Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials

Comparative effectiveness of pharmacological and non-pharmacological interventions for dyspnea management in advanced cancer: A systematic review and network meta-analysis

Objective

This study aimed to evaluate and rank the effectiveness of pharmacological and non-pharmacological interventions for managing dyspnea severity, anxiety, exercise capacity, and health-related quality of life (HRQoL) in patients with advanced cancer.

Methods

A comprehensive search of PUBMED, HINARI, CENTRAL, and ResearchGate was conducted to identify randomized controlled trials (RCTs) published up to March 2024. Network meta-analysis was performed to compare interventions, calculating mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI). P-scores were used to rank the interventions. Risk of bias was assessed using the Cochrane tool, and the quality of evidence (QOE) was evaluated using the GRADE framework.

Results

A total of 42 RCTs, encompassing 3,832 patients, were included in the analysis. Among the evaluated interventions, high-flow nasal cannula (HFNC) demonstrated the most significant improvement in dyspnea relief (SMD = -1.91; 95% CI: -3.32 to -0.49; QOE: moderate), followed by acupressure/reflexology (SMD = -1.04; 95% CI: -2.02 to -0.06; QOE: very low). Activity rehabilitation was the only intervention that significantly reduced anxiety compared to the control group (SMD = -0.64; 95% CI: -0.97 to -0.32; QOE: very low). While all interventions showed trends of improving exercise capacity, none reached statistical significance. Notably, acupressure/reflexology significantly enhanced HRQoL (SMD = 1.55; 95% CI: 0.22 to 2.88; QOE: moderate).

Conclusions

Non-pharmacological interventions, particularly HFNC and acupressure/reflexology, were more effective than pharmacological approaches in improving dyspnea relief and HRQoL. However, the low quality of evidence underscores the need for high-quality, large-scale trials to confirm these findings and refine treatment strategies for dyspnea management in advanced cancer patients.

Systematic review registration

PROSPERO CRD42023479041.

A meta-analysis on gender differences in prevalence estimates of mental disorders following exposure to natural hazards

Background: Women report higher rates of trauma-related disorders compared to men. With women being disproportionately impacted by the consequences of natural hazards, this gender disparity may increase in their aftermath.Objective: This meta-analysis aimed at quantifying gender gaps in mental disorder prevalence following natural hazards, considering both the recent and long-term aftermath of natural hazards, the developmental status of affected countries, and type of hazard.Method: A systematic search was conducted in MEDLINE, PsycINFO, and Web of Science in February 2024. Random effects models were used to calculate odds ratios (OR) based on point prevalences. OR adjusted for covariates were also descriptively reported.Results: In total, 141 reports (N = 3,726,153 independent participants) were included. The prevalence for posttraumatic stress disorder (PTSD), major depression (MD), and generalized anxiety disorder (GAD) within the first year after the hazard were 24.95%, 8.11%, and 14.24%, respectively. More than one-year post-natural hazard the prevalence for PTSD and MD were 22.89% and 13.51%, respectively. Women had significantly higher odds for PTSD (OR = 1.85) and MD (OR = 1.52) within the first year after the hazard, as well as in later assessments (OR = 1.83 for PTSD, OR = 1.41 for MD). Only four studies reported on GAD gender differences in the recent aftermath of natural hazards, resulting in a non-significant OR of 1.85. Subgroup analyses indicated no differences between developmental status of affected countries and adjusted OR showed no systematic variations upon the inclusion of covariates. Gender differences were larger in the aftermath of earthquakes.Conclusions: Significant gender differences for mental disorders following natural hazards exist, although these differences appear similar to other contexts. Gender-sensitive disaster response plans for mental health are essential.

Pregnancy urine biomarkers for effectively preeclampsia prediction: a systematic review and meta-analysis

Preeclampsia (PE) is a common multi-organ disorder in pregnancy. Urine as a source for test samples is noninvasive and easy to obtain. This study followed the Priority Reporting Project for Systematic Evaluation and Meta-Analysis protocol. We searched PubMed and Web of Science databases for studies relating to urine biomarker analysis for PE from inception to the 28th of February 2023. The Chi-squared test was utilized to evaluate the statistical heterogeneity of the results. The combined sensitivity, combined specificity, combined positive likelihood ratio, combined negative likelihood ratio, combined diagnostic odds ratio for urine analysis in the context of PE were calculated. Sixty-five studies were eventually included in the final analysis. In only hypertensive disorders of pregnancy (HDP) pregnant women, the the area under the summary receiver operating characteristic curve (AUC) of urine analysis to predict PE was 0.93 (0.91-0.95). The results show that spot random urine analysis or shortened-hour urinary analysis for the diagnosis of PE is a credible alternative method when 24-h urine collection is difficult to complete. The protein/creatinine ratio from spot random urine analysis may be an effective biomarker of the further progression of HDP into PE.

Clinical outcomes of atrial fibrillation screening: a meta-analysis of randomized controlled trials

BACKGROUND

Several randomized controlled trials (RCTs) have investigated the benefits of atrial fibrillation (AF) screening. However, since none have shown a significant reduction in stroke rates, the impact of screening on clinical outcomes remains uncertain.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis of RCTs reporting clinical outcomes of systematic AF screening in participants without known AF. Pooled risk ratios (RRs) were computed for all-cause stroke or systemic embolism, major bleeding, and all-cause mortality, comparing screening with no screening.

RESULTS

Seven RCTs encompassing 76 458 participants were identified. One trial utilized implantable loop recorders for rhythm monitoring, while the others employed non-invasive screening methods. Pooled results indicated that AF screening was associated with a significant reduction in all-cause stroke or systemic embolism (RR 0.932, 95% CI 0.873-0.996, I2 = 0%, p = 0.037), but had no effect on major bleeding (RR 0.996, 95% CI 0.935-1.060, I2 = 0%, p = 0.876) or all-cause mortality (RR 0.987, 95% CI 0.945-1.031, I2 = 0%, p = 0.550). We estimated a number needed to screen of 148 to prevent one stroke or systemic embolism over a 10-year period in a population of 75-year-olds. When only non-invasive screening methods were considered, the reduction in strokes was not statistically significant (RR 0.942, 95% CI 0.880-1.008, I2 = 0%, p = 0.083).

CONCLUSIONS

Systematic AF screening is associated with a modest yet statistically significant 7% relative reduction in stroke and systemic embolism, with no observed impact on major bleeding or all-cause mortality.

Comparative efficacy and safety of febuxostat and allopurinol in chronic kidney disease stage 3-5 patients with asymptomatic hyperuricemia: a network meta-analysis

OBJECTIVE

This study evaluates and compares the effectiveness and safety of febuxostat and allopurinol in chronic kidney disease (CKD) stages 3-5 patients with asymptomatic hyperuricemia using a network meta-analysis.

METHODS

A systematic review and network meta-analysis were conducted, adhering to PRISMA-NMA guidelines. Searches included PubMed, Embase, Cochrane Library, and Chinese databases up to June 2024. Randomized controlled trials (RCTs) and cohort studies were assessed for methodological rigor using GRADE.

RESULTS

A total of 12 RCTs and 4 cohort studies (n = 2,423 participants) were included. Febuxostat was associated with greater improvements in estimated glomerular filtration rate compared to allopurinol (MD, 4.99 mL/min/1.73 m2; 95%CI -0.65 to 10.78; certainty: low) and placebo (MD, 4.72 mL/min/1.73 m2; 95%CI 0.67 to 8.82; low). Serum uric acid reduction was also more pronounced with febuxostat (MD, -0.61 mg/dL; 95%CI -1.15 to -0.05; moderate). Safety outcomes, including major cardiovascular events and adverse events, showed no significant differences between febuxostat and allopurinol. Subgroup analyses revealed enhanced effectiveness of febuxostat at six months of treatment.

CONCLUSIONS

This analysis provides robust evidence that febuxostat might offers greater improvements in kidney function and uric acid levels compared to allopurinol or placebo in asymptomatic hyperuricemia with CKD stage 3-5 patients, without compromising safety. These findings can guide clinical decision-making and treatment optimization.

Effects of advance care planning for patients with advanced cancer: A meta-analysis of randomized controlled studies

BACKGROUND

Patients with advanced cancer often have to make difficult end-of-life decisions, which are closely associated with their access to anticipated care after loss of mental capacity. Advance care planning, an approach of discussing, documenting, and deciding on end-of-life preferences, helps with better decision-making. However, despite being recommended for oncology care, its efficacy for patients with advanced cancer remains unclear.

OBJECTIVE

To explore the effects of advance care planning in patients with advanced cancer.

DESIGN

Systematic review and meta-analysis.

METHODS

Twelve electronic databases, including Embase, Medline, the Cochrane Central Register of Controlled Trials, PsycINFO, Web of Science, CINAHL complete, CBM, CNKI, VIP, Wanfang, Google Scholar and Proguest Dissertations and Theses, were searched from inception to December 2024. The Cochrane Risk of Bias Tool 2.0 was used to evaluate the quality of the included studies. Meta-analysis was performed with R software, and outcomes not amenable to meta-analysis were narratively synthesized.

RESULTS

Fourteen studies were included. The results of the meta-analysis implied that advance care planning significantly improved the completion of advance directives (OR = 7.93, 95 % CI: 2.76-22.77, P = 0.0001) and palliative care utilization (OR = 1.39, 95 % CI: 1.08-1.78, P = 0.0009). Anxiety (SMD = -0.14, 95 % CI: -0.52-0.23, P = 0.45), depression (SMD = -0.10, 95 % CI: -0.55-0.34, P = 0.66), decisional conflicts (MD = -1.25, 95 % CI: -3.67-1.18, P = 0.31), patient satisfaction (SMD = 0.19, 95 % CI: -0.23-0.70, P = 0.47), and quality of life (SMD = 0.32, 95 % CI: -0.83-1.48, P = 0.58) were not improved. In the narrative synthesis, dignity was enhanced, but the effects of concordance between actual care received and preferences were inconsistent. In general, existing advance care planning is primarily delivered in a face-to-face format in hospitals and focuses on older patients.

CONCLUSIONS

Advance care planning may have desirable impacts on improving the completion of advance directives and palliative care utilization for patients with advanced cancer. It was not effective in improving anxiety, depression, decisional conflicts, patient satisfaction, and quality of life. The effects of dignity and care concordance need to be further validated. Young patient-specific, digital technology-based, and in-home advance care planning is encouraged, and the optimal timing of interventions also needs to be clarified.

Reporting quality and evidence support in randomized controlled trials of herbal medicine formulas for vestibular migraine

BACKGROUND

Vestibular migraine (VM) is a prevalent condition characterized by recurrent episodes of dizziness, vertigo, and/or headache, often posing diagnostic and therapeutic challenges. Numerous randomized controlled trials (RCTs) have highlighted potential benefits of herbal medicine formulas (HMFs) for treating VM. However, current evidence remains insufficient to recommend their routine clinical use. The validity of trial results relies heavily on the completeness of the reporting. Therefore, this study aimed to comprehensively evaluate the reporting quality and evidence support of RCTs investigating HMFs for VM.

METHODS

We performed a comprehensive search across eight databases from their inception to August 2024. The included studies were primarily RCTs assessing the effectiveness and safety of HMFs for treating VM. The quality of the RCTs was evaluated using the Consolidated Standards of Reporting Trials (CONSORT) guidelines, along with its extension for Chinese medicine formulas (CONSORT-CHM Formulas). A meta-analysis was conducted to assess the effectiveness and safety of HMFs for the treatment of VM following the Cochrane methodolog. High-frequency herbal medicines (HMs) for VM treatment were identified as those appearing with a cumulative frequency exceeding 50 % among the top-ranked HMs.

RESULTS

A total of 33 RCTs involving 2358 patients with VM were included. The mean score for CONSORT reporting items was 14.24, while the mean score for CONSORT-CHM reporting items was 13.64. Few trials adequately reported essential elements such as appropriate titles, sample size calculations, allocation concealment, randomization implementation, and descriptions of blinding within the CONSORT core items. For CONSORT-CHM, less than half of the studies specified the formula names, dosage forms, and targeted traditional Chinese medicine (TCM) patterns in their titles and abstracts. Most studies demonstrated a high risk of bias, particularly regarding randomization sequence generation, allocation concealment, and blinding. The meta-analysis indicates that HMFs are effective in treating VM with minimal adverse effects; however, the high heterogeneity in certain outcomes suggests a potential risk of bias. The five most frequently used herbs across all studies were, in descending order: Gastrodiae Rhizoma, Rhizoma Pinelliae, Rhizoma Chuanxiong, Poria, Atractylodis Macrocephalae Rhizoma.

CONCLUSIONS

The meta-analysis supports the effectiveness and safety of HMFs for treating VM, with a low incidence of adverse events. However, the CONSORT and CONSORT-CHM reporting items were underreported. Future RCTs should strictly adhere to these guidelines to enhance reporting quality, ensuring full transparency in study design and methodolog. This study contributes to a more rigorous evidence base for HMFs in VM treatment. It aims to improve the quality of future RCTs involving herbal formulas for VM, enabling clinicians to make better-informed decisions.

The prevalence of common mental disorders, stress, and sleep disturbance among international migrant workers: A meta-analysis with subgroup analysis

International migrant workers face an elevated risk of common mental disorders (CMDs), stress, and sleep disturbances due to various individual, psychosocial, and occupational factors. This meta-analysis systematically evaluated the prevalence of CMDs, stress, and sleep disturbance among international migrant workers. Two independent reviewers systematically searched the literature on five electronic databases from inception to June 2022. Random effects meta-analyses were performed to estimate the pooled prevalence of depressive symptoms, anxiety symptoms, stress, and sleep disturbance among international migrant workers. Additionally, subgroup analyses were conducted to examine potential modifiers for the prevalence rates. Of 8461 records, 57 studies (n = 29,481) were included in this meta-analysis. The pooled prevalence rates of depressive symptoms, anxiety symptoms, stress, and sleep disturbance were 20.3 %, 17.8 %, 17.3 %, and 25.3 %, respectively. Subgroup analyses revealed that the prevalence of CMDs and stress was statistically significantly modified by country of destination and type of work, stress by gender and country of origin, and anxiety by migration type. Potential publication bias was observed only in the meta-analysis of stress. Most of the studies included were of moderate to high methodological quality. However, given that the included studies were predominantly cross-sectional and used non-probability sampling, the results should be interpreted with caution. This meta-analysis highlights that CMDs, stress, and sleep disturbances are prevalent among international migrant workers, posing a significant public health concern for host countries. These findings underscore the urgent need for tailored mental health interventions for specific subgroups within this population.

Effect of Micronutrients on HIV-Related Clinical Outcomes Among Adults Living With HIV on Antiretroviral Therapy: Systematic Review and Meta-analysis

CONTEXT

Micronutrient deficiencies are common and frequently co-occurring among people living with HIV (PLHIV) globally, with consequences for their health and clinical outcomes. Previous reviews of the influence of micronutrient supplementation on HIV outcomes were conducted in the pre-highly active antiretroviral therapy (pre-HAART) era or included both HAART-naive and HAART-experienced individuals; thus, the evidence in the context of HAART is inconclusive.

OBJECTIVE

A systematic review and meta-analysis was conducted to evaluate the effect of micronutrient supplementation on important clinical outcomes among PLHIV on HAART.

DATA SOURCES

Original research articles published up to August 2022 in the following medical literature databases were identified and examined: PubMed/Medline, Embase, Web of Science, and Google Scholar.

DATA EXTRACTION

Randomized controlled trials (RCTs) and pre-post intervention studies that evaluated the relationship of micronutrient supplementation and HIV-related outcomes were included. A total of 32 studies investigating the effect of micronutrient supplementation on HIV outcomes in PLHIV on HAART were included. The main outcomes of interest were disease progression, CD4 lymphocyte count, viral load, weight, body mass index (BMI), hemoglobin, and anemia. The Cochrane Risk of Bias (RoB) 2 and ROBINS-I tools were used to assess the risk of bias in included studies, and GRADE was used to assess the certainty of the evidence.

DATA ANALYSIS

Vitamin D supplementation increased serum 25-hydroxyvitamin D concentration by 23.2 nmol/L (95% CI: 11.8 to 34.6; 6 RCTs, 567 participants; low-certainty evidence), but had little to no effect on CD4 lymphocyte counts (mean difference [MD]: 60 cells/µL; 95% CI: -35 to 155; 4 RCTs, 127 participants; low-certainty evidence). The effect of vitamin D on CD4 lymphocyte counts was greater among those with baseline CD4 count <350 cells/µL compared with counterparts with higher CD4 lymphocyte counts. Evidence from single RCTs suggests a beneficial effect of vitamin D on the incidence of sputum-smear-positive tuberculosis (hazard ratio = 0.54; 95% CI: 0.31, 0.92; 4000 participants; low-certainty evidence), and vitamin E (MD = 0.2 g/dL; 95% CI: 0.1, 0.3; 18 participants; moderate-certainty evidence) and selenium (MD = 0.30 g/dL; 95% CI: 0.29, 0.31; 97 participants; high-certainty evidence) on hemoglobin, and selenium on BMI (MD: -0.5; 95% CI: -0.51, -0.49; high-certainty evidence). Zinc supplementation had little to no effect on CD4 lymphocyte count overall, but for every 10-µg/dL higher serum zinc concentration, the predicted change in CD4 lymphocyte count from meta-regression was lower by 28 cells/µL (95% CI: -54, -3; 5 RCTs). Moderate- or high-certainty evidence indicates that there is probably no effect of zinc supplementation on log10 viral load, vitamin D on BMI and lumbar spine bone mineral density, and multiple micronutrient (MMN) supplementation on hemoglobin. The evidence is very uncertain about the effect of zinc supplementation on hemoglobin concentration and BMI, vitamin D supplementation on lumbar spine bone mineral density, vitamin E on CD4 lymphocyte count, and MMN supplementation on CD4 lymphocyte count.

CONCLUSION

Zinc and vitamin D supplementation may promote immune recovery in a substantial proportion of PLHIV on HAART, and selenium and vitamin E supplementation may prevent anemia.

The role of action anticipation in specific sport performance: A three-level meta-analysis and systematic review in temporal occlusion paradigm

Action anticipation is crucial for athletes, enabling them to make the most accurate decisions possible under time constraints and significantly impacting sports performance. This study systematically consolidates key findings from research on action anticipation in sports using the temporal occlusion paradigm to achieve the following five objectives: (1) quantifying the magnitude of the advantage of sports experts in action anticipation; (2) examining whether this expert advantage transfers to familiar and unfamiliar sports and, if so, quantifying its magnitude; (3) testing whether methodological manipulations significantly affect the quantification of action anticipation abilities; (4) reviewing whether temporal occlusion training can improve action anticipation abilities; and (5) inferring the relationship between action anticipation scores in the laboratory and actual movement performance in sports. We identified 111 original articles from databases including Web of Science, APA PsycInfo, PubMed, and Cochrane Library for qualitative analysis. Of these, 127 effect sizes contributed by 100 studies were analyzed using a three-level meta-analysis to achieve objectives (1) to (3), and 12 studies were included in a systematic review to achieve objectives (4) to (5). Corresponding to five objectives, our data indicate that: (1) The magnitude of the advantage of sports experts in action anticipation is strong (Hedges' g = 1.15, 95 % CI [0.97, 1.33], p < 0.001). (2) This expert advantage neither transfers to familiar sports nor unfamiliar sports. (3) Commonly used manipulations, such as stimulus size, response mode, participant selection, and sport category, in the temporal occlusion paradigm consistently yield substantial effects. (4) Temporal occlusion training can improve action anticipation abilities. (5) A small to moderate correlation exists between action anticipation scores in the laboratory and actual movement performance in sports. These findings provide a comprehensive understanding of the crucial role of action anticipation in specific sports performance.

Risk factors for depression, anxiety, and PTSS after loss: A systematic review and meta-analysis

BACKGROUND

Bereavement can lead to complicated grief reactions including clinically significant symptoms of depression, anxiety, and post-traumatic stress (PTSS) post-loss. Gaining insight into specific and shared risk factors for these complicated grief reactions can help identify individuals needing support.

METHODS

A comprehensive systematic review and meta-analysis of risk factors for post-loss depression, anxiety, and PTSS. PsycInfo, PubMed, Web of Science, and CINAHL were searched to identify risk factors for inclusion in the meta-analysis.

RESULTS

The systematic review included 144 studies. Most risk factors were of small magnitude. For depression, 21 risk factors were analyzed, with six analyses of adjusted risk factors reaching statistical significance. Pre-loss depression was the strongest risk factor (ESr = 0.25, 95 %CI [0.03,0.45]). Of nine analyzed risk factors for PTSS, four reached statistical significance, with the death of a close relative yielding the largest effect (ESr = 0.24, 95 %CI [0.01,0.44]). Only female gender significantly predicted anxiety (ESr = 0.21, 95 %CI [0.09,0.32]). Female gender, the death of a partner, and violent/unnatural losses were transdiagnostic risk factors.

CONCLUSIONS

An overview of risk factors for three complicated grief reactions, including their predictive strength, is presented. The results provide insights into transdiagnostic risk factors and can aid early identification of people at risk of complicated grief reactions.

The impact of feedback elements in serious games on nursing learning outcomes: A systematic review and meta-analysis

OBJECTIVE

This study evaluates the impact of different feedback elements in serious games (SGs) on nursing education outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

6546 English-language studies published between 2000 and 2023 were retrieved from seven electronic databases.

REVIEW METHODS

This systematic review and meta-analysis followed the PRISMA guidelines. The Cochrane Risk of Bias tool was used for quality assessment. Meta-analysis and subgroup analysis were conducted using RevMan 5.4, and the certainty of evidence for each outcome was assessed using the GRADE approach.

RESULTS

Eight studies were included in the meta-analysis. Findings showed that, compared to traditional learning methods, outcome feedback had a moderate effect size on knowledge (SMD = 0.51, 95 % CI [0.09, 0.92]), while comparative feedback had a small, non-significant effect size (SMD = 0.38, 95 % CI [-0.36, 1.12]). Immediate feedback had a large effect size on skills (SMD = 0.87, 95 % CI [0.61, 1.14]), and outcome feedback had a moderate effect size (SMD = 0.50, 95 % CI [0.21, 0.79]). Serious games with feedback had a large effect size on motivation (SMD = 1.31, 95 % CI [0.45, 2.17]). For confidence, outcome feedback had a moderately large effect size (SMD = 0.64, 95 % CI [-0.22, 1.51]), and comparative feedback had a small effect size (SMD = 0.24, 95 % CI [-0.44, 0.91]), but neither reached statistical significance. GRADE assessment showed high certainty for immediate feedback on skills, moderate certainty for outcome feedback on knowledge and skills, and very low certainty for comparative feedback on knowledge. Evidence certainty for motivation and confidence was low or very low.

CONCLUSION

Serious games incorporating feedback elements can enhance nursing students' motivation. Immediate feedback significantly improves nursing skills, while outcome feedback improves knowledge acquisition. However, further research is needed to validate these findings due to the limited number of studies and high heterogeneity.

Lactate as a Predictor of Citrate Accumulation in Patients Undergoing Continuous Renal Replacement Therapy? A Systematic Review

Regional citrate anticoagulation (RCA) is the preferred strategy for continuous renal replacement therapy (CRRT). However, impaired citrate metabolism, observed in patients with liver failure, mitochondrial dysfunction, and/or shock, can result in potentially lethal citrate accumulation (CA). We aimed to evaluate the ability of elevated lactate levels to predict CA in critically ill patients undergoing RCA-CRRT. We performed a comprehensive search in PubMed and Embase databases for studies involving adult critically ill patients who underwent RCA-CRRT, where both CA and lactate levels were assessed. The primary outcome was lactate levels in relation to patients with and without CA. The certainty of the effect estimates for each outcome and the quality of the included studies were assessed. We included seven observational studies comprising 1573 critically ill patients undergoing RCA-CRRT. Five studies were deemed good quality evidence and two poor to answer the research question. We found a significant mean difference (MD) in baseline lactate levels (MD: 0.87, 95% CI [0.04; 1.70] p = 0.04, six studies, 1474 patients) between the CA and the non-CA group with low confidence in the estimate. This difference was persistent between the two groups when using peak lactate levels (MD: 6.05, 95% CI [0.06; 12.03], p = 0.05, three studies, 271 patients), and the CA group had an overall higher mortality risk (OR: 5.24, 95% CI [1.05; 26.25], p = 0.04, five studies, 1427 patients). The evidence is very uncertain, but elevated lactate may be associated with an increased risk of CA in critically ill patients undergoing RCA-CRRT.

Efficacy and Safety of Tenofovir Plus Entecavir Combination Therapy Versus Tenofovir Monotherapy in Chronic Hepatitis B Virus Patients With Resistance or Partial Response to Entecavir: A Systematic Review and Meta-analysis

Background and objectives

Chronic hepatitis B virus remains a significant cause of liver disease in the developing world, leading to sequelae such as hepatocellular carcinoma. While entecavir (ETV) serves as a first-line treatment, its growing resistance rates underscore the need to explore viable alternatives. Tenofovir disoproxil fumarate (TDF) monotherapy and entecavir plus tenofovir (TDF + ETV) combination therapy are both employed as treatments, but one's efficacy over another is in question. This meta-analysis aims to investigate any primacy of either treatment.

Methods

We conducted a comprehensive literature search across PubMed/Medline, Embase, Cochrane Central, Web of Science, and China National Knowledge Infrastructure from inception till 7th October 2024. Studies comparing the safety and efficacy of TDF monotherapy versus TDF + ETV combination therapy in patients resistant to entecavir were considered. Data about the virologic response (VR), virologic breakthrough, HbeAg seroconversion, HbeAg/HbsAg seroclearance, and alanine aminotransferase normalization were extracted. Relative risks (RRs) and their corresponding 95% confidence intervals (CIs) were calculated, pooled, and analyzed in a random-effects model. P-value <0.05 was regarded as significant for all analyses.

Results

Nine studies, comprising 335 patients undergoing monotherapy and 352 patients undergoing combination therapy, satisfied the criteria. TDF + ETV combination therapy was found slightly advantageous to TDF monotherapy, stimulating a VR at 48 weeks (RR 1.081 95% CI: [1.001-1.167] P = 0.046, I2 = 0%), along with the HbeAg seroconversion rate (RR 1.711 95% CI: [1.005-2.913] P = 0.048, I2 = 0%). There were no significant adverse events in individual studies to warrant a meta-analysis.

Conclusions

TDF + ETV shows slightly better efficacy to TDF monotherapy over a 48-week treatment regimen, with minimal safety concerns. However, further high-quality studies like randomized controlled trials are needed to further solidify conclusions, with this meta-analysis only achieving borderline significances.

Registration

This review is registered on the PROSPERO database (ID: CRD42024581443).

Microbiota-based therapies as novel targets for autism spectrum disorder: A systematic review and meta-analysis

BACKGROUND

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition characterized by persistent deficits in social interaction and communication. Emerging evidence suggests that alterations in the gut-brain axis play a key role in the pathophysiology of ASD, and that microbiota-targeted interventions may offer therapeutic benefits. However, no clear consensus has been reached regarding the effectiveness of these strategies in ameliorating behavioral characteristics. This systematic review and meta-analysis (PROSPERO registration ID: CRD42023494067) aimed to evaluate the impact of microbiota-based interventions-including synbiotics, prebiotics, single-strain probiotics, probiotic blends, and fecal microbiota transplantation (FMT)-on behavioral outcomes in individuals with ASD, with particular emphasis on social functioning.

RESULTS

Of the 373 records initially identified, 20 studies met the inclusion criteria, comprising 16 randomized controlled trials and 4 open-label studies. The overall effect size indicated a statistically significant improvement in ASD-related behavioral symptoms following microbiota manipulation (Hedges' g = 0.47; 95 % CI: 0.30-0.64; p < 0.001; I2 = 33.01 %), representing a small but clinically relevant effect. Heterogeneity was classified as moderate. Among the interventions, FMT and probiotic blends yielded the most substantial effects. All major limitations of the current studies were thoroughly addressed and discussed to guide future experimental designs. Additionally, we examined preclinical evidence supporting the involvement of neural, immune, and metabolic pathways in mediating the observed behavioral improvements.

CONCLUSIONS

Our findings support the potential of microbiota-based therapies as a promising and well-tolerated strategy for improving behavioral symptoms in individuals with ASD. FMT and multi-strain probiotic formulations appear particularly effective. Nevertheless, further high-quality randomized controlled trials-especially involving FMT-are urgently needed to validate these results and guide clinical implementation. Thus, these findings provide a critical foundation for future investigations seeking to refine microbiota-based interventions and uncover the underlying mechanisms through which they influence ASD-related behaviors.

The Level and Nature of Impairment on the Iowa Gambling Task Following Acquired Brain Injury: A Meta-analysis

The Iowa Gambling Task (IGT) is a popular measure of risky decision-making, but to date, no formal quantitative reviews have been conducted, focused exclusively on IGT performance amongst individuals with acquired brain injury (ABI). Therefore, this meta-analytic study firstly explored performance differences between individuals with ABI vs controls. Second, we extended this comparison by investigating differences in IGT scoring and interpretive approaches (e.g., total score vs later block analysis). Finally, we explored potential IGT performance moderators (e.g., average age). A total of 25 studies, containing 39 samples (total n = 2188), were included. Overall findings suggested that the IGT is sensitive to the presence of ABI, particularly non-TBI and medically confirmed TBI, which becomes evident by block 2 of 5. Medium effect sizes were obtained for IGT total score, as well as indicators using later blocks only. Performance moderators such as population type and region influenced IGT performance, whilst average age, average education, and proportion of males did not. These results indicate that the IGT is sensitive to decision-making impairment following ABI, although we conclude that further research is needed to confirm the IGT's ability to detect impairment relative to specific brain regions.

CBT treatment delivery formats for generalized anxiety disorder: a systematic review and network meta-analysis of randomized controlled trials

OBJECTIVES

To assess the comparative efficacy and acceptability of different delivery formats of cognitive behavior therapy (CBT) in treating generalized anxiety disorder (GAD).

METHODS

We searched MEDLINE, Embase, PsycINFO, and the Web of Science from database inception to September, 2023, to identify randomized clinical trials (RCTs) of CBT for patients with GAD. Pairwise and network meta-analyses were conducted using a random-effects model.

RESULTS

Finally, 52 trials that randomized 4361 patients (mean age 43 years; 69.7% women) with generalized anxiety disorder met the inclusion criteria. The most studied treatment comparisons were individual and remote CBT versus waiting list. The quality of the evidence was typically of low or unclear risk of bias (39 out of 52 trials, 75%). The network meta-analysis including 30 studies showed that individual CBT was superior to remote CBT (SMD 0.96; 95% Cl 0.13-1.79), treatment as usual (SMD 1.12; 95% Cl 0.24-2.00) and waiting list (SMD 1.62; 95% Cl 1.03-2.22) in relieving anxiety symptoms of GAD. Group CBT (SMD 1.65; 95% Cl 0.47-2.84) was more efficacious than waiting list. Remote CBT was not superior to treatment as usual or waiting list. In terms of acceptability CBT delivery formats did not differ significantly from each other.

CONCLUSIONS

Our findings provide evidence for the consideration of group treatment formats as alternative to individual CBT in relieving anxiety symptoms in patients with GAD, but remote CBT may be less effective.

Safety of nanoparticle therapies during pregnancy: A systematic review and meta-analysis

The exclusion of pregnant women from clinical trials has led to insufficient safety data for many treatments, making it necessary to evaluate their potential benefits and risks during preclinical stages. Nanomedicines show potential for reduced toxicity but there is limited evidence about their safety for pregnant women and their fetuses. We conducted the first systematic review and meta-analysis of the effect of nanoparticles (NPs) on a key outcome of fetal toxicity (low birth weight) in murine models. In the meta-analysis of mouse models, negatively charged NPs tended to decrease birth weight (-69.8 mg, 95 % CI: -196 to 56.5), as did small (-191 mg, 95 % CI: -369 to -13.3) and plain inorganic nanosystems (-249 mg, 95 % CI: -535 to 37.4). In contrast, positively charged NPs resulted in increased birth weight (+29.3 mg, 95 % CI: 23.4 to 35.2). All findings were validated in studies with low heterogeneity and low risk of publication bias. Neither large NPs (+4.37 mg; 95 % CI: -45.3 to 54.0) nor polymer-coated NPs (+16.5 mg; 95 % CI: -44.7 to 77.6) had any clear association with birth weight. Similar results were observed in other models and experimental designs from articles not included in the meta-analysis, although no conclusions were drawn for other parameters due to high variability. Our findings pave the way for future research and the rational development of safer nanomedicines for use during pregnancy.

The presence of Enterococcus in root canal infections based on next-generation sequencing: A systematic review and meta-analysis

BACKGROUND

Studies based on next-generation sequencing (NGS) have reported conflicting evidence regarding the presence of Enterococcus in root canal infections.

OBJECTIVE

To determine whether Enterococcus prevalence differs among secondary root canal infection (SRCI), persistent root canal infection (PRCI) and primary root canal infection (PrRCI).

METHODS

Literature search was carried out across databases (PubMed, Web of Science, Scopus and Excerpta Medica Database) and other online resources from 1 September 2005, to 24 October 2024. Studies were selected according to inclusion and exclusion criteria. Risk of bias was evaluated according to the JBI Prevalence Critical Appraisal Checklist. The selection of 28 studies focused on the main and secondary outcomes. Pooled estimates of Odds Ratio (OR), prevalence and 95% Confidence Interval (CI) were determined with a common effect or random effects model. Multivariate meta-regression models were fitted. Subgroup analyses were conducted based on sample collection method, region and NGS platform. Sensitivity analysis was conducted to further investigate the robustness of results and to explore plausible causes for heterogeneity.

RESULTS

Among 28 included studies, 16 studies reporting the detection rate of Enterococcus were incorporated in the meta-analysis. The detection rate of Enterococcus was significantly higher in SRCI than in PrRCI (OR = 2.691; 95% CI: 1.234-5.868; p = .013). The pooled prevalences were 0.400 (95% CI: 0.235-0.565) for SRCI, 0.444 (95% CI: 0.000-0.976) for PRCI and 0.278 (95% CI: 0.087-0.470) for PrRCI, respectively. Within the PrRCI group, the cryogenic pulverization (CP) method yielded a significantly higher detection rate (0.768; 95% CI: 0.642-0.894) than the paper points/hand or rotary instruments (PP) method (0.113; 95% CI: 0.045-0.180). The relative abundance of Enterococcus ranged from 0.01% to 18.88% in SRCI, 2% to 10.5% in PRCI and 0.0008% to 2.03% in PrRCI.

DISCUSSION

Although a quantitative synthesis of Enterococcus prevalence has been conducted, the data of abundance remain insufficient in literatures.

CONCLUSION

A higher prevalence of Enterococcus was correlated with SRCI and PRCI compared to PrRCI. Sample collection method had a significant impact on the prevalence of Enterococcus in the PrRCI context. Enterococcus seems not to be a predominant genus in most studies based on its relatively low abundance.

REGISTRATION

PROSPERO database CRD42024609984.

Exercise-based interventions for preventing and treating cancer therapy-related cardiovascular toxicity: a systematic review and meta-analysis

PURPOSE

This review aimed to evaluate the effects of exercise-based interventions on cancer therapy-related cardiovascular toxicity (CTR-CVT) in individuals with cancer.

METHODS

Four databases (MEDLINE, Embase, Web of Science, and CENTRAL) were searched to identify eligible studies. Randomized controlled trials examining the effects of exercise-based interventions on CTR-CVT in cancer patients published in English were included. The risk of bias of included studies was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials. The meta-analysis was performed using statistical software R. The PRISMA statement was followed.

RESULTS

Thirty studies with 2484 participants were included. Our findings revealed that compared to the control group, exercise-based intervention improved VO2peak (mean difference [MD]: 1.62, 95% confidence interval [CI]: 0.94 to 2.30), resting diastolic blood pressure (MD: -4.43, 95% CI: -8.72 to -0.13), and resting heart rate (MD=-3.74, 95% CI: -6.59, -0.89) among individuals with cancer. Evidence on other study outcomes remains unclear.

CONCLUSION

The findings of this review demonstrate the potential role of exercises in preventing and treating CTR-CVT. Further research is warranted to strengthen the current evidence and fill the gaps identified in this review.

REGISTRATION

The review protocol was registered in PROSPERO (ID: CRD42022380550).

Risk of Ophthalmotoxicity Associated with Antibody-Drug Conjugates: A Systematic Review and Meta-analysis

BACKGROUND

Antibody-drug conjugates provide significant advantages in cancer therapy, but their associated ophthalmotoxicity remains insufficiently explored.

OBJECTIVE

Our objective was to determine the prevalence and risk of ophthalmotoxicity in patients receiving antibody-drug conjugates.

METHODS

We conducted a systematic search in MEDLINE, Embase, Web of Science, Cochrane, and ClinicalTrials.gov for phase II or III randomized clinical trials reporting ocular adverse events linked to antibody-drug conjugates up to 5 March, 2025. The Cochrane Bias Risk Assessment Tool was used to assess the risk of bias. The primary outcome was the risk of all-grade ocular adverse events induced by antibody-drug conjugates, measured by the risk ratio (RR) with 95% confidence intervals (CIs).

RESULTS

Thirty-one trials consisting of 18,490 patients were ultimately included. The pooled incidence of all-grade ocular adverse events following antibody-drug conjugate therapy was 10.45% (95% CI 4.51-18.42). Antibody-drug conjugates were linked to a potentially increased risk of ophthalmotoxicity (RR = 1.76, 95% CI 1.25-2.48), particularly with monomethyl auristatin E (RR = 2.73, 95% CI 1.42-5.28) and monomethyl auristatin F (RR = 3.01, 95% CI 2.58-3.52) payloads. Dry eye was the most common ocular manifestation (15.49%, 95% CI 7.66-25.38).

CONCLUSIONS

Antibody-drug conjugate therapy has been associated with an elevated risk of ophthalmotoxicity. Further research is needed to explore the influence of antibody-drug conjugate components, disease characteristics, and treatment regimens on ophthalmotoxicity risk.

CLINICAL TRIAL REGISTRATION

PROSPERO register name and registration number: Antibody-drug conjugates-related to ocular toxicity: a network meta-analysis and real-world pharmacovigilance study of the FAERS database (CRD42023458065).

Effects of core stability training on swimmers' specific performance: A systematic review with meta-analysis

OBJECTIVE

To determine the effects of core stability training on the specific performance of swimmers.

METHODOLOGY

A systematic search of trials up to August 2024 was performed in PubMed, Bireme, Scopus and WOS, following the guidelines of the Cochrane Handbook and PRISMA statements. Two reviewers independently selected studies, with disagreements resolved by a third reviewer. Risk of bias was assessed using the ROB2 scale, and publication bias was addressed using funnel plots and Egger regression. In addition, study quality was assessed with checklists (SIGN/CONSORT). Data were analyzed in RevMan-Web using fixed-effects meta-analysis, assessing heterogeneity with I2, χ2 tests and Galbraith plots. Finally, the certainty of evidence was determined employing the GRADE approach.

RESULTS

Out of 2328 records identified, 11 studies involving 218 swimmers (11-20 years) were selected. Core stability training improved performance in the 50-m freestyle with a decrease of -1.06 s (95% CI = -1.48, -0.63). However, the effect in the 100-m freestyle was inconclusive with a difference of -2.26 s (95% CI = -4.85, 0.33). The certainty of the evidence for the 50-m freestyle was classified as moderate, whereas for the 100-m freestyle it was considered low.

CONCLUSION

Sport scientists may consider implementing core stability training to optimize specific performance in the 50-m freestyle. However, its effect on the 100-m freestyle and other swimming distances and strokes is still unknown, which highlights the need for further research in these areas.

REGISTRATION NUMBER

CRD42024579857.

Prevalence and risk factors for lymph node metastasis in duodenal neuroendocrine tumors: a systematic review and meta-analysis

BACKGROUND

Although the status of lymph node metastasis (LNM) is crucial in determining treatment strategy for duodenal neuroendocrine tumors (D-NETs), robust evidence for their potential LNM risk remains lacking. This systematic review aimed to summarize the prevalence and risk factors of LNM in D-NETs.

METHODS

This systematic review of electronic databases identified eligible case-control and cohort studies for D-NET resected either endoscopically or surgically, published from 1990 to 2023. The primary outcome was the pooled prevalence of LNM in D-NETs. Secondary outcomes included the pooled prevalence of LNM according to tumor location and functionality, as well as identifying pathological risk factors for LNM. Meta-analysis was performed.

RESULTS

We identified 36 studies that involved 1,396 patients with D-NETs, including 326 with LNM. The pooled prevalence of LNM in D-NETs was 22.7% (95% confidence interval [CI] 17.3-29.2%). The prevalence was high in ampullary/peri-ampullary D-NETs and functional D-NETs (46.8 and 53.3%, respectively), whereas it was low in non-functional, non-ampullary D-NETs (NAD-NETs) (9.5%). Pathological risk factors for LNM in NAD-NETs included tumor size > 10 mm (odds ratio [OR] 7.31 [95% CI 3.28-16.31]), tumor invasion into the muscularis propria or deeper (OR 7.79 [3.65-16.61]), lymphovascular invasion (OR 5.67 [2.29-14.06]), and World Health Organization grading of G2 (OR 2.47 [1.03-5.92]).

CONCLUSION

Approximately one-fourth of the patients with D-NETs had LNM. Endoscopic resection might be acceptable for non-functional NAD-NETs with diameters of 10 mm or less, but additional surgical resection with lymphadenectomy may be recommended for cases exhibiting pathological risk factors.

Effects of SGLT2 inhibitors on health-related quality of life and functional capacity in patients with heart failure with and without diabetes: a meta-analysis of randomized controlled trials

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce major cardiovascular events among individuals with heart failure regardless the ejection fraction. The effect of SGLT2 inhibitors on health-related quality of life (HRQoL) and physical capacity are still unclear.

AIM

To investigate the effects of SGLT2 inhibitors on HRQoL and physical capacity in patients with heart failure.

METHOD

We systematically searched PubMed, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing SGLT2 inhibitors to placebo in this population. The outcomes analyzed were mean changes in Kansas City Cardiomyopathy Questionnaire (KCCQ) score and its domains: total symptoms score (TSS), physical limitations score (PLS), clinical summary score (CSS) and overall summary score (OSS), as well as the six-minute walk test (6MWT) and peak oxygen uptake (peak VO2).

RESULTS

Eighteen RCTs with 23,848 participants were included. There was a statistical significant improvement in KCCQ TSS (MD: 3.33; 95% CI 1.84 to 4.81; p < 0.001) in HFrEF, HFpEF and non-diabetic subgroups. Consistent findings were found in KCCQ PLS, KCCQ CSS, and KCCQ OSS. The distance covered in the 6MWT was significant higher (MD: 12.8; 95% CI 1.06 to 24.54; p = 0.03) and peak VO2 was increased (MD: 1.06; 95% CI 0.57 to 1.55; p < 0.001).

CONCLUSION

SGLT2 inhibitors improve HRQoL and functional capacity in patients with HF regardless the ejection fraction and co-diagnosis of diabetes.

Timing is everything: the age-related impact of plyometric training on lower limb explosive strength in male adolescents and its general effectiveness in female adolescents

OBJECTIVE

This study investigates the impact of plyometric training on age-related lower limb explosive strength in male adolescents and its effectiveness in female adolescents.

METHODS

A thorough search was conducted across five databases from their inception until September 20, 2024. Study quality was assessed using the Cochrane Risk Assessment Tool, and data analysis was performed with Stata 15 software.

RESULTS

Plyometric training positively affected countermovement jump (CMJ) (MD = 2.90 cm, 95% CI (2.35, 3.45)), squat jump (SJ) (MD = 2.57 cm, 95% CI (1.69, 3.44)), and 20-m sprint performance (MD = - 0.09 s, 95% CI (- 0.14, - 0.05)). Subgroup analysis revealed varying improvements across age stages. In CMJ, the early adolescence (EA) group (MD = 2.57 cm, 95% CI (1.74, 3.40)), mid-adolescence (MA) group (MD = 3.04 cm, 95% CI (2.30, 3.79)), and post-adolescence (PA) group (MD = 3.89 cm, 95% CI (1.96, 5.81)) showed progressive enhancement. The MA group exhibited superior improvements in SJ (MD = 3.78 cm, 95% CI (2.19, 5.36)) and 20-m sprint (MD = - 0.11 s, 95% CI (- 0.18, - 0.05)) compared to the EA group (SJ: MD = 2.10 cm, 95% CI (1.43, 2.77); sprint: MD = - 0.06 s, 95% CI (- 0.11, - 0.01)). The PA group showed no significant improvements (SJ: MD = 1.31 cm, 95% CI (- 1.05, 3.67); sprint: MD = - 0.27 s, 95% CI (- 0.61, 0.07)). For female adolescents, plyometric training effectively improved CMJ (MD = 2.55 cm, 95% CI (1.43, 3.66)), SJ (MD = 2.33 cm, 95% CI (1.36, 3.31)), and 20-m sprint performance (MD = - 0.22 s, 95% CI (- 0.33, - 0.12)).

CONCLUSION

Plyometric training significantly enhances lower limb explosive strength in both male and female adolescents, with age-dependent effects for male adolescents. The greatest improvement in CMJ was observed in the PA stage, followed by the MA stage, while the EA stage showed the least. The MA stage exhibited the best improvements in SJ and sprint performance.

TRAIL REGISTRY

The study has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023406914).

Effects of psychoeducation interventions on psychological outcomes among spousal caregivers of community-dwelling older adults: A systematic review and meta-analysis

BACKGROUND

Spouses often assume the role of primary informal caregivers for ageing partners. Spousal caregivers are more likely than other family members to experience negative psychological outcomes due to their unique identities. However, little is known as to whether psychoeducation interventions can support them in the caregiving process.

OBJECTIVES

To systematically identify and synthesise evidence regarding the effects of psychoeducation interventions on psychological outcomes among spousal caregivers of community-dwelling older adults.

DESIGN

A systematic review and meta-analysis.

METHODS

Eight electronic databases, including Cochrane Library, PubMed, CINAHL, MEDLINE, Embase, PsycINFO, Chinese Journal Net and Wanfang were searched from inception to August 2024. Randomised controlled trials of psychoeducation interventions on psychological outcomes in spousal caregivers of older adults were included. The quality of the evidence was evaluated using The Cochrane Risk of Bias Tool v2. The certainty of the evidence was assessed by the GRADE approach. Data synthesis methods, including meta-analysis and narrative synthesis, were conducted based on data availability. Meta-analysis was performed using a random-effects model given the substantial heterogeneity in the intervention design and outcomes. Sensitivity analyses were used to assess the robustness of the findings.

RESULTS

Among the 18 reviewed studies, the overall risk of bias indicated that four had low risk, eight had some concerns, and six had high risk. The pooled analysis suggested that psychoeducation interventions had significant effects on improving marital satisfaction (SMD = 0.28, 95 % CI: 0.09 to 0.47; low certainty) and positive aspects of caregiving (SMD = 1.30, 95 % CI: 0.44 to 2.16; very low certainty). However, the effects on depressive symptoms, caregiving burden, anxiety, mental health, coping and self-efficacy were negligible. Narrative synthesis of evidence suggested potential beneficial effects on posttraumatic growth, family functioning, family relationship and life satisfaction.

CONCLUSIONS

Psychoeducation interventions have potential to improve marital satisfaction and positive aspects of caregiving among spousal caregivers of older adults. However, the evidence has a low level of certainty with considerable variability in intervention design and outcome measures, indicating the need for further rigorous investigation. The non-significant effects on enhancing caregiving competence or alleviating negative psychological outcomes highlight the importance of exploring the specific needs and expectations of spousal caregivers.

REGISTRATION

PROSPERO (CRD42024498599).

Efficacy of gut-brain neuromodulators in irritable bowel syndrome: an updated systematic review and meta-analysis

BACKGROUND

Gut-brain neuromodulators might be efficacious for irritable bowel syndrome (IBS), but there has been no synthesis of evidence from randomised controlled trials (RCTs) of some drug classes, and whether they have pain-modifying properties in IBS is unclear. We updated a previous systematic review and meta-analysis of RCTs examining these questions.

METHODS

We searched MEDLINE (from Jan 1, 1946, to Jan 1, 2025), Embase and Embase Classic (from Jan 1, 1947, to Jan 1, 2025), and the Cochrane Central Register of Controlled Trials (from database inception to Jan 1, 2025). Trials recruiting adults with IBS and that compared gut-brain neuromodulators versus placebo over at least 4 weeks of treatment were eligible. Dichotomous symptom data were pooled using a random effects model to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% CI.

FINDINGS

The search strategy identified 3625 citations. 28 RCTs were eligible containing 2475 patients. Ten RCTs were identified since our previous meta-analysis, containing 1348 patients. The RR of global IBS symptoms not improving with gut-brain neuromodulators versus placebo in 22 RCTs (2222 patients) was 0·77 (95% CI 0·69-0·87). The best evidence in terms of persistence of global IBS symptoms was for tricyclic antidepressants (TCAs) in 11 trials (1144 patients; RR 0·70, 0·62-0·80). The RR of abdominal pain not improving with gut-brain neuromodulators versus placebo in 19 RCTs (1792 patients) was 0·72 (95% CI 0·62-0·83). The best evidence was for TCAs in seven trials (708 patients; RR 0·69, 0·54-0·87), but there was also a benefit of selective serotonin reuptake inhibitors in seven RCTs (324 patients; RR 0·74, 0·56-0·99), and serotonin and norepinephrine reuptake inhibitors in two trials (94 patients; RR 0·22, 0·08-0·59). Adverse events were not significantly more common with gut-brain neuromodulators, although rates of withdrawal due to adverse events were significantly higher. The certainty in the evidence for tricyclic antidepressants for global IBS symptoms was moderate, but it was low to very low for all other endpoints and drug classes studied.

INTERPRETATION

Some gut-brain neuromodulators are efficacious in reducing global symptoms and abdominal pain in IBS. The findings support guidelines that recommend use of tricyclic antidepressants for ongoing global symptoms or abdominal pain but also highlight a potential for SSRIs to be modestly effective for abdominal pain. More data for SNRIs, azapirones, and tetracyclic antidepressants in IBS are required.

FUNDING

None.

Sociodemographic barriers in epilepsy surgery in the United States: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to perform a systematic review and meta-analysis to identify sociodemographic barriers that could contribute to the underutilization of epilepsy surgery.

METHODS

PubMed, EMBASE, and Web of Science databases were systematically reviewed from January 2002 until August 2024. The studies examining the impact of sociodemographic barriers on epilepsy surgery were included. The primary outcomes were the odds ratio (OR) and 95 % confidence intervals (CI) for receiving surgery compared to not-receiving surgery in persons with epilepsy. Race/ethnicity, sex, and insurance had sufficient data to perform a meta-analysis of OR and 95 % CI.

RESULTS

Overall, 1,520,813 patients from 12 studies were evaluated, among which relevant studies were selected for comparing sex (338,170 males and 341,821 females), race (1,056,571 White, 224,693 Hispanic, and 239,549 Black/African-American [Black/AA]), and insurance (232,908 private, 190,849 Medicaid, and 204,478 Medicare). Black/AA patients were significantly less likely to have surgery compared to Whites (OR 0.46, CI 0.35-0.61) or Hispanics (OR: 0.54, CI 0.43-0.67). White patients were more likely to have surgery than other groups examined (OR 1.61, CI 1.28-2.02). There were no significant differences in surgical odds when comparing males to females (OR 1.00, CI 0.97-1.03). Compared to the private insurance, patients with Medicaid (OR 0.61, CI 0.49-0.75) or Medicare (OR: 0.49, CI 0.32-0.77) were less likely to obtain surgery.

CONCLUSION

This meta-analysis highlights the impact of race/ethnicity, sex, and insurance status in the likelihood of receiving epilepsy surgery and can inform targeted interventions and policies aimed at ensuring equity for disadvantaged groups.

The Difference of RCB 0 and RCB I in Prognosis of Breast Cancer After Neoadjuvant Therapy: A Meta-Analysis

BACKGROUND

The use of the residual cancer burden (RCB) for assessing breast cancer after neoadjuvant therapy (NAT) is increasingly common, but the prognostic difference between RCB 0 and RCB I is unclear.

METHODS

We systematically reviewed literature from PubMed, Embase, Web of Science, and oncology conferences until September 24, 2023. We used fixed- and random-effects models to calculate hazard ratio (HR) with 95% confidence interval (CI) for event-free survival (EFS), overall survival (OS), and distant disease-free survival (DDFS).

RESULTS

Our meta-analysis, encompassing 19 studies with 5894 patients, revealed that in the general population, RCB I had worse EFS (HR = 2.13; 95% CI: 1.75-2.58), OS (HR = 2.08; 95% CI: 1.48-2.93), and DDFS (HR = 2.10; 95% CI: 1.65-2.67) than RCB 0. Consistent with results from the general population, RCB I exhibited poorer EFS, OS, and DDFS in human epidermal growth factor 2-positive (HER2+) subtype and triple-negative breast cancer (TNBC) compared to RCB 0. Conversely, luminal subtype with RCB 0 and RCB I showed similar EFS (HR = 1.04; 95% CI: 0.62-1.72).

CONCLUSIONS

RCB I experienced a poorer prognosis compared to RCB 0 in the general population, a pattern also observed in the HER2+ subtype and TNBC. However, no significant prognostic disparity was noted between RCB 0 and RCB I in the luminal subtype.

Patient and informal caregiver-centered nursing interventions for adults with heart failure: A systematic review and meta-analysis

BACKGROUND

Heart failure management requires active participation in self-care by both patients and family caregivers as a dyad.

OBJECTIVE

This systematic review and meta-analysis aimed to examine the impact of dyadic self-care interventions on patient outcomes in heart failure management.

METHODS

We searched databases including PubMed, Embase, Cochrane Library, Web of Science, CINAHL, CNKI, and Wanfang through May 14, 2024. Following PRISMA guidelines, we used the Cochrane Risk of Bias tool for quality assessment and Review Manager 5.4 for data analysis.

RESULTS

Twenty studies (18 Randomized Controlled Trials, 2 quasi-experimental) involving 3,266 patients and 3,091 family caregivers were included. Dyadic self-care interventions showed significant effects on patients' self-care maintenance (MD: 9.07, 95 % CI: 6.17-11.98) and management (MD: 5.03, 95 % CI: 3.96-6.10) across all time periods. Self-care confidence improved only in short-term (MD: 6.32, 95 % CI: 5.32-7.32) and medium-term (MD: 4.23, 95 % CI: 0.26-8.20). Quality of life improved only in short-term. The interventions reduced readmission rates and healthcare costs but showed no effect on mortality, anxiety, or depression.

CONCLUSIONS

Dyadic interventions effectively reduced readmissions and improved quality of life in heart failure management. Future research should focus on sustainable, cost-effective strategies for long-term outcomes.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings support implementing dyadic interventions while emphasizing the need for continued focus on mental health and sustained support. Further research on caregiver outcomes is warranted.

Effectiveness of Acceptance and Commitment Therapy on Reducing Depression and Anxiety in Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the effectiveness of acceptance and commitment therapy (ACT) in reducing depressive and anxiety symptoms in older adults.

DESIGN

A systematic review and meta-analysis.

METHODS

Nine databases were searched for publications up to 2 April 2024, using combinations of search terms related to depression, anxiety, ACT, older adults and randomised controlled trials (RCTs). Two researchers were selected according to inclusion and exclusion criteria, data extraction and methodological quality evaluation, and Stata 16.0 software was used for meta-analysis.

RESULTS

Seven articles were included in a systematic review and six were in a meta-analysis. The results indicated that, compared to the control group, ACT had a small but significant effect in reducing depressive symptom (SMD = -0.22, 95% CI, -0.38 to -0.06, p < 0.001; 576 older adults; low-quality evidence), while it showed a small, non-significant effect on reducing anxiety symptoms (SMD = -0.29, 95% CI, -0.73 to 0.15, p = 0.194; 576 older adults; very low-quality evidence). Subgroup analysis based on the different control conditions may have some enlightenment on the sources of heterogeneity.

CONCLUSION

ACT can be an important component of future psychotherapy for older adults, as it may alleviate depressive symptoms. However, high-quality studies with large samples, multiple centres and long follow-up durations should be performed to further reliably assess the treatment effects of depressive symptoms and explore potential benefits for anxiety symptoms.

Caution is necessary in interpreting musculoskeletal physiotherapy intervention outcomes: a methodological review of physiotherapy neuromusculoskeletal reviews

OBJECTIVES

The physiotherapy literature lacks high-quality, registered systematic reviews (SRs) and 'trustworthy' randomized controlled trials (RCTs). It is unknown whether considering quality and 'trustworthiness' impact publication bias, heterogeneity, and the certainty of clinical recommendations observed in the literature.

METHODS

We performed a methodological review of SRs investigating physiotherapy treatment of neuromusculoskeletal conditions indexed by MEDLINE, between 1 January 2018, and 25 October 2023. Blinded reviewers examined the prospective intent and quality of SRs and the 'trustworthiness' of RCTs included therein. Blinded reviewers extracted data for the variables of interest (Numeric Pain Rating Scale and Visual Analog Scale).

RESULTS

Of the SRs identified (N = 677), 13 were included in the final review. These included a total of 109 RCTs, including duplicates. Only eight of these trials were deemed 'trustworthy.' Publication bias was identified, and heterogeneity across the trials (N = 55) included in the quantitative analysis was high (I2 = 80.11%, 95% CI [75.88, 83.60]). Publication bias and heterogeneity were eliminated (I2 = 0%, 95% CI [0.00, 37.44]) upon considering those prospectively registered (N = 14). Statistical significance, assessed via the p-value at baseline (<.001), was eliminated (p = .746) once prospective, external, and internal validity was considered. Statistical inference through estimation, evaluated via effect size, confidence intervals, and minimal detectable change, was not present at baseline and reduced throughout the screening process.

DISCUSSION

Trials of musculoskeletal interventions to manage pain in patients with neuromusculoskeletal conditions lack certainty and confidence in their treatment effects and exhibit high heterogeneity. Statistically significant effects and heterogeneity are eliminated when considering 'trustworthy' quality evidence.

CONCLUSIONS

Consistent with previous findings, null effects, and low heterogeneity arise when considering the best available evidence. Meaningful effects are likely rare when assessed holistically using statistical inference through estimation and the confidence and certainty of the estimated effect.

The temporal stability of problematic gaming and gaming disorder: A systematic review and meta-analysis

Classifying problematic gaming/gaming disorder as a formal psychiatric diagnosis requires data on its level of temporal stability: are the dysfunctional symptoms transient or can they persist in the absence of treatment? To evaluate this question, we conducted a literature review and meta-analysis to investigate temporal stability in problematic gaming/gaming disorder. We identified 50 relevant longitudinal studies on PubMed, PsycINFO, and SCOPUS. Our review and meta-analysis engaged on two types of temporal stability: categorical stability and dimensional stability. We used MetaXL to run the meta-analysis for categorical stability. Our meta-analysis revealed that overall, the categorical stability rate was approximately 34-38% for the 2-year follow-up studies and approximately 43-45% for the 1-year follow-up studies. This indicates that between 1/3 and 1/2 of the gamers who initially met the threshold for problematic gaming/gaming disorder continued to meet such a threshold at follow-ups. Our meta-analysis included predominantly adolescent groups, which should be noted when generalizing the obtained categorical stability rates. Our review results also showed that overall, the dimensional stability was positive and statistically significant, indicating moderate or high correlations between symptom severity at baseline and at follow-ups. Temporal stability can be a complex concept. Our results suggest that although the categorical stability of problematic gaming/gaming disorder is not as strong as some major psychiatric disorders such as schizophrenia and bipolar disorder, it is similar to personality disorder and gambling disorder. Many complex factors may affect the temporal stability of problematic gaming/gaming disorder, possibly including severity of the disorder, whether the data is from clinical or nonclinical populations, and an individual's age group or developmental stage. More methodologically rigorous longitudinal studies that address these issues are needed.

Efficacy of dietary interventions in irritable bowel syndrome: a systematic review and network meta-analysis

BACKGROUND

Patients with irritable bowel syndrome (IBS) are often interested in dietary interventions as a means of managing their symptoms. However, the relative efficacy of available diets for the management of IBS is unclear. We aimed to examine the relative efficacy of various dietary interventions in IBS.

METHODS

For this systematic review and network meta-analysis we searched MEDLINE, EMBASE, EMBASE Classic, and the Cochrane Central Register of Controlled Trials from database inception to Feb 7, 2025, to identify randomised controlled trials comparing an active dietary intervention requiring changes to the intake of more than one food in IBS with either a control intervention, such as a habitual diet, sham diet, a high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, or alternative miscellaneous dietary advice, or any other active dietary intervention requiring changes to the intake of more than one food. We assessed efficacy using dichotomous assessments of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. We pooled data using a random-effects model, with the efficacy of each intervention reported as pooled relative risks (RRs) with 95% CIs. We ranked interventions according to their P-score, which measures the mean extent of certainty that one intervention is better than another, averaged over all competing interventions.

FINDINGS

We identified 28 eligible randomised controlled trials (comprising 2338 patients) of 11 different dietary interventions compared with four control interventions, of which six (low FODMAP diet, British Dietetic Association/National Institute for Health and Care Excellence [BDA/NICE] diet, lactose-reduced diet, starch-reduced and sucrose-reduced diet, a personalised diet, and a Mediterranean diet) were studied in more than one trial. For global IBS symptoms, assessed in 28 randomised controlled trials and when considering only the dietary interventions studied in more than one trial, a starch-reduced and sucrose-reduced diet ranked first (RR of global IBS symptoms not improving 0·41 [95% CI 0·26-0·67]; P-score 0·84; two trials), a low FODMAP diet ranked fourth (0·51 [0·37-0·70]; P-score 0·71; 24 trials), and a BDA/NICE diet ranked tenth (0·62 [0·43-0·90]; P-score 0·44; eight trials), versus a habitual diet. For abdominal pain, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised controlled trial, a starch-reduced and sucrose-reduced diet ranked second (RR of abdominal pain not improving 0·54 [95% CI 0·33-0·90]; P-score 0·73; two trials), and a low FODMAP diet ranked fifth (0·61 [0·42-0·89]; P-score 0·64; 23 trials), versus a habitual diet. For abdominal bloating or distension, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised trial, only a low FODMAP diet (RR of abdominal bloating or distension not improving 0·55 [95% CI 0·37-0·80]; P-score 0·64; 23 trials) was superior to a habitual diet and ranked fourth. For bowel habit, assessed in 23 randomised trials, none of the dietary interventions was superior to any of the control interventions, but a low FODMAP diet was superior to a BDA/NICE diet (RR of bowel habit not improving 0·79 [95% CI 0·63-0·99]). All comparisons across the network were rated as low or very low confidence, except for direct comparisons between a low FODMAP diet or a starch-reduced and sucrose-reduced diet and habitual diet, both of which were rated as moderate confidence.

INTERPRETATION

In terms of dietary interventions for IBS, the most evidence exists for a low FODMAP diet, but other promising therapies are emerging and should be the subject of further study.

FUNDING

None.

TWIN-MIX INJECTION REDUCES POSTOPERATIVE COMPLICATIONS AFTER LOWER THIRD MOLAR REMOVAL-A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

The aim of this systematic review and meta-analysis was to assess whether pain, swelling and trismus following surgical removal of the lower third molar could be reduced by twin-mix injection.

MATERIALS AND METHODS

MEDLINE, Embase and Cochrane Trials were searched for randomized controlled trials (RCTs) until 17th November 2022. Eight RCTs were included in the systematic review, and 7 in the meta-analysis. In this study, the twin-mix was compared with the conventional anesthetic solution. Outcomes were assessed on postoperative days 1, 3 and 7. Primary outcomes were swelling and trismus. Secondary outcomes were postoperative pain, pain score on local anesthetic injection, duration of soft tissue anesthesia, and latency of anesthesia. Risk of bias was assessed using the Cochrane ROB2 tool. Certainty of evidence was evaluated with the GRADE tool.

RESULTS

On postoperative day 1, the twin-mix group showed significant reductions in facial swelling (MD: -3.51 mm; [-5.04 to -1.97]), trismus (MD: -1.7 mm; [-2.48 to -0.92]) and pain (MD: -1.07; [-1.49 to -0.65]). On day 3, swelling (MD: -4.64 mm; [-6.34 to -2.94]), trismus (MD: -1.08 mm; [-1.55 to -0.61]) and pain (MD: -0.62; [-1.09 to -0.15]) remained significantly reduced. On day 7, differences persisted for swelling (MD: -0.58 mm; [-0.76 to -0.40]) and trismus (MD: -0.42 mm; [-0.72 to -0.12]), but no significant difference was found in pain (MD: -0.29; [-0.65 to 0.07]). The twin-mix also significantly reduced pain under local anesthesia, shortened latency and prolonged duration of anesthesia.

CONCLUSION

In conclusion, the use of twin-mix is highly beneficial for pain relief, facial swelling and trismus following mandibular third molar surgical removal.

Effects of cupping therapy on chronic musculoskeletal pain and collateral problems: a systematic review and meta-analysis

OBJECTIVES

Chronic musculoskeletal pain (CMP) is a prevalent and distressing condition. Cupping therapy, one of the most popular complementary and alternative medicines, has been widely used to reduce CMP. But the evidence remains controversial on the effect of cupping therapy on CMP. The objective of this review and meta-analysis is to assess the effectiveness of cupping therapy in patients with CMP.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of Science, EBSCO, Cochrane Library and CNKI (China National Knowledge Infrastructure) were searched through 20 December 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised control trials that compared cupping therapy for patients with CMP on outcomes (ie, pain intensity, functional disability and mental health).

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included studies. Risk of bias was assessed using the Cochrane Collaboration and Evidence Project tools. Meta-analysis was conducted using random and fixed effects models. Findings were summarised in GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence profiles.

RESULTS

The results showed that cupping therapy (standardised mean difference (SMD)=-1.17; 95% CI=-1.93 to -0.42; p=0.002; I2=94%) had a significant reduction effect on patients with CMP's pain intensity with moderate quality based on a random-effect model. But cupping therapy had no improvement effects on functional disability (SMD=-0.24; 95% CI=-0.93 to 0.46; p=0.51; I²=93%) and mental health (SMD=0.08; 95% CI=-0.12 to 0.27; p=0.46; I²=0%).

CONCLUSIONS

This study indicates that cupping therapy may be efficient in alleviating pain intensity in patients with CMP with immediate effects. But it cannot improve functional disability and mental health significantly.

PROSPERO REGISTRATION NUMBER

CRD42023406219.

Adjuvant epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) for the treatment of people with resected stage I to III non-small-cell lung cancer and EGFR mutation

BACKGROUND

Postoperative adjuvant epidermal growth factor receptor (EGFR) inhibitor osimertinib is the standard care for stage IB-IIIB non-small-cell lung cancer (NSCLC) with EGFR exon 19 deletions or exon 21 L858R mutation, following complete tumour resection, with or without prior platinum-based adjuvant chemotherapy. However, the role of EGFR tyrosine kinase inhibitors (TKIs) in this setting is debated, particularly concerning long-term curative effects versus recurrence delay. Uncertainties persist around treatment duration, harms, and effectiveness across disease stages, prior chemotherapy, or EGFR-sensitising mutation types.

OBJECTIVES

To assess the effectiveness and harms of adjuvant EGFR tyrosine kinase inhibitors (TKIs) in people with resected stage I to III non-small-cell lung cancer (NSCLC) harbouring an activating EGFR mutation.

SEARCH METHODS

We searched major databases (CENTRAL, MEDLINE, Embase) to 9 December 2024, along with conference proceedings (from 2019) and clinical trial registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) reporting benefits or harms of adjuvant EGFR TKIs in adults with resected stage I-III NSCLC. Trials compared EGFR TKIs with platinum-based chemotherapy, placebo/best supportive care (BSC), or second-and/or third-generation EGFR TKIs versus first- and/or second-generation EGFR TKIs. Participants were adults with histologically confirmed stage I-III NSCLC.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed search results, resolving disagreements with a fourth author. Primary outcomes were overall survival (OS), disease-free survival (DFS), and adverse events (AEs); secondary outcomes included health-related quality of life (HRQoL), relapse risk during drug-off time, and brain relapse risk. We conducted meta-analyses using random-effects and fixed-effect models with hazard ratios (HRs) or risk ratios (RRs) and 95% confidence intervals (CIs). We assessed heterogeneity with the I² statistic.

MAIN RESULTS

We included nine RCTs involving 2603 participants, and identified six ongoing trials. Five trials compared EGFR TKIs with placebo/BSC, and four compared them with chemotherapy. We found no trials comparing second-and/or third-generation to first- and/or second-generation EGFR TKIs. Six trials had low selection bias risk; most had unclear or high risk for detection or performance bias; and four were high risk for other biases. The certainty of the evidence (GRADE) ranged from moderate to very low, depending on the outcome. First-, second-, and/or third-generation EGFR TKIs versus placebo/BSC EGFR TKIs probably improve overall survival compared to placebo/BSC (HR 0.54, 95% CI 0.40 to 0.73; 3 studies, 864 participants; moderate-certainty evidence). TKIs may improve disease-free survival compared to placebo/BSC, but the evidence is very uncertain (HR 0.34, 95% CI 0.28 to 0.41; 5 studies, 1153 participants). We are uncertain if there is a difference between groups in serious adverse events (≥ grade 3) as the evidence is very uncertain, with wide confidence intervals spanning both potential harm and no effect (RR 2.52, 95% CI 0.44 to 14.37; 4 studies, 1134 participants). Mild-to-moderate adverse events (grades 1 and 2) may be more frequent with EGFR TKIs compared to placebo/BSC, but the evidence is very uncertain (RR 1.57, 95% CI 1.08 to 2.29; 4 studies, 1134 participants). One study assessed HRQoL, with no clinically meaningful decline compared to placebo/BSC (592 participants; moderate-certainty evidence). First-, second-, and/or third-generation EGFR TKIs versus chemotherapy Overall survival was similar between EGFR TKIs and chemotherapy (HR 0.79, 95% CI 0.52 to 1.18; 4 studies, 878 participants; moderate-certainty evidence). TKIs may have improved disease-free survival compared to chemotherapy (HR 0.54, 95% CI 0.35 to 0.83; 4 studies, 878 participants; low-certainty evidence). TKIs may have reduced serious adverse events (≥ grade 3) compared to chemotherapy (RR 0.31, 95% CI 0.18 to 0.52; 4 studies, 811 participants; low-certainty evidence). TKIs may have increased mild-to-moderate adverse events (grades 1 and 2) (RR 2.13, 95% CI 1.20 to 3.78; 4 studies, 811 participants; low-certainty evidence). Two studies assessed HRQoL, showing no clear difference compared to chemotherapy, as assessed with the Functional Assessment of Cancer Therapy-Lung instrument (2 studies, 399 participants) and the Lung Cancer Symptom Scale (2 studies, 400 participants), both with moderate-certainty evidence.

AUTHORS' CONCLUSIONS

Adjuvant EGFR TKIs may improve disease-free survival compared to both placebo/BSC and chemotherapy. There is moderate-certainty evidence that EGFR TKIs increase overall survival compared to placebo/BSC. However, they likely result in little to no difference in overall survival compared to chemotherapy. We could not rule out a potential survival benefit of adjuvant chemotherapy in people with EGFR-mutant NSCLC. Approximately 50% of participants experienced relapse or death within one year of stopping TKI therapy, indicating that the disease-free survival benefit may wane after withdrawal. This raises the possibility that prolonged adjuvant TKI therapy could be associated with improved long-term outcomes, although further research is needed to clarify this.

Comparison of treatment-emergent resistance-associated mutations and discontinuation due to adverse events among integrase strand transfer inhibitor-based single-tablet regimens and cabotegravir + rilpivirine for the treatment of virologically suppressed people with HIV: A systematic literature review and network meta-analysis

OBJECTIVE

This study evaluated rates of treatment-emergent resistance-associated mutations (TE-RAMs) and discontinuation due to adverse events (DC-AEs) across integrase strand transfer inhibitor (INSTI)-based single-tablet regimens and injectable cabotegravir + rilpivirine (CAB + RPV) in virologically suppressed people with HIV.

METHODS

A systematic literature review was conducted for phase 2-4 randomized controlled trials with ≥48 weeks of follow-up involving virologically suppressed people with HIV aged ≥12 years and published January 2003-March 2024. A random-effects network meta-analysis estimated comparative rates of TE-RAMs and DC-AEs among regimens at 48 weeks. Risk of bias and strength of evidence were assessed using Cochrane RoB and CINeMA, respectively.

RESULTS

Fourteen (7509 participants) and nine (4656 participants) studies were included in the TE-RAMs and DC-AEs analyses, respectively. No significant differences in rates of TE-RAMs were observed; risk ratios (RRs) for TE-RAMs for bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF), dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) and CAB + RPV every 4 weeks (Q4W) versus CAB + RPV every 8 weeks (Q8W) were 0.22 (95% CI, 0.02-2.04), 0.22 (95% CI, 0.00-19.85) and 0.40 (95% CI, 0.14-1.09). Compared with CAB + RPV Q4W and Q8W, DC-AEs were significantly lower with B/F/TAF (RR, 0.15 [95% CI, 0.03-0.75] and RR, 0.16 [95% CI, 0.04-0.67], respectively) and DTG/ABC/3TC (RR, 0.05 [95% CI, 0.01-0.48] and RR, 0.05 [95% CI, 0.01-0.46], respectively).

CONCLUSIONS

In virologically suppressed people with HIV, switching to CAB + RPV Q8W yielded a non-significant increased risk of TE-RAMs compared with INSTI-based 2- and 3-drug regimens and CAB + RPV Q4W. Both CAB + RPV Q4W and Q8W had significantly higher risks of DC-AEs than B/F/TAF and DTG/ABC/3TC. Findings highlight the importance of considering both resistance and tolerability when switching regimens.

Lipid-Lowering Effects of Alpha-Mangostin: A Systematic Review and Meta-Analysis in Hyperlipidemic Animal Models

Hyperlipidemia is a major risk factor for cardiovascular and metabolic diseases. Although pharmacologic treatments are effective, their adverse effects have spurred interest in natural alternatives. Alpha-mangostin (AM), a xanthone from Garcinia mangostana, has shown lipid-lowering effects in animal studies, but its overall efficacy remains unclear. This systematic review and meta-analysis, conducted in accordance with PRISMA 2020 guidelines, evaluated AM's impact on lipid profiles in hyperlipidemic animal models. Databases including Scopus, PubMed, ScienceDirect, Cochrane Library, and Web of Science were searched for relevant controlled studies. Nine studies (N = 226 animals) met inclusion criteria, reporting data on triglycerides (TG), total cholesterol (TC), LDL-C, and HDL-C. Risk of bias, assessed using the Cochrane RoB 2 tool, was generally low-to-moderate. Meta-analysis using a random-effects model revealed that AM significantly reduced TG, TC, and LDL-C, while increasing HDL-C. Stronger effects were observed at doses <50 mg/kg/day. Subgroup and sensitivity analyses confirmed robustness and highlighted the influence of species, region, and treatment duration. These findings suggest that AM is a promising lipid-lowering agent in animal models. Further clinical trials are needed to validate efficacy in humans and determine optimal dosing.

Impact of e-Health Interventions on Mental Health and Quality of Life in Breast Cancer Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Objectives: The prevalence of breast cancer (BC) is significant globally. The malignancy itself and the related treatments have a considerable impact on patients' overall well-being. The adoption of e-health solutions for patients is increasing rapidly worldwide, since these innovative tools hold significant potential to positively impact the mental health and quality of life (QoL) of BC patients. However, their overall impact is still being explored, and further understanding and analysis are required. This review paper aims to present, quantify, and summarize the cumulative available randomized evidence on the state of the art of supportive interventions delivered via e-health applications for patients' mental health and QoL before, during, and after BC treatment. Methods: A systematic review was conducted following the PRISMA guidelines in the Scopus and PubMed databases on 7 November 2024 to identify studies that utilized internet-based interventions in BC patients. The inclusion criteria were as follows: adult men and women (aged > 18 years) diagnosed with breast cancer (BC) who received patient-directed e-health interventions, compared to standard care or control interventions. The studies had to focus on outcomes such as quality of life (QoL), anxiety, depression, and distress, and be limited to randomized controlled trials (RCTs). The PRISMA-P guidelines were followed. Risk of bias was assessed using the Cochrane risk-of-bias (RoB) tool for randomized controlled trials. Results: A total of 27 randomized studies, involving 2898 patients, were included in this systematic review. The e-health interventions significantly affected patients' anxiety (SMD = -0.80; 95% CI: -1.33 to -0.27; p < 0.01; and I2 = 94%), depression (SMD = -0.74; 95% CI: -1.40 to -0.09; p = 0.026; and I2 = 95%) and QoL (SMD = 0.65; 95% CI: 0.27 to 1.04; p < 0.01; and I2 = 90%) but had no significant effect on distress (SMD = -0.78; 95% CI: -1.93 to 0.37; p = 0.184; and I2 = 95%). Conclusions: This study showed that e-health interventions can improve QoL, reduce anxiety, and decrease depression in adult BC patients. However, no noticeable impact on reducing distress levels was observed. Additionally, given the diversity of interventions, these results should be interpreted with caution. To determine the optimum duration, validate different intervention approaches, and address methodological gaps in previous studies, more extensive clinical studies are needed.

Oral Bisphosphonates for Colorectal Cancer Prevention: A Meta-Analytic Reappraisal Beyond Bone Health

Background: Oral bisphosphonates (BPs) are the standard therapy for osteoporosis and skeletal metastases, and exhibit anti-tumor properties in preclinical models. Observational studies assessing their impact on colorectal cancer (CRC) risk have yielded inconsistent results. We aimed to systematically review and meta-analyze the association between oral bisphosphonate use and CRC risk, applying a unified exposure definition. Methods: A systematic search was conducted in PubMed, Embase, and Scopus (January 1966-April 2025) to identify cohort, nested case-control, or population-based case-control studies reporting adjusted estimates of relative risk, odds ratios (ORs), or hazard ratios (HRs) for CRC among oral bisphosphonate users. Two reviewers independently screened studies, extracted data, and assessed quality using the Newcastle-Ottawa Scale. Random-effects meta-analyses pooled risk estimates for "any use" of bisphosphonates, with subgroup analyses by duration of use (<1, 1-3, >3 years). We assessed publication bias through Egger's test and the trim-and-fill method. Results: A total of eight studies published between 2010 and 2020, including 29,169 CRC cases, fulfilled the inclusion criteria. Any bisphosphonate use was not significantly associated with CRC risk (pooled OR 0.97; 95% C.I., 0.90-1.03). However, 1-3 years of use conferred a protective effect (OR 0.86; 95% C.I., 0.73-0.99), as did >3 years (OR 0.91; 95% C.I., 0.85-0.97). Heterogeneity was moderate, and no significant publication bias was detected. Conclusions: While overall oral bisphosphonate exposure is not significantly linked to CRC risk, prolonged use (≥1 year) appears to reduce risk. Prospective studies and randomized trials are needed to confirm these chemo-preventive effects and guide clinical recommendations.

Impact of tracheostomy on ICU stay in adult patients with ARDS: A systematic review

OBJECTIVE

To investigate the impact of tracheostomy on clinical outcomes in adults with acute respiratory distress syndrome (ARDS) who require mechanical ventilation (MV).

METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Three electronic databases including PubMed, The Cochrane Library, and EMBASE to identify relevant studies on ARDS patients receiving MV were searched from inception to July 31, 2024. The reviewers assessed the risk of bias of included studies according to the Cochrane Risk of Bias 1 tool or JBI checklists, as appropriate. Two reviewers independently screened the literature and extracted the data. Outcomes among patients who underwent tracheostomy were compared and analyzed.

RESULTS

Twenty studies involving 4,022 patients with ARDS who required tracheostomy were included, comprising 2 randomized controlled trials, 5 prospective studies, 12 retrospective studies, and 1 case series. On average, tracheostomized patients spent 30.2 days in the ICU and 44.8 days in the hospital, with an overall mean duration of MV of 27 days. Tracheostomy-related adverse events were reported in 15 studies and local bleeding was the most common complication. Of the 1,074 patients with tracheostomy, 626 (58.3%) were successfully weaned from the ventilator. Mortality outcomes were documented in 18 studies, indicating that 883 out of 2,302 (38.4%) of these patients died during hospitalization.

CONCLUSION

Tracheostomy in MV patients with ARDS does not have a clearly defined impact on ICU length of stay due to variability in study findings. However, it remains a safe intervention with generally minor complications. Future research should focus on standardized weaning protocols and multidisciplinary rehabilitation strategies to potentially improve patient outcomes.

IMPLICATIONS FOR CLINICAL PRACTICE

Tracheostomy allows for a more controlled and gradual weaning process in patients with ARDS requiring prolonged MV. Moreover, although current evidence does not indicate a significant reduction in ICU length of stay, tracheostomy contributes to more effective patient management during the weaning by facilitating oral hygiene, improving mobility, and enabling both verbal communication and oral feeding.

Effectiveness of non-pharmacological interventions for post-stroke depression in stroke survivors: A systematic review with meta-analysis

ObjectivesTo evaluate the effectiveness of non-pharmacological interventions for managing post-stroke depression and identify the characteristics of optimal interventions.Data SourcesEight English databases and two Chinese databases were searched from inception to February 2025, alongside grey literature.MethodsTwo reviewers independently screened studies and extracted data from randomised controlled trials (RCTs) or pilot/feasibility RCTs. Study quality was evaluated with the Cochrane Risk of Bias 2 tool. Meta-analyses used Review Manager 5.3 when feasible; otherwise, narrative syntheses were conducted. Certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation system.ResultsSeventeen studies (1297 stroke survivors) were included. Two had a low risk of bias, two had a high risk, and 13 had some concerns. Meta-analyses showed cognitive-behavioural intervention had significant short-term effects (< one month) on depressive symptoms versus control (standardised mean difference SMD: -0.63, 95% CI: -1.00 to -0.26, p < 0.001, I2 = 81%; 7 studies; 693 participants). Cognitive-behavioural interventions without cognitive restructuring showed significant short-term (effect size ES = 0.52-1.08) and medium-term (1-6 months) effects (ES = 0.73-1.71). Preliminary evidence suggested that exercise with music, acceptance and commitment therapy, mindfulness meditation, and aromatherapy also improve depressive symptoms versus control.ConclusionNon-pharmacological interventions, including cognitive-behavioural intervention, exercise, acceptance and commitment therapy, mindfulness meditation, and aromatherapy, could improve post-stroke depressive symptoms. However, with very low evidence certainty, further rigorous RCTs are needed.

Effect of hypoxia conditioning on physical fitness in middle-aged and older adults-a systematic review and meta-analysis

Background

Hypoxic conditioning has emerged as a promising intervention for enhancing physiological adaptations. This systematic review and meta-analysis of randomized controlled trials aims to investigate the efficacy of hypoxic conditioning on physical fitness measures in aging populations.

Methods

The Embase, PubMed, Cochrane Library, and Web of Science were searched from inception to November 2024 (Prospero registration: CRD42023474570). The Cochrane Evaluation Tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework were used for risk of bias assessment and evidence certainty evaluation. Mean differences (MD) and standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated using the Review Manager software. Subgroup analysis was performed to explore possible associations between the study characteristics and the effectiveness of the intervention.

Results

A total of 13 randomized controlled trials (RCTs) with 368 subjects were included in the meta-analysis. High certainty evidence found hypoxic conditioning (HC) significantly improved peak oxygen uptake (VO2peak) (SMD = 0.31, 95% CI [0.01-0.61]; P < 0.05), while very low to moderate certainty evidence shown that hypoxic conditioning (HC) have not induced greater changes on functional outcomes (SMD = -0.21, 95% CI [-0.66-0.24]; P > 0.05), muscle strength (SMD = -0.19, 95% CI [-0.63-0.26]; P > 0.05), maximal power output (SMD = 0.29, 95% CI [-0.17-0.76]; P > 0.05), VO2max (SMD = -0.39, 95% CI [-1.12-1.90]; P > 0.05), and exercise workload (MD = -10.07, 95% CI [-34.95-14.80]; P > 0.05).

Conclusion

This study suggests that hypoxia conditioning has a greater effect on enhancing VO2peak compared to equivalent normoxic training in the middle-aged and older population. More high-quality RCTs are needed in the future to explore the optimal oxygen concentration and exercise intensity during hypoxia conditioning.

Endovascular thrombectomy plus intravenous thrombolysis versus endovascular thrombectomy alone for large ischemic stroke

BACKGROUND

Endovascular thrombectomy (EVT) is the gold standard for eligible acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). A few trials studied EVT in AIS-LVO with large ischemic infarcts. We investigated the impact of intravenous thrombolysis (IVT) on EVT outcomes in those patients.

METHODS

We conducted a meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and Cochrane Handbook of Systematic Reviews and Interventions. We searched 4 databases and performed our analysis utilizing a pooled risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Three studies investigated EVT with and without IVT in AIS-LVO patients with large ischemic infarcts. Regarding the modified Rankin Scale (mRS) score of 0-2 at 3 months, there was a statistically significant difference favoring EVT plus IVT (RR: 1.48, 95%CI: 1.27, 1.72, P < 0.00001). In respect of mRS score of 0-3, the analysis also favored EVT plus IVT (RR: 1.25, 95%CI: 1.11, 1.41, P = 0.0003). Regarding early neurological improvement (ENI) at 24 and 36 hours, our analysis favored EVT plus IVT (RR: 1.16, 95%CI: 1.01, 1.34, P = 0.03). In terms of mortality, our analysis favored EVT plus IVT (RR: 0.88, 95%CI: 0.77, 1, P = 0.04). There was no difference between the two groups across different types of intracranial hemorrhage (ICH).

CONCLUSION

Our results showed a beneficial impact of IVT on the outcomes of EVT in AIS-LVO patients with large ischemic infarcts in terms of functional outcomes and ENI. IVT was also associated with a lower mortality rate but not with an increased risk of ICH. Larger studies are needed to corroborate such results.

Optimal delivery of enteral protein in the critically ill: A protocol for a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The optimal dose of enteral protein to deliver during critical illness remains uncertain. International clinical practice guidelines recommend protein targets ranging from 1.2 to 2.0 g/kg body weight/day, which is greater than the amount recommended in health. This protocol details the conduct of a systematic review and meta-analysis to evaluate the effect of enteral protein delivered within the international recommended guidelines (1.2-2.0 g/kg/day) compared to less than international recommended guidelines (<1.2 g/kg/day) on mortality and morbidity outcomes.

METHODS

A systematic review and meta-analysis will be undertaken in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement. A comprehensive literature search of studies indexed in MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials will be conducted. Studies will be included if they are randomised controlled trials (RCTs) enrolling adult critically ill patients comparing predominately enteral protein delivery with one arm receiving 1.2-2.0 g/kg/day protein/kg/day ('greater protein') and another arm receiving <1.2 g protein/kg/day ('lesser protein'). Two independent reviewers will perform title and full text screening for study inclusion, extract data from included studies, and assess study quality using the Cochrane Risk of Bias 2 tool. The primary outcome will be mortality at 90 days. Secondary outcomes will be clinical (infectious complications, and durations of ICU and hospital stays and mechanical ventilation), patient-centred (discharge destination, physical function and quality of life) and muscle (muscle mass, strength) outcomes.

RESULTS

Random-effects meta-analysis will be fitted for all outcomes, and, for the primary outcome, risk ratios will be pooled using a random-effects meta-analysis model and pooled treatment effect presented as risk ratio (95% Confidence Interval).

CONCLUSIONS

This systematic review and meta-analysis will compile data to determine whether outcomes are optimised with greater or lesser amounts of enteral protein delivered during critical illness.

SYSTEMATIC REVIEW REGISTRATION

CRD42025547923.

Effect of vaccine education intervention on vaccine uptake and vaccine knowledge among older adults: A systematic review with meta-analysis

Educational intervention is one approach for providing vaccine knowledge and encouraging vaccine uptake. However, up till now, no systematic review reporting the effectiveness of vaccine educational intervention on vaccine uptake and/or knowledge enhancement for disease preventeable by the vaccine of interest, compared to conventional/standard or no intervention, for older adults aged 60 or above was found. Six databases, including PubMed, OVID, CINAHL, Web of Science, the Cochrane Library, and the British Nursing Index, were searched. Vaccine educational interventions in this study were interventions that encourage vaccine uptake and/or provide knowledge enhancement on diseases prevented by the vaccine. Conventional/standard or no intervention refers to vaccine educational intervention that existed prior to the commencement of the intervention or no vaccine educational intervention was performed at all. All included studies were randomized control trials. The appraisal was performed with the Cochrane Risk of Bias Tool Version 1 (RoB 1). Meta-analysis was performed with RevMan Web. Ten studies were included in the meta-analysis, with a sample size of 419,523. This review demonstrated that vaccine educational intervention improves vaccine uptake (Relative Risk: 1.19, p = 0.008, 95 % confidence interval: 1.05-1.35). Furthermore, interactive vaccine educational intervention had a statistically significant effect on improving vaccine uptake among older adults (Relative Risk = 1.33, 95 % confidence interval: 1.08-1.62, p = 0.006). Neither continuous nor conducted once only intervention were found to have statistically significant improvement in vaccine uptake in the subgroup analysis. Vaccine educational interventions were found to have statistically significant effects on vaccine knowledge enhancement (Mean Difference: 0.42, 95 % confidence interval: 0.11-0.74, p = 0.008). The findings demonstrate that educational interventions significantly encourage vaccine uptake and knowledge enhancement in older adults. However, the limited amount of included literature and the high heterogeneity observed may limit the generalizability of the findings of this study. Further RCTs are recommended to bring more assertive results.

Bleeding Definitions in Pediatric Extracorporeal Membrane Oxygenation (ECMO) Studies: A Systematic Review and Meta-Analysis

Extracorporeal membrane oxygenation (ECMO) supports severe cardiorespiratory failure but carries a significant bleeding risk. This systematic review aims to report bleeding definitions in studies involving neonates and children treated with ECMO and to determine how heterogeneity in bleeding definition affects bleeding prevalence. We conducted a meta-analysis including all studies from database inception until April 26, 2024. We evaluated the description of bleeding definitions and the reported prevalence of bleeding on ECMO. Of 6,482 screened studies, 169 were included (n = 154,046 subjects). There were 69 distinct bleeding definitions; intracranial hemorrhage (n = 42 studies) and the Extracorporeal Life Support Organization (ELSO) definition (n = 35 studies) were the most common bleeding definitions. The need for intervention, including transfusions, was included in bleeding definitions in 57% of the studies. The overall pooled prevalence of bleeding was 33%. Excluding studies that reported solely intracranial bleeding, the pooled prevalence of bleeding was 41% in studies using the ELSO definition and 39% in studies using other definitions, with high heterogeneity. Variations in bleeding definitions may account for the variability in the reported prevalence of bleeding in children on ECMO. Furthermore, variability in clinical practices regarding interventions to control bleeding may affect estimates of the prevalence of bleeding.

Literature reviews: typology and forensic applications

Secondary research models, such as literature reviews, are designed to summarize existing primary data. Literature reviews serve distinct purposes depending on their methodology and scope. In forensic science, they have been widely used to recover historical information, facilitate bibliometric investigations, compile and compare analytical techniques, promote best practices, and support decision-making. This study presented a comprehensive description of common literature review types, namely (1) narrative, (2) integrative, (3) scoping, (4) systematic (with or without meta-analysis), (5) bibliometric, and (6) umbrella reviews, highlighting their specific characteristics and applications in forensic science. Forensic experts, students, instructors, and research authors and readers must be familiar with the typology and appropriate use of literature reviews to effectively select the most suitable approach for their studies and professional practice. In this context, the goal of academic research, as pursued in the present work, is to strengthen forensic knowledge, enhance theoretical rigor, and ultimately improve practices in the field through education in scientific research methodology.

Risk Factors for Periprosthetic Fractures After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

PURPOSE

Periprosthetic fractures (PPFs) following total knee arthroplasty (TKA) result in repeated hospitalizations and incur substantial medical costs. However, the risk factors contributing to PPFs post-TKA remain highly debated. This study provides a comprehensive and quantitative analysis of these risk factors, offering scientific evidence to guide the development of clinical prevention strategies.

METHODS

A systematic literature search was conducted across PubMed, Embase, Web of Science, and the Cochrane Library databases up to October 1, 2024. We included all English-language studies that evaluated risk factors for PPFs after TKA. The Newcastle-Ottawa Scale (NOS) was leveraged to appraise the quality of the included studies, while odds ratios (OR) and 95% confidence intervals (CI) were utilized to assess the associations between various risk factors and the likelihood of PPFs following TKA.

RESULTS

This protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42024601636). A total of 24 studies were included, encompassing 3,759,394 TKA cases. The meta-analysis identified several risk factors for PPFs after TKA, including sex (OR = 1.81, 95% CI: [1.12 to 2.92]), presence of an anterior femoral notching (AFN) (OR = 3.12, 95% CI: [1.35 to 7.20]), osteoporosis (OR = 1.68, 95% CI: [1.51 to 1.87]), Parkinson's disease (PD) (OR = 7.48, 95% CI: [1.15 to 48.83]), cardiovascular diseases (OR = 2.23, 95% CI: [1.01 to 4.94]), and laterality (OR = 1.68, 95% CI: [1.01 to 2.79]).

CONCLUSIONS

Sex, osteoporosis, presence of AFN, laterality, PD, and cardiovascular diseases are significant risk factors for PPFs following TKA.