Methods to systematically review and meta-analyse observational studies: a systematic scoping review of recommendations

Association Between Picky Eating, Weight Status, Vegetable, and Fruit Intake in Children and Adolescents: Systematic Review and Meta-Analysis

Aim: Picky eating is a common appetitive trait reported among children and adolescents and may have detrimental effects on their weight, vegetable, and fruit intake, impacting health status. However, an updated systematic review of the literature and summary of effect estimates is required. This study aims to explore the association between picky eating with weight, vegetable and fruit intake, vegetable-only intake, and fruit-only intake. Methods: A systematic literature search of six electronic scientific databases and data extraction was performed between November 2022 and June 2023. Original articles that examined picky eating in association with weight, vegetable and/or fruit intake were included. PRISMA guidelines were followed and meta-analytical and meta-regression analyses were conducted to compute summary effect estimates and explore potential moderators. PROSPERO registration: CRD42022333043. Results: The systematic review included 59 studies of which 45 studies were included in the meta-analysis. Overall, the summarized effect estimates indicated that picky eating was inversely associated with weight [Cohen's dz: -0.27, 95% confidence interval (CI): -0.41 to -0.14, p < 0.0001]; vegetable and fruit intakes (Cohen's dz: -0.35, 95% CI: -0.45, -0.25, p < 0.0001); vegetable-only intake (Cohen's dz: -0.41, 95% CI: -0.56, -0.26, p < 0.0001), and fruit-only intake (Cohen's dz: -0.32, 95% CI: -0.45, -0.20, p < 0.0001). Picky eating was positively associated with underweight (Cohen's dz: 0.46, 95% CI: 0.20, 0.71 p = 0.0008). Conclusion: Although effect sizes were small, picky eating was inversely associated with weight, vegetable, and fruit intakes, and positively associated with underweight in children and adolescents aged birth to 17 years.

Physician Transfer Versus Patient Transfer for Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Physician transfer is an alternate option to patient transfer for expedient performance of mechanical thrombectomy in patients with acute ischemic stroke.

METHODS AND RESULTS

We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. A search of PubMed, Scopus, and Web of Science was undertaken, and data were extracted. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, death, and angiographic recanalization. A total of 12 studies (11 nonrandomized observational studies and 1 nonrandomized controlled trial) were included, with a total of 1894 patients. Physician transfer was associated with a significantly shorter time interval between stroke onset and recanalization with a pooled mean difference estimate of -62.08 (95% CI, -112.56 to -11.61]; P=0.016; 8 studies involving 1419 patients) with high between-study heterogeneity in the estimates (I2=90.6%). The odds for functional independence at 90 days were significantly higher (odds ratio, 1.29 [95% CI, 1.00-1.66]; P=0.046; 7 studies with 1222 patients) with physician transfer with low between-study heterogeneity (I2=0%). Physician transfer was not associated with higher odds of near-complete or complete angiographic recanalization (odds ratio, 1.18 [95% CI, 0.89-1.57; P=0.25; I2=2.8%; 11 studies with 1856 subjects).

CONCLUSIONS

Physician transfer was associated with a significant reduction in the mean of time interval between symptom onset and recanalization and increased odds for functional independence at 90 days with physician transfer compared with patient transfer among patients who undergo mechanical thrombectomy.

Modulation of human frontal midline theta by neurofeedback: A systematic review and quantitative meta-analysis

Human brain activity consists of different frequency bands associated with varying functions. Oscillatory activity of frontal brain regions in the theta range (4-8 Hz) is linked to cognitive processing and can be modulated by neurofeedback - a technique where participants receive real-time feedback about their brain activity and learn to modulate it. However, criticism of this technique evolved, and high heterogeneity of study designs complicates a valid evaluation of its effectiveness. This meta-analysis provides the first systematic overview over studies attempting to modulate frontal midline theta with neurofeedback in healthy human participants. Out of 1261 articles screened, 14 studies were eligible for systematic review and 11 for quantitative meta-analyses. Studies were evaluated following the DIAD model and the PRISMA guidelines. A significant across-study effect of medium size (Hedges' g = .66; 95%-CI [-0.62, 1.73]) with substantial between-study heterogeneity (Q(16) = 167.43, p < .001) was observed and subanalysis revealed effective frontal midline theta upregulation. We discuss moderators of effect sizes and provide guidelines for future research in this dynamic field.

Does suicide contagion (Werther effect) take place in response to social media? A systematic review

INTRODUCTION

The Werther, Copycat or contagion effect of suicidal behaviour is a complex phenomenon that can arise due to exposure to media stories in which identifiable people take their lives. On the contrary, the Papageno effect prevents people from suicide by promoting positives examples of suicidal crisis management. Impact of both effects has been widely studied in different types of situations, but its existence in social media is a source of much debate.

METHODS

A systematic search following the PRISMA guidelines of PubMed, Scopus, Embase, PsycInfo, Web of Science and the references of prior reviews yielded 25 eligible studies.

RESULTS

Most of the studies found were observational, with very different methodologies and generally with low risk of bias. In these, the results suggest the existence of the Werther effect in response to social media stories about suicide. This is mediated by multiple factors, including the characteristic of the users, the type of interaction and the content of the publications. At the same time, the Papageno effect is also described. Evidence found by type of social media and future implications are discussed.

CONCLUSION

Suicidal content on social media can be both contagious and protective. It is confirmed that the Werther and Papageno effects may occur in response to social media, so they could be an interesting target for preventive interventions.

A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Scoping review: Exploring the relationship between chrononutrition and glycemic responses in the adult population

Chrononutrition, an emerging body of evidence on the relationship between biological rhythms and metabolism, has been established to be associated with glycemic responses. However, the available evidence is inconsistent, due to protocol variations. Therefore, this review aims to summarize the findings on chrononutrition characteristics and their association with glycemic responses among adults. Systematic searches were conducted across six databases (PubMed, EBSCO Host, ProQuest Central, MEDLINE & Ovid, Scopus and Web of Science) to identify all relevant studies published from January 2012. Two reviewers independently screened the abstracts and full-text articles based on the inclusion and exclusion criteria. Details about population characteristics, study methods and key findings were extracted following the PRISMA-ScR guideline. The quality of selected studies was evaluated using the mixed methods appraisal tool. The searchers identified 49 studies eligible for analysis. The results showed that meal timing, particularly night-time eating and snacking were associated with glycemic responses. Regarding meal regularity, skipping breakfast may affect glycemic responses, but no clear conclusion was drawn about its effect on insulin. The association between meal frequency and glycemic responses was inconclusive. Night fasting duration and restricted eating window are potentially associated with glycemic responses. The current review extensively investigates the association between chrononutrition factors and glycemic responses in adults. However, more prospective cohort and interventional studies are needed to better understand this causal-effect relationship.

Impact of Treatment Modality and Route of Administration on Cytokine Release Syndrome in Relapsed or Refractory Multiple Myeloma: A Meta-Analysis

B-cell maturation antigen (BCMA)-targeting immunotherapies (e.g., chimeric antigen receptor T cells (CAR-T) and bispecific antibodies (BsAbs)) have achieved remarkable clinical responses in patients with relapsed and/or refractory multiple myeloma (RRMM). Their use is accompanied by exaggerated immune responses related to T-cell activation and cytokine elevations leading to cytokine release syndrome (CRS) in some patients, which can be potentially life-threatening. However, systematic evaluation of the risk of CRS with BCMA-targeting BsAb and CAR-T therapies, and comparisons across different routes of BsAb administration (intravenous (i.v.) vs. subcutaneous (s.c.)) have not previously been conducted. This study utilized a meta-analysis approach to compare the CRS profile in BCMA-targeting CAR-T vs. BsAb immunotherapies administered either i.v. or s.c. in patients with RRMM. A total of 36 studies including 1,560 patients with RRMM treated with BCMA-targeting CAR-T and BsAb therapies were included in the analysis. The current analysis suggests that compared with BsAbs, CAR-T therapies were associated with higher CRS incidences (88% vs. 59%), higher rates of grade ≥ 3 CRS (7% vs. 2%), longer CRS duration (5 vs. 2 days), and more prevalent tocilizumab use (44% vs. 25%). The proportion of CRS grade ≥ 3 may also be lower (0% vs. 4%) for BsAb therapies administered via the s.c. (3 studies, n = 311) vs. i.v. (5 studies, n = 338) route. This meta-analysis suggests that different types of BCMA-targeting immunotherapies and administration routes could result in a range of CRS incidence and severity that should be considered while evaluating the benefit-risk profiles of these therapies.

Annual Research Review: Mapping the multifaceted approaches and impacts of adverse childhood experiences - an umbrella review of meta-analyses

Adverse childhood experiences (ACEs) significantly impact lifelong health and well-being. Despite extensive research, a comprehensive understanding of ACEs' multifaceted impacts continues to be challenging to achieve. This study synthesizes meta-analytic evidence to provide a comprehensive view of ACEs' effects, addressing various approaches to conceptualizing ACEs and their diverse outcomes. Employing an umbrella synthesis methodology, this review integrated findings from 99 meta-analyses involving 592 effect sizes. We examined ACEs through specificity, lumping, dimensional, and child maltreatment-centric approaches, assessing their impact across six domains: biological system dysregulation, neuropsychological impairments, physical health complications, mental health conditions, social and behavioral challenges, and criminal justice involvement. The findings reveal a small to moderate overall effect size of ACEs across outcome domains. Specific ACE approaches exhibited varying impact levels, with notable differences in effects on mental health, social/behavioral issues, and criminal justice involvement. When ACEs were aggregated without distinguishing between different types, but with consideration of their cumulative effects, adverse outcomes were significantly exacerbated. The child maltreatment-centric approach consistently demonstrated substantial effects across all evaluated domains. This review underscores the heterogeneity in ACEs' impacts, influenced by the type of ACE and specific outcomes considered. It highlights the necessity for comprehensive approaches to understanding, preventing, and mitigating the effects of ACEs. These insights are vital for developing targeted interventions and informing policy-making, emphasizing the complexity and varied nature of ACEs' influence on individual development and societal well-being.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Evidence for clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications among adults with peripheral artery disease: protocol for a systematic review and meta-analysis

INTRODUCTION

International guidelines recommend that adults with peripheral artery disease (PAD) be prescribed antiplatelet, statin and antihypertensive medications. However, it is unclear how often people with PAD are underprescribed these drugs, which characteristics predict clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications, and whether underprescription and non-adherence are associated with adverse health and health system outcomes.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2006 onwards. Two investigators will independently review abstracts and full-text studies. We will include studies that enrolled adults and reported the incidence and/or prevalence of clinician underprescription of or patient non-adherence to guideline-recommended cardiovascular medications among people with PAD; adjusted risk factors for underprescription of/non-adherence to these medications; and adjusted associations between underprescription/non-adherence to these medications and outcomes. Outcomes will include mortality, major adverse cardiac and limb events (including revascularisation procedures and amputations), other reported morbidities, healthcare resource use and costs. Two investigators will independently extract data and evaluate study risk of bias. We will calculate summary estimates of the incidence and prevalence of clinician underprescription/patient non-adherence across studies. We will also conduct subgroup meta-analyses and meta-regression to determine if estimates vary by country, characteristics of the patients and treating clinicians, population-based versus non-population-based design, and study risks of bias. Finally, we will calculate pooled adjusted risk factors for underprescription/non-adherence and adjusted associations between underprescription/non-adherence and outcomes. We will use Grading of Recommendations, Assessment, Development and Evaluation to determine estimate certainty.

ETHICS AND DISSEMINATION

Ethics approval is not required as we are studying published data. This systematic review will synthesise existing evidence regarding clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications in adults with PAD. Results will be used to identify evidence-care gaps and inform where interventions may be required to improve clinician prescribing and patient adherence to prescribed medications.

PROSPERO REGISTRATION NUMBER

CRD42022362801.

Multicomponent (bio)markers for obesity risk prediction: a scoping review protocol

INTRODUCTION

Despite international efforts, the number of individuals struggling with obesity is still increasing. An important aspect of obesity prevention relates to identifying individuals at risk at early stage, allowing for timely risk stratification and initiation of countermeasures. However, obesity is complex and multifactorial by nature, and one isolated (bio)marker is unlikely to enable an optimal risk stratification and prognosis for the individual; rather, a combined set is required. Such a multicomponent interpretation would integrate biomarkers from various domains, such as classical markers (eg, anthropometrics, blood lipids), multiomics (eg, genetics, proteomics, metabolomics), lifestyle and behavioural attributes (eg, diet, physical activity, sleep patterns), psychological traits (mental health status such as depression) and additional host factors (eg, gut microbiota diversity), also by means of advanced interpretation tools such as machine learning. In this paper, we will present a protocol that will be employed for a scoping review that attempts to summarise and map the state-of-the-art in the area of multicomponent (bio)markers related to obesity, focusing on the usability and effectiveness of such biomarkers.

METHODS AND ANALYSIS

PubMed, Scopus, CINAHL and Embase databases will be searched using predefined key terms to identify peer-reviewed articles published in English until January 2024. Once downloaded into EndNote for deduplication, CADIMA will be employed to review and select abstracts and full-text articles in a two-step procedure, by two independent reviewers. Data extraction will then be carried out by several independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews and Peer Review of Electronic Search Strategies guidelines will be followed. Combinations employing at least two biomarkers from different domains will be mapped and discussed.

ETHICS AND DISSEMINATION

Ethical approval is not required; data will rely on published articles. Findings will be published open access in an international peer-reviewed journal. This review will allow guiding future directions for research and public health strategies on obesity prevention, paving the way towards multicomponent interventions.

Synthesis methods used to combine observational studies and randomised trials in published meta-analyses

BACKGROUND

This study examined the synthesis methods used in meta-analyses pooling data from observational studies (OSs) and randomised controlled trials (RCTs) from various medical disciplines.

METHODS

We searched Medline via PubMed to identify reports of systematic reviews of interventions, including and pooling data from RCTs and OSs published in 110 high-impact factor general and specialised journals between 2015 and 2019. Screening and data extraction were performed in duplicate. To describe the synthesis methods used in the meta-analyses, we considered the first meta-analysis presented in each article.

RESULTS

Overall, 132 reports were identified with a median number of included studies of 14 [9-26]. The median number of OSs was 6.5 [3-12] and that of RCTs was 3 [1-6]. The effect estimates recorded from OSs (i.e., adjusted or unadjusted) were not specified in 82% (n = 108) of the meta-analyses. An inverse-variance common-effect model was used in 2% (n = 3) of the meta-analyses, a random-effects model was used in 55% (n = 73), and both models were used in 40% (n = 53). A Poisson regression model was used in 1 meta-analysis, and 2 meta-analyses did not report the model they used. The mean total weight of OSs in the studied meta-analyses was 57.3% (standard deviation, ± 30.3%). Only 44 (33%) meta-analyses reported results stratified by study design. Of them, the results between OSs and RCTs had a consistent direction of effect in 70% (n = 31). Study design was explored as a potential source of heterogeneity in 79% of the meta-analyses, and confounding factors were investigated in only 10% (n = 13). Publication bias was assessed in 70% (n = 92) of the meta-analyses. Tau-square was reported in 32 meta-analyses with a median of 0.07 [0-0.30].

CONCLUSION

The inclusion of OSs in a meta-analysis on interventions could provide useful information. However, considerations of several methodological and conceptual aspects of OSs, that are required to avoid misleading findings, were often absent or insufficiently reported in our sample.

Re-expressing coefficients from regression models for inclusion in a meta-analysis

Meta-analysis poses a challenge when original study results have been expressed in a non-uniform manner, such as when regression results from some original studies were based on a log-transformed key independent variable while in others no transformation was used. Methods of re-expressing regression coefficients to generate comparable results across studies regardless of data transformation have recently been developed. We examined the relative bias of three re-expression methods using simulations and 15 real data examples where the independent variable had a skewed distribution. Regression coefficients from models with log-transformed independent variables were re-expressed as though they were based on an untransformed variable. We compared the re-expressed coefficients to those from a model fit to the untransformed variable. In the simulated and real data, all three re-expression methods usually gave biased results, and the skewness of the independent variable predicted the amount of bias. How best to synthesize the results of the log-transformed and absolute exposure evidence streams remains an open question and may depend on the scientific discipline, scale of the outcome, and other considerations.

Global Prevalence of Varicella-Associated Complications: A Systematic Review and Meta-Analysis

INTRODUCTION

Varicella (chickenpox) is an infectious disease caused by the varicella zoster virus affecting children, adolescents, and adults. Varicella symptoms are usually self-limiting; however, different complications with widespread and systemic manifestations can occur. This systematic literature review aims to explore and quantify varicella-associated complication rates.

METHODS

Two databases (Embase and MEDLINE), congress abstracts, and reference lists of systematic reviews were screened to identify evidence on varicella complications. Complications were identified and grouped into 14 clinically relevant categories. Proportional meta-analyses were conducted using a random-effects model and tests for heterogeneity and publication bias were performed. Subgroup, sensitivity, and meta-regression analyses were also conducted. A total of 78 studies, spanning 30 countries, were included in the meta-analysis.

RESULTS

Pooled prevalence was highest in severe varicella (22.42%; 95% confidence interval [CI] 10.13-37.77), skin-related complications (20.12%; 95% CI 15.48-25.20), and infection-related complications (10.03%; 95% CI 7.47-12.90). Cardiovascular (0.55%; 95% CI 0.08-1.33), genitourinary (1.17%; 95% CI 0.55-1.99), and musculoskeletal (1.54%; 95% CI 1.06-2.11) complications had the lowest pooled prevalence. The remaining complication categories ranged between 1% and 10%. Subgroup analysis showed that complications were more prevalent in children versus adults and in hospitalized patients versus outpatients. Meta-regression analysis found that no ecological level covariates were accurate predictors for the overall prevalence of varicella-associated complications. There was substantial heterogeneity and publication bias across all meta-analyses.

CONCLUSION

Results suggest that different types of varicella-associated complications could be frequent, impacting quality of life, and healthcare resource utilisation and budgets. These findings are crucial to raise awareness of the health and economic burden of varicella disease.

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT).

METHODS

We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT.

RESULTS

A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons.

CONCLUSION

Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.

Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis

Background: Adverse childhood experiences (ACEs) have been shown to negatively affect health in adulthood. Estimates of associations between ACEs and chronic painful conditions are lacking.Objectives: This systematic review and meta-analysis aimed to evaluate associations between exposure to ACEs and chronic pain and pain-related disability in adults.Methods: We searched 10 electronic databases from inception to February 2023. We included observational studies assessing associations between direct ACEs (childhood sexual, physical, emotional abuse, or neglect) alone or in combination with indirect ACEs (witnessing domestic violence, household mental illness), and adult chronic pain (≥3 months duration) and pain-related disability (daily activities limited by chronic pain). Pairs of reviewers independently extracted data and assessed study risks of bias. Random-effect models were used to calculate pooled adjusted odds ratios [aOR]. Tau square [T2], 95% prediction intervals [95%PI] and I2 expressed the amount of heterogeneity, and meta-regressions and subgroup meta-analyses investigated sources of heterogeneity (PROSPERO: CRD42020150230).Results: We identified 85 studies including 826,452 adults of which 57 studies were included in meta-analyses. Study quality was generally good or fair (n = 70). The odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (aOR, 1.45, 95%CI, 1.38-1.53). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (aOR, 1.50, 95CI, 1.39-1.64) and pain-related disability (1.46, 95CI, 1.03-2.08) during adulthood. Exposure to any ACEs alone or combined with indirect ACEs significantly increase the odds of adult chronic painful conditions (aOR, 1.53, 95%CI, 1.42-1.65) and pain-related disability (aOR, 1.29; 95%CI, 1.01-1.66). The risk of chronic pain in adulthood significantly increased from one ACE (aOR, 1.29, 95%CI, 1.22-1.37) to four or more ACEs (1.95, 95%CI, 1.73-2.19).Conclusions: Single and cumulative ACEs are significantly associated with reporting of chronic pain and pain-related disability as an adult.

Prevalence of polypharmacy among older adults in Ethiopia: a systematic review and meta-analysis

Polypharmacy is a significant concern for older adults. Taking multiple medicines to prevent and treat comorbidities is very common in older adults, potentially leading to polypharmacy. Polypharmacy is associated with the development of geriatric syndromes, including cognitive impairment, delirium, falls, frailty, urinary incontinence, and weight loss. The prevalence of polypharmacy varies according to the literature. There is a paucity of data regarding the prevalence of polypharmacy among older adults. Therefore, this study aimed to estimate the pooled prevalence of polypharmacy among older adults in Ethiopia. A comprehensive search of databases, including PubMed, MEDLINE, EMBASE, Hinari, Cumulative Index to Nursing and Allied Health Literature, International Scientific Indexing, Cochrane library and Web of Science, and Google Scholar, was conducted. STATA statistical software (version 17) was used to analyze the data. Forest plot and I2 heterogeneity test were computed to examine the existence of heterogeneity. Subgroup analysis and sensitivity analysis were done to explore the source of heterogeneity. Publication bias was evaluated by using funnel plots and Egger's test. A random effect model was used to determine the pooled prevalence of polypharmacy. After reviewing 123 studies, 13 studies with a total of 3547 older adults fulfilled the inclusion criteria and were included in this meta-analysis. The result from 13 studies revealed that the pooled prevalence of polypharmacy among older adults in Ethiopia was 37.10% (95CI: 28.28-45.91). A Subgroup Meta-analysis showed that the heterogeneity level was slightly lower among studies done in Oromia region (I2 = 46.62, P-value = 0.154). Higher pooled polypharmacy prevalence was found among older adults with cardiovascular disorders (42.7%) and admitted patients (51.4%). In general, it was found that the pooled prevalence of polypharmacy among older adults in Ethiopia was high. More than one in three older adults take five or more medications at a time. Thus, intervention focusing on rational geriatric pharmacotherapy is significant to prevent unnecessary pill burden, adverse drug events, medical costs, geriatric morbidity, and mortality. Furthermore, enhancing pharmacist roles towards medication therapy management and safety monitoring in older adults is also indicated.

Clinical systematic reviews - a brief overview

OBJECTIVE

Systematic reviews answer research questions through a defined methodology. It is a complex task and multiple articles need to be referred to acquire wide range of required knowledge to conduct a systematic review. The aim of this article is to bring the process into a single paper.

METHOD

The statistical concepts and sequence of steps to conduct a systematic review or a meta-analysis are examined by authors.

RESULTS

The process of conducting a clinical systematic review is described in seven manageable steps in this article. Each step is explained with examples to understand the method evidently.

CONCLUSION

A complex process of conducting a systematic review is presented simply in a single article.

Psychological Coping Factors Associated With Breast Cancer-Related Fatigue: A Systematic Review of Recent Evidence for Stages 0 to III

Cancer-related fatigue (CRF) is a common, distressing, and difficult to treat symptom for both breast cancer patients and survivors. This review investigates psychological coping factors associated with breast CRF (BCRF) for women who are stage 0 to III breast cancer patients or survivors. A focus was made on active factors that can be practically targeted in a fatigue focused intervention aimed at providing immediate results. A comprehensive literature search was conducted in PsycInfo, Scopus, and PubMed using variations of the keywords Psychology, Breast cancer, Fatigue, and Coping. Guidelines for systematic reviews were followed, and inter-rater reliability between 2 raters was conducted. Seven studies were finally selected out of 1610 publications. A preliminary heuristic psychological coping model was constructed based on the following results: Sense of coherence and reassurance of worth were negatively associated with total BCRF. Subjective/perceived stress, meaning focused coping, and breast-related stereotype threat were positively associated with total BCRF. Reassurance of worth, nurturance, and optimism were negatively associated with mental fatigue. Optimism was also negatively associated with reduced motivation. This research can inform interventions, therapy, and care development by gaining insight into evidence-based factors that can facilitate or hinder BCRF and by utilizing the constructed heuristic model. The factors identified in this research are consistent with previous research and should be tested for their efficacy in practical applications. A larger timeframe and a full picture of all perspectives can lead to a comprehensive psychological coping model and core article on the topic.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

INTRODUCTION

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

METHODS

Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

RESULTS

Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

CONCLUSIONS

The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Efficacy and safety of carbon dioxide laser therapy compared with sham for genitourinary syndrome of menopause management: a meta-analysis of randomized clinical trials

IMPORTANCE

Data on whether the carbon dioxide (CO 2 ) laser is useful for treatment of genitourinary syndrome of menopause (GSM) are inconsistent.

OBJECTIVE

This meta-analysis evaluated the benefits and safety of CO 2 laser compared with sham treatment of GSM.

EVIDENCE REVIEW

A relevant literature search of Europe PMC, MEDLINE, Scopus, and ClinicalTrials.gov databases using specific keywords was conducted. The results of continuous variables were pooled into the standardized mean difference (SMD), whereas dichotomous variables were pooled into odds ratio with 95% confidence intervals (95% CI) using random-effects models. A funnel plot was used to assess for the presence of publication bias.

FINDINGS

A total of six randomized clinical trials were included. Pooled analysis revealed that CO 2 laser therapy was associated with a higher reduction in the Vaginal Assessment Scale (SMD, -0.81 [95% CI, -1.59 to -0.04]; P = 0.04; I2 = 88%) and Urinary Distress Inventory short form (SMD, -0.45 [95% CI, -0.84 to -0.06]; P = 0.02; I2 = 0%), and greater patient satisfaction rate (odds ratio, 5.46 [95% CI, 2.23 to 13.37]; P = 0.0002; I2 = 0%) when compared with sham-only treatment. Meanwhile, the Female Sexual Function Index, Vaginal Health Index, and Patient Global Impression Improvement did not differ significantly between groups. Adverse events were only mild with no serious adverse events reported.

CONCLUSIONS AND RELEVANCE

CO 2 laser therapy may improve the overall treatment of GSM with a relatively good safety profile. However, further randomized clinical trials with larger sample sizes are still needed to confirm the results of this study.

Sociodemographic determinants of digital health literacy: A systematic review and meta-analysis

INTRODUCTION

Differences in digital health literacy levels are associated with a lack of access to digital tools, usage patterns, and the ability to effectively use digital technologies. Although some studies have investigated the impact of sociodemographic factors on digital health literacy, a comprehensive evaluation of these factors has not been conducted. Therefore, this study sought to examine the sociodemographic determinants of digital health literacy by conducting a systematic review of the existing literature.

METHODS

A search of four databases was conducted. Data extraction included information on study characteristics, sociodemographic factors, and the digital health literacy scales used. Meta-analyses for age and sex were conducted using RStudio software with the metaphor package.

RESULTS

A total of 3922 articles were retrieved, of which 36 were included in this systematic review. Age had a negative effect on digital health literacy (B = -0.05, 95%CI [-0.06; -0.04]), particularly among older adults, whereas sex appeared to have no statistically significant influence among the included studies (B = - 0.17, 95%CI [-0.64; 0.30]). Educational level, higher income, and social support also appeared to have a positive influence on digital health literacy.

DISCUSSION

This review highlighted the importance of addressing the digital health literacy needs of underprivileged populations, including immigrants and individuals with low socioeconomic status. It also emphasizes the need for more research to better understand the influence of sociodemographic, economic, and cultural differences on digital health literacy.

CONCLUSIONS

Overall, this review suggests digital health literacy is dependent on sociodemographic, economic, and cultural factors, which may require tailored interventions that consider these nuances.

Association between immediate oxygenation response and survival in preterm infants receiving rescue inhaled nitric oxide therapy for hypoxemia from pulmonary hypertension: A systematic review and meta-analysis

PURPOSE

To investigate whether immediate response to inhaled nitric oxide (iNO) therapy is associated with reduced mortality in preterm infants with hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH).

METHODS

A systematic review and meta-analysis of observational studies was conducted to examine the association between immediate response (improved oxygenation ≤6 h) compared to non-response, and all-cause mortality among preterm infants <34 weeks gestational age without congenital anomalies or genetic disorders who received iNO treatment. Adjusted and unadjusted odds ratio, were pooled using a random effects meta-analysis Hartung-Knapp-Sidik-Jonkman approach. Subgroup analyses were planned for infants with preterm premature rupture of membranes (PPROM) and those treated within 72 h after birth.

RESULTS

The primary analysis included 5 eligible studies, a total of 400 infants (196 responders; 204 non-responders). The studies were rated as low to moderate risk of bias based on the Quality in Prognostic Studies tool. Immediate iNO responsiveness was associated with reduced odds of mortality [odds ratio (OR) 0.22, 95 % confidence interval (95 % CI) (0.10-0.49)]. Although there was insufficient data for a subgroup analysis of infants with PPROM, infants treated with iNO within 72 h demonstrated consistent findings of reduced mortality [OR 0.21 95 % CI (0.13-0.36)]. Based on the GRADE approach, considering the risk of bias of included studies, the overall strength of evidence was rated as moderate.

CONCLUSION

There is evidence to suggest that immediate improvement in oxygenation following iNO therapy is associated with reduced odds of mortality before discharge in preterm infants with HRF and clinically suspected or confirmed PH.

Hospital length of stay prediction tools for all hospital admissions and general medicine populations: systematic review and meta-analysis

Background

Unwarranted extended length of stay (LOS) increases the risk of hospital-acquired complications, morbidity, and all-cause mortality and needs to be recognized and addressed proactively.

Objective

This systematic review aimed to identify validated prediction variables and methods used in tools that predict the risk of prolonged LOS in all hospital admissions and specifically General Medicine (GenMed) admissions.

Method

LOS prediction tools published since 2010 were identified in five major research databases. The main outcomes were model performance metrics, prediction variables, and level of validation. Meta-analysis was completed for validated models. The risk of bias was assessed using the PROBAST checklist.

Results

Overall, 25 all admission studies and 14 GenMed studies were identified. Statistical and machine learning methods were used almost equally in both groups. Calibration metrics were reported infrequently, with only 2 of 39 studies performing external validation. Meta-analysis of all admissions validation studies revealed a 95% prediction interval for theta of 0.596 to 0.798 for the area under the curve. Important predictor categories were co-morbidity diagnoses and illness severity risk scores, demographics, and admission characteristics. Overall study quality was deemed low due to poor data processing and analysis reporting.

Conclusion

To the best of our knowledge, this is the first systematic review assessing the quality of risk prediction models for hospital LOS in GenMed and all admissions groups. Notably, both machine learning and statistical modeling demonstrated good predictive performance, but models were infrequently externally validated and had poor overall study quality. Moving forward, a focus on quality methods by the adoption of existing guidelines and external validation is needed before clinical application.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021272198.

A Scoping Review of Antimicrobial Usage and Antimicrobial Resistance in Beef Cow-Calf Herds in the United States and Canada

BACKGROUND

The magnitude and knowledge gaps regarding antimicrobial use (AMU) and antimicrobial resistance (AMR) have not been summarized for the North American cow-calf production sector, although estimates of AMU and AMR are essential to AMR risk analysis. The objectives of this scoping review were to map AMU and AMR in the beef cow-calf sector in Canada and the United States, summarize published AMU/AMR predictors, and identify research gaps.

METHODS

An electronic search was conducted of four bibliographic databases and Google Scholar, augmented by a hand-search of captured studies.

RESULTS

Twenty-three of three-hundred and forty-three publications screened advanced to data extraction. Of these, 10 were conducted in the USA and 13 in Canada. Thirteen studied AMR and twelve studied AMU, with two reporting both. Of twelve captured AMU studies, nine presented counts of herd AMU by antimicrobial class or specific antimicrobial. Antimicrobial resistance in Escherichia coli (E. coli) was reported in nine studies. Risk factors for AMU include herd size, vaccine use, and start date of calving season.

CONCLUSIONS

Overall, a small number of AMR studies were available for synthesis in primarily one population (cows) reporting E. coli AMR. Additional studies targeting reasons for AMU in calves, the impact of management procedures on AMU, potential environmental AMR sources, and AMR in respiratory pathogens and enteric organisms other than E. coli for pre-weaning calves are required to inform AMR risk mitigation strategies.

The height premium: A systematic review and meta-analysis

The taller people are, the more money they tend to earn. This phenomenon is widely known as the height premium. However, it is not yet known whether the height premium is universal, or whether it varies by context. To that end, a systematic review of the literature was performed. Five databases were searched until August 2020. Ultimately, a list of 42 studies were included in a narrative synthesis, and 17 studies were included in a meta-analysis. Based on the meta-analysis, we found evidence that the height premium varied by context: the height premium was smaller in the U.S. and Australia, and larger in Latin America and Asia. Within geographies, there appeared to be a larger height premium for men than for women. Cultural factors, labor market structures and biology may play a role in determining the strength of the height premium.

Evaluation of the psychometric properties of the Reproductive Autonomy Scale for use in the UK

BACKGROUND

Reproductive autonomy-control over outcomes including contraceptive use and childbearing-is a human right and vital to women's empowerment. Those whose reproductive autonomy is threatened by the structures and relationships in their lives are at risk of coercion and unplanned pregnancy and could benefit from additional services. The Reproductive Autonomy Scale (RAS) was developed in the USA to assess women's reproductive autonomy; this study evaluates the RAS for use in the UK.

METHODS

After testing, the RAS was incorporated into an online survey of women of reproductive age. Those who were sexually active were asked to complete the RAS, which was evaluated according to classical test theory. Reliability was assessed via internal consistency and a 3-month test-retest. Construct validity was assessed using hypothesis testing and confirmatory factor analysis.

RESULTS

For 826 women the RAS was highly acceptable, with a response rate of >97.7%. Almost the whole range of reproductive autonomy scores were captured. Internal consistency was good, with a Cronbach's α of 0.75. Test-retest reliability was fair-good with an intraclass correlation coefficient of 0.67. Construct validity analysis found the scale to be valid based on our hypothesis that among women who want to avoid pregnancy, those with higher reproductive autonomy will be more likely to use contraception. The three-factor structure of the scale was confirmed on confirmatory factor analysis.

CONCLUSION

The RAS is valid and reliable for use in the UK. This tool holds potential utility across research, clinical practice, health interventions and policy development.

Longitudinal Movements and Stiffness of Lower Extremity Nerves Measured by Ultrasonography and Ultrasound Elastography in Symptomatic and Asymptomatic Populations: A Systematic Review With Meta-analysis

This study was aimed at analyzing the effectiveness of ultrasonography (US) and ultrasound elastography (UE) in evaluating longitudinal sliding and stiffness of nerves. In line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, we analyzed 1112 publications (range: 2010-2021) extracted from MEDLINE, Scopus and Web of Science focusing on specific outcomes, including shear wave velocity (m/s), shear modulus (kPa), strain ratio (SR) and excursion (mm). Thirty-three papers were included and evaluated for overall quality and risk of bias. From the analysis of data concerning 1435 participants, mean shear wave velocity (SWV) in the sciatic nerve was 6.70 ± 1.26 m/s in controls and 7.51 ± 1.73 m/s in participants presenting with leg pain; in the tibial nerve, mean SWV was 3.83 ± 0.33 m/s in controls and 3.42 ± 3.53 m/s in participants presenting with diabetic peripheral neuropathy (DPN). The mean shear modulus (SM) was 20.9 ± 9.33 kPa for sciatic nerve, whereas it was an average of 23.3 ± 7.20 kPa for the tibial nerve. Considering 146 subjects (78 experimental, 68 controls) no significant difference was observed in SWV when comparing participants with DPN with controls (standard mean difference [SMD]: 1.26, 95% confidence interval [CI]: 0.54, 1.97), whereas a significant difference was observed in the SM (SMD: 1.78, 95% CI: 1.32, 2.25); furthermore, we found significant differences between left and right extremity nerves (SMD:1.14. 95% CI: 0.45, 1.83) among 458 participants (270 with DPN and 188 controls). No descriptive statistics are available for excursion because of the variability in participants and limb positions, whereas SR is considered only a semiquantitative outcome and therefore not comparable among different studies. Despite the presence of some limitations in study designs and methodological biases, on the basis of our findings, we can conclude that US and UE are effective methods in assessing longitudinal sliding and stiffness of lower extremity nerves in both symptomatic and asymptomatic subjects.

Is movement variability altered in people with chronic non-specific low back pain? A systematic review

BACKGROUND

Variability in spine kinematics is a common motor adaptation to pain, which has been measured in various ways. However, it remains unclear whether low back pain (LBP) is typically characterised by increased, decreased or unchanged kinematic variability. Therefore, the aim of this review was to synthesise the evidence on whether the amount and structure of spine kinematic variability is altered in people with chronic non-specific LBP (CNSLBP).

METHODS

Electronic databases, grey literature, and key journals were searched from inception up to August 2022, following a published and registered protocol. Eligible studies must investigated kinematic variability in CNSLBP people (adults ≥18 years) while preforming repetitive functional tasks. Two reviewers conducted screening, data extraction, and quality assessment independently. Data synthesis was conducted per task type and individual results were presented quantitatively to provide a narrative synthesis. The overall strength of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation guidelines.

FINDINGS

Fourteen observational studies were included in this review. To facilitate the interpretation of the results, the included studies were grouped into four categories according to the task preformed (i.e., repeated flexion and extension, lifting, gait, and sit to stand to sit task). The overall quality of evidence was rated as a very low, primarily due to the inclusion criteria that limited the review to observational studies. In addition, the use of heterogeneous metrics for analysis and varying effect sizes contributed to the downgrade of evidence to a very low level.

INTERPRETATION

Individuals with chronic non-specific LBP exhibited altered motor adaptability, as evidenced by differences in kinematic movement variability during the performance of various repetitive functional tasks. However, the direction of the changes in movement variability was not consistent across studies.

Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol

INTRODUCTION

Rheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults in low-income and middle-income countries. Additionally, the global COVID-19 pandemic has forced the emergency restructuring of many health systems, which has had a broad impact on health in general, including cardiovascular disease. Despite significant cost to the health system and estimates from 2015 indicating both high incidence and prevalence of RHD in South Africa, no cohesive national strategy exists. An updated review of national burden of disease estimates, as well as literature on barriers to care for patients with RHD, will provide crucial information to assist in the development of a national RHD programme.

METHODS AND ANALYSIS

Using predefined search terms that capture relevant disease processes from Group A Streptococcal (GAS) infection through to the sequelae of RHD, a search of PubMed, Scopus, ISI Web of Science, Sabinet African Journals, SA Heart and Current and Completed Research databases will be performed. All eligible studies on RHD, acute rheumatic fever and GAS infection published from April 2014 to December 2022 will be included. Vital registration data for the same period from Statistics South Africa will also be collected. A standardised data extraction form will be used to capture results for both quantitative and qualitative analyses. All studies included in burden of disease estimates will undergo quality assessment using standardised tools. Updated estimates on mortality and morbidity as well as a synthesis of work on primary, secondary and tertiary prevention of RHD will be reported.

ETHICS AND DISSEMINATION

No ethics clearance is required for this study. Findings will be disseminated in a peer-reviewed journal and submitted to national stakeholders in RHD.

PROSPERO REGISTRATION NUMBER

CRD42023392782.

The Association Between Congenital Heart Disease and Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

Congenital heart disease (CHD) is linked to an increased incidence of neurodevelopmental impairments in young patients. Given the number of published studies on this topic, a synthesis of the literature is timely and needed. We performed a systematic review and meta-analysis of the medical literature to assess the evidence linking CHD to incidence of autism spectrum disorder (ASD). A systematic review of studies on CHD and ASD in PubMed, Cochrane and Institute for Scientific Information (ISI) from 1965 to May 2021 was conducted. Quantitative estimates of association between CHD and ASD were extracted from eligible studies for the meta-analysis. Pooled estimates were obtained using a random effect models fit by a generalised linear mixed model. We screened 2709 articles and 24 articles were included in this review. Among the 24 studies, there was a total of 348,771 subjects (12,114 CHD, 9829 ASD and 326,828 controls). Seven of 24 studies were eligible for the meta-analysis, which included information on a total of 250,611 subjects (3984 CHD, 9829 ASD, and 236,798 controls). The summary estimate indicated that having CHD is associated with almost double the odds of ASD compared with patients without CHD (OR 1.99, 95% CI 1.77-2.24, p < 0.01). Early developmental delay, perinatal factors, and genetics were potential risk factors and etiologies for the onset of ASD symptoms in CHD patients. Having CHD is associated with an increased risk of presenting with a diagnosis or symptoms suggestive of ASD.

Propensity score matching analysis of laparoscopic surgery vs. open approach in 4 297 adult patients with acute appendicitis, acute cholecystitis or gastrointestinal tract perforation: a prospective multicentre study of nationwide outcomes

BACKGROUND AND AIMS

Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking.

METHODS

Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach.

RESULTS

The study included 2 645 patients with acute appendicitis [32 years (22-51), 44.3% women], 1 182 with acute cholecystitis [65 years (48-76); 46.7% women], and 470 with gastrointestinal tract perforation [65 years (50-76); 34% women]. After propensity score matching, hospital stays decreased in acute appendicitis [open, 2 days (2-4); lap, 2 days (1-4); P <0.001], acute cholecystitis [open, 7 days (4-12); lap, 4 days (3-6); P <0.001], and gastrointestinal tract perforation [open, 11 days (7-17); lap, 6 days (5-8.5); P <0.001]. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P <0.001), acute cholecystitis (open, 41%; lap, 21.7%; P <0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P <0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P =0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P =0.013).

CONCLUSIONS

This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.

A 7-Step Guideline for Qualitative Synthesis and Meta-Analysis of Observational Studies in Health Sciences

Objectives: To provide a step-by-step, easy-to-understand, practical guide for systematic review and meta-analysis of observational studies. Methods: A multidisciplinary team of researchers with extensive experience in observational studies and systematic review and meta-analysis was established. Previous guidelines in evidence synthesis were considered. Results: There is inherent variability in observational study design, population, and analysis, making evidence synthesis challenging. We provided a framework and discussed basic meta-analysis concepts to assist reviewers in making informed decisions. We also explained several statistical tools for dealing with heterogeneity, probing for bias, and interpreting findings. Finally, we briefly discussed issues and caveats for translating results into clinical and public health recommendations. Our guideline complements "A 24-step guide on how to design, conduct, and successfully publish a systematic review and meta-analysis in medical research" and addresses peculiarities for observational studies previously unexplored. Conclusion: We provided 7 steps to synthesize evidence from observational studies. We encourage medical and public health practitioners who answer important questions to systematically integrate evidence from observational studies and contribute evidence-based decision-making in health sciences.

Indeterminate results of interferon gamma release assays in the screening of latent tuberculosis infection: a systematic review and meta-analysis

Objectives

We aimed to evaluate the indeterminate rate of interferon gamma release assays (IGRAs) in the detection of latent tuberculosis infection (LTBI).

Methods

On 15 November 2022, we searched the PubMed® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), and Cochrane Library databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two investigators independently extracted the study data and assessed their quality using a modified quality assessment of diagnostic accuracy studies (i.e., QUADAS-2) tool. A random-effects model was used to calculate pooled results.

Results

We included 403 studies involving 486,886 individuals and found that the pooled indeterminate rate was 3.9% (95% CI 3.5%-4.2%). The pooled indeterminate rate for QuantiFERON®-TB (QFT) was similar to that for T-SPOT®.TB (T-SPOT) [odds ratio (OR) = 0.88, 95% CI 0.59-1.32]; however, the indeterminate rate for a new generation of QFT (QFT-plus) was lower than that of T-SPOT (OR = 0.24, 95% CI 0.16-0.35). The indeterminate rate in the immunocompromised population was significantly higher than that in healthy controls (OR = 3.51, 95% CI 2.11-5.82), and it increased with the reduction of CD4+ cell count in HIV-positive patients. Children's pooled indeterminate rates (OR = 2.56, 95% CI 1.79-3.57) were significantly higher than those of adults, and the rates increased as the children's age decreased.

Conclusion

On average, 1 in 26 tests yields indeterminate IGRA results in LTBI screening. The use of advanced versions of the QuantiFERON-TB assay (QFT-plus), may potentially reduce the occurrence of an indeterminate result. Our study emphasizes the high risk of immunosuppression and young age in relation to indeterminate IGRA, which should receive more attention in the management of LTBI.

Systematic review registration

PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020211363, CRD42020211363.

Opioid Agonist Therapies and Pregnancy Outcomes for Pregnant People With Opioid Use Disorder: Protocol for a Systematic Review

BACKGROUND

Opioid use disorder (OUD) during pregnancy presents a significant risk to maternal, fetal, and neonatal health, increasing the likelihood of adverse events, such as maternal overdose, pregnancy loss, stillbirth, preterm birth, low birth weight, and neonatal abstinence syndrome. In order to reduce the risk of these outcomes, the standard of care for OUD during pregnancy in many jurisdictions within the United States and Canada is opioid agonist therapy (OAT). OAT refers to prescription medications that alleviate or eliminate opioid withdrawal symptoms, so that opioid use can be managed more safely. Although OAT has been recognized as a safe option for pregnant people with OUD, many jurisdictions do not have treatment guidelines regarding pharmacological options, dosing recommendations, side effect management, and individual preferences. There is currently a lack of systematic evidence on the impacts of different OAT regimens on pregnancy outcomes.

OBJECTIVE

We aim to evaluate the impacts of specific OAT agents on pregnancy outcomes and inform recommendations for practitioners treating pregnant people with OUD.

METHODS

The MEDLINE, Embase, CINAHL, and PsycINFO databases will be searched for published quantitative studies assessing pregnancy outcomes for individuals on OAT. Given the substantially increased risk of preterm birth, low birth weight, small for gestational age, and stillbirth among pregnant people with OUD, these four end points will comprise our primary outcomes. Database searches will not be restricted by date, and conference abstracts will be restricted to the past 2 years. Titles, abstracts, and full-text articles will be independently screened by 2 reviewers. Data will be extracted independently and in duplicate, using a data extraction form to reduce the risk of reviewer bias. The risk of bias within individual studies will be assessed by using the appropriate CASP (Critical Appraisal Skills Programme) checklists. For studies that consider the same research questions, interventions, or outcomes, meta-analyses will be conducted to synthesize the pooled effect size. In the event that studies cannot be compared directly, results will be synthesized in a narrative account. Between-study heterogeneity will be measured by using the τ² statistic. If more than 10 studies are available for pooling, publication bias will be evaluated by using the Egger regression test.

RESULTS

As of January 2023, a total of 3266 abstracts have been identified for screening. Data extraction is expected to commence in February 2023.

CONCLUSIONS

The topic of OAT and its effect on pregnancy is an understudied area that has the potential to improve health outcomes, clinical practice, education, and community advocacy. The results of our review will be used to inform clinical practice guidelines and improve health outcomes for pregnant people. Findings will be disseminated to diverse groups of stakeholders, including policy makers, clinicians, community partners, and individuals with lived experience of drug use.

TRIAL REGISTRATION

PROSPERO CRD42022332082; https://tinyurl.com/2p94pkx5.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42417.

Anxiety among children and adolescents during the COVID-19 pandemic in Europe: a systematic review protocol

BACKGROUND

A growing number of studies point to a high mental health burden among children and adolescents during the COVID-19 pandemic, particularly concerning anxiety. However, the study quality and effect direction are heterogeneous in the existing primary studies with a lacking overview for the European continent. Therefore, this systematic review aims to critically synthesise the evidence regarding the impact of the COVID-19 pandemic on anxiety among children and adolescents in Europe compared to a pre-pandemic baseline.

METHODS

A systematic literature search will be performed in six databases (MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and WHO COVID-19 database) with a peer reviewed search strategy according to the evidence-based checklist Peer Review of Electronic Search Strategies (PRESS). Inclusion criteria are children and adolescents ≤ 19 years living in Europe and data report during the COVID-19 pandemic with an appropriate pre-pandemic baseline. Primary outcomes are general anxiety symptoms and clinically relevant anxiety rates. Risk of bias will be assessed using the 'Risk of Bias in Non-randomised Studies of Exposure' (ROBINS-E). Data extraction will systematically include information on study design, population characteristics, COVID-19 determinants, pre-pandemic baseline, diagnostic instruments and outcome. The certainty of evidence for each outcome will be evaluated by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach adapted to the use of non-randomised studies. All process steps will be performed independently by two reviewers; any discrepancies will be discussed and, if necessary, resolved by a third author. Also, subgroup analysis, sensitivity analysis, publication bias analysis, and meta-regression analysis, if applicable, will be performed. The systematic review was registered in the Prospective Register of Systematic Reviews (PROSPERO) and the protocol was prepared in accordance to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement.

DISCUSSION

This systematic review will address the lack of a critical and comprehensive summary of findings on the COVID-19 pandemic impact on anxiety among children and adolescents in Europe. In addition, it aims to identify pandemic-policy differences, such as the effect of school-closures, and identify particularly vulnerable risk groups.

SYSTEMATIC REVIEW REGISTRATION

CRD42022303714 (PROSPERO).

Radiographic Outcomes of Robot-Assisted Versus Conventional Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Total knee arthroplasty (TKA) has long been considered the definitive treatment for knee osteoarthritis. Although tremendous improvements have been made in surgical techniques for conventional TKA, a substantial dissatisfaction rate among patients has persisted because of moderate-to-severe pain and stiffness following TKA. Robot-assisted TKA was developed as an alternative to conventional TKA with the goal of improving operative precision and producing better clinical outcomes with minimal postoperative complications. The aim of this study was to compare the radiographic outcomes, duration of surgery, and complication rate between robot-assisted TKA and conventional TKA.

Methods

We conducted relevant literature searches of Medline, Scopus, ClinicalTrials.gov, and the Cochrane Library databases with use of specific keywords. The outcomes for continuous variables were pooled into mean differences, whereas the outcomes for dichotomous variables were pooled into odds ratios with 95% confidence intervals with use of random-effects models.

Results

A total of 12 randomized clinical trials were included. Our pooled analysis revealed that robot-assisted TKA was associated with fewer outliers in the hip-knee-ankle (HKA) angle (p < 0.0001), femoral component (coronal) angle (p = 0.0006), femoral component (sagittal) angle (p = 0.009), tibial component (coronal) angle (p = 0.05), and tibial component (sagittal) angle (p = 0.01) when compared with conventional TKA. The postoperative HKA angle was also significantly more neutral in the robot-assisted TKA group (mean difference, -0.77°; p < 0.0001). However, the complication rate did not differ significantly between the 2 groups.

Conclusions

Robot-assisted TKA may produce more accurate placement of the prosthetic component and better joint alignment accuracy than conventional TKA as shown by fewer outliers in several joint angles.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Rapid methods for identifying barriers and solutions to improve access to community health services: a scoping review protocol

OBJECTIVES

Low attendance rates for community health services reflect important barriers that prevent people from receiving the care they need. Services and health systems that seek to advance Universal Health Coverage need to understand and act on these factors. Formal qualitative research is the best way to elicit barriers and identify potential solutions, however traditional approaches take months to complete and can be very expensive. We aim to map the methods that have been used to rapidly elicit barriers to accessing community health services and identify potential solutions.

METHODS AND ANALYSIS

We will search MEDLINE, Embase, the Cochrane Library and Global Health for empirical studies that use rapid methods (<14 days) to elicit barriers and potential solutions from intended service beneficiaries. We will exclude hospital-based and 100% remotely delivered services. We will include studies conducted in any country from 1978 to present. We will not limit by language. Two reviewers will independently perform screening and data extraction, with disagreements resolved by a third reviewer. We will tabulate the different approaches used and present data on time, skills and financial requirements for each approach, as well as the governance framework and any strengths and weaknesses presented by the study authors. We will follow Joanna Briggs Institute (JBI) scoping review guidance and report the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

ETHICS AND DISSEMINATION

Ethical approval is not required. We will share our findings in the peer-reviewed literature, at conferences, and with WHO policymakers working in this space.

REGISTRATION

Open Science Framework (https://osf.io/a6r2m).

Metanalyses on metformin's role in pancreatic cancer suffer from severe bias and low data quality - An umbrella review

AIMS

Discrepancies in the preclinical evidence, retrospective studies, and randomized trials evaluating metformin's role in pancreatic cancer are difficult to disentangle. We aimed to critically and systematically examine the quality and sources of heterogeneity between meta-analyses investigating the association between metformin intake and the prognosis of patients with pancreatic cancer.

MATERIALS AND METHODS

We performed a literature search on PubMed, MEDLINE, Embase, and Scopus on October 31, 2021 to identify meta-analyses investigating the impact of metformin treatment on the prognosis of patients with pancreatic cancer. Meta-analyses quality was assessed using according to the AMSTAR 2 criteria. We assessed bias in individual studies included in the meta-analyses, with particular attention to immortal time bias and quality of reporting.

RESULTS

Eleven meta-analyses describing 24 individual studies were included. All meta-analyses were rated low (n = 5) or critically low (n = 6) quality. Only 4 followed PRISMA reporting guidelines and only in 5 presented data were sufficient to replicate the analyses. Most meta-analyses combined results from clinical trials and retrospective studies (n = 6); patients with different cancer stages (resectable vs advanced) and from studies with different control group definitions. Immortal time bias was present and not accounted for in most (65.2%) of the individual retrospective studies; almost all (n = 9) meta-analyses failed to identify and correct for this source of bias.

CONCLUSIONS

Meta-analyses describing the association of metformin use in patients with pancreatic cancer are plagued by various types of bias inherent in retrospective studies. The quality of evidence linking metformin to decreased pancreatic cancer mortality is generally low.

Efficacy and safety of ceftazidime-avibactam compared to other antimicrobials for the treatment of infections caused by carbapenem-resistant Klebsiella pneumoniae strains, a systematic review and meta-analysis

INTRODUCTION

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a significant public health issue. CRKP infections can increase the mortality of severely ill hospitalised patients and elevate the financial burden of their hospitalisation globally. Colistin and tigecycline are the main antimicrobials which have been widely used for the treatment of CRKP infections. However, novel antimicrobials have been recently launched. Ceftazidime-avibactam (CAZ-AVI) seems one of the most efficient ones.

AIM

The aim of the current systematic literature review and meta-analysis is to assess the efficacy and safety of CAZ-AVI compared to other antimicrobials in adult patients (aged >18) with CRKP infection.

METHODS

All data were retrieved using PubMed/Medline, the Web of Science and Cochrane library. The main outcome was the effective treatment of CRKP infection or the microbiological eradication of CRKP in the culture of biological samples. Secondary outcomes included the impact on 28- or 30-day mortality and adverse effects, if available. Pooled analysis was conducted using Review Manager v. 5.4.1 software (RevMan). The level of statistical significance was set at p < 0.05.

RESULTS

CAZ-AVI was proved more effective than other antimicrobials against CRKP infections and CRKP bloodstream infections (p < 0.00001 and p < 0.0001, respectively). Patients in the CAZ-AVI arm displayed statistically lower 28- and 30-day mortality rates (p = 0.002 and p < 0.00001, respectively). Concerning the microbiological eradication, no meta-analysis was feasible due to high heterogeneity.

CONCLUSION

The promotion of CAZ-AVI for treating CRKP infections over other antimicrobials seems favourable. However, there is a long way ahead to reveal additional scientific findings to further strengthen this statement.

Heterogeneity of design features in studies included in systematic reviews with meta-analysis of cognitive outcomes in children born very preterm

BACKGROUND

Meta-analyses of the voluminous scientific literature on the impact of very preterm (VPT, <32 weeks' gestation) birth on cognition find a marked deficit in intelligence quotient (IQ) among children born VPT relative to term-born peers, but with unexplained between-study heterogeneity in effect size.

OBJECTIVES

To conduct an umbrella review to describe the design and methodology of primary studies and to assess whether methodological heterogeneity affects the results of meta-analyses.

DATA SOURCES

Primary studies from five systematic reviews with meta-analysis on VPT birth and childhood IQ.

STUDY SELECTION AND DATA EXTRACTION

Information on study design, sample characteristics and results was extracted from studies. Study features covered study type, sample size, follow-up rates, adjustment for social context, management of severe impairments and test type.

SYNTHESIS

We used random-effects subgroup meta-analyses and meta-regressions to investigate the contribution of study features to between-study variance in standardised mean differences (SMD) in IQ between groups.

RESULTS

In 58 cohorts (56%), children with severe impairments were excluded, while 23 (22%) cohorts accounted for social factors. The least reported feature was the follow-up rate (missing in 38 cohorts). The largest difference in SMDs was between studies using full scale IQ tests (61 cohorts, SMD -0.89, 95% CI -0.96, -0.82) versus short-form tests (27 cohorts, SMD -0.68, 95% CI -0.79, -0.57). The proportion of between-study variance explained by the type of test was 14%; the other features explained less than 1% of the variance.

CONCLUSIONS

Study design and methodology varied across studies, but most of them did not affect the variance in effect size, except the type of cognitive test. Key features, such as the follow-up rate, were not consistently reported limiting the evaluation of their potential contribution. Incomplete reporting limited the evaluation of the full impact of this methodological diversity.

The physiological sonographic features of the ovary in healthy subjects: a joint systematic review and meta-analysis by the Italian Society of Gynecology and Obstetrics (SIGO) and the Italian Society of Endocrinology (SIE)

PURPOSE

There is a lack of uniformity in the definition of normal ovary ultrasound parameters. Our aim was to summarize and meta-analyze the evidence on the topic. Full-text English articles published through December 31, 2020 were retrieved via MEDLINE and Embase. Data available for meta-analysis included: ovarian follicular count, ovarian volume, and ovarian Pulsatility Index (PI) assessed by Doppler ultrasound.

METHODS

Cohort, cross-sectional, prospective studies with a single or double arm were considered eligible. Interventional studies were included when providing baseline data. Both studies on pre- and post-menopausal women were screened; however, data on menopausal women were not sufficient to perform a meta-analysis. Studies on pre-pubertal girls were considered separately. Eighty-one papers were included in the meta-analysis.

RESULTS

The mean ovarian volume was 6.11 [5.81-6.42] ml in healthy women in reproductive age (5.81-6.42) and 1.67 ml [1.02-2.32] in pre-pubertal girls. In reproductive age, the mean follicular count was 8.04 [7.26-8.82] when calculated in the whole ovary and 5.88 [5.20-6.56] in an ovarian section, and the mean ovarian PI was 1.86 [1.35-2.37]. Age and the frequency of the transducers partly modulated these values. In particular, the 25-30-year group showed the higher mean follicular count (9.27 [7.71-10.82]), followed by a progressive age-related reduction (5.67 [2.23-9.12] in fertile women > 35 years). A significant difference in follicular count was also found according to the transducer's upper MHz limit.

CONCLUSION

Our findings provide a significant input to improve the interpretation and diagnostic accuracy of ovarian ultrasound parameters in different physiological and pathological settings.

Does Professional Development Effectively Support the Implementation of Inclusive Education? A Meta-Analysis

Inclusive education is a reform aimed at educating all students in general classrooms, independent of diversity features such as special educational needs, giftedness, or migration. Its successful implementation requires teachers with professional knowledge about inclusive education, skills to address the diverse needs in the classroom, and positive beliefs toward inclusive education. Teachers are provided with professional development opportunities, but are these effective in improving their learning process and positively impacting students’ behavior? We conducted a meta-analysis to address this question. The screening of 12,050 search results revealed 342 eligible studies with more than 155,000 participants and 1123 effects from four outcome categories: teachers’ knowledge, skills, and beliefs and students’ behavior. We observed positive, though varying, effects on all four outcome categories: large effects on teachers' knowledge regarding inclusive education (g = 0.93), moderate effects on teachers’ skills (g = 0.49), small effects on teachers’ beliefs (g = 0.23), and small-to-moderate effects on student behavior (g = 0.37). We also examined factors that might explain the differences in the strength of training effects. The data suggest that long-term training with high practical relevance and active learning opportunities facilitates transfer to schools.

Systematic review of candidate prognostic factors for falling in older adults identified from motion analysis of challenging walking tasks

The objective of this systematic review is to identify motion analysis parameters measured during challenging walking tasks which can predict fall risk in the older population. Numerous studies have attempted to predict fall risk from the motion analysis of standing balance or steady walking. However, most falls do not occur during steady gait but occur due to challenging centre of mass displacements or environmental hazards resulting in slipping, tripping or falls on stairs. We conducted a systematic review of motion analysis parameters during stair climbing, perturbed walking and obstacle crossing, predictive of fall risk in healthy older adults. We searched the databases of Pubmed, Scopus and IEEEexplore.A total of 78 articles were included, of which 62 simply compared a group of younger to a group of older adults. Importantly, the differences found between younger and older adults did not match those found between older adults at higher and lower risk of falls. Two prospective and six retrospective fall history studies were included. The other eight studies compared two groups of older adults with higher or lower risk based on mental or physical performance, functional decline, unsteadiness complaints or task performance. A wide range of parameters were reported, including outcomes related to success, timing, foot and step, centre of mass, force plates, dynamic stability, joints and segments. Due to the large variety in parameter assessment methods, a meta-analysis was not possible. Despite the range of parameters assessed, only a few candidate prognostic factors could be identified: older adults with a retrospective fall history demonstrated a significant larger step length variability, larger step time variability, and prolonged anticipatory postural adjustments in obstacle crossing compared to older adults without a fall history. Older adults who fell during a tripping perturbation had a larger angular momentum than those who did not fall. Lastly, in an obstacle course, reduced gait flexibility (i.e., change in stepping pattern relative to unobstructed walking) was a prognostic factor for falling in daily life. We provided recommendations for future fall risk assessment in terms of study design.In conclusion, studies comparing older to younger adults cannot be used to explore relationships between fall risk and motion analysis parameters. Even when comparing two older adult populations, it is necessary to measure fall history to identify fall risk prognostic factors.

Trajectory of knee health in runners with and without heightened osteoarthritis risk: the TRAIL prospective cohort study protocol

INTRODUCTION

Running is one of the most popular recreational activities worldwide, due to its low cost and accessibility. However, little is known about the impact of running on knee joint health in runners with and without a history of knee surgery. The primary aim of this longitudinal cohort study is to compare knee joint structural features on MRI and knee symptoms at baseline and 4-year follow-up in runners with and without a history of knee surgery. Secondary aims are to explore the relationships between training load exposures (volume and/or intensity) and changes in knee joint structure and symptoms over 4 years; explore the relationship between baseline running biomechanics, and changes in knee joint structure and symptoms over 4 years. In addition, we will explore whether additional variables confound, modify or mediate these associations, including sex, baseline lower-limb functional performance, knee muscle strength, psychological and sociodemographic factors.

METHODS AND ANALYSIS

A convenience sample of at least 200 runners (sex/gender balanced) with (n=100) and without (n=100) a history of knee surgery will be recruited. Primary outcomes will be knee joint health (MRI) and knee symptoms (baseline; 4 years). Exposure variables for secondary outcomes include training load exposure, obtained daily throughout the study from wearable devices and three-dimensional running biomechanics (baseline). Additional variables include lower limb functional performance, knee extensor and flexor muscle strength, biomarkers, psychological and sociodemographic factors (baseline). Knowledge and beliefs about osteoarthritis will be obtained through predefined questions and semi-structured interviews with a subset of participants. Multivariable logistic and linear regression models, adjusting for potential confounding factors, will explore changes in knee joint structural features and symptoms, and the influence of potential modifiers and mediators.

ETHICS AND DISSEMINATION

Approved by the La Trobe University Ethics Committee (HEC-19524). Findings will be disseminated to stakeholders, peer-review journals and conferences.

Humans not heroes: Canadian emergency physician experiences during the early COVID-19 pandemic

BACKGROUND

The pandemic has upended much clinical care, irrevocably changing our health systems and thrusting emergency physicians into a time of great uncertainty and change. This study is a follow-up to a survey that examined the early pandemic experience among Canadian emergency physicians and aimed to qualitatively describe the experiences of these physicians during the global pandemic. The study was conducted at a time when Canadian COVID-19 case numbers were low.

METHODS

The investigators engaged in an interview-based study that used an interpretive description analytic technique, sensitised by the principles of phenomenology. One-to-one interviews were conducted, transcribed and then analysed to establish a codebook, which was subsequently grouped into key themes. Results underwent source triangulation (with survey data from a similar period) and investigator-driven audit trail analysis.

RESULTS

A total of 16 interviews (11 female, 5 male) were conducted between May and September 2020. The isolated themes on emergency physicians' experiences during the early pandemic included: (1) disruption and loss of emergency department shift work; (2) stress of COVID-19 uncertainty and information bombardment; (3) increased team bonding; (4) greater personal life stress; (5) concern for patients' isolation, miscommunication and disconnection from care; (6) emotional distress.

CONCLUSIONS

Canadian emergency physicians experienced emotional and psychological distress during the early COVID-19 pandemic, at a time when COVID-19 prevalence was low. This study's findings could guide future interventions to protect emergency physicians against pandemic-related distress.

The human clavicle's nutrient foramen's prevalence, number, location, and direction: A systematic review and meta-analysis

INTRODUCTION

The clavicle's nutrient foramen is a surrogate marker for its nutrient artery. Knowing its location may be useful for interpreting fractures and to avoid iatrogenic lesions. The aim of this review was to determine the prevalence, number, location, and direction of the nutrient foramen.

METHODS

Embase, Medline, PubMed, Scopus, and Web of Science were searched and supplemented by Google Scholar, hand-searching major anatomical journals, and the reference list of included studies (updated March 08, 2022). Titles and abstracts were screened for eligibility, and observational studies with quantitative data were included based on full text evaluation. Internal validity was assessed using the anatomical quality assessment tool. Pooled prevalence proportions were derived using a random effects DerSimonian-Laird model using the Freeman-Tukey double arcsine transformation with Miller's inverse back-transformation.

RESULTS

From 18,889 unique reports, 33 studies with 3760 clavicles and 3358 foramina were included. All studies suffered from untransparent reporting. The prevalence of the nutrient foramen was 97.75%, 95% confidence interval 94.70%-99.60%. It was mainly found as a single foramen on the middle third segment's posterior surface with acromial (lateral) obliquity. Results were stable over time, robust to sensitivity analyses, albeit limited by unexplained heterogeneity and asymmetry.

CONCLUSION

This review may aid in interpreting fractures passing through a high-risk area (mean foraminal index range 36.31-61.03%) for lesions to the nutrient artery. Practical implications are a need to update current inaccurate textbook descriptions and further advocate evidence-based anatomy to improve conduct and reporting of anatomical research.

Implementation strategies to increase smoking cessation treatment provision in primary care: a systematic review of observational studies

BACKGROUND

Internationally, there is an 'evidence-practice gap' in the rate healthcare professionals assess tobacco use and offer cessation support in clinical practice, including primary care. Evidence is needed for implementation strategies enacted in the 'real-world'.

AIM

To identify implementation strategies aiming to increase smoking cessation treatment provision in primary care, their effectiveness, cost-effectiveness and any perceived facilitators and barriers for effectiveness.

METHODS

'Embase', 'Medline', 'PsycINFO', 'CINAHL', 'Global Health', 'Social Policy & Practice', 'ASSIA Applied Social Sciences Index and Abstracts' databases, and grey literature sources were searched from inception to April 2021. Studies were included if they evaluated an implementation strategy implemented on a nation-/state-wide scale, targeting any type of healthcare professional within the primary care setting, aiming to increase smoking cessation treatment provision.

PRIMARY OUTCOME MEASURES

implementation strategy identification, and effectiveness (practitioner-/patient-level).

SECONDARY OUTCOME MEASURES

perceived facilitators and barriers to effectiveness, and cost-effectiveness. Studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was conducted using the Expert Recommendations for Implementing Change (ERIC) compilation and the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Of 49 included papers, half were of moderate/low risk of bias. The implementation strategy domains identified involved utilizing financial strategies, changing infrastructure, training and educating stakeholders, and engaging consumers. The first three increased practitioner-level smoking status recording and cessation advice provision. Interventions in the utilizing financial strategies domain also appeared to increase smoking cessation (patient-level). Key facilitator: external policies/incentives (tobacco control measures and funding for public health and cessation clinics). Key barriers: time and financial constraints, lack of free cessation medications and follow-up, deprioritisation and unclear targets in primary care, lack of knowledge of healthcare professionals, and unclear messaging to patients about available cessation support options. No studies assessed cost-effectiveness.

CONCLUSIONS

Some implementation strategy categories increased the rate of smoking status recording and cessation advice provision in primary care. We found some evidence for interventions utilizing financial strategies having a beneficial impact on cessation. Identified barriers to effectiveness should be reduced. More pragmatic approaches are recommended, such as hybrid effectiveness-implementation designs and utilising Multiphase Optimization Strategy methodology.

PROTOCOL REGISTRATION

PROSPERO:CRD42021246683.

Prevalence of inappropriate drug dose adjustment and associated factors among inpatients with renal impairment in Africa: A systematic review and meta-analysis

Objective

There is a high prevalence of inadequate dose adjustment among inpatients with renal insufficiency worldwide. There is, however, a paucity of studies that summarizes the topic in the African context. Therefore, this study aims to summarize the prevalence of inappropriate drug dose adjustment (IDDA) and associated factors among inpatients with renal impairment in Africa.

Methods

A literature search for English-language articles was conducted using reputable databases such as PubMed/MEDLINE, Google Scholar, and Science Direct. The search was carried out between 3 February and 3 March of 2022. All published articles that were online at the time of data collection were considered. Observational studies that examined the prevalence of IDDA for any type of drug in renal impairment as a primary or secondary outcome were included in our analysis. Statistical software such as Open Meta Analyst and Review Manager were used to examine outcome measures. I² statistics, Logit event rate, and Der Simonian and Laird's random effect models were also used.

Results

Seven articles were qualified for the systematic review and meta-analysis. All included studies comprised a total of 1918 patients. A total of 5072 prescriptions were assessed, and 1879 (37%) of them had at least one drug that required a dose adjustment. The pooled prevalence of IDDA among adult patients with renal impairment was 13.7% (95% confidence interval (CI) = 7.9%-19.5%) in Africa. Based on the number of prescriptions containing medications that required dose adjustment, the pooled prevalence accounts for 39.3% (95% CI = 24.1%-54.4%) (932/1879). Factors associated with inappropriate drug prescribing and usage concerning renal function were the number/types of prescribed medicines (most common), age, stage of renal impairment, comorbidity, and unemployment.

Conclusions

In this study, IDDA practice appears to be a common challenge among inpatients with renal insufficiency in Africa. The number and type of medications prescribed, age, stage of renal impairment, comorbidity, and unemployment were factors associated with inappropriate drug prescribing and use. In addition to expanding such studies, hospitals across Africa must conduct research on the clinical outcomes of IDDA practices in patients with renal impairment.