Systematic reviews of evaluations of prognostic variables

Comparing suicide completion rates in bipolar I versus bipolar II disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) has a high disease burden and the highest mortality risk in BD comes from suicide. Bipolar disorder type II (BD-II) has been described as a milder form of bipolar disorder; however, extant literature is inconsistent with this description and instead describe illness burden and notably suicidality comparable to persons with bipolar I disorder (BD-I). Towards quantifying the hazard of BD-II, herein we aim via systematic review and meta-analysis to evaluate the rates of completed suicide in BD-I and BD-II.

METHOD

We conducted a literature search on PubMed, OVID (Embase, Medline) and PsychINFO databases from inception to June 30th, 2023, according to PRISMA guidelines. Articles were selected based on the predetermined eligibility criteria. A meta-analysis was performed, comparing the risk of completed suicide between individuals diagnosed with BD-I to BD-II.

RESULTS

Four out of eight studies reported higher suicide completion rates in persons living with BD-II when compared to persons living with BD-I; however, two of the studies reported non-significance. Two studies reported significantly higher suicide completion rates for BD-I than BD-II. The pooled odds ratio of BD-II suicide rates to BD-I was 1.00 [95 % CI = 0.75, 1.34].

LIMITATIONS

The overarching limitation is the small number of studies and heterogeneity of studies that report on suicide completion in BD-I and BD-II.

CONCLUSION

Our study underscores the severity of BD-II, with a risk for suicide not dissimilar from BD-I. The greater propensity to depression, comorbidity and rapid-cycling course reported in BD-II are contributing factors to the significant mortality hazard in BD-II.

The role of piRNAs in predicting and prognosing in cancer: a focus on piRNA-823 (a systematic review and meta-analysis)

INTRODUCTION

This article examines the potential of using liquid biopsy with piRNAs to study cancer survival outcomes. While previous studies have explored the relationship between piRNA expression and cancer patient outcomes, a comprehensive investigation is still lacking. To address this gap, we conducted a systematic review and meta-analysis of existing literature.

METHODS

We searched major online databases up to February 2024 to identify articles reporting on the role of piRNA in cancer patient survival outcomes. Our meta-analysis used a random-effects model to pool hazard ratios with 95% confidence intervals (CI) and assess the prognostic value of deregulated piRNA-823. For survival analysis, the Kaplan-Meier method and COX analysis were used.

RESULTS

Out of 6104 articles screened, 20 met our inclusion criteria. Our analysis revealed that dysregulated piRNA expression is associated with cancer patient survival outcomes. Specifically, our meta-analysis found that overexpression of piR-823 is significantly linked with poorer overall survival in patients with colorectal cancer and renal cell cancer (HR: 3.82, 95% CI = [1.81, 8.04], I2 = 70%).

CONCLUSION

Our findings suggest that various piRNAs may play a role in cancer survival outcomes and that piRNA-823 in particular holds promise as a prognostic biomarker for multiple human cancers.

IMPLICATIONS FOR CANCER SURVIVORS

Our systematic review and meta-analysis of piRNA-823 has important implications for cancer survivors. Our findings suggest that piRNA-823 can be used as a prognostic biomarker for predicting cancer recurrence and survival rates. This information can help clinicians develop personalized treatment plans for cancer survivors, which can improve their quality of life and reduce the risk of recurrence.

The clinical course of acute, subacute and persistent low back pain: a systematic review and meta-analysis

BACKGROUND

Understanding the clinical course of low back pain is essential to informing treatment recommendations and patient stratification. Our aim was to update our previous systematic review and meta-analysis to gain a better understanding of the clinical course of acute, subacute and persistent low back pain.

METHODS

To update our 2012 systematic review and meta-analysis, we searched the Embase, MEDLINE and CINAHL databases from 2011 until January 2023, using our previous search strategy. We included prospective inception cohort studies if they reported on participants with acute (< 6 wk), subacute (6 to less than 12 wk) or persistent (12 to less than 52 wk) nonspecific low back pain at study entry. Primary outcome measures included pain and disability (0-100 scale). We assessed risk of bias of included studies using a modified tool and assessed the level of confidence in pooled estimates using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. We used a mixed model design to calculate pooled estimates (mean, 95% confidence interval [CI]) of pain and disability at 0, 6, 12, 26 and 52 weeks. We treated time in 2 ways: time since study entry (inception time uncorrected) and time since pain onset (inception time corrected). We transformed the latter by adding the mean inception time to the time of study entry.

RESULTS

We included 95 studies, with 60 separate cohorts in the systematic review (n = 17 974) and 47 cohorts (n = 9224) in the meta-analysis. Risk of bias of included studies was variable, with poor study attrition and follow-up, and most studies did not select participants as consecutive cases. For the acute pain cohort, the estimated mean pain score with inception time uncorrected was 56 (95% CI 49-62) at baseline, 26 (95% CI 21-31) at 6 weeks, 22 (95% CI 18-26) at 26 weeks and 21 (95% CI 17-25) at 52 weeks (moderate-certainty evidence). For the subacute pain cohort, the mean pain score was 63 (95% CI 55-71) at baseline, 29 (95% CI 22-37) at 6 weeks, 29 (95% CI 22-36) at 26 weeks and 31 (95% 23-39) at 52 weeks (moderate-certainty evidence). For the persistent pain cohort, the mean pain score was 56 (95% CI 37-74) at baseline, 48 (95% CI 32-64) at 6 weeks, 43 (95% CI 29-57) at 26 weeks and 40 (95% CI 27-54) at 52 weeks (very low-certainty evidence). The clinical course of disability was slightly more favourable than the clinical course of pain.

INTERPRETATION

Participants with acute and subacute low back pain had substantial improvements in levels of pain and disability within the first 6 weeks ( moderate-certainty evidence); however, participants with persistent low back pain had high levels of pain and disability with minimal improvements over time (very low-certainty evidence). Identifying and escalating care in individuals with subacute low back pain who are recovering slowly could be a focus of intervention to reduce the likelihood of transition into persistent low back pain.

PROTOCOL REGISTRATION

PROSPERO - CRD42020207442.

Indocyanine green clearance tests to assess liver transplantation outcomes: a systematic review

BACKGROUND

Liver transplantation (LT) is the gold standard for end-stage liver disease, yet postoperative complications challenge patients and physicians. Indocyanine green (ICG) clearance, a quantitative dynamic test of liver function, is a rapid, reproducible, and reliable test of liver function. This study aimed to systematically review and summarize current literature analyzing the association between ICG tests and post-LT outcomes.

METHODS

This systematic review was conducted according to PRISMA guidelines. MEDLINE and Cochrane Library, as main databases, and other sources were searched until August 2022 to identify articles reporting the prognostic value of postoperative ICG tests associated with outcomes of adult LT recipients.Risk of bias of included articles was assessed using Quality In Prognosis Studies tool. Methodological quality varied from low to high across risk of bias domains.

RESULTS

Six studies conducted between 1994 and 2018 in Europe, America, and Asia were included. The study population ranged from 50 to 332 participants. ICG clearance on the first postoperative day was associated with early allograft dysfunction, graft loss, 1-month and 3-month patient survival probability, prolonged ICU, and hospital stay. The dichotomized ICG plasma disappearance rate (PDR) provided a strong association with medium-term and long-term outcomes: PDR less than 10%/min with 1-month mortality or re-transplantation (odds ratio: 7.89, 95% CI 3.59-17.34, P <0.001) and PDR less than 16.0%/min with 3-month patient survival probability (hazard ratio: 13.90, 95% CI 4.67-41.35, P <0.01). The preoperative model for end-stage liver disease and body mass index were independent prognostic factors for early allograft dysfunction, early complications, and prolonged ICU stay; post-LT prothrombin time and INR were independently associated with graft loss and bilirubin with a prolonged hospital stay.

CONCLUSION

This review shows that ICG clearance tests are associated with graft function recovery, suggesting that a potential prognostic role of ICG test, as an aid in predicting the post-LT course, could be considered.

Postprandial plasma GLP-1 levels are elevated in individuals with postprandial hypoglycaemia following Roux-en-Y gastric bypass - a systematic review

BACKGROUND AND AIMS

Bariatric surgery is the most effective treatment in individuals with obesity to achieve remission of type 2 diabetes. Post-bariatric surgery hypoglycaemia occurs frequently, and management remains suboptimal, because of a poor understanding of the underlying pathophysiology. The glucoregulatory hormone responses to nutrients in individuals with and without post-bariatric surgery hypoglycaemia have not been systematically examined.

MATERIALS AND METHODS

The study protocol was prospectively registered with PROSPERO. PubMed, EMBASE, Web of Science and the Cochrane databases were searched for publications between January 1990 and November 2021 using MeSH terms related to post-bariatric surgery hypoglycaemia. Studies were included if they evaluated individuals with post-bariatric surgery hypoglycaemia and included measurements of plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin, C-peptide and/or glucagon concentrations following an ingested nutrient load. Glycated haemoglobin (HbA1c) was also evaluated. A random-effects meta-analysis was performed, and Hedges' g (standardised mean difference) and 95% confidence intervals were reported for all outcomes where sufficient studies were available. The τ2 estimate and I2 statistic were used as tests for heterogeneity and a funnel plot with the Egger regression-based test was used to evaluate for publication bias.

RESULTS

From 377 identified publications, 12 were included in the analysis. In all 12 studies, the type of bariatric surgery was Roux-en-Y gastric bypass (RYGB). Comparing individuals with and without post-bariatric surgery hypoglycaemia following an ingested nutrient load, the standardised mean difference in peak GLP-1 was 0.57 (95% CI, 0.32, 0.82), peak GIP 0.05 (-0.26, 0.36), peak insulin 0.84 (0.44, 1.23), peak C-peptide 0.69 (0.28, 1.1) and peak glucagon 0.05 (-0.26, 0.36). HbA1c was less in individuals with hypoglycaemia - 0.40 (-0.67, -0.12). There was no evidence of substantial heterogeneity in any outcome except for peak insulin: τ2 = 0.2, I2 = 54.3. No publication bias was evident.

CONCLUSION

Following RYGB, postprandial peak plasma GLP-1, insulin and C-peptide concentrations are greater in individuals with post-bariatric surgery hypoglycaemia, while HbA1c is less. These observations support the concept that antagonism of GLP-1 would prove beneficial in the management of individuals with hypoglycaemia following RYGB.PROSPERO Registration Number: CRD42021287515.

Effectiveness of community mobilisation and group-based interventions for preventing intimate partner violence against women in low- and middle-income countries: A systematic review and meta-analysis

Background

Intimate partner violence (IPV) is a challenge affecting one in three women in their lifetime, and gender-transformative interventions have been identified as a promising prevention strategy. We systematically reviewed and meta-analysed randomised controlled trials (RCTs) of community-level or group-based interventions to prevent IPV in lower- and middle-income countries, seeking to answer the following research question: do community- or group-based gender-transformative interventions reduce IPV, compared to a control arm of status-quo programming?

Methods

We conducted a systematic search from the inception of all databases employed until 20 July 2021. Eligible study outcomes included past-year experience of physical, sexual, emotional or economic IPV self-reported by women and perpetration of physical or sexual IPV self-reported by men. We assessed study risk of bias using the updated Cochrane tool for RCTs. We estimated the pooled odds ratio (OR) using a multilevel random-effects meta-analysis and also conducted a multilevel meta-regression to analyse how study characteristics moderated the effect size.

Results

After screening 7363 unique records, we included 30 studies on 27 unique RCTs. Our meta-analysis suggested that community-level or group-based interventions reduced the odds of women experiencing IPV in the past year: pooled adjusted odds ratio (aOR) = 0.78; 95% confidence interval (CI) = 0.63-0.97. While there was significant heterogeneity in the effect sizes between trials (I2 = 83%), potentially reflecting the diverse contexts of the included trials, our meta-regression did not indicate a significant association between intervention effectiveness and intervention type or target population. There was evidence of significant associations between effectiveness and intervention components and duration.

Discussion

There is strong evidence that community-level and group-based interventions reduce IPV against women. Unpacking what intervention modalities are effective in which contexts can further inform prevention strategies.

Registration

PROSPERO (CRD42021290193).

Sham controls in device trials for chronic pain - tricky in practice-a review article

Background

Chronic pain affects one in four people and this figure is likely to increase further in line with an ageing population. Efforts to evaluate nonpharmacological interventions to support this patient population have become a priority for pain research. For device trials, the use of a sham control can add to the scientific validity and quality of a study. However, only a small proportion of pain trials include a sham control, and many are of poor quality. To facilitate the conduct of high-quality trials there is a need for a comprehensive overview to guide researchers within this area. The objective of this review was to synthesise the published data to address this need.

Methods

We identified studies that considered the evaluation, design, and conduct of sham-controlled trials in chronic pain by searching MEDLINE, CINAHL and Science Direct to November 2022. Studies that included sufficient content to inform the conduct/design of future research were included. An inductive thematic analysis approach was used to identify themes that require consideration when conducting sham-controlled trials. These are presented as a narrative review.

Results

37 articles were included. Identified themes related to the type of sham device, sham design, bias, study population and ethics.

Conclusions

To conduct good quality research the challenges surrounding the use of sham interventions need to be better considered. We highlight salient issues and provide recommendations for the conduct and reporting of sham-controlled device trials in chronic pain.

Microalbuminuria and mortality in individuals with coronary heart disease: A meta-analysis of a prospective study

AIM

Microalbuminuria has been elevated as an outcome predictor in cardiovascular medicine. However, due to the small number of studies investigating the association of microalbuminuria and mortality in the coronary heart disease (CHD) population, the prognosis value of microalbuminuria in CHD remains under debate. The objective of this meta-analysis was to investigate the relationship between microalbuminuria and mortality in individuals with CHD.

METHOD

A comprehensive literature search was performed using Pubmed, EuroPMC, Science Direct, and Google Scholar from 2000 to September 2022. Only prospective studies investigating microalbuminuria and mortality in CHD patients were selected. The pooled effect estimate was reported as risk ratio (RR).

RESULTS

5176 patients from eight prospective observational studies were included in this meta-analysis. Individuals with CHD have a greater overall risk of all-cause mortality (ACM) [rR = 2.07 (95% CI = 1.70-2.44); p = 0.0003; I2 = 0.0%] as well as cardiovascular mortality (CVM) [rR = 3.23 (95% CI = 2.06-4.39), p < 0.0001; I2 = 0.0%]. Subgroup analysis based on follow-up duration and a subset of CHD patients were similarly associated with an increased risk of ACM.

CONCLUSION

This meta-analysis indicates that microalbuminuria is associated with a higher risk of mortality in individuals with CHD. Microalbuminuria can serve as a predictor of poor outcomes in CHD patients.

Prognostic factors for chronic post-surgical pain after lung and pleural surgery: a systematic review with meta-analysis, meta-regression and trial sequential analysis

Chronic post-surgical pain is known to be a common complication of thoracic surgery and has been associated with a lower quality of life, increased healthcare utilisation, substantial direct and indirect costs, and increased long-term use of opioids. This systematic review with meta-analysis aimed to identify and summarise the evidence of all prognostic factors for chronic post-surgical pain after lung and pleural surgery. Electronic databases were searched for retrospective and prospective observational studies as well as randomised controlled trials that included patients undergoing lung or pleural surgery and reported on prognostic factors for chronic post-surgical pain. We included 56 studies resulting in 45 identified prognostic factors, of which 16 were pooled with a meta-analysis. Prognostic factors that increased chronic post-surgical pain risk were as follows: higher postoperative pain intensity (day 1, 0-10 score), mean difference (95%CI) 1.29 (0.62-1.95), p < 0.001; pre-operative pain, odds ratio (95%CI) 2.86 (1.94-4.21), p < 0.001; and longer surgery duration (in minutes), mean difference (95%CI) 12.07 (4.99-19.16), p < 0.001. Prognostic factors that decreased chronic post-surgical pain risk were as follows: intercostal nerve block, odds ratio (95%CI) 0.76 (0.61-0.95) p = 0.018 and video-assisted thoracic surgery, 0.54 (0.43-0.66) p < 0.001. Trial sequential analysis was used to adjust for type 1 and type 2 errors of statistical analysis and confirmed adequate power for these prognostic factors. In contrast to other studies, we found that age had no significant effect on chronic post-surgical pain and there was not enough evidence to conclude on sex. Meta-regression did not reveal significant effects of any of the study covariates on the prognostic factors with a significant effect on chronic post-surgical pain. Expressed as grading of recommendations, assessment, development and evaluations criteria, the certainty of evidence was high for pre-operative pain and video-assisted thoracic surgery, moderate for intercostal nerve block and surgery duration and low for postoperative pain intensity. We thus identified actionable factors which can be addressed to attempt to reduce the risk of chronic post-surgical pain after lung surgery.

Clinical outcomes of antimicrobial resistance in cancer patients: a systematic review of multivariable models

BACKGROUND

Infections are major causes of disease in cancer patients and pose a major obstacle to the success of cancer care. The global rise of antimicrobial resistance threatens to make these obstacles even greater and hinder continuing progress in cancer care. To prevent and handle such infections, better models of clinical outcomes building on current knowledge are needed. This internally funded systematic review (PROSPERO registration: CRD42021282769) aimed to review multivariable models of resistant infections/colonisations and corresponding mortality, what risk factors have been investigated, and with what methodological approaches.

METHODS

We employed two broad searches of antimicrobial resistance in cancer patients, using terms associated with antimicrobial resistance, in MEDLINE and Embase through Ovid, in addition to Cinahl through EBSCOhost and Web of Science Core Collection. Primary, observational studies in English from January 2015 to November 2021 on human cancer patients that explicitly modelled infection/colonisation or mortality associated with antimicrobial resistance in a multivariable model were included. We extracted data on the study populations and their malignancies, risk factors, microbial aetiology, and methods for variable selection, and assessed the risk of bias using the NHLBI Study Quality Assessment Tools.

RESULTS

Two searches yielded a total of 27,151 unique records, of which 144 studies were included after screening and reading. Of the outcomes studied, mortality was the most common (68/144, 47%). Forty-five per cent (65/144) of the studies focused on haemato-oncological patients, and 27% (39/144) studied several bacteria or fungi. Studies included a median of 200 patients and 46 events. One-hundred-and-three (72%) studies used a p-value-based variable selection. Studies included a median of seven variables in the final (and largest) model, which yielded a median of 7 events per variable. An in-depth example of vancomycin-resistant enterococci was reported.

CONCLUSIONS

We found the current research to be heterogeneous in the approaches to studying this topic. Methodological choices resulting in very diverse models made it difficult or even impossible to draw statistical inferences and summarise what risk factors were of clinical relevance. The development and adherence to more standardised protocols that build on existing literature are urgent.

Some magnetic resonance imaging findings may predict future low back pain and disability: a systematic review

QUESTIONS

Do magnetic resonance imaging (MRI) findings predict future low back pain (LBP), associated disability and global recovery in people with current LBP? Do MRI findings predict these outcomes in people with no current LBP? Do MRI findings predict these outcomes in a mixed sample of people with and without current LBP?

DESIGN

This review is an update of a previous systematic review investigating the relationship between lumbar spine MRI findings and future LBP.

PARTICIPANTS

People with or without LBP with lumbar MRI scans.

OUTCOME MEASURES

MRI findings, pain and disability.

RESULTS

Of the included studies, 28 reported on participants with current LBP, eight reported on participants with no LBP and four reported on a mixed sample. Most results were based on single studies and did not demonstrate clear relationships between MRI findings and future LBP. In populations with current LBP, pooling demonstrated that the presence of Modic type 1 changes alone or Modic type 1 and 2 changes were associated with slightly worse pain or disability outcomes in the short term, and the presence of disc degeneration was associated with worse pain and disability outcomes in the long term. In populations with current LBP, pooling demonstrated no evidence of an association between the presence of nerve root compression and disability outcomes in the short term, and no evidence of an association between the presence of disc height reduction, disc herniation, spinal stenosis, high-intensity zone and clinical outcomes in the long term. In populations with no LBP, pooling demonstrated that the presence of disc degeneration may increase the likelihood of experiencing pain in the long term. In mixed populations, no pooling was possible; however, single studies demonstrated that Modic type 1, 2 or 3 changes and disc herniation were each associated with worse pain in the long term.

CONCLUSIONS

The results suggest that some MRI findings may have weak associations with future LBP; however, larger high-quality studies are needed to resolve uncertainty.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021252919.

Biological and psychological early prognostic factors in complex regional pain syndrome: A systematic review

BACKGROUND AND OBJECTIVE

Several risk factors for the onset of CRPS have been found, but evidence for prognostic factors associated with the progression of this condition remains sparse. However, the detection and management of these factors are necessary to design secondary prevention strategies. The objective of this systematic review was to identify prognostic factors in adult individuals with early CRPS.

DATABASE AND DATA TREATMENT

PubMed, Embase, PsycINFO, Cochrane Library and Scopus, were published between January 1990 and November 2021. Two independent investigators selected cross-sectional and longitudinal studies looking at early (<12 weeks from onset) prognostic factors for pain, CRPS severity score, disability, return to work, or quality of life. The quality in prognostic studies (QUIPS) tool was used to assess the risk of bias. A qualitative meta-synthesis was performed.

RESULTS

Out of 4652 different articles, six studies met the inclusion criteria. We identified 21 early factors associated with a poorer prognosis in type I CRPS. We found moderate evidence to support six of them: higher pain intensity, self-rated disability, anxiety, pain-related fear, being a female and high-energy triggering event. Only two studies had an overall low risk of bias.

CONCLUSIONS

This study showed an important lack of information on early prognostic factors in CRPS. Only one article investigated the link with psychological characteristics. There is a crucial need for larger studies, with a well-defined population using validated measures.

SIGNIFICANCE

This systematic review highlights the lack of knowledge about early prognostic factors in CRPS. A few putative prognostic factors were identified. Most of the moderate evidence is related to a single cohort. Future research is required to find out which patients are vulnerable to chronification.

The effectiveness of intratissue percutaneous electrolysis for the treatment of tendinopathy: a systematic review

Background

Tendinopathy is highly prevalent in the general public and common in athletes. It makes up nearly 50% of all sport injuries. A number of treatment techniques with varying evidence of effectiveness are currently available. Intratissue percutaneous electrolysis (EPI) is one such modality, however little consensus exists for EPI's efficacy or the most effective treatment parameters.

Objective

To review and appraise available evidence for Intratissue Percutaneous Electrolysis (EPI) in the treatment of tendinopathy, examining the effectiveness of EPI in conjunction with other modalities and identifying the strengths and limitations of the evidence base for EPI in order to make evidence-based recommendation for future studies of EPI.

Methods

PubMed, Embase and Scopus were searched with keywords related to EPI and tendinopathy. Grey literature searches were conducted with Embase, OpenGrey, and ProQuest. Extensive citation searching was undertaken. Randomised controlled trials (RCTs), uncontrolled and observational studies of the application of EPI in patients aged 18-65 years with Magnetic Resonance Imaging (MRI) or clinical Ultrasonography (US) confirmed diagnosis of tendinopathy were eligible.

Results

Eleven studies met inclusion criteria: six randomised control trials (RCTs) and five uncontrolled studies. Clinical trials of EPI as an adjunct modality with physical therapy reporting greater decreased pain and return to function than treatment with physical therapy alone. The evidence for EPI is limited and influenced by small sample sizes, varying treatment protocols, clinical heterogeneity and high risk of bias.

Conclusion

It is currently not possible to conclude that EPI is an effective modality for the treatment of tendinopathy. RCTs with clearly described EPI treatment protocols, larger sample sizes and intervention reporting sufficient to support reproducibility are needed to determine the effectiveness of EPI for the treatment of tendinopathy.

The prognostic value of elevated neutrophil-lymphocyte ratio for cardiac surgery-associated acute kidney injury: A systematic review and meta-analysis

BACKGROUND

Patients undergoing cardiac surgery are at significant risk of developing postoperative acute kidney injury (AKI). Neutrophil-lymphocyte ratio (NLR) is a widely available inflammatory biomarker which may be of prognostic value in this setting.

METHODS

We conducted a systematic review and meta-analysis of studies reporting associations between perioperative NLR with postoperative AKI. We searched Medline, Embase and the Cochrane Library, without language restriction, from inception to May 2022 for relevant studies. We meta-analysed the reported odds ratios (ORs) with 95% confidence intervals (CIs) for both elevated preoperative and postoperative NLR with risk of postoperative AKI and need for renal replacement therapy (RRT). We conducted a meta-regression to explore inter-study statistical heterogeneity.

RESULTS

Twelve studies involving 10,724 participants undergoing cardiac surgery were included, with eight studies being deemed at high risk of bias using PROBAST modelling. We found statistically significant associations between elevated preoperative NLR and postoperative AKI (OR 1.45, 95% CI 1.18-1.77), as well as postoperative need for RRT (OR 2.37, 95% CI 1.50-3.72). Postoperative NLR measurements were not of prognostic significance.

CONCLUSIONS

Elevated preoperative NLR is a reliable inflammatory biomarker for predicting AKI following cardiac surgery.

Use of artificial neural networks in the prognosis of musculoskeletal diseases-a scoping review

To determine the current evidence on artificial neural network (ANN) in prognostic studies of musculoskeletal diseases (MSD) and to assess the accuracy of ANN in predicting the prognosis of patients with MSD. The scoping review was reported under the Preferred Items for Systematic Reviews and the Meta-Analyses extension for Scope Reviews (PRISMA-ScR). Cochrane Library, Embase, Pubmed, and Web of science core collection were searched from inception to January 2023. Studies were eligible if they used ANN to make predictions about MSD prognosis. Variables, model prediction accuracy, and disease type used in the ANN model were extracted and charted, then presented as a table along with narrative synthesis. Eighteen Studies were included in this scoping review, with 16 different types of musculoskeletal diseases. The accuracy of the ANN model predictions ranged from 0.542 to 0.947. ANN models were more accurate compared to traditional logistic regression models. This scoping review suggests that ANN can predict the prognosis of musculoskeletal diseases, which has the potential to be applied to different types of MSD.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

Does primary trauma lead to developmental defects in permanent teeth?

Introduction A systematic review of existing evidence to determine if trauma in the primary dentition causes alteration in the development of the underlying permanent dentition.Data sources Six electronic databases (PubMed, Medline, MEDES, Scopus, Lilacs and Embase) were used to search a range of dental terms relating to dental trauma to locate studies between 1972-2020.Study selection Study selection was carried out by two authors by reviewing title, abstract and then full articles. A third author was consulted if consensus for inclusion was needed. Eligibility criteria included all scientific articles concerning sequalae to the human permanent dentition following trauma to the primary dentition. Only English, German and Spanish languages were included. For evaluation, the studies must have satisfied the following: a) minimum sample of 50 children to be representative; b) radiographic examination; and c) appropriate follow-up period up to permanent successor eruption.From 537 studies, 18 studies were identified for consideration in the review, comprising of 13 cross-sectional studies, two cohort studies and three case control studies.Data extraction and synthesis The Newcastle-Ottawa Scale was used to extract data and determine study quality. Only studies determined as high quality were included in the review. Four cross-sectional studies and three case control studies, totalling seven studies, were used. Data from these high-quality studies was summarised into table format.Results Large variation in study sample size existed from 138-753 traumatised teeth and 78-879 children. Both sexes were included in all studies and the children were aged between 0-17 years.Some studies found there was no difference in rate of trauma between girls and boys, while others found there was a higher incidence of trauma in boys than girls. The most frequently traumatised teeth were the upper primary central incisors. Whilst most studies covered all types of primary trauma, two only studied intrusion and one specified the type of primary trauma as luxation or fracture injuries.Whilst some of the studies concluded a higher frequency of defects to permanent teeth following primary intrusion trauma aged four and under, others showed no significant differences between the age of intrusion and the effect to the successor incisor.Enamel defects of the permanent teeth were the most common sequalae with a wide prevalence reported between 4.5-68.8%. Enamel defects were classified as hypoplasia and hypocalcification. Ectopic or altered eruption, crown or root dilacerations and odontoma development were observed less often, with the latter very rarely.Conclusions Primary tooth intrusion trauma causes the highest proportion of sequalae presenting as enamel defects. Younger patients experiencing primary trauma are more likely to obtain damage to the succeeding dentition. The existing quality of evidence is limited due to the observational nature of the studies available.

Association between time-to-treatment and outcomes in non-small cell lung cancer: a systematic review

BACKGROUND

National targets for timely diagnosis and management of a potential cancer are driven in part by the perceived risk of disease progression during avoidable delays. However, it is unclear to what extent time-to-treatment impacts prognosis for patients with non-small cell lung cancer, with previous reviews reporting mixed or apparently paradoxical associations. This systematic review focuses on potential confounders in order to identify particular patient groups which may benefit most from timely delivery of care.

METHODS

Medline, EMBASE and Cochrane databases were searched for publications between January 2012 and October 2020, correlating timeliness in secondary care pathways to patient outcomes. The protocol is registered with PROSPERO (the International Prospective Register of Systematic Reviews; ID 99239). Prespecified factors (demographics, performance status, histology, stage and treatment) are examined through narrative synthesis.

RESULTS

Thirty-seven articles were included. All but two were observational. Timely care was generally associated with a worse prognosis in those with advanced stage disease (6/8 studies) but with better outcomes for patients with early-stage disease treated surgically (9/12 studies). In one study, patients with squamous cell carcinoma referred for stereotactic ablative radiotherapy benefited more from timely care, compared with patients with adenocarcinoma. One randomised controlled trial supported timeliness as being advantageous in those with stage I-IIIA disease.

CONCLUSION

There are limitations to the available evidence, but observed trends suggest timeliness to be of particular importance in surgical candidates. In more advanced disease, survival trends are likely outweighed by symptom burden, performance status or clinical urgency dictating timeliness of treatment.

Women living with HIV and dual contraceptive use in Ethiopia: systematic review and meta-analysis

BACKGROUND

Despite different preventive strategies that have been implemented in the country, the prevalence of HIV/AIDS is still significantly increasing in Ethiopia. The concurrence of HIV and unintended pregnancy makes the use of dual contraception a back bone for the simultaneous protection against HIV, and unintended pregnancy. As a result, this systematic review and meta-analysis aimed to assess the prevalence and associated factors of dual contraceptive use among women living with HIV in Ethiopia.

METHOD

We used databases; (PubMed, Google Scholar, EMBASE, Cochrane Library, African Online Journals, and Hinary), other gray and online repository accessed studies were searched using different search engines. For critical appraisal of studies Newcastle-Ottawa Quality Assessment Scale (NOS) was used. The analysis was done using STATA 11 software. The Cochran Q test and I2 test statistics were used to assess the heterogeneity. To detect publication bias funnel plot and Egger's test were used. The pooled prevalence of dual contraception use and the odds ratio (OR) with a 95% confidence interval was presented by using forest plots.

RESULT

Eleven studies were included in this review, with a total of 4083 women living with HIV in Ethiopia. The pooled prevalence of dual contraception use in Ethiopia was 34.08% (95%CI: 20.77-47.38). Having open partner discussion (OR = 3.96, 95%CI:2.3,6.8), provision of post test counseling (AOR = 4.38, 95%CI:2.93,6.54), disclosed HIV status to sexual partners (OR = 5.9, 95%CI:4.19,8.33), partner involvement in post-test counseling (OR = 3.52, 95%CI:2.37,5.23), and being on highly active antiretroviral therapy (HAART) (OR = 2.9, 95%CI:1.56,5.46) were the determinant factors of dual contraceptive use in Ethiopia.

CONCLUSION

The overall prevalence of dual contraceptive use among women living with HIV in Ethiopia was low. Having open partner discussion, provision of post-test counseling, disclosed HIV status to sexual partner, partner involvement in post-test counseling, and currently on highly active antiretroviral therapy (HAART) were the associated factors of dual contraceptive use. Therefore, efforts should be made to provide post-test counseling, and initiate partner involvement in post-test counseling. Moreover, promoting open partner discussion, counseling to disclose HIV status to their sexual partner and to start HAART will be helpful in enhancing the use of dual contraceptive method use.

Structured reporting to improve transparency of analyses in prognostic marker studies

BACKGROUND

Factors contributing to the lack of understanding of research studies include poor reporting practices, such as selective reporting of statistically significant findings or insufficient methodological details. Systematic reviews have shown that prognostic factor studies continue to be poorly reported, even for important aspects, such as the effective sample size. The REMARK reporting guidelines support researchers in reporting key aspects of tumor marker prognostic studies. The REMARK profile was proposed to augment these guidelines to aid in structured reporting with an emphasis on including all aspects of analyses conducted.

METHODS

A systematic search of prognostic factor studies was conducted, and fifteen studies published in 2015 were selected, three from each of five oncology journals. A paper was eligible for selection if it included survival outcomes and multivariable models were used in the statistical analyses. For each study, we summarized the key information in a REMARK profile consisting of details about the patient population with available variables and follow-up data, and a list of all analyses conducted.

RESULTS

Structured profiles allow an easy assessment if reporting of a study only has weaknesses or if it is poor because many relevant details are missing. Studies had incomplete reporting of exclusion of patients, missing information about the number of events, or lacked details about statistical analyses, e.g., subgroup analyses in small populations without any information about the number of events. Profiles exhibit severe weaknesses in the reporting of more than 50% of the studies. The quality of analyses was not assessed, but some profiles exhibit several deficits at a glance.

CONCLUSIONS

A substantial part of prognostic factor studies is poorly reported and analyzed, with severe consequences for related systematic reviews and meta-analyses. We consider inadequate reporting of single studies as one of the most important reasons that the clinical relevance of most markers is still unclear after years of research and dozens of publications. We conclude that structured reporting is an important step to improve the quality of prognostic marker research and discuss its role in the context of selective reporting, meta-analysis, study registration, predefined statistical analysis plans, and improvement of marker research.

Prognostic factors related to overall survival in adolescent and young adults with medulloblastoma: a systematic review

Background

Medulloblastoma is a rare diagnosis among adolescents and young adults (AYA). Though prognostic factors and treatment are well characterized among children with medulloblastoma, equivalent data for AYA are sparse. We conducted a systematic review to identify predictors of survival among AYA with medulloblastoma.

Methods

We searched for primary studies of AYA (age 15–39 at diagnosis) with medulloblastoma in high-income countries within OVID MEDLINE, EMBASE, and EBM Reviews-Cochrane library databases from inception to August 2020. Patient demographics, primary outcomes, and univariate and multivariable data on all prognostic factors were collected from included studies. Prognosticators were characterized as patient, disease, or treatment-related.

Results

We identified 18 articles. 5-year overall survival ranged between 40% and 89%, while disease-free survival ranged from 49% to 89%. Study quality was low as assessed by the Quality in Prognostic factor Studies tool. Though meta-analyses were not possible due heterogeneity, narrative summaries suggested that lower disease burden, superior postoperative functional status, and higher doses and larger fields of radiation were associated with improved survival. Reported chemotherapy regimens were heterogeneous in timing, agents, and relationship with radiation, precluding meaningful comparisons. Only one study included molecular subgroups for analysis, with the majority (76.5%) of tumors classified as Sonic Hedgehog (SHH).

Conclusions

Prognostication and treatment of AYA medulloblastoma is limited by a dearth of primary evidence and lack of specificity for patients aged 15–39. Dedicated prospective trials to delineate the benefit of various chemotherapy and radiation regimens are required in this population to identify prognosticators and ideal treatment regimens.

The Effect of Subclinical Hypothyroidism on Coagulation and fibrinolysis: A Systematic Review and Meta-Analysis

BACKGROUND

Despite patients with thyroid dysfunction show obvious abnormal hemostatic indicators in the peripheral blood, the current research on whether and how subclinical hypothyroidism (SCH) influence hemostatic function (the coagulation and fibrinolytic system) still remains controversial.

OBJECTIVE

We conducted this study to evaluate how SCH influence on the coagulation and fibrinolytic system in human body.

METHODS

Prior to March 2022, Web of Science, Embase, PubMed, WanFang, CNKI data and reference lists were searched to identify eligible researches. Two of us independently extracted the data and evaluated study quality. The effect size is represented by standard mean difference (SMD). Both fixed and random-effects models were used where appropriate. Review Manager 5.3 and STATA 16.0 were used to analyze the eligible data.

RESULTS

1325 patients from twelve observational studies were involved in our research. Our study revealed that SCH changed the heamostatic balance towards hypercoagulable and hypofibrinolytic conditions accompanied by an increase in tissue fibrinogen, plasminogen activator and plasminogen activator inhibitor-1. By contrast, there was no statistically difference in acivated partial thromboplastin time (APTT) and D-Dimer in SCH group compared with that in control subjects.

CONCLUSIONS

Our study confirmed that SCH is related with a prothrombotic state, as reflected by changes in both coagulation and fibrinolysis. It is highly recommended for screening cardiovascular risk factors in combination with an adequate evaluation of SCH state.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/#recordDetails] PROSPERO [CRD42021275313].

Donor Cardiac Troponin for Prognosis of Adverse Outcomes in Cardiac Transplantation Recipients: a Systematic Review and Meta-analysis

BACKGROUND

Cardiac troponin is a highly specific and widely available marker of myocardial injury, and elevations in cardiac transplant donors may influence donor selection. We aimed to investigate whether elevated donor troponin has a role as a prognostic biomarker in cardiac transplantation.

METHODS

In a systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library, without language restriction, from inception to December 2020. We included studies reporting the association of elevated donor troponin with recipient outcome after cardiac transplant. We generated summary odds ratios and hazard ratios for the association of elevated donor troponin with short- and long-term adverse outcomes. Methodological quality was monitored using the Quality In Prognosis Studies tool, and interstudy heterogeneity was assessed using a series of sensitivity and subgroup analyses.

RESULTS

We included 17 studies involving 15 443 patients undergoing cardiac transplantation. Elevated donor troponin was associated with increased odds of graft rejection at 1 y (odds ratio, 2.54; 95% confidence interval, 1.22-5.28). No significant prognostic relationship was found between donor troponin and primary graft failure, short- to long-term mortality, cardiac allograft vasculopathy, and pediatric graft loss.

CONCLUSIONS

Elevated donor troponin is not associated with an increased short- or long-term mortality postcardiac transplant despite increasing the risk of graft rejection at 1 y. Accordingly, an elevated donor troponin in isolation should not exclude donation.

Adolescent and young adult glioma: systematic review of demographic, disease, and treatment influences on survival

BACKGROUND

Prognostic factors in adolescent and young adult (AYA) glioma are not well understood. Though clinical and molecular differences between pediatric and adult glioma have been characterized, their application to AYA populations is less clear. There is a major need to develop more robust evidence-based practices for managing AYA glioma patients.

METHODS

A systematic review using PRISMA methodology was conducted using multiple databases with the objective of identifying demographic, clinical, molecular and treatment factors influencing AYA glioma outcomes.

RESULTS

40 Studies met inclusion criteria. Overall survival was highly variable across studies depending on glioma grade, anatomic compartment and cohort characteristics. Thirty-five studies suffered from high risk of bias in at least one domain. Several studies included older adults within their cohorts; few captured purely AYA groups. Despite study heterogeneity, identified favorable prognosticators included younger age, higher functional status at diagnosis, low-grade pathology, oligodendroglioma histology and increased extent of surgical resection. Though isocitrate dehydrogenase (IDH) mutant status was associated with favorable prognosis, validity of this finding within AYA was compromised though may studies including older adults. The prognostic influence of chemotherapy and radiotherapy on overall survival varied across studies with conflicting evidence.

CONCLUSION

Existing literature is heterogenous, at high risk of bias, and rarely focused solely on AYA patients. Many included studies did not reflect updated pathological and molecular AYA glioma classification. The optimal role of chemotherapy, radiotherapy, and targeted agents cannot be determined from existing literature and should be the focus of future studies.

Association Between TP53 Mutation and Prognosis in Wilms Tumor: A Meta-Analysis

BackgroundTP53 mutation has been suggested to have prognostic value for patients with Wilms tumor (WT), but the results are still controversial. Methods: Relevant studies published until August 1, 2019 were identified by searching PubMed, EMBASE and Cochrane Library. A random-effect model was performed to assess pooled data. Begg's and Egger's test were used to evaluate the potential publication bias. Sensitivity analysis was used to evaluate the stability of results. Results: A total of seven eligible articles were included. There was no significant difference in the risk of death among patients with WT with different TP53 mutation status (odds ratio [OR] = 3.09, 95% confidence interval[CI]: 0.81-11.84). Combined hazard ratio (HR) suggested that TP53 mutation had an unfavorable impact on overall survival (OS) (HR = 4.17, 95% CI: 1.97-6.36) and disease-free survival (DFS) (HR = 2.23, 95% CI: 1.29-3.17) in WT. Conclusions: This meta-analysis demonstrates that TP53 mutations are associated with poorer prognosis in WT.

Outcomes After Receipt of Neuraxial or Regional Anesthesia Instead of General Anesthesia for Lower Limb Revascularization Surgery: Protocol for a Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing lower limb revascularization surgery for peripheral artery disease (PAD) have a high risk of perioperative morbidity and mortality and often have long hospital stays. Use of neuraxial or regional anesthesia instead of general anesthesia may represent one approach to improving outcomes and reducing resource use among these patients.

OBJECTIVE

The aim is to conduct a systematic review and meta-analysis to determine whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes and costs and a shorter length of hospitalization.

METHODS

We will search electronic bibliographic databases (MEDLINE, EMBASE, the seven databases in Evidence-Based Medicine Reviews, medRxiv, bioRxiv, and Google Scholar), review papers identified during the search, and included article bibliographies. We will include randomized and nonrandomized studies comparing the use of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD. Two investigators will independently evaluate the risk of bias. The primary outcome will be short-term (in-hospital or 30-day) mortality. Secondary outcomes will include longer-term mortality; major adverse cardiovascular, pulmonary, renal, and limb events; delirium; deep vein thrombosis or pulmonary embolism; neuraxial or regional anesthesia-related complications; graft-related outcomes; length of operation and hospital stay; costs; and patient-reported or functional outcomes. We will calculate summary odds ratios (ORs) and standardized mean differences (SMDs) using random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. We will assess for publication bias using the Begg and Egger tests and use the trim-and-fill method to estimate the potential influence of this bias on summary estimates. Finally, we will use Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to make an overall rating of the quality of evidence in our effect estimates.

RESULTS

The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We executed the peer-reviewed search strategy on March 2, 2021. We completed the review of titles and abstracts on July 30, 2021, and plan to complete the review of full-text papers by September 30, 2021. We will complete full-text study data extraction and the risk-of-bias assessment by November 15, 2021, and conduct qualitative and then quantitative data synthesis and GRADE assessment of results by January 1, 2022, before drafting the manuscript. We anticipate that we will be able to submit the manuscript for peer review by the end of February 2022.

CONCLUSIONS

This study will synthesize existing evidence regarding whether receipt of neuraxial or regional anesthesia instead of general anesthesia in adults undergoing lower limb revascularization surgery for PAD results in improved health outcomes, graft patency, and costs and a shorter length of hospital stay. Study results will be used to inform practice and future research, including creation of a pilot and then multicenter randomized controlled trial.

TRIAL REGISTRATION

Prospero CRD42021237060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=237060.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/32170.

Neoadjuvant Chemotherapy for Advanced Gallbladder Cancer: Do We have Enough Evidence? A Systematic Review

Background

Recently for advanced gallbladder carcinoma, neoadjuvant chemotherapy has emerged as an important strategy in place of adjuvant chemotherapy with the hope that it will help to improve the resectability and survival.

Aim and objective

The goal was to conduct a systematic review of published publications on the benefits of neoadjuvant chemotherapy for advanced gallbladder cancer treatment.

Materials and methods

This systematic review followed the Meta-analysis Of Observational Studies in Epidemiology standards. The clinical benefit rate of neoadjuvant chemotherapy, curative resectability rate, and R0 resection were the major outcomes of interest. The secondary outcomes of interest were overall and disease-free survival.

Results

Six published papers were included (n = 420). One-hundred and twenty-eight cases (30.47%) despite receiving neoadjuvant chemotherapy had disease progression. Although 67.38% of patients (283 of 420) in this systematic review showed good response to the neoadjuvant chemotherapy, just 51.66% (217 of 420 cases) were operated, out of which only 171 cases were deemed to be feasible for surgical resection and had curative resection. Out of the cases that underwent curative surgery, 91.81% had R0 resection (157 out of 171 patients). The overall survival rate was found to be 18.5–50.1 months for patients in whom curative surgery was done and 5.0–10.8 months for nonsurgery patients.

Conclusion

No sufficient data exist to advocate the regular use of neoadjuvant chemotherapy in advanced gallbladder carcinoma, as data showed that only 1/3 of patients benefited and had a R0 resection. Further research should be the randomized controlled trials to further quantify the benefit of neoadjuvant chemotherapy in advanced gallbladder carcinoma.

How to cite this article

Naveed S, Qari H, Thau CM, et al. Neoadjuvant Chemotherapy for Advanced Gallbladder Cancer: Do We have Enough Evidence? A Systematic Review. Euroasian J Hepato-Gastroenterol 2021;11(2):87–94.

Mammographic density, endocrine therapy and breast cancer risk: a prognostic and predictive biomarker review

BACKGROUND

Endocrine therapy is effective at preventing or treating breast cancer. Some forms of endocrine therapy have been shown to reduce mammographic density. Reduced mammographic density for women receiving endocrine therapy could be used to estimate the chance of breast cancer returning or developing breast cancer in the first instance (a prognostic biomarker). In addition, changes in mammographic density might be able to predict how well a woman responds to endocrine therapy (a predictive biomarker). The role of breast density as a prognostic or predictive biomarker could help improve the management of breast cancer.

OBJECTIVES

To assess the evidence that a reduction in mammographic density following endocrine therapy for breast cancer prevention in women without previous breast cancer, or for treatment in women with early-stage hormone receptor-positive breast cancer, is a prognostic or predictive biomarker.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers on 3 August 2020 along with reference checking, bibliographic searching, and contact with study authors to obtain further data.

SELECTION CRITERIA

We included randomised, cohort and case-control studies of adult women with or without breast cancer receiving endocrine therapy. Endocrine therapy agents included were selective oestrogen receptor modulators and aromatase inhibitors. We required breast density before start of endocrine therapy and at follow-up. We included studies published in English.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed risk of bias using adapted Quality in Prognostic Studies (QUIPS) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tools. We used the GRADE approach to evaluate the certainty of the evidence. We did not perform a quantitative meta-analysis due to substantial heterogeneity across studies.

MAIN RESULTS

Eight studies met our inclusion criteria, of which seven provided data on outcomes listed in the protocol (5786 women). There was substantial heterogeneity across studies in design, sample size (349 to 1066 women), participant characteristics, follow-up (5 to 14 years), and endocrine therapy agent. There were five breast density measures and six density change definitions. All studies had at least one domain as at moderate or high risk of bias. Common concerns were whether the study sample reflected the review target population, and likely post hoc definitions of breast density change. Most studies on prognosis for women receiving endocrine therapy reported a reduced risk associated with breast density reduction. Across endpoints, settings, and agents, risk ratio point estimates (most likely value) were between 0.1 and 1.5, but with substantial uncertainty. There was greatest consistency in the direction and magnitude of the effect for tamoxifen (across endpoints and settings, risk ratio point estimates were between 0.3 and 0.7). The findings are summarised as follows. Prognostic biomarker findings: Treatment Breast cancer mortality Two studies of 823 women on tamoxifen (172 breast cancer deaths) reported risk ratio point estimates of ~0.4 and ~0.5 associated with a density reduction. The certainty of the evidence was low. Recurrence Two studies of 1956 women on tamoxifen reported risk ratio point estimates of ~0.4 and ~0.7 associated with a density reduction. There was risk of bias in methodology for design and analysis of the studies and considerable uncertainty over the size of the effect. One study of 175 women receiving an aromatase inhibitor reported a risk ratio point estimate of ~0.1 associated with a density reduction. There was considerable uncertainty about the effect size and a moderate or high risk of bias in all domains. One study of 284 women receiving exemestane or tamoxifen as part of a randomised controlled trial reported risk ratio point estimates of ~1.5 (loco-regional recurrence) and ~1.3 (distance recurrence) associated with a density reduction. There was risk of bias in reporting and study confounding, and uncertainty over the size of the effects. The certainty of the evidence for all recurrence endpoints was very low. Incidence of a secondary primary breast cancer Two studies of 451 women on exemestane, tamoxifen, or unknown endocrine therapy reported risk ratio point estimates of ~0.5 and ~0.6 associated with a density reduction. There was risk of bias in reporting and study confounding, and uncertainty over the effect size. The certainty of the evidence was very low. We were unable to find data regarding the remaining nine outcomes prespecified in the review protocol. Prevention Incidence of invasive breast cancer and ductal carcinoma in situ (DCIS) One study of 507 women without breast cancer who were receiving preventive tamoxifen as part of a randomised controlled trial (51 subsequent breast cancers) reported a risk ratio point estimate of ~0.3 associated with a density reduction. The certainty of the evidence was low. Predictive biomarker findings: One study of a subset of 1065 women from a randomised controlled trial assessed how much the effect of endocrine therapy could be explained by breast density declines in those receiving endocrine therapy. This study evaluated the prevention of invasive breast cancer and DCIS. We found some evidence to support the hypothesis, with a risk ratio interaction point estimate ~0.5. However, the 95% confidence interval included unity, and data were based on 51 women with subsequent breast cancer in the tamoxifen group. The certainty of the evidence was low.

AUTHORS' CONCLUSIONS

There is low-/very low-certainty evidence to support the hypothesis that breast density change following endocrine therapy is a prognostic biomarker for treatment or prevention. Studies suggested a potentially large effect size with tamoxifen, but the evidence was limited. There was less evidence that breast density change following tamoxifen preventive therapy is a predictive biomarker than prognostic biomarker. Evidence for breast density change as a prognostic treatment biomarker was stronger for tamoxifen than aromatase inhibitors. There were no studies reporting mammographic density change following endocrine therapy as a predictive biomarker in the treatment setting, nor aromatase inhibitor therapy as a prognostic or predictive biomarker in the preventive setting. Further research is warranted to assess mammographic density as a biomarker for all classes of endocrine therapy and review endpoints.

Comparing the performance of the palliative prognostic (PaP) score with clinical predictions of survival: A systematic review

BACKGROUND

In patients with advanced cancer, prognosis is usually determined using clinicians' predictions of survival (CPS). The palliative prognostic (PaP) score is a prognostic algorithm that was developed to predict survival in patients with advanced cancer. The score categorises patients into three risk groups in accordance with their probability of surviving for 30 days. The relative accuracy of PaP and CPS is unclear.

DESIGN

This was a systematic review of MEDLINE, Embase, AMED, CINAHL Plus and the Cochrane Database of Systematic Reviews and Trials from inception up to June 2021. The inclusion criteria were studies in adults with advanced cancer reporting data on performance of both PaP and CPS. Data were extracted on accuracy of prognoses and where available on discrimination (area under the receiver operating characteristic curve or C-index) and/or diagnostic performance (sensitivity, specificity).

RESULTS

Eleven studies were included. One study reported a direct comparison between PaP risk groups and equivalent risk groups defined by CPS and found that PaP was as accurate as CPS. Five studies reported discrimination of PaP as a continuous total score (rather than using the previously validated risk categories) and reported C-statistics that ranged from 0.64 (95% confidence interval [CI] 0.54, 0.74) up to 0.90 (95% CI 0.87, 0.92). Other studies compared PaP against CPS using non-equivalent metrics (e.g. comparing probability estimates against length of survival estimates).

CONCLUSIONS

PaP risk categories and CPS are equally able to discriminate between patients with different survival probabilities. Total PaP scores show good discrimination between patients in accordance with their length of survival. The role of PaP in clinical practice still needs to be defined.

TRIAL REGISTRATION

PROSPERO (CRD42021241074, 5th March 2021).

Are saliva and deep throat sputum as reliable as common respiratory specimens for SARS-CoV-2 detection? A systematic review and meta-analysis

OBJECTIVE

The COVID-19 pandemic raises an urgent need for large-scale control through easier, cheaper, and safer diagnostic specimens, including saliva and sputum. We aimed to conduct a systemic review and meta-analysis on the reliability and sensitivity of SARS-CoV-2 detection in saliva and deep throat sputum (DTS) compared to nasopharyngeal, combined naso/oropharyngeal, and oropharyngeal swabs.

METHODS

This systematic review and meta-analysis was performed according to the PRISMA statement. The inclusion criteria were studies that specifically assessed a sample of saliva or DTS with at least one other respiratory specimen in patients with COVID-19 infection, based on RT-PCR tests. The DerSimonian-Laird bivariate random-effects model analysis performed using STATA software with the "metaprop" package.

RESULTS

From 1598 studies, we retrieved 33 records, of which 26 studies were included for quantitative analysis. We found an overall sensitivity of 97% (95% confidence interval [CI], 86-100) for bronchoalveolar lavage fluid, 92% (95% CI, 80-99) for double naso/oropharyngeal swabs, 87% (95% CI, 77-95) for nasopharyngeal swabs, 83% (95% CI, 77-89) for saliva, 82% (95% CI, 76-88) for DTS, and 44% (95% CI, 35-52) for oropharyngeal swabs among symptomatic patients, respectively. Regardless of the type of specimens, the viral load and sensitivity in the severe patients were higher than mild and in the symptomatic patients higher than asymptomatic cases.

CONCLUSIONS

The present review provides evidence for the diagnostic value of different respiratory specimens and supports saliva and DTS as promising diagnostic tools for first-line screening of SARS-CoV-2 infection. However, the methods of sampling, storing, and laboratory assay need to be optimized and validated before introducing as a definitive diagnosis tool. Saliva, DTS, and nasopharyngeal swab showed approximately similar results, and sensitivity was directly related to the disease severity. This review revealed a relationship between viral load, disease severity, and test sensitivity. None of the specimens showed appropriate diagnostic sensitivity for asymptomatic patients.

Perioperative Neutrophil-Lymphocyte Ratio Predicts Mortality After Cardiac Surgery: Systematic Review and Meta-Analysis

OBJECTIVES

Neutrophil-lymphocyte ratio (NLR) is an inflammatory biomarker that has been evaluated across a variety of surgical disciplines and is widely predictive of poor postoperative outcome, but its value in cardiac surgery is unclear. The authors did this systematic review and meta-analysis to determine the impact of elevated perioperative NLR on survival after cardiac surgery.

DESIGN

Systematic review and meta-analysis of study-level data.

SETTING

Multiple hospitals involved in an international pool of studies.

PARTICIPANTS

Adults undergoing cardiac surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors searched multiple databases from inception until November 2020. They generated summary hazard ratios (HR) and odds ratios (OR) for the association of elevated preoperative NLR with long-term and short-term mortality following cardiac surgery. They separately reported on elevated postoperative NLR. Between-study heterogeneity was explored using metaregression. The authors included 12 studies involving 13,262 patients undergoing cardiac surgery. Elevated preoperative NLR was associated with worse long-term (>30 days) (hazard ratio [HR] 1.56; 95% CI [confidence interval], 1.18-2.06; 8 studies) and short-term (<30 days) mortality (OR 3.18; 95% CI, 1.90-5.30; 7 studies). One study reported the association of elevated postoperative NLR with long-term mortality (HR 8.58; 95% CI, 2.55-28.85). There was considerable between-study heterogeneity for the analysis of long-term mortality (I² statistic 94.39%), which mostly was explained by study-level variables, such as the number of variables adjusted for by included studies and how many of these significantly increased the risk of long-term mortality, high risk of bias, and number of study centers, as well as participant level factors, such as average participant age and hypertension prevalence.

CONCLUSIONS

Perioperative NLR is an independent predictor of short-term and long-term postoperative mortality following cardiac surgery. Further research is required to determine which patient-level factors modify the prognostic value of NLR and to evaluate its role in routine clinical practice.

Prognostic factors for chronic post-surgical pain after lung or pleural surgery: a protocol for a systematic review and meta-analysis

INTRODUCTION

Chronic post-surgical pain (CPSP) after lung or pleural surgery is a common complication and associated with a decrease in quality of life, long-term use of pain medication and substantial economic costs. An abundant number of primary prognostic factor studies are published each year, but findings are often inconsistent, methods heterogeneous and the methodological quality questionable. Systematic reviews and meta-analyses are therefore needed to summarise the evidence.

METHODS AND ANALYSIS

The reporting of this protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. We will include retrospective and prospective studies with a follow-up of at least 3 months reporting patient-related factors and surgery-related factors for any adult population. Randomised controlled trials will be included if they report on prognostic factors for CPSP after lung or pleural surgery. We will exclude case series, case reports, literature reviews, studies that do not report results for lung or pleural surgery separately and studies that modified the treatment or prognostic factor based on pain during the observation period. MEDLINE, Scopus, Web of Science, Embase, Cochrane, CINAHL, Google Scholar and relevant literature reviews will be searched. Independent pairs of two reviewers will assess studies in two stages based on the PICOTS criteria. We will use the Quality in Prognostic Studies tool for the quality assessment and the CHARMS-PF checklist for the data extraction of the included studies. The analyses will all be conducted separately for each identified prognostic factor. We will analyse adjusted and unadjusted estimated measures separately. When possible, evidence will be summarised with a meta-analysis and otherwise narratively. We will quantify heterogeneity by calculating the Q and I² statistics. The heterogeneity will be further explored with meta-regression and subgroup analyses based on clinical knowledge. The quality of the evidence obtained will be evaluated according to the Grades of Recommendation Assessment, Development and Evaluation guideline 28.

ETHICS AND DISSEMINATION

Ethical approval will not be necessary, as all data are already in the public domain. Results will be published in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42021227888.

PARP (Poly ADP-Ribose Polymerase) inhibitors for locally advanced or metastatic breast cancer

BACKGROUND

Locally advanced and metastatic breast cancer remains a challenge to treat. With emerging study results, it is important to interpret the available clinical data and apply the evidence offering the most effective treatment to the right patient. Poly(ADP Ribose) Polymerase (PARP) inhibitors are a new class of drug and their role in the treatment of locally advanced and metastatic breast cancer is being established.

OBJECTIVES

To determine the efficacy, safety profile, and potential harms of Poly(ADP-Ribose) Polymerase (PARP) inhibitors in the treatment of patients with locally advanced or metastatic breast cancer. The primary outcome of interest was overall survival; secondary outcomes included progression-free survival, tumour response rate, quality of life, and adverse events.

SEARCH METHODS

On 8 June 2020, we searched the Cochrane Breast Cancer Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OvidSP, Embase via OvidSP, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) search portal and ClinicalTrials.gov. We also searched proceedings from the major oncology conferences as well as scanned reference lists from eligible publications and contacted corresponding authors of trials for further information, where needed.

SELECTION CRITERIA

We included randomised controlled trials on participants with locally advanced or metastatic breast cancer comparing 1) chemotherapy in combination with PARP inhibitors, compared to the same chemotherapy without PARP inhibitors or 2) treatment with PARP inhibitors, compared to treatment with other chemotherapy. We included studies that reported on our primary outcome of overall survival and secondary outcomes including progression-free survival, tumour response rate, quality of life, and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures defined by Cochrane. Summary statistics for the endpoints used hazard ratios (HR) with 95% confidence intervals (CI) for overall survival and progression-free survival, and odds ratios (OR) for response rate (RR) and toxicity.

MAIN RESULTS

We identified 49 articles for qualitative synthesis, describing five randomised controlled trials that were included in the quantitative synthesis (meta-analysis). A sixth trial was assessed as eligible but had ended prematurely and no data were available for inclusion in our meta-analysis. Risk of bias was predominately low to unclear across all studies except in regards to performance bias (3/5 high risk) and detection bias for the outcomes of quality of life (2/2 high risk) and reporting of adverse events (3/5 high risk). High-certainty evidence shows there may be a small advantage in overall survival (HR 0.87, 95% CI 0.76 to 1.00; 4 studies; 1435 patients). High-certainty evidence shows that PARP inhibitors offer an improvement in PFS in locally advanced/metastatic HER2-negative, BRCA germline mutated breast cancer patients (HR 0.63, 95% CI 0.56 to 0.71; 5 studies; 1474 patients). There was no statistical heterogeneity for these outcomes. Subgroup analyses for PFS outcomes based on trial level data were performed for triple-negative breast cancer, hormone-positive and/or HER2-positive breast cancer, BRCA1 and BRCA2 germline mutations, and patients who had received prior chemotherapy for advanced breast cancer or not. The subgroup analyses showed a persistent PFS benefit regardless of the subgroup chosen. Pooled analysis shows PARP inhibitors likely result in a moderate improvement in tumour response rate compared to other treatment arms (66.9% vs 48.9%; RR 1.39, 95% CI 1.24 to 1.54; 5 studies; 1185 participants; moderate-certainty evidence). The most common adverse events reported across all five studies included neutropenia, anaemia and fatigue. Grade 3 or higher adverse events probably occur no less frequently in patients receiving PARP inhibitors (59.4% for PARP arm versus 64.5% for non-PARP arm, RR 0.98, 95% CI 0.91 to 1.04; 5 studies; 1443 participants; moderate-certainty evidence). Only two studies reported quality of life outcomes so this was not amenable to meta-analysis. However, both studies that did assess quality of life showed PARP inhibitors were superior compared to physician's choice of chemotherapy in terms of participant-reported outcomes.

AUTHORS' CONCLUSIONS

In people with locally advanced or metastatic HER2-negative, BRCA germline mutated breast cancer, PARP inhibitors offer an improvement in progression-free survival, and likely improve overall survival and tumour response rates. This systematic review provides evidence supporting the use of PARP inhibitors as part of the therapeutic strategy for breast cancer patients in this subgroup. The toxicity profile for PARP inhibitors is probably no worse than chemotherapy but more information is required regarding quality of life outcomes, highlighting the importance of collecting such data in future studies. Future studies should also be powered to detect clinically important differences in overall survival and could focus on the role of PARP inhibitors in other relevant breast cancer populations, including HER2-positive, BRCA-negative/homologous recombination repair-deficient and Programmed Death-Ligand 1 (PDL1) positive.

Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide

BACKGROUND

Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide.

OBJECTIVES

To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide.

SEARCH METHODS

We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014.

SELECTION CRITERIA

Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals.

MAIN RESULTS

We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status.

AUTHORS' CONCLUSIONS

PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.

Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

BACKGROUND

Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).

METHODS

We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.

RESULTS

Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.

CONCLUSIONS

Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

Albumin-to-alkaline phosphatase ratio as a promising indicator of prognosis in human cancers: is it possible?

Background

The impact of albumin-to-alkaline phosphatase ratio (AAPR) on prognosis in cancer patients remains uncertain, despite having multiple relevant studies in publication.

Methods

We systemically compiled literatures from 3 databases (Cochrane Library, PubMed, and Web of Science) updated to May 24th, 2020. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed and synthesized using STATA 14, values were then pooled and utilized in order to assess the overall impact of AAPR on patient’s prognosis.

Results

In total, 18 studies involving 25 cohorts with 7019 cases were incorporated. Pooled results originated from both univariate and multivariate analyses (HR = 2.14, 95%CI:1.83–2.51, random-effects model; HR = 1.93, 95%CI:1.75–2.12, fixed-effects model; respectively) suggested that decreased AAPR had adverse effect on overall survival (OS). Similarly, pooled results from both univariate and multivariate analysis of fixed-effects model, evinced that decreased AAPR also had adverse effect on disease-free survival (DFS) (HR = 1.81, 95%CI:1.60–2.04, I² = 29.5%, P = 0.174; HR = 1.69, 95%CI:1.45–1.97, I² = 13.0%, P = 0.330; respectively), progression-free survival (PFS) (HR = 1.71, 95%CI:1.31–2.22, I² = 0.0%, P = 0.754; HR = 1.90, 95%CI:1.16–3.12, I² = 0.0%, P = 0.339; respectively), and cancer-specific survival (CSS) (HR = 2.22, 95%CI:1.67–2.95, I² = 5.6%, P = 0.347; HR = 1.88, 95%CI:1.38–2.57, I² = 26.4%, P = 0.244; respectively). Admittedly, heterogeneity and publication bias existed, but stratification of univariate meta-analytic results, as well as adjusted meta-analytic results via trim and fill method, all showed that AAPR still significantly correlated with poor OS despite of confounding factors.

Conclusions

In summary, decreased AAPR had adverse effect on prognosis in cancer patients. As an inexpensive and convenient ratio derived from liver function test, AAPR might become a promising indicator of prognosis in human cancers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07921-6.

Knee osteoarthritis and time-to all-cause mortality in six community-based cohorts: an international meta-analysis of individual participant-level data

BACKGROUND

Osteoarthritis (OA) is a chronic joint disease, with increasing global burden of disability and healthcare utilisation. Recent meta-analyses have shown a range of effects of OA on mortality, reflecting different OA definitions and study methods. We seek to overcome limitations introduced when using aggregate results by gathering individual participant-level data (IPD) from international observational studies and standardising methods to determine the association of knee OA with mortality in the general population.

METHODS

Seven community-based cohorts were identified containing knee OA-related pain, radiographs, and time-to-mortality, six of which were available for analysis. A two-stage IPD meta-analysis framework was applied: (1) Cox proportional hazard models assessed time-to-mortality of participants with radiographic OA (ROA), OA-related pain (POA), and a combination of pain and ROA (PROA) against pain and ROA-free participants; (2) hazard ratios (HR) were then pooled using the Hartung-Knapp modification for random-effects meta-analysis.

FINDINGS

10,723 participants in six cohorts from four countries were included in the analyses. Multivariable models (adjusting for age, sex, race, BMI, smoking, alcohol consumption, cardiovascular disease, and diabetes) showed a pooled HR, compared to pain and ROA-free participants, of 1.03 (0.83, 1.28) for ROA, 1.35 (1.12, 1.63) for POA, and 1.37 (1.22, 1.54) for PROA.

DISCUSSION

Participants with POA or PROA had a 35-37% increased association with reduced time-to-mortality, independent of confounders. ROA showed no association with mortality, suggesting that OA-related knee pain may be driving the association with time-to-mortality.

FUNDING

Versus Arthritis Centre for Sport, Exercise and Osteoarthritis and Osteoarthritis Research Society International.

Natural history of non-bullous impetigo: a systematic review of time to resolution or improvement without antibiotic treatment

Background

Non-bullous impetigo is typically treated with antibiotics. However, the duration of symptoms without their use has not been established, which hampers informed decision making about antibiotic use.

Aim

To determine the natural history of non-bullous impetigo.

Design and setting

Systematic review.

Method

The authors searched PubMed up to January 2020, as well as reference lists of articles identified in the search. Eligible studies involved participants with impetigo in either the placebo group of randomised trials, or in single-group prognostic studies that did not use antibiotics and measured time to resolution or improvement. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were percentage of participants who had either symptom resolution, symptom improvement, or failed to improve at any timepoint. Adverse event data were also extracted.

Results

Seven randomised trials (557 placebo group participants) were identified. At about 7 days, the percentage of participants classified as resolved ranged from 13% to 74% across the studies, whereas the percentage classified as ‘failure to improve’ ranged from 16% to 41%. The rate of adverse effects was low. Incomplete reporting of some details limited assessment of risk of bias.

Conclusion

Although some uncertainty around the natural history of non-bullous impetigo remains, symptoms resolve in some patients by about 7 days without using antibiotics, with about one-quarter of patients not improving. Immediate antibiotic use may not be mandatory, and discussions with patients should include the expected course of untreated impetigo and careful consideration of the benefits and harms of antibiotic use.

Doug Altman: Driving critical appraisal and improvements in the quality of methodological and medical research

Doug Altman was a visionary leader and one of the most influential medical statisticians of the last 40 years. Based on a presentation in the "Invited session in memory of Doug Altman" at the 40th Annual Conference of the International Society for Clinical Biostatistics (ISCB) in Leuven, Belgium and our long-standing collaborations with Doug, we discuss his contributions to regression modeling, reporting, prognosis research, as well as some more general issues while acknowledging that we cannot cover the whole spectrum of Doug's considerable methodological output. His statement "To maximize the benefit to society, you need to not just do research but do it well" should be a driver for all researchers. To improve current and future research, we aim to summarize Doug's messages for these three topics.

Factors associated with outcome following exercise interventions for Achilles tendinopathy: A systematic review

OBJECTIVE

This systematic review aimed to synthesize current evidence on contributing factors influencing outcome following exercise management for Achilles tendinopathy (AT).

DATA SOURCES

Databases (PubMed, Embase, and Cochrane Library) were searched from inception to February 2020.

STUDY SELECTION

Studies investigating factors (e.g., age, BMI) associated with outcome (e.g., pain and function questionnaires) following exercise interventions for AT were included.

DATA EXTRACTION

Data were extracted into a standardized form, including patient demographics, population sample, study type, factors associated with outcome, and outcome measures.

DATA SYNTHESIS

Meta-analysis was planned to be performed, where appropriate. Where data could not be pooled, we summarized the findings descriptively.

RESULTS

Six studies investigating 11 different factors were included; overall the quality of evidence was poor. There was conflicting evidence that imaging measures had an association with a change in VISA-A outcome. These included signal intensity and tendon size determined by MRI, and Ultrasound Tissue Characterization echopattern. Three studies found that duration of symptoms was not associated with a change in VISA-A. Also, three studies found that age, and one study found that prior sporting activity level, were not associated with outcome. Baseline pain with activity, baseline VISA-A, sex, and BMI were inconsistently associated with specific outcomes.

CONCLUSION

Due to the poor quality of evidence overall, no firm conclusions can be drawn. At best, there was inconsistent evidence that imaging factors, baseline pain and function, BMI, and sex showed some associations with outcomes, but these findings need to be confirmed in more extensive studies.

Prediction of outcomes after acute kidney injury in hospitalised patients: protocol for a systematic review

INTRODUCTION

Acute kidney injury (AKI) is common and is associated with negative long-term outcomes. Given the heterogeneity of the syndrome, the ability to predict outcomes of AKI may be beneficial towards effectively using resources and personalising AKI care. This systematic review will identify, describe and assess current models in the literature for the prediction of outcomes in hospitalised patients with AKI.

METHODS AND ANALYSIS

Relevant literature from a comprehensive search across six databases will be imported into Covidence. Abstract screening and full-text review will be conducted independently by two team members, and any conflicts will be resolved by a third member. Studies to be included are cohort studies and randomised controlled trials with at least 100 subjects, adult hospitalised patients, with AKI. Only those studies evaluating multivariable predictive models reporting a statistical measure of accuracy (area under the receiver operating curve or C-statistic) and predicting resolution of AKI, progression of AKI, subsequent dialysis and mortality will be included. Data extraction will be performed independently by two team members, with a third reviewer available to resolve conflicts. Results will be reported using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Risk of bias will be assessed using Prediction model Risk Of Bias ASsessment Tool.

ETHICS AND DISSEMINATION

We are committed to open dissemination of our results through the registration of our systematic review on PROSPERO and future publication. We hope that our review provides a platform for future work in realm of using artificial intelligence to predict outcomes of common diseases.

PROSPERO REGISTRATION NUMBER

CRD42019137274.

Prognostication in Home-Dwelling Patients with Advanced Dementia: The Palliative Support DEMentia Model (PalS-DEM)

OBJECTIVE

Difficulties with prognostication prevent more patients with advanced dementia from receiving timely palliative support. The aim of this study is to develop and validate a prognostic model for 6-month and 1-year mortality in home-dwelling patients with advanced dementia.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The data set of 555 home-dwelling patients with dementia at Functional Assessment Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280) cohorts.

METHODS

Cox proportional hazards regression modeled survival in the derivation cohort using prognostic variables identified in univariate analysis. The model was validated internally and using 10-fold cross-validation. Area under the receiver operating characteristic curve measured the accuracy of the final model.

RESULTS

Four hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin level, dementia etiology, number of homecare admission criteria fulfilled, presence of moderate to severe chronic kidney disease, peripheral vascular disease, quality of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute and Non-Acute Patient palliative care phase. The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute Patient palliative care phase, and 30-day readmission frequency for the prediction of 1-year mortality. The area under the receiver operating characteristic curve was 0.65 (95% confidence interval 0.59-0.70). Risk scores categorized patients into 3 prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246), and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk (≥5) groups, respectively.

CONCLUSIONS AND IMPLICATIONS

The PalS-DEM identifies patients at high risk of death in the next 1 year. The model produced consistent survival results across the derivation, validation, and cross-validation cohorts and will help healthcare providers identify patients with advanced dementia earlier for palliative care.

Histopathological prognostic factors for colorectal liver metastases: A systematic review and meta-analysis of observational studies

INTRODUCTION

Resection is the mainstay of treatment for colorectal liver metastases (CRLMs). Many different histopathological factors related to the primary colorectal tumour have been well studied; however, histopathological prognostic factors related to CRLMs are still under evaluation.

OBJECTIVE

To identify histopathological factors related to overall survival (OS) and disease-free survival (DFS) in patients with resected CRLMs.

METHODS

A systematic review was performed with the following databases up to August 2020: PubMed, EMBASE, Web of Science, SciELO, and LILACS. The GRADE approach was used to rate the overall certainty of evidence by outcome.

RESULTS

Thirty-three studies including 4,641 patients were eligible. We found very low certainty evidence that the following histopathological prognostic factors are associated with a statistically significant decrease in OS: presence of portal vein invasion (HR, 0,50 [95% CI, 0,37 to 0,68]; I²=0%), presence of perineural invasion (HR, 0,55 [95% CI, 0,36 to 0,83]; I²=0%), absence of pseudocapsule (HR, 0,41 [CI 95%, 0,29 to 0,57], p<0,00001; I²=0%), presence of satellite nodules (OR, 0,45 [95% CI, 0,26 to 0,80]; I²=0%), and the absence of peritumoural inflammatory infiltrate (OR, 0,20 [95% CI, 0,08 to 0,54]; I²=0%). Outcome data on DFS were scarce, except for tumour borders, which did not present a significant impact, precluding the meta-analysis.

CONCLUSION

Of the histopathological prognostic factors studied, low- to moderate-certainty evidence shows that vascular invasion, perineural invasion, absence of pseudocapsule, presence of satellite nodules, and absence of peritumoral inflammatory infiltrate are associated with shorter overall survival in CRLMs.

Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review

OBJECTIVES

To identify and appraise the methodological rigour of multivariable prognostic models predicting in-hospital paediatric mortality in low-income and middle-income countries (LMICs).

DESIGN

Systematic review of peer-reviewed journals.

DATA SOURCES

MEDLINE, CINAHL, Google Scholar and Web of Science electronic databases since inception to August 2019.

ELIGIBILITY CRITERIA

We included model development studies predicting in-hospital paediatric mortality in LMIC.

DATA EXTRACTION AND SYNTHESIS

This systematic review followed the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies framework. The risk of bias assessment was conducted using Prediction model Risk of Bias Assessment Tool (PROBAST). No quantitative summary was conducted due to substantial heterogeneity that was observed after assessing the studies included.

RESULTS

Our search strategy identified a total of 4054 unique articles. Among these, 3545 articles were excluded after review of titles and abstracts as they covered non-relevant topics. Full texts of 509 articles were screened for eligibility, of which 15 studies reporting 21 models met the eligibility criteria. Based on the PROBAST tool, risk of bias was assessed in four domains; participant, predictors, outcome and analyses. The domain of statistical analyses was the main area of concern where none of the included models was judged to be of low risk of bias.

CONCLUSION

This review identified 21 models predicting in-hospital paediatric mortality in LMIC. However, most reports characterising these models are of poor quality when judged against recent reporting standards due to a high risk of bias. Future studies should adhere to standardised methodological criteria and progress from identifying new risk scores to validating or adapting existing scores.

PROSPERO REGISTRATION NUMBER

CRD42018088599.

Natural history of uncomplicated urinary tract infection without antibiotics: a systematic review

BACKGROUND

Although uncomplicated urinary tract infection (UTI) is commonly treated with antibiotics, the duration of symptoms without their use is not established; this hampers informed decision making about antibiotic use.

AIM

To determine the natural history of uncomplicated UTI in adults.

DESIGN AND SETTING

Systematic review.

METHOD

PubMed was searched for articles published until November 2019, along with reference lists of articles identified in the search. Eligible studies were those involving adults with UTIs in either the placebo group of randomised trials or in single-group prognostic studies that did not use antibiotics and measured symptom duration. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were the percentage of patients who, at any time point, were symptom free, had symptom improvement, or had worsening symptoms (failed to improve). Adverse event data were also extracted.

RESULTS

Three randomised trials (346 placebo group participants) were identified, all of which specified women only in their inclusion criteria. The risk of bias was generally low, but incomplete reporting of some details limited assessment. Over the first 9 days, the percentage of participants who were symptom free or reported improved symptoms was reported as rising to 42%. At 6 weeks, the percentage of such participants was 36%; up to 39% of participants failed to improve by 6 weeks. The rate of adverse effects was low and, in two trials, progression to pyelonephritis was reported in one placebo participant.

CONCLUSION

Although some uncertainty around the natural history of uncomplicated UTIs remains, some women appear to improve or become symptom free spontaneously, and most improvement occurs in the first 9 days. Other women either failed to improve or became worse over a variable timespan, although the rate of serious complications was low.

Neoadjuvant therapy in locally advanced colon cancer: a meta-analysis and systematic review

Background

The role of perioperative or neoadjuvant chemotherapy for locally advanced colon cancer is unclear. Emerging evidence such as the FOXTROT trial is challenging the conventional norm of upfront operation for these patients. However, these trials have yet to reach statistical significance.

Methods

MEDLINE, Embase, Cochrane Library, China Knowledge Resource Integrated Database (CNKI) and ClinicalTrials.gov were searched. Randomized controlled trials (RCTs) and observational studies of patients with locally advanced colon cancer were included. The intervention arm was neoadjuvant chemotherapies while the comparator arm was adjuvant chemotherapies. Studies which reported outcomes of interests included overall survival, disease-free survival, R0 resection rate, perioperative complications and adverse effects of chemotherapy were chosen.

Results

We identified five eligible randomized trials and two observational studies, including 29,504 patients. Neoadjuvant therapies exhibited statistically significant improvement in overall survival [hazard ratio (HR) =0.76, 95% confidence interval (CI): 0.65-0.89, P=0.0005], and disease-free survival (HR =0.74, 95% CI: 0.58-0.95, P=0.02). R0 resection rate fell slightly short of significance [odds ratio (OR) =1.86, 95% CI: 0.95-3.62, P=0.07]. Risk of peri-operative complications did not differ between groups when examining abdominal infection [risk ratio (RR) =1.14, 95% CI: 0.59-2.18, P=0.70] and anastomotic leakage (RR =0.83, 95% CI: 0.53-1.31, P=0.42). No statistical differences in complications from chemotherapy were reported.

Conclusions

This meta-analysis highlights the potential survival benefit of neoadjuvant chemotherapy compared to adjuvant chemotherapy for locally advanced colon cancer, without an increase in surgical morbidity. Neoadjuvant or perioperative approaches may be considered an alternative to upfront surgery followed by chemotherapy for locally advanced colon cancer.