversial. This study aims to assess the short-term efficacy and safety of CI, NF, and LF for the treatment of DC.

Methods

We included randomized controlled trials of CI compared with placebo, NF and LF for patients with DC. PubMed, Embase and the Cochrane Library were searched from inception to August 2021. Contracture reduction rates in treated joints (within 0–5° of full extension within 30 days), relative reduction in total passive extension deficit (TPED), occurrence of one or more adverse events and number of treatment-related adverse events per patient were the outcomes of interest. The Cochrane risk-of-bias tool was employed for quality assessment of the studies. A network meta-analysis was performed using MetaXL.

Results

Nine studies met our inclusion criteria (n = 903). Overall, risk bias was mixed and mostly low. Short term TPED reduction achieved with LF was superior compared to CI and NF. Although CI achieved greater TPED reduction compared to NF, it was associated with the highest risk of overall adverse effects. The analyzed data was limited to a maximum three-year follow-up period and therefore insufficient for long-term outcome evaluation.

Conclusions

In DC, LF may be able to provide patients with severe disease, superior flexion contracture release postoperatively. CI is a valid treatment alternative to NF, however the higher risk of overall adverse effects must be considered. The quality-of-evidence is limited due to short-term follow-up periods and a lack of standardized definitions of complications and adverse events.

The optimal dose of oral tranexamic acid in melasma: A network meta-analysis

Background

Melasma is a chronic skin condition that adversely impacts quality of life. Although many therapeutic modalities are available there is no single best treatment for melasma. Oral tranexamic acid has been used for the treatment of this condition but its optimal dose is yet to be established.

Objectives

We used network meta-analysis to determine the optimal dose of oral tranexamic acid for the treatment of melasma.

Methods

We conducted a comprehensive search of all studies of oral tranexamic acid for the treatment of melasma up to September 2020 using PubMed, EMBASE and the Cochrane Library database. The quality of the studies was evaluated using the Jadad score and the Cochrane’s risk of bias assessment tool. Only high quality randomised controlled trials were selected. Some studies lacked standard deviation of changes from baseline and these were estimated using the correlation coefficient obtained from another similar study.

Results

A total of 92 studies were identified of which 6 randomized controlled trials comprising 599 patients were included to form 3 pair-wise network comparisons. The mean age of the patients in these studies ranged from 30.3 to 46.5 years and the treatment duration ranged from 8 to 12 weeks. The Jadad scores ranged from 5 to 8.

The optimal dose and duration of oral tranexamic acid was estimated to be 750 mg per day for 12 consecutive weeks.

Limitations

Some confounding factors might not have been described in the original studies. Although clear rules were followed, the Melasma Area and Severity Index and the modified Melasma Area and Severity Index were scored by independent physicians and hence inter-observer bias could not be excluded.

Conclusion

Oral tranexamic acid is a promising drug for the treatment of melasma. This is the first network meta-analysis to determine the optimal dose of this drug and to report the effects of different dosages. The optimal dose is 250 mg three times per day for 12 weeks, but 250 mg twice daily may be an acceptable option in poorly adherent patients. Our findings will allow physicians to balance drug effects and medication adherence. Personalized treatment plans are warranted.

Comparative efficacy of medical treatments for vernal keratoconjunctivitis in children and young adults: a systematic review with network meta-analyses

PURPOSE

To systematically review the literature on the treatment of vernal keratoconjunctivitis (VKC) in children and young adults and conduct comparative efficacy analysis on clinical signs and symptoms using network meta-analyses.

METHODS

We systematically searched the databases PubMed/MEDLINE, EMBASE, Cochrane Central and Web of Science on 21 October 2019 for randomized controlled trials (RCT). Studies considered had patients with VKC < 20 years of age randomized into either intervention (any medical intervention) or comparator (active treatment, placebo treatment or non-treatment control), where pre-defined outcomes (data from ≥2 weeks and as close as possible to 2 months) of symptoms (itching, tearing, photophobia and foreign body sensation) and signs (hyperaemia, punctate keratitis, Horner-Trantas dots and macropapillae) were reported. Risk of bias within studies was evaluated using the Cochrane risk of bias tool. Comparisons were made using network meta-analyses.

RESULTS

We identified 39 studies with data on 2046 individuals. Twenty-three studies were eligible for quantitative analyses. None were systemic therapy. Temporal trend analysis showed that an initial focus on topical mast cell stabilizers turned to a focus on calcineurin inhibitors and a more diverse variety of pharmacological strategies. Studies varied in population, treatment duration and quality. The quantitative analysis revealed that efficacy of different therapies differed substantially across important clinical signs and symptoms, but there was a general trend of superior efficacy when using topical corticosteroids with stronger efficacy of the more potent corticosteroids.

CONCLUSION

We provide an overview of RCTs comparing the efficacy of treatments for VKC in children and young adults, which we find differs across symptoms and signs. Overall, we saw a general trend of superior efficacy with topical corticosteroids. However, our findings highlight the need for better studies, consensus on core outcomes and potential for individualized therapy.

Efficacy and safety of different basal and prandial insulin analogues for the treatment of type 2 diabetes: a network meta-analysis of randomized controlled trials

AIM

The aim of the present network meta-analysis is to assess the efficacy and safety across different long and short-acting analogs for the treatment of type 2 diabetes.

METHODS

A PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases search (20th May, 2020) for all trials with a duration ≥24 weeks comparing an analogue with another or human insulin was performed. Indirect comparisons were performed by NMA choosing glargine U100 and human regular insulin, as the reference for long- and short-acting analogues, respectively. Primary endpoints were HbA1c at 24, 52, and 104 weeks. The weighted difference in means (WDM) and Mantel-Haenzel Odds Ratio [MH-OR] with 95% Confidence Intervals (CI) were calculated for categorical and continuous variables, respectively.

RESULTS

Fifty trials (n = 43) and 7 for basal and prandial analogues, respectively, enrolling 25,554 and 3184 patients with type 2 and 1 diabetes, respectively, were included. At NMA, detemir was less effective than glargine U-100 at 52 weeks. A significant reduction of 24-week HbA1c (WMD [IC]: -0.10 [-0.17, -0.03]%); and risk of total (MH-OR [IC]: 0.80 [0.70, 0.91]), and nocturnal hypoglycemia (MH-OR [IC]: 0.57 [0.45, 0.73]) was observed for basal analogues versus NPH insulin. At NMA, glargine U300 and degludec were associated with a significant reduction in the risk of nocturnal hypoglycemia. No significant differences across different short-acting insulin were observed.

CONCLUSIONS

This paper supports the use of long-acting analogues, rather than NPH insulin, as basal insulin for the treatment of type 2 diabetes, without any preferences for any individual long-acting analogue over the others. The evidence on short acting analogues is limited.

Reversal of direct oral anticoagulants in adult hip fracture patients. A systematic review and meta-analysis

BACKGROUND

Increasing numbers of patients are taking Direct Oral Anticoagulants at the time of hip fracture. Evidence is limited on how and if the effects of DOAC's should be reversed before surgical fixation. Wide variations in practice exist. We conducted a systematic review to investigate outcomes for three reversal strategies. These were: "watch and wait" (also referred to as "time-reversal"), plasma product reversal and reversal with specific antidotes.

METHODS

A systematic search was conducted using multiple databases. Results were obtained for studies directly comparing different DOAC reversal strategies in hip fracture patients and for studies comparing DOAC-taking hip fracture patients (including patients "reversed" using any method and "non-reversed" patients) against matched controls taking either a vitamin-K antagonist or not receiving anticoagulation therapy. This allowed construction of a network meta-analysis to indirectly compare outcomes between "reversed" and "non-reversed" DOAC patients. With respect to "watch and wait"/"time-reversal", a cut-off time to surgery of 36 hours was used to distinguish between "time-reversed" and "non time-reversed" DOAC patients. The primary outcome was early/inpatient mortality, reported as Odds Ratios (OR).

RESULTS

No studies investigating plasma products or reversal agents specifically in hip fracture patients were obtained. Fourteen studies were suitable for analysis of "watch and wait"/"time- reversal". Two studies directly compared "time-reversed" and "non time-reversed" DOAC-taking hip fracture patients (58 "time-reversed", 62 "non time-reversed"). From 12 other studies we used indirect comparisons between "time-reversed" and "non time-reversed" DOAC patients (total, 357 "time-reversed", 282 "non time-reversed"). We found no statistically significant differences in mortality outcomes between "time-reversal" and "non time-reversal" (OR 1.48 [95%CI: 0.29-7.53]). We also did not find a statistically significant difference between "time reversal" and "non time-reversal" in terms of blood transfusion requirements (OR 1.16 [95% CI 0.42-3.23]). However, several authors described that surgical delay is associated with worse outcomes related to prolonged hospitalisation, and that operating within 36 hours is safe.

CONCLUSIONS

We suggested against "watch and wait" to reverse the DOAC effect in hip fractures. Further work is required to assess the optimal timing for surgery as well as the use of plasma products or specific antidotes in DOAC-taking hip fracture patients.

Efficacy and effects of bariatric surgery in the treatment of obesity: Network meta-analysis of randomized controlled trials

AIMS

Bariatric surgery (BS) is recommended for subjects with a Body Mass Index (BMI) over of 40 kg/m² or with a BMI between 35 and 40 kg/m² with obesity-related comorbidities. Aim of the study was to compare different types of BS with medical therapy (MT) for the treatment of obesity.

DATA SYNTHESIS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different BS techniques versus MT in people with obesity, with a duration ≥24 weeks (PROSPERO, #CRD42020160359). Primary endpoint was BMI. Indirect comparisons of different types of surgery were performed by NMA. Types of BS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); Laparoscopic Vertical Banded Gastroplasty (LVBG) and duodenal switch (DS). 43 trials were retrieved in this metanalysis. BS was associated with a significant reduction in BMI, systolic blood pressure, triglyceride and fasting glucose, and with a significant increase of HDL cholesterol when compared to MT. In direct comparisons, RYGB was more effective than LAGB, LVBG, and GCP, but less effective than DS, whereas LAGB was less effective than LVBG and SG. In the NMA, DS and BPD appeared to be more effective than other procedures.

CONCLUSIONS

BS produces a greater weight loss than MT in morbidly obese patients, inducing a greater improvement of obesity-associated metabolic parameters. Available data are insufficient to assess the effect of BS on mortality. Different surgical procedures are heterogeneous for efficacy and safety.

Efficacy of a 3-day pretravel schedule of tafenoquine for malaria chemoprophylaxis: a network meta-analysis

BACKGROUND

Chemoprophylaxis with weekly doses of tafenoquine (200 mg/day for 3 days before departure [loading dose], 200 mg/week during travel and 1-week post-travel [maintenance doses]) is effective in preventing malaria. Effectiveness of malaria chemoprophylaxis drugs in travellers is often compromised by poor compliance. Shorter schedules that can be completed before travel, allowing 'drug-free holidays', could increase compliance and thus reduce travel-related malaria. In this meta-analysis, we examined if a loading dose of tafenoquine alone is effective in preventing malaria in short-term travellers.

METHODS

Four databases were searched in November 2020 for randomized controlled trials (RCTs) that assessed efficacy and/or safety of tafenoquine for chemoprophylaxis. Network meta-analysis using the generalized pair-wise modelling framework was utilized to estimate the odds ratio (OR) of malaria infection in long-term (>28 days) and short-term (≤28 days) travellers, as well as adverse events (AEs) associated with receiving loading dose of tafenoquine alone, loading dose of tafenoquine followed by maintenance doses, loading dose of mefloquine followed by maintenance doses, or placebo.

RESULTS

Nine RCTs (1714 participants) were included. In long-term travellers, compared to mefloquine, tafenoquine with maintenance doses (OR = 1.05; 95% confidence interval [CI]: 0.44-2.46) was equally effective in preventing malaria, while there was an increased risk of infection with the loading dose of tafenoquine alone (OR = 2.89; 95% CI: 0.78-10.68) and placebo (OR = 62.91; 95% CI: 8.53-463.88). In short-term travellers, loading dose of tafenoquine alone (OR = 0.98; 95% CI: 0.04-22.42) and tafenoquine with maintenance doses (OR = 1.00; 95% CI: 0.06-16.10) were as effective as mefloquine. The risk of AEs with tafenoquine with maintenance doses (OR = 1.03; 95% CI: 0.67-1.60) was similar to mefloquine, while loading dose of tafenoquine alone (OR = 0.58; 95% CI: 0.20-1.66) was associated with lower risk of AEs, although the difference was not statistically significant.

CONCLUSIONS

For short-term travellers, loading dose of tafenoquine alone was equally effective, had possibly lower rate of AEs, and likely better compliance than standard tafenoquine or mefloquine chemoprophylaxis schedules with maintenance doses. Studies are needed to confirm if short-term travellers remain free of infection after long-term follow-up.

REGISTRATION

The meta-analysis was registered in PROSPERO (CRD42021223756).

HIGHLIGHT

Tafenoquine is the latest approved drug for malaria chemoprophylaxis. A loading dose of tafenoquine (200 mg/day for 3 days before departure) is as effective in preventing malaria in short-term (≤28 days) travellers as chemoprophylaxis schedules of tafenoquine or mefloquine with maintenance doses, allowing travellers to have a 'drug-free holiday'.

Comparison of immunogenicity and safety of licensed Japanese encephalitis vaccines: A systematic review and network meta-analysis

INTRODUCTION

Annually more than 100,000 Japanese encephalitis (JE) cases and 25,000 deaths worldwide are caused by JE virus infection. More than 15 JE vaccines are currently in use worldwide. It is unknown whether any of the vaccines is superior to the others in terms of immunogenicity and safety.

METHODS

Four databases were systematically searched for randomised controlled trials that compared two or more types of JE vaccines. Vaccines were classified into four classes: inactivated mouse brain-derived (oldest class), inactivated Vero cell, live chimeric, and live attenuated. Network meta-analysis was used to generate mixed effect estimates against inactivated mouse brain-derived vaccines for seroconversion, and against placebo for adverse event (AE) and severe adverse event (SAE).

RESULTS

23 studies (38,496 participants) were included. All newer vaccine classes had better immunogenicity, the difference was statistically significant for inactivated Vero cell (OR = 2.98; 95 %CI: 1.02-8.65) and live chimeric (OR = 5.93; 95 %CI: 1.73-20.32) vaccines. Inactivated mouse-derived vaccines had the highest odds for AEs (OR = 2.27; 95 %CI: 1.59-3.23), the odds of AE of newer vaccines was not different to placebo. There was no difference in SAEs across vaccine classes.

CONCLUSIONS

All newer JE vaccines have comparable safety profiles, live chimeric and inactivated Vero cell vaccines are the most immunogenic among the newer vaccine classes.

Efficacy and safety of glucose-lowering agents in patients with type 2 diabetes: A network meta-analysis of randomized, active comparator-controlled trials

AIM

Aim of the present network meta-analysis (NMA) is the comparison across glucose-lowering drugs (GLA) concerning their effects on glucose control, body weight, hypoglycemia, gastrointestinal adverse events, and quality of life.

DATA SYNTHESIS

This NMA includes randomized clinical trials comparing different head-to-head comparison trials with EMA-approved GLA in type 2 diabetes, with a duration of ≥52 weeks. All drugs have to be administered at the maximal approved dose. Primary endpoints were HbA1c at 12, 52, and 104+ weeks. Secondary endpoints were body weight, quality of life, hypoglycemia, and gastrointestinal disorders. Indirect comparisons of different GLA were performed by NMA choosing metformin as reference. The standardized difference in means (SDM) and Mantel-Haenzel Odds Ratio [MH-OR] (using random-effect models) with 95% Confidence Intervals were calculated for categorical and continuous variables, respectively. We included 68 trials fulfilling all inclusion criteria. At 12 weeks, when considering indirect comparisons, insulin secretagogues (IS) were associated with a significantly greater reduction in comparison with metformin (SDM, -0.3 [-0.4;-0.2]%); a significantly lower efficacy was observed for pioglitazone. At 52 weeks, IS were no longer associated with a greater reduction of HbA1c; whereas a significant decrease in HbA1c was observed for GLP-1 RA (SDM, -0.2 [-0.1;-0.3]%). At 104+ weeks, only SGLT-2 inhibitors showed a significantly greater HbA1c reduction (SDM, -0.2 [-0.1;-0.3]%), whereas sulfonylureas and insulin showed a significantly lower efficacy (SDM, 0.1 [0.0; 0.2]%), and 0.4 [0.3; 0.5]%, respectively).

CONCLUSIONS

The results of this meta-analysis should be considered together with evidence on long-term outcomes for selecting the most appropriate drugs for individual patients.

PD-(L)1 Inhibitors as Monotherapy for the First-Line Treatment of Non-Small-Cell Lung Cancer Patients with High PD-L1 Expression: A Network Meta-Analysis

Programmed cell death-ligand 1 (PD-L1) has emerged as a potential biomarker for selection of patients more likely to respond to immunotherapy and as a prognostic factor in non-small cell lung cancer (NSCLC). In this network meta-analysis, we aimed to evaluate the efficacy of first-line anti-PD-(L)1 monotherapy in advanced NSCLC patients with high PD-L1 expression (≥50%) compared to platinum-based chemotherapy. We also evaluated efficacy outcomes according to tumor mutational burden (TMB). To that end, we conducted a systematic review. Six clinical trials with 2111 patients were included. In head-to-head comparisons, immunotherapy showed a significant improvement in progression-free survival (PFS: HRpooled = 0.69, 95% CI: 0.52-0.90, p = 0.007), overall survival (OS: HRpooled = 0.69, 95% CI: 0.61-0.78; p < 0.001) and overall response rate (ORR) (Risk ratio (RR)pooled = 1.354, 95% CI: 1.04-1.762, p = 0.024). In the assessment of relative efficacy for PFS through indirect comparisons, pembrolizumab (results from KEYNOTE-024) ranked highest followed by cemiplimab and atezolizumab, with statistical significance determined for some of the drugs. In terms of OS, cemiplimab ranked highest followed by atezolizumab and pembrolizumab, although non-significant OS was determined for these drugs. In conclusion, PD-(L)1 inhibitor monotherapy improves efficacy outcomes in the first line setting of advanced NSCLC patients with high PD-L1 expression. Evaluations with longer follow up are still needed to determine the superiority of any specific drug.

Lipid-modifying effects of krill oil vs fish oil: a network meta-analysis

CONTEXT

Krill oil is a good source of n-3 phospholipids and has greater bioavailability than fish oil, which contains n-3 triglycerides. However, it is unclear whether krill oil affects circulating lipid concentrations more beneficially than fish oil.

OBJECTIVE

A network meta-analysis was conducted to compare the lipid-modifying effects of krill oil and fish oil.

DATA SOURCES

PubMed and Embase databases were searched.

STUDY SELECTION

A total of 64 randomized controlled trials that determined the lipid-modifying effects of krill oil or fish oil were selected.

DATA EXTRACTION

The MetaXL program was used for meta-analysis. A subgroup analysis and a network meta-regression were conducted to investigate the dose-response effect of the n-3 fatty acid content of fish oil and krill oil.

RESULTS

Krill oil was associated with significantly lower triglyceride levels than control supplements (weighted mean difference [WMD] -23.26 [95%CI, -38.84 to -7.69]). However, the net differences in triglycerides (WMD -4.07 [95%CI, -15.22 to 7.08]), low-density lipoprotein cholesterol (WMD 3.01 [95%CI, -5.49 to 11.51]), high-density lipoprotein cholesterol (WMD 1.37 [95%CI, -3.73 to 6.48]), and total cholesterol (WMD 1.69 [95%CI, -6.62 to 10.01]) were not significantly different between the krill oil and fish oil groups. One gram of n-3 fatty acids contained in fish oil and krill oil lowered median triglycerides by 8.971 mg/dL (95% credible interval [CrI], 2.27 to 14.04) and 9.838 mg/dL (95%CrI, 0.72 to 19.40), respectively.

CONCLUSIONS

The lipid-modifying effects of krill oil and fish oil do not differ. The reduction in triglycerides depends on the dose of n-3 fatty acids consumed.

Metformin is comparable to insulin for pharmacotherapy in gestational diabetes mellitus: A network meta-analysis evaluating 6046 women

CONTEXT

The comparative efficacy of gestational diabetes (GDM) treatments lack conclusive evidence for choice of first-line treatment.

OBJECTIVES

The aim of this study was to compare the efficacy of metformin and glibenclamide to insulin using a core outcome set (COS) to unify outcomes across trials investigating the treatment of gestational diabetes mellitus.

STUDY DESIGN

A network meta-analysis (NMA) was conducted.

DATA-SOURCE

PubMed, Embase, and Cochrane Controlled Register of Trials were searched from inception to January 2020.

STUDY SELECTION

RCTs that enrolled pregnant women who were diagnosed with GDM and that compared the efficacy of different pharmacological interventions for the treatment of GDM were included.

META-ANALYSIS

A generalized pairwise modelling framework was employed.

RESULTS

A total of 38 RCTs with 6046 participants were included in the network meta-analysis. Compared to insulin, the estimated effect of metformin indicated improvements for weight gain (WMD -2·39 kg; 95% CI -3·31 to -1·46), maternal hypoglycemia (OR 0.34; 95% CI 0.12 to 0·97) and LGA (OR 0.61; 95% CI 0.38 to 0·98). There were also improvements in estimated effects for neonatal hypoglycemia (OR 0.48; 95% CI 0.19 to 1·25), pregnancy induced hypertension (OR 0.63; 95% CI 0.37 to 1·06), and preeclampsia (OR 0.74; 95% CI 0.538 to 1·04), though with limited evidence against our model hypothesis of equivalence with insulin for these outcomes.

CONCLUSION

Metformin is, at least, comparable to insulin for the treatment of GDM. Glibenclamide appears less favorable, in comparison to insulin, than metformin.

Design of pulmonary rehabilitation programmes during acute exacerbations of COPD: a systematic review and network meta-analysis

This systematic review aimed to systematise the different designs used to deliver pulmonary rehabilitation during acute exacerbations of COPD (AECOPD) and explore which ones are the most effective. PubMed, Scopus, Web of Science, EBSCO and Cochrane were searched. Randomised controlled trials comparing pulmonary rehabilitation or at least one of its components with usual care or comparing different components of pulmonary rehabilitation were included. Network meta-analysis was conducted in MetaXL 5.3 using a generalised pairwise modelling framework. Pooled effects compared each treatment to usual care. 42 studies were included. Most studies were conducted in an inpatient setting (57%) and started the intervention 24-48 h after hospital admission (24%). Exercise training (71%), education and psychosocial support (57%) and breathing techniques (55%) were the most used components. Studies combining exercise with breathing techniques presented the larger effects on exercise capacity (weighted mean difference (WMD) -41.06, 95% CI -131.70-49.58) and health-related quality of life (WMD 16.07, 95% CI 10.29-21.84), and breathing techniques presented the larger effects on dyspnoea (WMD 1.90, 95% CI 0.53-3.27) and length of hospitalisation (effect size =0.15, 95% CI -0.28-0.57). A few minor adverse events were found.Pulmonary rehabilitation is a safe intervention during AECOPD. Exercise, breathing techniques, and education and psychosocial support seem to be the core components for implementing pulmonary rehabilitation during AECOPD. Studies may now focus on comparisons of optimal timings to start the intervention, total duration of the intervention, duration and frequency of sessions, and intensity for exercise prescription.

Needling after trabeculectomy - does augmentation by anti-metabolites provide better outcomes and is Mitomycin C better than 5-Fluoruracil? A systematic review with network meta-analyses

PURPOSE

Favourable outcome after glaucoma surgery depends on proper control of the inflammatory response. Failing filtration bleb and consequently increased intraocular pressure is an important cause of continuous visual field deterioration after uncomplicated glaucoma surgery. The present systematic review and meta-analysis aimed to compare the effects of employing either Mitomycin C (MMC), 5-Fluoruracil (5-FU) or no anti-metabolite in needling revision of trabeculectomies.

METHODS

We performed a systematic literature search in PubMed, Cochrane and EMBASE to identify randomized and non-randomized trials published between year 2000 and March 2019 comparing the efficacy of needling filtering blebs when using no anti-fibrotic agent, MMC or 5-FU in patients with glaucoma. Efficacy was defined as intraocular pressure at 12 months or latest follow-up, rate of complications, rates of success and the number of re-needling cases. Comparisons were made using network meta-analyses.

RESULTS

We identified one randomized trial and five retrospective trials. Twelve months after needling revision of trabeculectomy, no significant difference was observed when comparing the effect of the use of MMC with 5-FU or without any use of anti-metabolite on intraocular pressure, complication rates, qualified success, complete success or number of re-needling cases.

CONCLUSION

We found no significant difference in the efficacy of using either MMC, 5-FU or no anti-metabolite in needling revision of trabeculectomies. The number of studies meeting our inclusion criteria was limited. Considering the design of studies, only one was randomized leading to an overall low quality of evidence on the subject matter. Further research is warranted.

Metabolic surgery for the treatment of type 2 diabetes: A network meta-analysis of randomized controlled trials

AIM

To compare different types of metabolic surgery (MS) with medical therapy (MT) for the treatment of type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different MS techniques versus MT in people with T2D, with a duration of ≥24 weeks. Primary endpoints were glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and diabetes remission. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and Mantel-Haenzel odds ratios for categorial variables, were calculated using random effect models. Types of MS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); and duodenojejunal bypass.

RESULTS

The 24 retrieved trials included 1351 patients (1014 with MS and 337 with MT). The mean baseline BMI was 36.8 kg/m² . MS was associated with significantly greater reductions in HbA1c and FPG and greater diabetes remission when compared to MT. In the NMA, a significant reduction in HbA1c was observed with OAGB and SG. All surgical procedures were associated with a significant increase in diabetes remission, except GCP and LAGB. All procedures were associated with a reduction of body mass index (BMI).

CONCLUSIONS

Metabolic surgery is an interesting option for the treatment of T2D, although further data are needed to demonstrate its long-term efficacy and safety. Present data are not sufficient to modify current recommendations, which consider MS a possible treatment for T2D in those with a BMI >35 kg/m² .

Systematic reviews and meta-analysis in nutrition research

There exists an ever-increasing number of systematic reviews, with or without meta-analysis, in the field of nutrition. Concomitant with this increase is the increased use of such to guide future research as well as both practice and policy-based decisions. Given this increased production and consumption, a need exists to educate both producers and consumers of systematic reviews, with or without meta-analysis, on how to conduct and evaluate high-quality reviews of this nature in nutrition. The purpose of this paper is to try and address this gap. In the present manuscript, the different types of systematic reviews, with or without meta-analyses, are described as well as the description of the major elements, including methodology and interpretation, with a focus on nutrition. It is hoped that this non-technical information will be helpful to producers, reviewers and consumers of systematic reviews, with or without meta-analysis, in the field of nutrition.

Comparative effectiveness and safety of direct-acting oral anticoagulants (DOACS) for the reduction of recurrent venous thromboembolism in cancer patients: A protocol for systematic review and network meta-analysis using a generalized pairwise modeling methodology

BACKGROUND

There has been a significant improvement in both our understanding and therapeutic choices available to clinicians for the management of cancer associated thrombosis (CAT). Even with the recent publication of a systematic review and landmark trials demonstrating the non-inferiority of DOACS-based anticoagulation strategy compared to the standard of care in patients with CAT, there is unresolved uncertainty regarding the exact hierarchy of risks and effectiveness of various DOAC analogues in these cohorts of patients.

METHOD

We will carry out a network meta-analyses, utilizing a novel generalized pairwise methodology to generate direct and indirect comparisons between the various DOAC analogues. We will search the following databases for studies that satisfies pre-specified inclusions criteria; these include PubMed, EMBASE, Cochrane library, Clinicaltrials.gov, conference abstracts among other sources. The primary efficacy and safety outcomes are recurrent VTE and major hemorrhagic events, respectively. Two reviewers will Search the databases independently with the view to identify studies that meet eligibility criteria. The methodological quality of the included studies will be determined using a recently validated risk of bias assessment tool.

RESULTS

We expect that the result of this review will ascertain the hierarchy of risks and effectiveness of various DOAC analogues in patients with CAT.

CONCLUSION

Results of this review will assist in informed decisions making regarding therapeutic guidelines of DOAC in CAT.

Efficacy of Anthelminthic Drugs and Drug Combinations Against Soil-transmitted Helminths: A Systematic Review and Network Meta-analysis

Background

Periodic mass distribution of benzimidazole anthelminthic drugs is the key strategy to control soil-transmitted helminths (STHs) globally. However, benzimidazoles have low efficacy against Trichuris trichiura, and there are concerns about benzimidazole resistance potentially emerging in humans. Therefore, identifying alternative drug regimens is a pressing priority. We present a systematic review and network meta-analysis comparing the efficacy of 21 different anthelminthic drug regimens, including standard, novel, and combination treatments.

Methods

We searched PubMed, Medline, Embase, Web of Science, and Cochrane databases and identified studies comparing anthelminthic treatments to each other or placebo. The outcomes calculated were relative risk (RR) of cure and difference in egg reduction rates (dERR). We used an automated generalized pairwise modeling framework to generate mixed treatment effects against a common comparator, the current standard treatment (single-dose albendazole).

Results

Our search identified 4876 studies, of which 114 were included in the meta-analysis. Results identified several drug combinations with higher efficacy than single-dose albendazole for T. trichiura, including albendazole-ivermectin (RR of cure, 3.22 [95% confidence interval {CI}, 1.84-5.63]; dERR, 0.97 [95% CI, .21-1.74]), albendazole-oxantel pamoate (RR, 5.07 [95% CI, 1.65-15.59]; dERR, 0.51 [95% CI, .50-.52]), mebendazole-ivermectin (RR, 3.37 [95% CI, 2.20-5.16]), and tribendimidine-oxantel pamoate (RR, 4.06 [95% CI, 1.30-12.64]).

Conclusions

There are several promising drug combinations that may enhance the impact of STH control programs on T. trichiura, without compromising efficacy against Ascaris lumbricoides and hookworm. We suggest further, large-scale trials of these drug combinations and consideration of their use in STH control programs where T. trichiura is present.

International Prospective Register of Systematic Reviews Registration

CRD42016050739.

Efficacy of sodium-glucose co-transporter 2 inhibitors in patients with type II diabetes: A protocol for systematic review of randomised controlled clinical trials utilising a generalised pairwise modelling methodology

BACKGROUND

Recent systematic reviews have evaluated the efficacy of sodium-glucose co-transporter 2 inhibitors (SGLT2) inhibitors (SGLT2I) in improving glycaemic control and mortality in patients with type II diabetes mellitus. None have incorporated the most recent study or utilized the generalized pairwise modeling methodology network meta-analysis (NMA), as well as a novel bias risk assessment approach.

METHODS

We propose to conduct literature search of all randomized controlled clinical trials published in English language evaluating the efficacy of (SGLT2I) versus placebo or usual standard of care from the inception of following databases to September 30, 2019: Controlled Clinical Trials Cochrane Controlled Trials Register (CCTR), Cochrane Database of Systematic Reviews (CDSR), EMBASE, Database of Abstracts of Reviews of Effectiveness (DARE), PubMed. Two reviewers will independently search these databases to identify studies that satisfy pre-specified eligibility criteria. Study bias risk assessment amongst other methodology quality evaluation of the studies will be carried out using a novel risk bias assessment tool.

RESULTS

We anticipate that the result of this review will provide additional insight into the ranking of the efficacy of various (SGLT2I) in type II diabetic patients especially as it relates to mortality, glycemic control, and body weight reduction.

CONCLUSION

The result of this review will be useful informing therapeutic decisions by policy makers with regards to commissioning of diabetic care.Prospero registration number: CRD42019139708.

Effectiveness of Different Topical Treatments in the Healing of Pressure Injuries: A Network Meta-analysis

OBJECTIVES

Pressure injuries (PIs) are one of the most common types of complex wounds and impose a huge economic burden on the healthcare system and the patients. A plethora of topical treatments is widely available for PI treatment, yet there is a paucity of evidence with regard to the most effective treatment. The objective of this study was to compare the effect of various topical treatments and identify the best treatment choice(s) for PI healing.

DESIGN

Systematic review and network meta-analysis.

SETTING AND PARTICIPANTS

All published randomized controlled trials that compared the effectiveness of 2 or more of the following dressing groups: basic, foam, active, hydroactive, and other wound dressings.

MEASURES

The outcome was the relative risk (RR) of complete healing following treatment and the generalized pairwise modeling framework was used to generate mixed treatment effects against hydroactive wound dressing, currently the standard of treatment for PIs. All treatments were then ranked by their point estimates.

RESULTS

40 studies (1757 participants) comparing 5 dressing groups were included in the analysis. All dressings groups ranked better than basic (ie, saline gauze or similar inert dressing). The foam [RR 1.18; 95% confidence interval (CI) 0.95-1.48] and active wound dressing (RR 1.16; 95% CI 0.92-1.47) ranked better than hydroactive wound dressing in terms of healing of PIs when the latter was used as the reference group.

CONCLUSIONS/IMPLICATIONS

There was substantial uncertainty around the point estimates; however, evidence from our analysis supports the use of hydroactive wound dressings to replace basic dressings. Foam and active wound dressing groups seem promising and therefore need further investigation. High-quality, rigorously conducted research about the clinical effectiveness of the topical treatments in these 2 groups developed in consultation with health professionals, patients, and their carers is needed to identify if indeed foam and active wound dressings provide advantages over hydroactive dressings.

Comparative effectiveness of malaria prevention measures: a systematic review and network meta-analysis

Background

Malaria causes significant morbidity and mortality worldwide. There are several preventive measures that are currently employed, including insecticide-treated nets (ITNs, including long-lasting insecticidal nets and insecticidal-treated bed nets), indoor residual spraying (IRS), prophylactic drugs (PD), and untreated nets (UN). However, it is unclear which measure is the most effective for malaria prevention. We therefore undertook a network meta-analysis to compare the efficacy of different preventive measures on incidence of malaria infection.

Methods

A systematic literature review was undertaken across four medical and life sciences databases (PubMed, Cochrane Central, Embase, and Web of Science) from their inception to July 2016 to compare the effectiveness of different preventive measures on malaria incidence. Data from the included studies were analysed for the effectiveness of several measures against no intervention (NI). This was carried out using an automated generalized pairwise modeling (GPM) framework for network meta-analysis to generate mixed treatment effects against a common comparator of no intervention (NI).

Results

There were 30 studies that met the inclusion criteria from 1998–2016. The GPM framework led to a final ranking of effectiveness of measures in the following order from best to worst: PD, ITN, IRS and UN, in comparison with NI. However, only ITN (RR: 0.49, 95% CI: 0.32–0.74) showed precision while other methods [PD (RR: 0.24, 95% CI: 0.004–15.43), IRS (RR: 0.55, 95% CI: 0.20–1.56) and UN (RR: 0.73, 95% CI: 0.28–1.90)] demonstrating considerable uncertainty associated with their point estimates.

Conclusion

Current evidence is strong for the protective effect of ITN interventions in malaria prevention. Even though ITNs were found to be the only preventive measure with statistical support for their effectiveness, the role of other malaria control measures may be important adjuncts in the global drive to eliminate malaria.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-2783-y) contains supplementary material, which is available to authorized users.