Bias in meta-analysis detected by a simple, graphical test

Risk factors for hepatocellular carcinoma: an umbrella review of systematic review and meta-analysis

BACKGROUND

Numerous meta-analyses have identified various risk factors for hepatocellular carcinoma (HCC), prompting a comprehensive study to synthesize evidence quality and strength.

METHODS

This umbrella review of meta-analyses was conducted throughout PubMed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. Evidence strength was evaluated according to the evidence categories criteria.

RESULTS

We identified 101 risk factors throughout 175 meta-analyses. 31 risk factors were classified as evidence levels of class I, II, or III. HBV and HCV infections increase HCC risk by 12.5-fold and 11.2-fold, respectively. These risks are moderated by antiviral treatments and virological responses but are exacerbated by higher HBsAg levels, anti-HBc positivity, and co-infection. Smoking, obesity, non-alcoholic fatty liver disease, diabetes, low platelet, elevated liver enzymes and liver fluke infection increase HCC risk, while coffee consumption, a healthy diet, and bariatric surgery lower it. Medications like metformin, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), aspirin, statins, and selective serotonin reuptake inhibitors reduce HCC risk, while acid suppressive agents, particularly proton pump inhibitors, elevate it. Blood type O reduces the risk of HCC, while male gender and older age increase the risk.

CONCLUSIONS

HBV and HCV are major HCC risk factors, with risk mitigation through antiviral treatments. Lifestyle habits such as smoking and alcohol use significantly increase HCC risk, highlighting the importance of cessation. Certain drugs like aspirin, statins, GLP-1 RAs, and metformin may reduce HCC occurrence, but further research is needed to confirm these effects.

Team based learning pedagogy enhances the education quality: a systematic review and meta-analysis

BACKGROUND

In medical education, Lecture Based Learning (LBL) is the most common way of disseminating information. Team Based Learning (TBL), a new teaching method, is a teacher-guided method that employs teams in a class, showing suitability for medical education. Two teaching methods represent distinct educational approaches, each with its own set of advantages and limitations. In this study, we performed a systemic review on the efficacy of TBL pedagogy in medical education.

METHODS

MEDLINE, EMBASE, the Cochrane Library, and Web of Science database were searched through July 2022. Standard mean difference (SMD) and 95% confidence intervals (CIs) were calculated.

RESULTS

The analysis included 33 studies. Our analysis revealed that students utilizing the TBL method exhibited significantly higher pre-( SMD = 0.51, 95%CI 0.11 to 0.92) /post-test (SMD = 0.96, 95%CI 0.70 to 1.22) scores than students with LBL. Students in TBL classes had better development of scores, retention (SMD = 1.03, 95%CI 0.38 to 1.69), engagement (SMD = 2.26, 95%CI 0.23 to 4.29) and higher satisfactory rate (SMD = 1.08, 95%CI 0.87 to 1.29). However, students required more time to independently complete reading materials and preparatory tasks.

CONCLUSION

Our study indicates the gratifying effectiveness of TBL application in medical education. TBL pedagogy is compatible with the present medical education and should be generalized in more classrooms.

Efficacy of repeated peripheral magnetic stimulation on upper limb motor function after stroke: a systematic review and meta-analysis of randomized controlled trials

Background

Post-stroke patients with upper motor neuron lesions have limited motor function in the upper limbs, and spasticity occurs in the limbs, thus affecting functional recovery and activities of daily living. Repetitive peripheral magnetic stimulation (rPMS) is a non-invasive treatment often used in clinical rehabilitation. Recent studies have shown that it can reduce spasticity and improve motor function in patients.

Objective

This study aimed to evaluate the effectiveness of rPMS on upper limb motor function and spasticity in stroke patients by meta-analysis.

Materials and methods

Randomized controlled trials (RCTs) of rPMS in post-stroke patients were searched in PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials. Databases from the date of creation to 25 August 2024 were evaluated using the Cochrane Collaboration tool. Methodological quality was assessed using the Cochrane Collaboration tools, and meta-analyses were performed using RevMan (version 5.4) and Stata (version 14.0).

Results

A total of 8 studies were included. RPMS improved patients' FMA-UE scores compared with controls (MD = 3.34, 95% CI = [0.53, 6.15], p = 0.02 < 0.05). RPMS also reduced spasticity (MD = -0.66, 95% CI = [-1.16, -0.15], p = 0.01 < 0.05) and increased patients' ability to live independently (MD = 0.85, 95% CI = [0.19, 1.51], p = 0.01 < 0.05). Subgroup analyses showed that the efficacy of treatment frequency ≤ 20 Hz was better than that of frequency > 20 Hz; the treatment time using 15-20 min was more effective than using 30 min; and the application of round coil treatment was more effective than other types of coils.

Conclusion

The results suggest that if rPMS is used in post-stroke patients, their upper limb motor function and spasticity may improve. However, the number of studies is small, and further research is needed to extend the current analysis results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42024584040.

The prevalence of oral mucositis after radiotherapy in patients with Head and Neck Cancer and its associated factors: a meta-analysis

OBJECTIVES

Although the discussion about oral mucositis in Head and Neck Cancer (HNC) patients has become a prominent issue, its incidence and influencing factors have not been thoroughly synthesized. This meta-analysis aims to integrate the prevalence and associated factors of radiation-induced oral mucositis among HNC patients.

METHODS

This study searched the following electronic databases: PubMed, the Cochrane Database, the Web of Science, EMBASE, CNKI, the Wanfang Database, and the VIP Database. The publication timeframe for the included studies ranged from January 2005 until January 2024. Two investigators used the NOS scale and AHRQ evaluation criteria for quality evaluation. All qualified studies and statistical analyses were conducted using RevMan 5.2 and Stata 17.0.

RESULTS

Thirty eligible studies were included in the analysis. The results show that the prevalence of radiation-induced oral mucositis in HNC patients was 94% [95% CI (89%, 98%)]. Furthermore, the prevalence of severe radiation-induced oral mucositis in HNC patients is 37% [95%CI (29%, 45%)]. Chemotherapy, smoking history, diabetes, oral PH ≤ 7.0, and alcohol consumption are the main risk factors for radioactive oral mucositis. In addition, BMI > 24.0 kg/m2, no use of antibiotics, and no use of oral mucosal protective agents are associated with radioactive oral mucositis.

CONCLUSIONS

This meta-analysis underscores a significantly high prevalence of radiation-induced oral mucositis in HNC patients. Establishing healthy lifestyle habits and maintaining a healthy oral environment are pivotal in preventing radiation-induced oral mucositis.

Optimal exercise parameters of Baduanjin for balance in older adults: a systematic review and meta-analysis

Purpose

Baduanjin represents an affordable and secure method of exercising both the mind and body, and has been observed to enhance balance in older adults. Nevertheless, the existing research on the impact of Baduanjin on various balance functions is still insufficient, and the optimal dosage parameters for performing Baduanjin exercises have not been studied.

Methods

To conduct a systematic review and meta-analysis, five English databases and three Chinese databases were performed. Relevant studies were searched by GOOGLE SCHOLAR, Web of Science, Cochrane, Embase, Pubmed, CNKI, SinoMed, and WangfangMed using "Baduanjin" and "balance." Subgroup analyses were conducted to investigate the influence of different exercise parameters on the observed outcomes. Meta-regression was employed to identify potential moderating factors. The Physical Therapy Evidence Database (PEDro) scale was used for quality assessment.

Results

A total of 40 studies were included in the analysis, while the majority of studies report promising outcomes, the overall quality of these studies is relatively low. The results of the meta-analysis showed Baduanjin significantly enhanced static balance (SMD = 0.87, 95%CI: 0.69-1.05), dynamic balance (SMD = 0.85, 95%CI: 0.50-1.19), proactive balance (SMD = -1.00, 95%CI: -1.33--0.67) and balance test battery (SMD = 1.04, 95%CI: 0.81-1.28) in older adults. Additionally, the findings indicated a notable reduction in the risk of falls (SMD = -2.19, 95%CI: -3.35--1.04) and an improvement in fall efficacy (SMD: 0.57, 95%CI: 0.36-0.78).

Conclusion

Baduanjin has been demonstrated to improve balance and reduce the risk of falls in older adults. Studies have found that significant gains begin to be achieved with a minimum of 12 weeks of practice and that 30-49 min of practice, 5-7 times per week, works best for developing different balances. However, most of the included studies were limited by a lack of blinding and follow-up visits, and there was an insufficient number of short-term or long-term studies to establish complete optimal parameters robustly.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=548345, identifier: CRD42024548345.

Neutrophils as indicators of obesity-associated inflammation: A systematic review and meta-analysis

INTRODUCTION

The aim of this study is to evaluate and compare the suitability of routine blood neutrophil values as indicators of obesity-associated inflammation.

METHODS

In this systematic review and meta-analysis, we assess absolute neutrophil counts (ANCs) and neutrophil-to-lymphocyte ratio (NLR) values in subjects with and without obesity and analyze the weight of both parameters on the disease. Additionally, correlation studies between ANC and NLR with BMI, a parameter internationally accepted to define obesity are performed.

RESULTS

Quantitative data from 12 (ANC) and 11 (NLR) studies were included, with a total of 4475 participants. The meta-analysis shows that while both parameters are increased in the obesity group, ANC values present higher differences with the control and less heterogeneity among studies. Additionally, unlike NLR, ANC demonstrates a positive and significant correlation with BMI.

CONCLUSION

Overall, this meta-analysis demonstrates that ANC is a more reliable and stable parameter than NLR for the assessment of obesity-related inflammation, which offers clinicians a novel tool to assist in preventing complications related to obesity.

Effect of Low-Fat Diet on Depression Score in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

CONTEXT

Current evidence on the effect of a low-fat (LF) diet on depression scores has been inconsistent.

OBJECTIVE

To explore the effect of an LF diet on depression scores of adults by systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

The PubMed, ISI Web of Science, Scopus, and CENTRAL databases were searched from inception to June 7, 2023, to identify trials investigating the effect of an LF diet (fat intake ≤30% of energy intake) on the depression score.

DATA EXTRACTION

Random-effects meta-analyses were used to estimate pooled summary effects of an LF diet on the depression score (as Hedges g).

DATA ANALYSIS

Finding from 10 trials with 50 846 participants indicated no significant change in depression score following LF diets in comparison with usual diet (Hedges g = -0.11; 95% CI, -0.25 to 0.03; P = 0.12; I2 = 70.7% [for I2, 95% CI, 44%, 85%]). However, a significant improvement was observed in both usual diet and LF diets when the content of protein was 15-20% of calorie intake (LF, normal protein diet: n = 5, Hedges g = -0.21, 95% CI, -0.24 to -0.01, P = 0.04, I2 = 0%; usual, normal protein diet: n = 3, Hedges g = -0.28, 95% CI, -0.51 to -0.05, P = 0.01, I2 = 0%). Sensitivity analysis also found the depression score improved following LF diet intervention in participants without baseline depression.

CONCLUSION

This study revealed that LF diet may have small beneficial effect on depression score in the studies enrolled mentally healthy participants. Moreover, achieving to adequate dietary protein is likely to be a better intervention than manipulating dietary fat to improve depression scores. However, it is not clear whether this effect will last in the long term. Conducting more studies may change the results due to the low-certainty of evidence.

SYSTEMATIC REVIEW REGISTRATION

CRD42023420978 (https://www.crd.york.ac.uk/PROSPERO).

Correlation Between Gaze Behaviors and Social Communication Skills of Young Autistic Children: A Meta-Analysis of Eye-Tracking Studies

This meta-analysis examined correlations between eye-tracking measures of gaze behaviors manifested during dynamic salient social stimuli and behavioral assessment measures of social communication skills of young autistic children. We employed a multilevel model with random effects to perform three separate meta-analyses for correlation between social communication skills and (a) all gaze behaviors, (b) gaze duration, and (c) gaze transition. Subsequently, we performed meta-regression to assess the role of four moderators, including age, continuum of naturalness of stimuli, gaze metric, and area of interest, on correlation effect sizes that were heterogeneous at the population level. A total of 111 correlation coefficients from 17 studies for 1132 young autistic children or children with high-likelihood for autism (Mage range = 6-95 months) were included in this meta-analysis. The correlation effect sizes for all three meta-analyses were significant, supporting the relation between improved gaze behaviors and better social communication skills. In addition, age, gaze metric, and area of interest were significant moderators. This suggests the importance of identifying meaningful gaze behaviors related to social communication skills and the increasingly influential role of gaze behaviors in shaping social communication skills as young autistic children progress through the early childhood stage. The continuum of naturalness of stimuli, however, was revealed to trend towards having a significant moderating effect. Lastly, it is important to note the evidence of potential publication bias. Our findings are discussed in the context of early identification and intervention and unraveling the complex nature of autism.

Family therapy and cognitive behavior therapy for eating disorders in children and adolescents in routine clinical care: a systematic review and meta-analysis

Family therapy for eating disorders (ED) is well-established and represents the treatment choice for ED in children and adolescents according to guidelines, with cognitive behavior therapy (CBT) as a second line treatment. There is limited knowledge about how these treatments work in routine clinical care. The goal of the present meta-analysis is to investigate the effectiveness of family therapy and CBT for various EDs in children and adolescents when carried out in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were searched for articles published until December 2023. The outcome of family therapy and CBT, methodological quality, risk of bias, and moderators of treatment outcome were examined and benchmarked by meta-analytically comparing with ED efficacy studies. Forty-four effectiveness studies comprising 3251 family therapy or CBT patients were included. Large to very large within-group effect sizes (ES) were found for ED-psychopathology (0.80) and weight measures for AN (1.64) at post treatment. The attrition rate was 15%. Risk of bias was considerable. Moderate to large ES were found for family therapy and CBT, respectively. The benchmarking analysis showed that effectiveness studies had comparable ESs to efficacy studies (0.80 and 0.84 for the ED-psychopathology at post treatment). The findings support family therapy and CBT for ED in children and adolescents as effective treatments when delivered in routine clinical care, with effects comparable with those found in efficacy studies. The evidence needs to be interpreted with caution because of the risk of bias in a high proportion of studies.PROSPERO [CRD42023441794].

Men's knowledge of obstetrics danger sign and associated factors in low-income countries: a systematic review and meta-analysis

Obstetric danger signs refer to unexpected signs that arise during pregnancy, childbirth, or the postpartum period, indicating potential complications that require immediate medical attention. Globally, approximately 15% of pregnant women experience such complications, contributing to an estimated 287,000 maternal deaths annually-equivalent to nearly 800 deaths each day. This review evaluates the literature on men's knowledge of obstetric danger signs, a critical factor in enhancing maternal health outcomes. We performed a comprehensive search for articles using PubMed, Web of Science, Scopus, Hinari, and Google Scholar databases. To identify relevant studies, we employed search terms such as "knowledge," "awareness," "information," "recognition," "pregnancy danger signs," "obstetric danger signs," "obstetric warning signs," and "labor complications," combined with "low-income countries." six reviewers independently screened the articles and extracted data. The included articles in the review are cross-sectional studies, conducted in low-income countries and published in English, with no restrictions of publication years. Study quality was evaluated using a Newcastle-Ottawa Scale. The study was reported following the PRISMA checklist and the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (protocol ID: CRD42024488979). Of the 366 articles initially screened by title and abstract, 13 studies met the inclusion criteria. All the included studies assessed men's knowledge of obstetric danger signs during pregnancy, and childbirth, while only ten assessed their knowledge during the postpartum period. The pooled random-effects meta-analysis indicated that men's knowledge of obstetric danger signs was 36.96% during pregnancy, 40.86% during childbirth, and 35.84% during the postpartum period, with an overall knowledge level of 37.29% based on the summarized random-effects meta-analysis. Key factors influencing men's knowledge included urban residence, educational attainment, access to antenatal care, participation in the health development army, and previous experience with obstetric complications. In low-income countries, men's knowledge of obstetric danger signs remains notably low, potentially hindering their ability to seek timely obstetric care for their partners during complications. Addressing this gap requires strengthening counseling services during antenatal care, expanding community meetings, and enhancing community-based health education on obstetric danger signs.

Gonadotropin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHa) are commonly used in assisted reproduction technology (ART) cycles to prevent a luteinising hormone (LH) surge during controlled ovarian hyperstimulation (COH) prior to planned oocyte retrieval, thus optimising the chances of live birth. We compared the benefits and risks of the different GnRHa protocols used.

OBJECTIVES

To evaluate the effectiveness and safety of different GnRHa protocols used as adjuncts to COH in women undergoing ART.

SEARCH METHODS

We searched the following databases in December 2022: the Cochrane Gynaecology and Fertility Group's Specialised Register, CENTRAL, MEDLINE, Embase, and registries of ongoing trials. We also searched the reference lists of relevant articles and contacted experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any two protocols of GnRHa, or variations of the protocol in terms of different doses or duration, used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles in subfertile women.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcome measures were number of live births or ongoing pregnancies and incidence of ovarian hyperstimulation syndrome (OHSS) per woman/couple randomised. Our secondary outcome measures included number of clinical pregnancies, pregnancy losses, number of oocytes retrieved, amount of gonadotropins used, and cost and acceptability of the treatment protocols.

MAIN RESULTS

We included 40 RCTs (4148 women). The trials evaluated 10 different comparisons between protocols. The evidence is current to December 2022. Only half of the studies reported the primary outcome of live birth or ongoing pregnancy rates. We restricted the primary analysis of live birth and ongoing pregnancy to trials with low risk of selection and reporting bias. Nineteen studies compared long and short protocols. The primary analysis restricted to trials with low risk of bias included five studies reporting on live birth or ongoing pregnancy rates. Results showed little or no difference when the long protocol was compared with a short protocol (odds ratio (OR) 1.45, 95% confidence interval (CI) 0.83 to 2.52; I² = 0%; 5 studies, 381 women; low-certainty evidence). For the same comparison, there was evidence that the long protocol may improve clinical pregnancy rates when compared to the short protocol (OR 1.56, 95% CI 1.01 to 2.40; I² = 23%; 8 studies, 552 women; low-certainty evidence). No study in this comparison reported on OHSS. We are uncertain if there is a difference between groups in terms of live birth and ongoing pregnancy rates when the following GnRHa protocols were compared: long versus ultrashort (OR 1.78, 95% CI 0.72 to 4.36; 1 study, 150 women; very low-certainty evidence); long luteal versus long follicular phase (OR 1.89, 95% CI 0.87 to 4.10; 1 study, 223 women; very low-certainty evidence); GnRHa reduced-dose versus GnRHa same-dose continued in the long protocol (OR 1.59, 95% CI 0.66 to 3.87; 1 study, 96 women; very low-certainty evidence); GnRHa administration for two versus three weeks before stimulation (OR 0.88, 95% CI 0.37 to 2.05; 1 study, 85 women; very low-certainty evidence); GnRHa continued versus discontinued after human chorionic gonadotropin (HCG) administration in the long protocol (OR 0.89, 95% CI 0.49 to 1.64; 1 study, 181 women; very low-certainty evidence); and 500 µg dose versus 80 µg dose in the short protocol (OR 0.31, 95% CI 0.10 to 0.98; 1 study, 200 women; very low-certainty evidence). Clinical pregnancy rates may improve with a 100 µg dose compared to a 25 µg dose in the short protocol (OR 2.30, 95% CI 1.06 to 5.00; 2 studies, 133 women; low-certainty evidence). Only four of the 40 included studies reported adverse events. We are uncertain of any difference in OHSS rate in the GnRHa reduced-dose versus GnRHa same-dose regimen in the long protocol (OR 0.47, 95% CI 0.04 to 5.35; 1 study, 96 women; very low-certainty evidence) or when administration of GnRHa lasted for two versus three weeks before stimulation (OR 0.93, 95% CI 0.06 to 15.37; 1 study, 85 women; very low-certainty evidence). Regarding miscarriage rates, we are uncertain of any difference when the GnRHa long protocol was administered for two versus three weeks before stimulation (OR 0.93, 95% CI 0.18 to 4.87; 1 study, 85 women; very low-certainty evidence) and when a 500 µg dose was compared with an 80 µg dose in the short protocol (OR 3.15, 95% CI 0.32 to 31.05; 1 study, 131 women; very low-certainty evidence). No studies reported on cost-effectiveness or acceptability of the different treatment protocols. The certainty of the evidence ranged from low to very low. The main limitations were failure to report live birth or ongoing pregnancy rates, poor reporting of methods in the primary studies, imprecise findings due to lack of data, and insufficient data regarding adverse events. Only eight of the 40 included studies were conducted within the last 10 years.

AUTHORS' CONCLUSIONS

When comparing long and short GnRHa protocols, we found little or no difference in live birth and ongoing pregnancy rates, but there was evidence that the long protocol may improve clinical pregnancy rates overall. We were uncertain of any difference in OHSS and miscarriage rates for all comparisons, which were reported by only two studies each. There was insufficient evidence to draw any conclusions regarding other adverse effects or the cost-effectiveness and acceptability of the different treatment protocols.

Non-prescription antibiotic use and its predictors among children in low- and middle-income countries: a systematic review and meta-analysis

Globally antibiotics are among the most commonly used drugs. Non-prescription use of antibiotics is a major factor for the emergence and spread of antimicrobial resistance one of the top global public health and development threats. This systematic review and meta-analysis aim to assess non-prescription antibiotic use and predictors among children in Low and middle-income countries.A comprehensive search of electronic databases was conducted from PubMed, Scopus and HINARI to identify primary studies published between 2000 and 2024. Observational studies conducted among children ≤ 18 years old and published in English language were included in the review. After screening, the studies were assessed using Joanna Briggs Institute (JBI) critical appraisal tool and data were extracted using a checklist. Heterogeneity was assessed using forest plot, Chocran's Q Test and I2. The random effects meta-analysis model was employed to pool the prevalence of non-prescription antibiotic use among children in low-and middle-income countries. Sub-group analysis and meta-regression were performed to identify the sources of heterogeneity. Publication bias was assessed using funnel plots with Egger's test.The review was conducted among 32 cross-sectional studies with a sample size of 80,133 participants. The pooled prevalence of non-prescription antibiotic use among children in low-and middle-income countries was 38.86% (95% CI 34.32, 43.40; P < 0.0001) with high heterogeneity (I2 = 99.38%, p < 0.001). The prevalence of non-prescribed antibiotic use among studies conducted in upper middle-income countries (30.85% (24.49%, 37.21%)) was low when compared to studies conducted in LMICs (44.00% (37.72%, 52.09%). Penicillin was the most often antibiotic class used without prescription, while upper respiratory infections were the most prevalent illness/symptoms that prompted non-prescription antibiotic use.The pooled prevalence of non-prescription antibiotic use among children in low-and middle-income countries is high indicating that two out of five children used non-prescribed antibiotics. This review is important for international organizations, ministry of health of the low-and middle- income countries, regulatory bodies and researchers.

Chinese herbal medicine for obstructive sleep apnoea: a systematic review with meta-analysis

PURPOSE

Chinese Herbal Medicine (CHM) may have a place in the treatment of obstructive sleep apnoea (OSA), but the evidence has not been systematically assessed. The objective of this study is to evaluate the evidence for the effectiveness of CHM for OSA.

METHODS

CENTRAL, EMBase, PubMed, CINAHL, CNKI, Wanfang and Chongqing VIP were searched from database inception to the 13th of August 2023. Randomised-controlled trials in which the effect of CHM on sleep variables was tested in the treatment of OSA were selected. The primary outcomes of this review and meta-analysis were the apnoea hypopnoea index (AHI) measured with polysomnography.

RESULTS

A total of 58 studies, involving 4,590 participants, were included. The meta-analysis showed that CHM reduced AHI more significantly than placebo (mean difference = -7.10 events/hour, 95% CI = -11.95, -2.25, P < 0.01, 7 studies, 583 participants) and the combination of CHM and Continuous Positive Airway Pressure (CPAP) more effective than CPAP alone (mean difference = -4.71 events/hour, 95% CI = -5.62, -3.80, P < 0.001, 28 studies, 2,267 participants). CHM improved sleepiness, quality of life, body weight, oxidative biomarkers, inflammatory biomarkers, cognitive function, blood pressure and respiratory function.

CONCLUSION

Our results suggest that CHM, alone and as an adjunct treatment, can improve various aspects of OSA and its comorbidities and is therefore a viable therapeutic option for OSA.

Prevalence of subthreshold depression in older adults: A systematic review and meta-analysis

BACKGROUND

The prevalence of subthreshold depression (StD) in older adults shows considerable variation across studies. This study aimed to determine the prevalence of subthreshold depression in elderly people.

METHODS

We conducted a thorough literature search across multiple databases, including PubMed, Web of Science, Medline, Cochrane Library, SinoMed, Wan Fang Data, CNKI, and VIP. Statistical analyses were carried out using STATA version 16.0. Our study was prospectively registered with PROSPERO (CRD42023494210).

RESULTS

Seventy-seven studies involving 225,232 individuals were included in this meta-analysis. The overall prevalence of subthreshold depression was 18.6 % (95 % CI: 16.0 %-21.2 %, I2 =99.8 %, p<0.001. Subgroup analyses showed the prevalence of StD in older adults varied depending on the screening tools used and the continent of the study. Funnel plots and Egger's test did not reveal any significant publication bias (Egger's test: p = 0.057).

CONCLUSION

The prevalence of subthreshold depression in older adults is high, suggesting attention needs to be paid to the mental health of the elderly. To prevent a larger public health issue, it is imperative to implement timely and effective preventive measures and interventions, focusing on early detection and intervention.

Intramedullary nail fixation versus open reduction and internal fixation for treatment of adult diaphyseal forearm fractures: a systematic review and meta-analysis

BACKGROUND

Diaphyseal radius and ulna fractures require surgical fixation in adults. Open reduction and internal fixation (ORIF) have been considered the gold standard of treatment. The recent development of an interlocking intramedullary nail (IMN) has provided an alternative treatment method for these fractures. The objective of this meta-analysis is to compare the outcomes and complications of IMN versus ORIF for diaphyseal forearm fractures in adults.

METHODS

MEDLINE and Embase were searched from January 1, 2000, through January 7, 2024. All English-language studies were included comparing radiographic and functional outcomes for interlocking IMN fixation and ORIF of diaphyseal forearm fractures in adults (age ≥ 18 years). Study demographics, fracture data, functional outcomes, radiographic outcomes, and complications were extracted. Study quality was determined using the ROBINS-I criteria for cohort studies and the Cochrane risk of bias 2.0 (RoB 2) tool for randomized controlled trials. Meta-analysis of included studies used odds ratios and standardized mean difference when appropriate. Data was analyzed using subgroups of all diaphyseal fractures (including isolated radius or ulna fractures) and those with BBFFs.

RESULTS

Nine studies were included for analysis. There were 42 isolated radius, 80 isolated ulna, and 116 both-bone fractures (BBFF) treated with IMN and 36 radius, 81 ulna, and 116 both-bone fractures treated with ORIF. Compared to ORIF, IMN of diaphyseal forearm fractures appeared to be associated with shorter operative times and a lower overall complication rate. Time-to-union and the rate of nonunion following IMN were similar to ORIF. According to the Grace-Eversmann score, functional outcomes tended to be better following IMN, but DASH scores were similar between fixation strategies.

CONCLUSIONS

Our findings suggest that interlocking IMN can be a safe and effective treatment option for simple and complex diaphyseal forearm fractures in adults. Further high-quality studies are needed to define indications for treating diaphyseal fractures with an interlocking IMN.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Efficacy of 8-week daclatasvir-sofosbuvir regimen in chronic hepatitis C: a systematic review and meta-analysis

BACKGROUND

The high rates of the sustained virologic response 12 weeks after treatment (SVR12) in real world settings provoked the adoption of shortened courses of the costly direct-acting antivirals (DAAs) regimens. This study provides, to our knowledge, the first systematic review and meta-analysis for the efficacy of the shortened 8-week course of sofosbuvir (SOF) plus daclatasvir (DCV), the most accessible DAAs in the low-middle income countries (LMICs).

METHODS

We performed a proportion meta-analysis to determine a reliable rate of SVR12 by pooling all studies that evaluated the results of the 8-week regimen of DCV + SOF. In addition, we applied sensitivity analyses using two imputation paradigms: a conservative approach, and a pragmatic approach to avoid overestimating the efficacy of the 8-week regimen in studies that followed a response-guided treatment (RGT) approach.

RESULTS

Six studies with a total of 159 patients were included. The pooled SVR12 rate ranged from 91 to 97% in the included scenarios. The pragmatic scenario showed that the pooled SVR12 was 97% (95% confidence interval (CI) 91%; 100%) with lower variability as assessed by the prediction interval. The conservative approach revealed an SVR12 of 93% (95% CI 84%; 95%).

CONCLUSION

The 8-week course of 60 mg DCV with SOF provided a comparable SVR12 to the standard 12-week regimen in treatment-naïve, non-HIV co-infected patients with a minimum estimated efficacy of 90%.

Is There a Relationship Between Online Health Information Seeking and Health Anxiety? A Systematic Review and Meta-Analysis

The internet has revolutionized how we live, providing unprecedented convenience and up-to-date information. Consequently, an increasing number of individuals are turning to the internet for health-related information, despite research suggesting a correlation between this behavior and health anxiety. Therefore, drawing on cognitive - behavioral theory, we explore the link between online health information seeking and health anxiety via a systematic review and meta-analysis of cross-sectional studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis, we ran searches in multiple databases, including PubMed, Web of Science, Embase, Elsevier/Science Direct, Cochrane Database, China National Knowledge Infrastructure, VIP Chinese Database, and Wanfang Data. Our searches identified 16 studies eligible for review, involving 4,920 participants across seven countries. The random-effects meta-analysis revealed a significant positive correlation between online health information seeking and health anxiety (r = 0.28, 95% confidence interval [0.16, 0.41], p < .0001), despite considerable heterogeneity. Furthermore, meta-regression analysis demonstrated that the identity characteristics of the sample, female percentage, sample size, and country all contributed to the heterogeneity across studies. Overall, this meta-analysis provides support for the association between online health information seeking and health anxiety, and helps to elucidate the cognitive - behavioral theory underpinning this phenomenon.

Magnesium and Potassium Supplementation for Systolic Blood Pressure Reduction in the General Normotensive Population: A Systematic Review and Subgroup Meta-Analysis for Optimal Dosage and Treatment Length

BACKGROUND/OBJECTIVES

Studies have shown that consistent reductions of 2 mm Hg in systolic blood pressure (SBP) for the general normotensive population can result in significant decreases in mortality from heart disease and stroke. The purpose of this meta-analysis was to determine the optimal dose and duration of treatment for magnesium and potassium supplementation, having previously discovered that both reduce SBP by -2.79 and -2.10 mm Hg, respectively.

METHODS

Placebo-controlled, randomized clinical trials examining the effects of magnesium and potassium supplementation on SBP were identified. Pairwise meta-analyses with subgroups for dosage and treatment duration were run.

RESULTS

Magnesium at dosages of ≤360 mg/day and durations greater than 3 months reduced SBP by -3.03 and -4.31 mm Hg, respectively. Potassium at dosages of ≤60 mmol/day and durations greater than 1 month reduced SBP by -2.34 and -2.80 mm Hg, respectively.

CONCLUSIONS

Both supplements demonstrated greater reductions in SBP for the general population at lower dosages and longer treatment durations. Future studies are needed to validate these findings and provide tailored recommendations. These studies could investigate varying dosages over long-term follow-up to provide robust data on optimal dosages and treatment durations, as our findings were limited due to reliance on previously published trials.

Antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: an updated systematic review and meta-analysis

BACKGROUND

The efficacy and necessity of prophylactic antibiotics in clean and clean-contaminated surgery remains controversial.

METHODS

The studies were screened and extracted using databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials.gov according to predefined eligibility criteria. Randomized controlled trials (RCTs) comparing the effect of preoperative and postoperative prophylactic antibiotic use on the incidence of surgical site infections (SSIs) in patients undergoing any clean or clean-contaminated surgery.

RESULTS

A total of 16 189 participants in 48 RCTs were included in the primary meta-analysis following the eligibility criteria. The pooled odds ratio (OR) for SSI with antibiotic prophylaxis versus placebo was 0.60 (95% CI: 0.53-0.68). The pooled OR among gastrointestinal, oncology, orthopedics, neurosurgery, oral, and urology surgery was 3.06 (95% CI: 1.05-8.91), 1.16 (95% CI: 0.89-1.50), 2.04 (95% CI: 1.09-3.81), 3.05 (95% CI: 1.25-7.47), 3.55 (95% CI: 1.78-7.06), and 2.26 (95% CI: 1.12-4.55), respectively. Furthermore, the summary mean difference (MD) for patients' length of hospitalization was -0.91 (95% CI: -1.61, -0.16). The results of sensitivity analyses for all combined effect sizes showed good stability.

CONCLUSION

Antibiotics are both effective, safe, and necessary in preventing surgical wound infections in clean and clean-contaminated procedures, attributed to their reduction in the incidence of surgical site infections as well as the length of patient hospitalization.

Effectiveness of online psychological interventions to prevent perinatal depression in fathers and non-birthing partners: A systematic review and meta-analysis of randomized controlled trials

Little is known about the effectiveness of online preventive interventions for paternal perinatal depression (PPD). This systematic review (SR) and meta-analysis (MA) of randomized controlled trials (RCTs) evaluated the effectiveness of online psychological interventions to prevent PPD in fathers and non-birthing partners. The PRISMA 2020 guidelines were followed. The search was conducted in eight electronic databases and other sources from inception to 12 May 2023. The pooled standardized mean difference (SMD) was computed using random-effect models. Seven RCTs were included in the SR and 6 were included in the MA, representing 1.042 fathers from five different countries. No trials focused on non-birthing partners were found. The pooled SMD was -0.258 [95 % confidence interval - 0.513 to -0.004; p < 0.047]. The heterogeneity was moderate (I2 = 51 %; 95%CI [0 % to 81 %]) and nonsignificant (p = 0.070). However, sensitivity analyses showed that the effectiveness was stable only when the fixed effect model and the Egger's g were used to estimate the pooled SMD. No publication bias was found. Only two RCTs had an overall low risk of bias assessed by using the Cochrane ROB 2.0 tool. The quality of evidence based on GRADE was very low. In conclusion, online psychological interventions may be effective for the prevention of PPD. More high-quality evidence is warranted.

Prevalence of nonalcoholic fatty liver disease in Pakistan: a systematic review and meta-analysis

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver condition globally and the leading cause of liver-related death and morbidity. The goal of this study was to collect current data in order to calculate the pooled prevalence of NAFLD in Pakistan. We conducted a comprehensive literature search on four electronic databases until March 2024 to find studies on the prevalence of NAFLD in Pakistan. Pooled prevalence estimates of NAFLD were obtained using random-effects meta-analytic models. The chi-square test was used to account for study heterogeneity, whereas the I2 statistic was used to assess inconsistency. The data were stratified by the general population (average risk) and individuals with metabolic diseases (high risk). Two reviewers thoroughly and independently screened, reviewed, and assessed all studies. In total, 468 studies were reviewed, and 34 were included. The pooled NAFLD prevalence in the general population was 29.82% (95% CI 21.39-39.01%; prediction interval: 2.98-68.92%) based on 13 studies. In individuals with metabolic disorders, the prevalence of NAFLD in patients with diabetes, hypertension, and obesity, was 58.47% (95% CI 54.23-62.64%; prediction interval: 38.16-77.40%), 74.08% (95% CI 60.50-85.70%), and 47.43% (95% CI 30.49-64.66%), respectively. There was no evidence of publication bias, although a statistically significant level of heterogeneity was seen among the studies (I2 ranged from 57.5 to 98.69%). The findings of this study indicate a substantial prevalence of NAFLD in the population of Pakistan. The Pakistani government must formulate a comprehensive approach and plan aimed at augmenting awareness, control, prevention, and treatment of fatty liver disease.Prospero Registration no: CRD42022356607.

Unmasking the silent epidemic: a comprehensive systematic review and meta-analysis of undiagnosed diabetes in Ethiopian adults

Background

Undiagnosed diabetes mellitus poses a significant global public health concern, exerting a substantial impact on the well-being of individuals, their families, and societies at large. Those individuals with undiagnosed diabetes miss opportunities to maintain quality of life and prevent diabetes-related complications. Even if there are ample primary studies on undiagnosed diabetes in Ethiopia, the results reveal conflicting results. Therefore, a comprehensive national picture of undiagnosed diabetes is essential for designing effective strategies at the national level.

Methods

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for prevalence studies (PROSPERO ID: CRD42021266676). PubMed, Web of Science and the World Health Organization's Hinari portal were searched using a strategy developed in collaboration with Liberians. The inclusion criteria comprised studies reporting undiagnosed diabetes in Ethiopia. Two independent reviewers conducted a quality assessment using a 10-item appraisal tool. Meta-analysis and meta-regression were performed using a random-effects model.

Result

Twenty-five studies with 22,193 participants met the inclusion criteria. The pooled prevalence of undiagnosed diabetes among the Ethiopian adult population was 5.68% (95% CI: 4.53 - 6.83, I2 = 75.4). Factors significantly associated with undiagnosed diabetes include age, waist circumference, overweight, family history of diabetes, and a history of hypertension.

Conclusion

Our systematic review found a noteworthy prevalence of undiagnosed diabetes in Ethiopia. The majority of factors linked with undiagnosed diabetes in this review were modifiable. This underscores the importance of targeted factors and public health interventions to improve early detection and reduce the burden of undiagnosed diabetes and its complications in Ethiopia.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42021266676.

Single versus two-stage management of long-bone chronic osteomyelitis in adults: a systematic review and meta-analysis

BACKGROUND

Chronic osteomyelitis is a debilitating bone infection, characterized by a persistent infection over months to years, poses diagnostic and therapeutic challenges due to its insidious nature and potential for severe bone and soft tissue destruction. This systematic review and meta-analysis aims to review the literature on the treatment of chronic osteomyelitis in long bones and assess cure rates in single versus two-stage surgery.

METHODS

Following the PRISMA guidelines and registered with PROSPERO (ID: CRD42021231237), this review included studies that reported on the management of chronic osteomyelitis in long bones using either a planned one-stage or two-stage surgical approach in adult patients. Databases searched included Medline, Embase, Web of Science, CINAHL, HMIC, and AMED, using keywords related to osteomyelitis, long bones, and surgical management. Eligibility criteria focused on adults with chronic osteomyelitis in long bones, with outcomes reported after a minimum follow-up of 12 months. The meta-analysis utilized the random-effects model to pool cure rates.

RESULTS

The analysis included 42 studies with a total of 1605 patients. The overall pooled cure rate was 91% (CI 95%) with no significant difference observed between single-stage and two-stage surgeries (X2 = 0.76, P > 0.05). Complications were reported in 26.6% of cases in single-stage procedures and 27.6% in two-stage procedures, with prolonged wound drainage noted as a common issue. Dead space management techniques varied across studies, with antibiotic-loaded calcium sulphate beads used in 30.4% of cases.

CONCLUSION

This meta-analysis reveals no significant difference in cure rates between single and two-stage surgical treatments for chronic osteomyelitis in long bones, supporting the efficacy of both approaches. The current treatment strategy should include a combination of debridement, dead space management using local and systematic antibiotics and soft tissue reconstruction if necessary.

Effect of core strength training on the badminton player's performance: A systematic review & meta-analysis

BACKGROUND

Core strength training (CST) has been shown to improve performance in several sports disciplines. CST is recognized as one of the crucial elements that enhance athletic performance, particularly impacting badminton skills. Despite its popularity as a strength training method among badminton players, there is a lack of comprehensive studies examining the effectiveness of CST on the performance of these athletes.

OBJECTIVE

This study aims to ascertain CST's effects on badminton players' performance.

METHOD

This study followed PRISMA principles and conducted comprehensive searches in well-known academic databases (SCOPUS, Pubmed, CNKI, Web of Science, Core Collection, and EBSCOhost) up to August 2023. The inclusive criteria were established using the PICOS framework. Following their inclusion based on PICOS criteria, the selected studies underwent literature review and meta-analysis. The methodological quality of the assessments was evaluated using Cochrane Collaboration's risk of bias tools bias risk tools and recommendations for a graded assessment, development, and evaluation.

RESULTS

The analysis included participants aged 10-19 years from 13 studies of moderate quality, totaling 208 individuals. The CST intervention s lasted between 4 to 16 weeks, with a frequency of 1 to 4 sessions per week and each session lasting 20 to 120 minutes. Sample sizes across these studies ranged from 8 to 34 participants. According to the meta-analysis, CST significantly influenced badminton performance, particularly in areas of explosive power (ES = 0.03 P = 0.04), front-court skill (ES = 2.53, P = 0.003), and back-court skill (ES = 2.33, P = 0.002).

CONCLUSION

CST enhances badminton players' fitness (strength, power, balance, and stability), in situ (front/back-court) skills, and movement position hitting. However, its effects on speed, endurance, agility, flexibility, and coordination are unclear, revealing a research gap. The precise benefits of CST, especially on flexibility and specific hitting skills (smashes, clears, drives, net shots, crosscourt, push, and lift shots), need more investigation. Additionally, research on CST's impact on female athletes is significantly lacking.

The effect of non-pharmacological prenatal interventions on fear of childbirth: an overview of systematic reviews and meta-analysis

BACKGROUND

During pregnancy and childbirth, alongside positive feelings, women undergo feelings such as fear of childbirth (FoC) and worry about its consequences, which could leave negative effects on the mother and her child during pregnancy, delivery, and postpartum. The study was carried out to determine the effectiveness of prenatal non-pharmacological interventions on reducing the FoC.

METHODS

The protocol of the study was registered in PROSPERO (ID: CRD42023468547). PubMed, Web of Science, Cochrane, Scopus, SID (Scientific Information Database) and Google Scholar search engine databases were systematically searched until July 27, 2023 with no limitation of time and limited to Persian and English studies in order to perform this overview. Certainty of evidence was assessed using GRADE, methodological quality using AMSTAR 2 and reporting quality using PRISMA score. Meta-analysis was performed on the data extracted from the original trials to evaluate the effect of different interventions on reducing the FoC. Sub-group analysis and meta-regression models were used to examine high heterogeneity, and sensitivity analysis was used to eliminate the effect of high risk of bias studies on the study findings.

RESULTS

Overall, 15 systematic reviews (SRs) were included in the overview, among which meta-analysis was performed in 9 studies. Considering methodological quality, these SRs were in low to critically low status and had relatively complete reports regarding reporting quality. Meta-analysis findings indicated that psychological interventions (SMD -2.02, 95% CI -2.69 to -1.36, 16 trials, 1057 participants, I2 = 95%) and prenatal educations (SMD -0.88, 95% CI -1.16 to -0.61, 4 trials, 432 participants, I2 = 72.8%) cause a significant reduction in FoC relative to prenatal usual cares with low certainty of evidence. Distraction techniques lead to a significant reduction in FoC relative to prenatal usual care with high certainty of evidence (SMD -0.75, 95% CI -1.18 to -0.33, 4 trials, 329 participants, I2 = 69%), but enhanced cares do not result in a significant decrease FoC relative to prenatal usual care with very low certainty of evidence (SMD -1.14, 95% CI -2.85 to 0.58, 3 trials, 232 participants, I2 = 97%).

CONCLUSIONS

Distraction techniques are effective in reducing FoC. Regarding the effect of psychological interventions and prenatal educations on the reduction of FoC, the findings indicated that the interventions may result in the reduction of FoC. Very uncertain evidence showed that enhanced cares are not effective in reducing the FoC.

Vitamin E Does not Favor Recovery After Exercises: Systematic Review and Meta-analysis

This review aimed to verify the effects of vitamin E supplementation on oxidative stress, inflammatory response, muscle damage, soreness, and strength in healthy adults after exercise. We searched the MEDLINE, EMBASE, SPORTDiscus, Cochrane CENTRAL, and Web of Science from inception to August 2023, with no language restrictions. We included randomized placebo-controlled trials evaluating the supplementation of vitamin E on the abovementioned outcomes after a bout of physical exercise in healthy participants (no restriction for publication year or language). Meta-analyses were conducted to compare vitamin E and placebo supplementations to obtain a 95% confidence interval (95%IC). Twenty studies were included (n=298 participants). The effect of supplementation was assessed between 0 h and 96 h after the exercise. Compared to placebo, vitamin E had no effects on lipid (95%IC= -0.09 to 0.42), protein (-2.44 to 3.11), SOD (-1.05 to 0.23), interleukin-6 (-0.18 to 1.16), creatine kinase (-0.33 to 0.27), muscle soreness (-1.92 to 0.69), and muscle strength (-1.07 to 0.34). Heterogeneity for the analyses on carbonyls, interleukin-6 (1 h and 3 h), and muscle soreness ranged between 70 to 94%. Supplementing with vitamin E should not be recommended to support the recovery process in healthy individuals after exercise, given the lack of efficacy in the analyzed variables following an exercise session.

Prevalence and predictors of medication adherence among adolescents and adults with asthma in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

This review aimed to estimate the pooled prevalence and predictors of medication adherence among adolescents and adults with asthma in Ethiopia.

DATA SOURCES

Primary studies were searched from PubMed, Scopus, HINARI, and Google Scholar from January 1, 2010 to December 10, 2023. In addition, we have used citation tracking.

STUDY SELECTIONS

Observational studies (cross sectional, case control, and cohort) conducted among asthmatic patients ≥15 years old in Ethiopia, published in English language were included. After screening, the studies were assessed using Joanna Briggs Institute (JBI) critical appraisal tool and data were extracted using a checklist. Heterogeneity was assessed using forest plot, Q-statistics and I2.

RESULTS

The review was performed among 13 institution-based studies with a total of 2901 participants with asthma. About 1058 participants had comorbid disease and 354 were cigarette smokers. The pooled prevalence of adherence to medications among patients with asthma was 40.50% (95% CI: 28.05, 52.96; p value < 0.001) with high heterogeneity (I2 = 98.25%, p < 0.001). Getting health education about asthma and having comorbid disease were predictors of medication adherence among adolescents and adults with asthma in Ethiopia.

CONCLUSIONS

The pooled prevalence of medication adherence among adolescents and adults with asthma in Ethiopia is low and indicated that three out of five adolescents and adults with asthma were non-adherent to medications. This implies the Ministry of Health should develop different strategies to improve medication adherence including patient education and strengthening the health care system. Multicenter longitudinal studies should be further conducted by using objective methods of adherence measurement and large sample size.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications

PURPOSE

The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults.

METHODS

Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time.

RESULTS

A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively.

CONCLUSIONS

Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

LEVEL OF EVIDENCE III

Effect of dietary and physical activity behavioral interventions on reducing postpartum weight retention among women with recent gestational diabetes: A systematic review and meta-analysis of randomized controlled trials

Postpartum weight retention (PPWR) increases the risk of long-term obesity and metabolic disease in women with recent gestational diabetes mellitus (GDM). This systematic review aimed to assess the effectiveness of dietary and physical activity behavior interventions in reducing PPWR. We systematically searched 13 electronic databases to retrieve articles published in English or Chinese before October 22, 2022. Randomized controlled trials (RCTs) that assessed dietary and/or physical activity behaviors interventions on the outcomes of PPWR among women with recent GDM were included. Twelve studies researched a total of 5672 participants. The meta-analysis indicated that dietary and physical activity behaviors interventions showed significant effects on the pooled effect size of body weight changes (WMD = -2.19, 95% CIs: -3.39, -0.98 kg), body mass index (WMD = -0.98, 95% CIs: -1.56, -0.39 kg/m2 ), and waist circumference (WMD = -1.20, 95% CIs: -2.49, 0.08 cm). Furthermore, the intervention group was more likely to achieve weight reduction (OR = 0.76, 95% CIs: 0.67, 0.87) than the control group. Postpartum dietary and physical activity behavior interventions for women with a recent GDM can reduce PPWR, and 1 year postpartum may be a window of opportunity.

Health Impacts of Wildfire Smoke on Children and Adolescents: A Systematic Review and Meta-analysis

PURPOSE OF REVIEW

Wildfire smoke is associated with human health, becoming an increasing public health concern. However, a comprehensive synthesis of the current evidence on the health impacts of ambient wildfire smoke on children and adolescents, an exceptionally vulnerable population, is lacking. We conduct a systematic review of peer-reviewed epidemiological studies on the association between wildfire smoke and health of children and adolescents.

RECENT FINDINGS

We searched for studies available in MEDLINE, EMBASE, and Scopus from database inception up to October 11, 2022. Of 4926 studies initially identified, 59 studies from 14 countries were ultimately eligible. Over 33.3% of the studies were conducted in the USA, and two focused on multi-countries. The exposure assessment of wildfire smoke was heterogenous, with wildfire-specific particulate matters with diameters ≤ 2.5 µm (PM2.5, 22.0%) and all-source (22.0%) PM2.5 during wildfire period most frequently used. Over half of studies (50.6%) focused on respiratory-related morbidities/mortalities. Wildfire smoke exposure was consistently associated with enhanced risks of adverse health outcomes in children/adolescents. Meta-analysis results presented a pooled relative risk (RR) of 1.04 (95% confidence interval [CI], 0.96-1.12) for all-cause respiratory morbidity, 1.11 (95% Ci: 0.93-1.32) for asthma, 0.93 (95% CI, 0.85-1.03) for bronchitis, and 1.13 (95% CI, 1.05-1.23) for upper respiratory infection, whilst - 21.71 g for birth weight (95% CI, - 32.92 to - 10.50) per 10 µg/m3 increment in wildfire-specific PM2.5/all-source PM2.5 during wildfire event. The majority of studies found that wildfire smoke was associated with multiple adverse health outcomes among children and adolescents, with respiratory morbidities of significant concern. In-utero exposure to wildfire smoke may increase the risk of adverse birth outcomes and have long-term impacts on height. Higher maternal baseline exposure to wildfire smoke and poor family-level baseline birthweight respectively elevated risks in preterm birth and low birth weight associated with wildfire smoke. More studies in low- and middle-income countries and focusing on extremely young children are needed. Despite technological progress, wildfire smoke exposure measurements remain uncertain, demanding improved methodologies to have more precise assessment of wildfire smoke levels and thus quantify the corresponding health impacts and guide public mitigation actions.

Asbestos Exposure and Ovarian Cancer: A Meta-analysis

Background

The International Agency for Research on Cancer (IARC) Monograph conducted a systematic review of the relationship between asbestos and ovarian cancer. However, there may have been information bias due to the undue weight given to few articles. To address this limitation, the present study performed a meta-analysis integrating studies published both before and after the 2012 IARC Monograph on Asbestos, with the aim of investigating the association between asbestos exposure and ovarian cancer.

Methods

A comprehensive search of major journal databases was conducted to identify studies examining the relationship between asbestos exposure and ovarian cancer, including those featured in the 2012 IARC Monograph on Asbestos. A meta-analysis on asbestos exposure and cancer risk was performed.

Results

The meta-analysis of studies published after the 2012 IARC Monograph on Asbestos found a summary Standardized Mortality Ratio (SMR) of 2.04 (95% CI: 1.03-4.05; p = 0.0123; 5 studies), with a significant degree of heterogeneity among the studies (I2 = 72.99%). The combined analysis of 15 studies before and after the 2012 IARC Monograph showed an overall summary SMR of 1.72 (95% CI: 1.43-2.06; p = 0.0349; 15 studies), with a moderate degree of heterogeneity (I2 = 42.99%).

Conclusion

This meta-analysis provides evidence of a significant association between asbestos exposure and ovarian cancer mortality. While the possibility of misdiagnosis in earlier studies cannot be completely ruled out, recent findings suggest a robust correlation between asbestos exposure and ovarian cancer. This highlights the importance of sustained efforts to minimize asbestos exposure and protect public health.

Effectiveness of multiple health behavior change interventions in reducing symptoms of anxiety in the adult population: A systematic review and meta-analysis of randomized controlled trials

There is limited evidence regarding the effectiveness of preventive interventions for anxiety disorders. We aim to test the effectiveness of multiple health behavior change (MHBC) interventions in the reduction of symptoms of anxiety in the adult population. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted by searching the most relevant databases and registry platforms in the area. Reference lists of included articles and relevant systematic reviews and meta-analyses of MHBC interventions that examined anxiety or depression as outcomes were also manually searched. To identify RCTs that evaluated preventive interventions, we excluded studies in which the target population included only patients meeting the diagnostic criteria for anxiety disorders. To pool results, the standardized mean difference (SMD) was calculated using the random effects model. Sensitivity, subgroup and meta-regression analyses were performed. Forty-six RCTs were included in the qualitative synthesis, and 34 RCTs were included in the meta-analysis. Thirty RCTs were focused on promoting healthy diet and physical activity, whereas the other 16 studies also focused on smoking cessation. The pooled SMD was small (-0.183; 95% CI -0.276 to -0.091) but significant (p < 0.001). The effect became non-significant when only studies with a low risk of bias were included. There was substantial and significant heterogeneity between the studies. There is currently insufficient evidence regarding the effectiveness of MHBC interventions to reduce symptoms of anxiety in the adult population.

Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

Cognitive behavior therapy for adult eating disorders in routine clinical care: A systematic review and meta-analysis

OBJECTIVE

Cognitive behavior therapy (CBT) is a recommended treatment for eating disorders (ED) in adults given its evidence, mainly based on efficacy studies. However, little is known about how CBT works in routine clinical care. The goal of the present meta-analysis is to investigate how CBT works for various ED when carried out in routine clinical settings.

METHOD

Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until June 2023. The outcome of CBT, methodological quality, risk of bias (RoB), and moderators of treatment outcome were examined and benchmarked by meta-analytically comparing with efficacy studies for ED. Fifty studies comprising 4299 participants who received CBT were included.

RESULTS

Large within-group effect sizes (ES) were obtained for ED-psychopathology at post-treatment (1.12), and follow-up (1.22), on average 9.9 months post-treatment. Attrition rate was 25.5% and RoB was considerable in the majority of studies. The benchmarking analysis showed that effectiveness studies had very similar ESs as efficacy studies (1.20 at post-treatment and 1.28 at follow-up).

CONCLUSION

CBT for ED is an effective treatment when delivered in routine clinical care, with ESs comparable to those found in efficacy studies. However, the evidence needs to be interpreted with caution due to the RoB in a high proportion of studies.

PUBLIC SIGNIFICANCE

Eating disorders are common in the population and often lead to multiple negative consequences. CBT has been found effective for ED and is recommended in clinical guidelines. Since these recommendations are primarily based on university studies we wanted to investigate how CBT performs in routine clinical care. Our meta-analysis found that CBT worked as well in routine care as in university setting studies.

The Perils of Misinterpreting and Misusing "Publication Bias" in Meta-analyses: An Education Review on Funnel Plot-Based Methods

Publication bias refers to a systematic deviation from the truth in the results of a meta-analysis due to the higher likelihood for published studies to be included in meta-analyses than unpublished studies. Publication bias can lead to misleading recommendations for decision and policy making. In this education review, we introduce, explain, and provide solutions to the pervasive misuses and misinterpretations of publication bias that afflict evidence syntheses in sport and exercise medicine, with a focus on the commonly used funnel-plot based methods. Publication bias is more routinely assessed by visually inspecting funnel plot asymmetry, although it has been consistently deemed unreliable, leading to the development of statistical tests to assess publication bias. However, most statistical tests of publication bias (i) cannot rule out alternative explanations for funnel plot asymmetry (e.g., between-study heterogeneity, choice of metric, chance) and (ii) are grossly underpowered, even when using an arbitrary minimum threshold of ten or more studies. We performed a cross-sectional meta-research investigation of how publication bias was assessed in systematic reviews with meta-analyses published in the top two sport and exercise medicine journals throughout 2021. This analysis highlights that publication bias is frequently misused and misinterpreted, even in top tier journals. Because of conceptual and methodological problems when assessing and interpreting publication bias, preventive strategies (e.g., pre-registration, registered reports, disclosing protocol deviations, and reporting all study findings regardless of direction or magnitude) offer the best and most efficient solution to mitigate the misuse and misinterpretation of publication bias. Because true publication bias is very difficult to determine, we recommend that future publications use the term "risk of publication bias".

Global prevalence of perinatal depression and anxiety during the COVID-19 pandemic: An umbrella review and meta-analytic synthesis

INTRODUCTION

The prevalence of depression and anxiety symptoms in pregnant and postpartum women during the COVID-19 pandemic was assessed by several systematic reviews (SRs) and meta-analyses which provided contrasting and different results. We aimed to summarize the evidence relating to the global prevalence of anxiety and depression among pregnant and postpartum women during the COVID-19 pandemic.

MATERIAL AND METHODS

An umbrella review of SRs and meta-analyses was performed. Searches were conducted in electronic databases up to April 2023. SRs and meta-analyses reporting the prevalence of perinatal anxiety and depression during the COVID-19 pandemic were selected for eligibility. Primary studies extracted from eligible meta-analyses were included in the quantitative synthesis. The research protocol was registered on PROSPERO (CRD42020173125).

RESULTS

A total of 25 SRs (198 primary studies) and 12 meta-analyses (129 primary studies) were included in the qualitative and quantitative synthesis, respectively. Studies involved data from five continents and 45 countries. The pooled prevalence of antenatal and postpartum depression was 29% (n = 55; 95% CI: 25%-33%) and 26% (n = 54; 95% CI: 23%-30%), respectively. In the case of anxiety, the pooled antenatal and postnatal prevalence was 31% (n = 44; 95% CI: 26%-37%; n = 16; 95% CI: 24%-39%). Differences emerged between continents, with Africa having the highest prevalence of perinatal depression and Oceania and Europe having the highest prevalence of antenatal and postnatal anxiety. The prevalence also varied depending on the assessment tools, especially for antenatal anxiety. A medium-high quality of the studies was observed. One SR assessed strength-of-evidence, reporting very low strength.

CONCLUSIONS

During the COVID-19 pandemic, depression and anxiety were common, affecting almost one in three perinatal women globally. A high heterogeneity and a risk of publication bias were found, partially due to the variety of assessment tools and cut-offs. The results may not be generalized to minorities. Studies on the prevalence of clinical diagnoses are needed. Based on our results it is not possible to firmly affirm that the COVID-19 pandemic was the main factor that directly increased perinatal depression and anxiety during the past few years. Future studies should study other factors' impact.

Prevalence of medication adherence among adult asthmatic patients in four African countries: A systematic review and meta-analysis

Non-adherence to medications has many deleterious effects including poor treatment outcomes, increased economic burden, increased morbidity, hospitalization rate, health care utilization, productivity loss, and mortality. Therefore, this review aimed to estimate the pooled prevalence of medication adherence among asthmatic adults in 4 African countries. Primary studies were extensively searched from databases such as PubMed, HINARI, Cochrane Library, CINHALand, Google Scholar, and Google search engines. After screening and assessing the quality of studies, data were extracted using a checklist. Heterogeneity was assessed using forest plot, Chocran's Q Test and I2. The random effects meta-analysis model was employed to pool the prevalence of medication adherence among adult asthmatic patients in Africa. Sub-group analysis and meta-regression were performed to identify the sources of heterogeneity. Publication bias was assessed using funnel plots with Egger's test. A sensitivity analysis was performed to assess the influence of individual studies on the overall estimate. The review was performed among 16 studies of which 14 were cross-sectional with a total of 4019 participants. The pooled random effects prevalence of adherence to medications among adult patients with asthma in Africa was 39% (95% CI: 32, 47; p < 0.001) with a heterogeneity (I2 = 94.82, p < 0.001). The pooled prevalence of medication adherence among adult asthmatic patients in Africa is low. Researchers should conduct further multicenter longitudinal studies by using objective methods of adherence measurement.

Photobiomodulation improves depression symptoms: a systematic review and meta-analysis of randomized controlled trials

Background

Depression is a common mental illness that is widely recognized by its lack of pleasure, fatigue, low mood, and, in severe cases, even suicidal tendencies. Photobiomodulation (PBM) is a non-invasive neuromodulation technique that could treat patients with mood disorders such as depression.

Methods

A systematic search of ten databases, including randomized controlled trials (RCTs) for depression, was conducted from the time of library construction to September 25, 2023. The primary outcome was depression. The secondary outcome was sleep. Meta-analysis was performed using RevMan (version 5.4) and Stata (version 14.0). Subgroup analyses were performed to identify sources of heterogeneity. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

Results

Three thousand two hundred and sixty-five studies were retrieved from the database and screened for inclusion in eleven trials. The forest plot results demonstrated that PBM alleviated depression (SMD = -0.55, 95% CI [-0.75, -0.35], I2 = 46%). But it is not statistically significant for patients' sleep outcomes (SMD = -0.82, 95% CI [-2.41, 0.77], I2 = 0%, p > 0.05). Subgroup analysis showed that s-PBM was superior to t-PBM in relieving symptoms of depression. The best improvement for t-PBM was achieved using a wavelength of 823 nm, fluence of 10-100 J/cm2, irradiance of 50-100 mW/cm2, irradiance time of 30 min, treatment frequency < 3/week, and number of treatments >15 times. The best improvement for s-PBM was achieved using a wavelength of 808 nm, fluence ≤1 J/cm2, irradiance of 50-100 mW/cm2, irradiance time ≤ 5 min, treatment frequency ≥ 3/week, number of treatments >15 times. All results had evidence quality that was either moderate or very low, and there was no bias in publication.

Conclusion

We conclude that PBM is effective in reducing depression symptoms in patients. However, the current number of studies is small, and further studies are needed to extend the current analysis results.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42023444677.

Half of the adolescent idiopathic scoliosis patients may have lumbar adjacent segment degeneration following spinal fusion: A systemic review and meta-analysis

OBJECTIVE

This study aims to assess the impact of surgical approaches and other factors on the incidence of Adjacent Segment Degeneration (ASD) following Spinal Fusion for Adolescent Idiopathic Scoliosis (AIS).

METHODS

We conducted a comprehensive search of four electronic databases from their inception until March 30, 2023. Two independent reviewers screened titles, abstracts, and full texts and evaluated the methodological quality of the studies. A random-effects model was used to calculate the incidence of ASD.

RESULTS

Our analysis included 14 studies involving 651 individuals. The overall incidence of ASD was 47% (95%CI: 0.37, 0.56). Subgroup analyses revealed that the prevalence of ASD increased with postoperative time (53% (95%CI: 0.31, 0.75) versus 48% (95%CI: 0.36, 0.60) versus 39% (95%CI: 0.22, 0.56)). For the number of fused segments, a group with more than 10 segments had a higher prevalence (49% (95%CI: 0.38, 0.60) versus 44% (95%CI: 0.21, 0.69)). In terms of regions, East Asia had the highest prevalence, followed by Occident and West Asia (52% (95%CI: 0.41, 0.62) versus 43% (95%CI: 0.20, 0.68) versus 37% (95%CI: 0.17, 0.59)). However, the surgical approach, male ratio, and the position of the lowest instrumented vertebra (LIV) did not show significant differences between groups. Funnel plots and Egger's test did not reveal any significant publication bias (Egger's test: t = 1.62, p-value = .1274).

CONCLUSION

This meta-analysis found that nearly half of AIS patients following spinal fusion surgery experienced ASD. Long-term follow-up, regular screening, and timely interventions are essential to reduce the prevalence of ASD.

The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety.

DATA SOURCES

Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

STUDY ELIGIBILITY REQUIREMENTS

The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated.

RESULTS

Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I2=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I2=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]).

CONCLUSION

Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Effectiveness and safety of PD-1/PD-L1 inhibitors in advanced or recurrent endometrial cancer: a systematic review and meta-analysis

Background: Studies in recent years have shown that PD-1/PD-L1 inhibitors may have better effectiveness in patients with advanced or recurrent endometrial cancer. The effectiveness of PD-1/PD-L1 inhibitors is thought to be related to mismatch repair-deficient (dMMR) and mismatch repair-proficient (pMMR) classification in advanced or recurrent endometrial cancer. This study aims to evaluate the effectiveness of PD-1/PD-L1 inhibitors in patients classified as dMMR and pMMR. Methods: Medical databases were searched to identify relevant publications up to 30 November 2022. The primary outcome was comparison of objective response rate (ORR) in patients with dMMR and pMMR following treatment with PD-1/PD-L1 inhibitors; secondary outcomes were single-group ORR in patients with dMMR and in patients with pMMR, respectively. Results: Eleven studies were eligible for analysis and patients with advanced or recurrent endometrial cancer with molecular classification of dMMR had a higher total ORR than those with pMMR [odds ratio (OR), 7.70; 95% confidence interval (CI), 3.22-18.38; p < 0.01], with low evidence of between-study heterogeneity (I2 = 0%). The total ORR of patients with advanced or recurrent endometrial cancer with molecular type dMMR was 51.9% (95% CI, 33.6%-69.9%). The overall ORR of patients with advanced or recurrent endometrial cancer with molecular type pMMR was 16.1% (95% CI, 5.5%-30.3%). Conclusion: In our including studies, the patients with advanced or recurrent endometrial cancer with molecular types of dMMR and pMMR, following treatment with PD-1/PD-L1 inhibitors, the total ORR of patients with dMMR was higher than that of patients with pMMR. Since the current number of studies is not very large, it is possible that more studies will be published in the future and more precise results will be discussed further.

Could endothelial progenitor cells complement the diagnosis of inflammatory arthritis? A systematic review and meta-analysis

The objective of this meta-analysis was to systematically review existing evidence and evaluate variations in levels of circulating endothelial progenitor cells (EPCs) among individuals with psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), and rheumatoid arthritis (RA). Relevant studies were identified through database searches, and 20 records were enrolled. We used the fixed-effect model or random-effect model to estimate the pooled standardized mean difference (SMD) with 95% confidence intervals (CIs) in circulating EPC levels between inflammatory arthritis patients and controls. The results showed that circulating EPC levels differed among subtypes of inflammatory arthritis, with significantly lower levels in patients with RA (SMD = -0.848, 95% CI = -1.474 to -0.221, p = 0.008) and PsA (SMD = -0.791, 95% CI = -1.136 to -0.446, p < 0.001). However, no statistically significant difference was found in circulating EPC levels between patients with JIA and controls (SMD = -1.160, 95% CI = -2.578 to 0.259, p = 0.109). Subgroup analyses suggested that in patients with RA, circulating EPC levels were influenced by age, disease activity, and duration. Although many studies have investigated circulating EPC levels in patients with inflammatory arthritis, the results have been inconsistent. This meta-analysis offers a comprehensive overview of the existing evidence and emphasizes the association between levels of circulating EPCs and various types of arthritis. However, further research is needed to determine the specific mechanisms underlying the observed differences in EPC levels in different types of arthritis and to establish the clinical utility of this biomarker.

Effectiveness of behavioural economics-informed interventions to promote physical activity: A systematic review and meta-analysis

OBJECTIVE

For beneficial health outcomes sufficient and sustained physical activity levels are recommended but difficult to achieve. This systematic review evaluates the effectiveness of behavioural economics (BE)-informed interventions to increase individuals' physical activity level in the long-term.

METHODS

We conducted a systematic literature search using Medline (via PubMed), PsycInfo, and EconLit (both via EBSCOhost) including randomized controlled trials of at least 24 weeks duration that evaluated BE-informed interventions to promote physical activity in adults. Potential BE approaches were commitment devices, social incentives, motivational feedback, goal setting, gamification, and financial incentives. Risk of bias was assessed using the revised Cochrane risk-of-bias tool for (cluster-) randomized trials. A random-effects meta-analysis was conducted to summarize the outcome measure daily step count.

RESULTS

Based on 13 studies with 4347 participants, the BE-informed interventions most often applied were commitment lotteries (n = 8) and social incentives (n = 7). Risk of bias assessment classified five studies as low, six as moderate, and two as high risk of bias. Significant results on study level towards BE-informed interventions were observed for commitment lotteries (n = 3) and gamification (n = 4). Including healthy and diseased individuals in the meta-analysis (n = 10), the increase in daily step count in experimental groups compared to control was statistically significant for the intervention period (standardized mean difference (SMD) = 0.13, 95%-CI: 0.00-0.25, I2 = 59%, p = 0.04) but not for the follow-up (SMD = 0.08, 95%-CI: -0.00-0.17, I2 = 17%, p = 0.06). Excluding high risk of bias studies (n = 2) resulted in statistically significant effects with reduced heterogeneity for both periods.

CONCLUSION

Our review reveals a potential effect of BE-informed interventions to promote physical activity. The small effect underlines the importance to evaluate the behavioural channels which may explain the heterogeneity in individuals' responses to BE strategies.

Significant potential of melatonin therapy in Parkinson's disease - a meta-analysis of randomized controlled trials

Objective

Since its discovery as an antioxidant, melatonin has been increasingly recognized for its therapeutic potential beyond sleep disturbances in neurodegenerative disorders. This study aims to evaluate efficacy of various melatonin doses, treatment durations, and formulations, in alleviating motor symptoms and sleep disturbances in Parkinson's disease, the second most common neurodegenerative disorder worldwide.

Methods

PubMed, Cochrane Library, ClinicalTrials.gov and other databases were systematically searched to retrieve randomized controlled trials (RCTs) administrating melatonin to Parkinson's disease patients until June 10th, 2023. Outcomes including Unified Parkinson Disease Rating Scale (UPDRS) scores and Pittsburgh Sleep Quality Index (PSQI) scores, were pooled and reported as mean differences (MD) with 95% confidence intervals (CIs). Meta-analysis was performed using an inverse variance random-effects model in Review Manager 5.4 software. Trial Sequential Analysis was performed to avoid false-positive results from random errors.

Results

Five RCTs with a total of 155 patients were included. Statistically significant reductions in UPDRS total scores were observed in groups receiving Melatonin ≥10 mg/day (MD = -11.35, 95% CI: -22.35 to -0.35, I2 = 0%, p = 0.04) and immediate release formulations (MD = -11.35, 95% CI: -22.35 to -0.35, I2 = 0%, p = 0.04). No significant effects on individual UPDRS II, III, and IV scores were observed, regardless of melatonin dosage and treatment duration. Moreover, significant improvements in PSQI scores were observed with only immediate-release melatonin formulations (MD = -2.86, 95% CI: -4.74 to -0.97, I2 = 0%, p = 0.003).

Conclusion

Melatonin ≥10 mg/day for a minimum duration of ≥12 weeks in immediate-release formulations consistently demonstrated significant therapeutic potential in improving motor symptom and sleep disturbances in Parkinson disease. However, further trials are warranted to investigate its impact when initiated early in the disease course to fully explore its true therapeutic potential.

Systematic review registration

Unique identifier: CRD42023427491 (PROSPERO).

Risk of long COVID main symptoms after SARS-CoV-2 infection: a systematic review and meta-analysis

This review aimed to summarise the relative risk (RR) of the main symptoms of long COVID in people infected with SARS-CoV-2 compared to uninfected controls, as well as the difference in health-related quality of life (HRQoL) after infection. MEDLINE, EMBASE, PubMed, NLM-LitCovid, WHO-COVID-19, arXiv and Europe-PMC were searched up to 23rd March 2022. Studies reporting risk (four or more weeks after infection) of fatigue, shortness of breath, and cognitive dysfunction, as well as comparative HRQoL outcomes, were included. Pairwise random-effects meta-analyses were performed to pool risks of individual symptoms. Thirty-three studies were identified; twenty studies reporting symptom risks were included in the meta-analyses. Overall, infection with SARS-CoV-2 carried significantly higher risk of fatigue (RR 1.72, 95% confidence intervals [CIs] 1.41, 2.10), shortness of breath (RR 2.60, 95% CIs 1.96, 3.44), memory difficulties (RR 2.53, 95% CIs 1.30, 4.93), and concentration difficulties (RR 2.14, 95% CIs 1.25, 3.67). Quality of life findings were varied and comparisons between studies were challenging due to different HRQoL instruments used and study heterogeneity, although studies indicated that severe hospitalised COVID is associated with a significantly poorer HRQoL after infection. These risks are likely to constantly change as vaccines, reinfections, and new variants alter global immunity.

The prognostic effects of circulating myeloid-derived suppressor cells in non-small cell lung cancer: systematic review and meta-analysis

Immunotherapy is the main standard treatment for non-small cell lung cancer (NSCLC) patients. Immune suppressive cells in tumor microenvironment can counteract its efficacy. Myeloid-derived suppressor cells (MDSCs) include two major subsets: polymorphonuclear (PMN-MDSCs) and monocytic (M-MDSCs). Many studies explored the prognostic impact of these cell populations in NSCLC patients. The aim of this systematic review is to select studies for a meta-analysis, which compares prognosis between patients with high vs low circulating MDSC levels. We collected hazard ratios (HRs) and relative 95% confidence intervals (CIs) in terms of progression-free survival (PFS) or recurrence-free survival (RFS), and overall survival (OS). Among 139 studies retrieved from literature search, 14 eligible studies (905 NSCLC patients) met inclusion criteria. Low circulating MDSC levels favor a better PFS/RFS (HR = 1.84; 95% CI = 1.28-2.65) and OS (HR = 1.78; 95% CI = 1.29-2.46). The subgroup analysis based on MDSC subtypes (total-, PMN-, and M-MDSCs) obtained a statistical significance only for M-MDSCs, both in terms of PFS/RFS (HR = 2.67; 95% CI = 2.04-3.50) and OS (HR = 2.10; 95% CI = 1.61-2.75). NSCLC patients bearing high M-MDSC levels in peripheral blood experience a worse prognosis than those with low levels, both in terms of PFS/RFS and OS. This finding suggests that detecting and targeting this MDSC subset could help to improve NSCLC treatment efficacy.

Effects of non-pharmacological interventions on depressive symptoms and risk of major depressive disorder in adults with subthreshold depression: A systematic review and meta-analysis

Subthreshold depression (StD) is a condition that significantly reduces the quality of life and increases the risk of developing major depressive disorder (MDD). In order to investigate the effectiveness of non-pharmacological interventions (NPIs) in preventing the onset of MDD and improving depressive symptoms in adults with StD (AStDs), we conducted a systematic search of nine databases and included a total of 15 studies. Standardized mean differences (SMDs) were calculated using random effects models. RoB2 tool and GRADEpro software were used to assess the methodological quality and evidence. Funnel plots, Egger's, and Begg's tests were used to analyze publication bias. Sensitivity, subgroup and meta-regression analyses were performed to explore potential sources of heterogeneity. The results showed that NPIs had a significant effect in preventing the onset of MDD and improving depressive symptoms. Subgroup analysis revealed that NPIs were particularly effective in general adult populations, during short-term follow-up (FU) periods, among pregnant women, and in universal prevention programs. The results were found to be robust and credible, as they were less sensitive to changes in the analysis method. Timely detection and treatment of StD is feasible and important, as it can effectively delay or prevent the onset of MDD.

Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis

BACKGROUND

Hip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS).

METHOD

We searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I² < 50%). Otherwise, the random effects model was selected (heterogeneity, I² > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant.

RESULTS

30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05).

CONCLUSIONS

Our meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.

Stereotactic body radiotherapy for Ultra-Central lung Tumors: A systematic review and Meta-Analysis and International Stereotactic Radiosurgery Society practice guidelines

BACKGROUND

Stereotactic body radiotherapy (SBRT) is an effective and safe modality for early-stage lung cancer and lung metastases. However, tumors in an ultra-central location pose unique safety considerations. We performed a systematic review and meta-analysis to summarize the current safety and efficacy data and provide practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS).

METHODS

We performed a systematic review using PubMed and EMBASE databases of patients with ultra-central lung tumors treated with SBRT. Studies reporting local control (LC) and/or toxicity were included. Studies with <5 treated lesions, non-English language, re-irradiation, nodal tumors, or mixed outcomes in which ultra-central tumors could not be discerned were excluded. Random-effects meta-analysis was performed for studies reporting relevant endpoints. Meta-regression was conducted to determine the effect of various covariates on the primary outcomes.

RESULTS

602 unique studies were identified of which 27 (one prospective observational, the remainder retrospective) were included, representing 1183 treated targets. All studies defined ultra-central as the planning target volume (PTV) overlapping the proximal bronchial tree (PBT). The most common dose fractionations were 50 Gy/5, 60 Gy/8, and 60 Gy/12 fractions. The pooled 1- and 2-year LC estimates were 92 % and 89 %, respectively. Meta-regression identified biological effective dose (BED10) as a significant predictor of 1-year LC. A total of 109 grade 3-4 toxicity events, with a pooled incidence of 6 %, were reported, most commonly pneumonitis. There were 73 treatment related deaths, with a pooled incidence of 4 %, with the most common being hemoptysis. Anticoagulation, interstitial lung disease, endobronchial tumor, and concomitant targeted therapies were observed risk factors for fatal toxicity events.

CONCLUSION

SBRT for ultra-central lung tumors results in acceptable rates of local control, albeit with risks of severe toxicity. Caution should be taken for appropriate patient selection, consideration of concomitant therapies, and radiotherapy plan design.

The success rate of radiofrequency catheter ablation in Wolff-Parkinson-White-Syndrome patients: A systematic review and meta-analysis

INTRODUCTION

radiofrequency catheter ablation (RFA) is the first-line therapy for symptomatic Wolff Parkinson White (WPW) patients according to the American Heart Association. We conducted this study to assess the success rate, recurrence rate, and rate of complications associated with the utilization of radiofrequency catheter ablation for managing patients with WPW.

METHOD

We searched PubMed, Cochrane library, Web of Science and Scopus databases using all identified keywords and index terms through 4 January 2022. We included all studies conducted on WPW patients who were treated with ablation. We conducted the analysis using Open Meta Analyst and MedCalc version 19.1.

RESULTS

Among 2268 unique articles identified, only 11 articles met our inclusion criteria. The pooled effect estimates showed high success rate (94.1%[95%CI:92.3-95.9], p < 0.001)), low recurrence rate (6.2% [95%CI:4.5-7.8, p < 0.001]) and low rate of complications (1%[95%CI:0.4-1.5, p < 0.001]).

CONCLUSION

RFA showed a high success rate, low recurrence rate and low rate of complications in WPW patients.