Meta-Analysis of a Complex Network of Non-Pharmacological Interventions: The Example of Femoral Neck Fracture

Is the Revision Rate for Femoral Neck Fracture Lower for Total Hip Arthroplasty Than for Hemiarthroplasty?: A Comparison of Registry Data for Contemporary Surgical Options

BACKGROUND

When arthroplasty is indicated for a femoral neck fracture (FNF), it is unclear whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is best. This study compares data from the Australian Orthopaedic Association National Joint Replacement Registry using contemporary surgical options.

METHODS

Patients from 60 to 85 years old who were treated with arthroplasty for FNF, between September 1999 and December 2019, were included if the femoral stems were cemented. Only THAs with femoral heads of ≥36 mm or dual-mobility articulations were included. Patients who had monoblock HA were excluded. Rates of revision for all aseptic failures and dislocation were compared. Competing risks of revision and death were considered using the cumulative incidence function. Subdistribution hazard ratios (HRs) for revision or death from a Fine-Gray regression model were used to compare THA and HA. Interactions of procedure with age group and sex were considered. Secondary analysis adjusting for body mass index (BMI) and American Society of Anesthesiologists (ASA) classification was also considered.

RESULTS

There were 4,551 THA and 29,714 HA procedures included. The rate of revision for THA was lower for women from 60 to 69 years old (HR = 0.58 [95% confidence interval (CI), 0.39 to 0.85]) and from 70 to 74 years old (HR = 0.65 [95% CI, 0.43 to 0.98]) compared with HA. However, women from 80 to 85 years old (HR = 1.56 [95% CI, 1.03 to 2.35]) and men from 75 to 79 years old (HR = 1.61 [95% CI, 1.05 to 2.46]) and 80 to 85 years old (HR = 2.73 [95% CI, 1.89 to 3.95]) had an increased rate of revision when THA was undertaken compared with HA. There was no difference in the rate of revision for dislocation between THA and HA for either sex or age categories.

CONCLUSIONS

When contemporary surgical options for FNF are used, there is a benefit with respect to revision outcomes for THA in women who are <75 years old and a benefit for HA in women who are ≥80 years old and men who are ≥75 years old. There is no difference in dislocation rates.

LEVEL OF EVIDENCE

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

Curative efficacy of surgical procedures for older patients with femoral neck fracture: a network meta-analysis and systematic review

BACKGROUND

Femoral neck fractures have a higher incidence in older people with poor prognosis, inducing serious social problems. Common treatment methods include total hip arthroplasty, bipolar hemiarthroplasty, double-screw fixation, multiple-screw fixation, and dynamic hip system.

METHODS

We searched through four electronic databases, including PubMed, Web of Science, Cochrane Library, and Embase databases, for articles regarding femoral neck fractures, bone screw, and hip prosthesis published up to February 11, 2020. All included articles were used for quality evaluation and data extraction. Extracted data were expressed as odds ratios or weighted mean differences, with 95% confidence intervals. We conducted a network meta-analysis for Harris hip score, complications, 1-year mortality rate, reoperation rate, intraoperative blood loss, and duration of operation using STATA version 16.0 software.

RESULTS

Twenty-two randomized controlled trials and nine cohort studies included in this study involved 3861 patients. Total hip arthroplasty significantly improved the postoperative function of patients with femoral neck fractures. The surface under the cumulative ranking curve value of the Harris hip score for more than 1 year after total hip arthroplasty was 98.2.

CONCLUSIONS

This meta-analysis indicated no significant difference in mortality among different treatment groups. Total hip arthroplasty can provide satisfactory outcomes in hip joint function, and double-screw fixation results in the lowest intraoperative risk. In general, total hip arthroplasty results in a lower incidence of adverse events and is especially recommended for patients with femoral neck fractures. This article has been retrospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) on November 27, 2020. Registration number: INPLASY2020110123.

Cognitive Impairment Level and Elderly Hip Fracture: Implications in Rehabilitation Nursing

PURPOSE

The aim of the study was to determine the cognitive impairment level influence in descriptive characteristics, comorbidities, complications, and pharmacological features of older adults with hip fracture.

DESIGN

Cross-sectional study.

METHOD

Five hundred fifty-seven older adults with hip fracture were recruited and divided into cognitive impairment levels (severe/moderate, mild, no impairment). Descriptive characteristics, comorbidities, complications, and pharmacological data were collected.

FINDINGS

Significant differences (p < .05, R = .012-.475) between cognitive impairment levels were shown. Shorter presurgery hospital length of stay and lower depression and Parkinson comorbidities; delirium complication; and antidepressants, antiparkinsonians, and neuroleptics use were shown for the no-impairment group. With regard to the cognitive impairment groups, lower presence of cardiopathy and hypertension; higher presence of dementia; antihypertensives, antiplatelets, and antidementia medication; infection/respiratory insufficiency complications; and lower constipation complications were shown.

CONCLUSION

Cognitive impairment levels may determine the characteristics, comorbidities, pharmacology, and complications of older adults with hip fracture.

CLINICAL RELEVANCE

Cognitive impairment level may impact rehabilitation nursing practice, education, and care coordination.

Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis

BACKGROUND

Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP.

METHODS/DESIGN

We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model.

DISCUSSION

Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018102527.

Functionality, comorbidity, complication & surgery of hip fracture in older adults by age distribution

BACKGROUND

Hip fractures may be the greatest complication secondary to osteoporotic disorder. The objective of this study was to determine the influence of age distribution in the functionality, comorbidity, complications and surgical features of older adults with hip fractures.

METHODS

A prospective cohort study was carried out from 2013 to 2014. A sample of 557 adults over 75 years old with osteoporotic hip fractures was recruited from the Orthogeriatric Unit of the León University Hospital (Spain). Age distributions of 75-84, 85-90 and >90 years old were considered. Firstly, sociodemographic data, fracture type and hospital staying days were collected. Secondly, baseline functionality (Barthel index), ambulation, cognitive impairment and comorbidities were described. Thirdly, surgical intervention, urgency, type, American Association of Anesthesiologists (ASA) scores, non-surgical cause, and baseline pharmacologic treatments were determined. Finally, complications and features at hospital discharge were observed.

RESULTS

The age ranges did not show any statistically-significant differences (P<.05; R2=.000-.005) for gender, fracture type, or number of hospital staying days. Statistically-significant differences (P<.05; R2=.011-.247) between age groups were observed for Barthel index, cognitive impairment, dementia, osteoporosis, Parkinson's disease, aortic stenosis, surgery type, ASA-score, non-surgical cause, benzodiazepines, antidementia, anti-osteoporosis, insulin, pharmacologic treatments, renal function alteration, heart failure, destination and ambulation features. All other measurements did not show statistically-significant differences (P>.05; R2=.000-.010).

CONCLUSION

Age distributions greater than 75 years old may determine the functionality, comorbidities, surgical features, baseline pharmacologic treatments, complications and features at hospital discharge for older adults who suffer a hip fracture.

An innovative and comprehensive technique to evaluate different measures of medication adherence: The network meta-analysis

BACKGROUND

Poor medication adherence is associated with adverse health outcomes and higher costs of care. However, inconsistencies in the assessment of adherence are found in the literature.

OBJECTIVE

To evaluate the effect of different measures of adherence in the comparative effectiveness of complex interventions to enhance patients' adherence to prescribed medications.

METHODS

A systematic review with network meta-analysis was performed. Electronic searches for relevant pairwise meta-analysis including trials of interventions that aimed to improve medication adherence were performed in PubMed. Data extraction was conducted with eligible trials evaluating short-period adherence follow-up (until 3 months) using any measure of adherence: self-report, pill count, or MEMS (medication event monitoring system). To standardize the results obtained with these different measures, an overall composite measure and an objective composite measure were also calculated. Network meta-analyses for each measure of adherence were built. Rank order and surface under the cumulative ranking curve analyses (SUCRA) were performed.

RESULTS

Ninety-one trials were included in the network meta-analyses. The five network meta-analyses demonstrated robustness and reliability. Results obtained for all measures of adherence were similar across them and to both composite measures. For both composite measures, interventions comprising economic + technical components were the best option (90% of probability in SUCRA analysis) with statistical superiority against almost all other interventions and against standard care (odds ratio with 95% credibility interval ranging from 0.09 to 0.25 [0.02, 0.98]).

CONCLUSION

The use of network meta-analysis was reliable to compare different measures of adherence of complex interventions in short-periods follow-up. Analyses with longer follow-up periods are needed to confirm these results. Different measures of adherence produced similar results. The use of composite measures revealed reliable alternatives to establish a broader and more detailed picture of adherence.

Introduction of a guide based on a femoral neck section for fixation with multiple screws: a cadaveric study

BACKGROUND

The design and application of assisted instrumentation for internal fixation of femoral neck fractures with multiple screws are still evolving. A novel guide based on a femoral neck section was designed to improve the accuracy of screw placement, and its efficacy was evaluated.

METHODS

A guide based on a femoral neck section was designed for assisted fixation of femoral neck fractures with multiple screws. Femoral specimens from 10 adults (20 femurs) underwent assisted internal fixation for a femoral neck fracture with 3 cannulated screws using the new guide technique or conventional technique. The accuracy of screw orientation and entry point, the accuracy of optimal screw positioning, and drilling attempts, operative time, and fluoroscopy time were recorded.

RESULTS

Among all 20 specimens, 60 screws were inserted successfully. Screw parallelism, operative time, and fluoroscopy time showed no statistical difference between the new guide technique and conventional technique (P > 0.05). The accuracy of optimal screw positioning was determined by the contained screw area ratio, distance between screws, distance from the centre of the femoral neck section, distance between screws and the femoral neck cortex, and Drilling attempts were statistical significantly better (data in the first three were larger and in the latter two was smaller) with the new guide technique, than with conventional technique (P < 0.05).

CONCLUSIONS

This new, two-dimensional, fluoroscopy-assisted, percutaneous guide technique enables accurate and optimal screw positioning in internal fixation of femoral neck fractures, compared with conventional technique.

Evidence based management of intracapsular neck of femur fractures

Neck of femur fractures are occurring at an increased incidence. Functionally independent patients without cognitive impairment can expect reasonable life expectancy. This indicates the need for a durable surgical option that optimises the chance to return to pre-injury functional status, with minimal risk of complications and reoperation. Most fractures are displaced. Surgical options include internal fixation, hemiarthroplasty or total hip arthroplasty (THA). Evidence is conclusive that arthroplasty options outperform internal fixation in terms of function, quality of life and reoperation rates. In anyone other than young patients where head preserving surgery is required, arthroplasty is the standard of care. Hemiarthroplasty is the heavily favoured arthroplasty option for surgeons. However, in patients other than the extreme elderly, medically infirm, neurologically impaired, or with little or no ambulatory capacity, the evidence to support hemiarthroplasty is lacking. In functionally independent patients without cognitive impairment, THA should be considered the gold standard, producing better functional and quality of life outcomes, lower reoperation rates and better cost effectiveness, with no difference in complications or mortality. An increased risk of dislocation does exist. This may be reduced with modern surgical technique and implant options. Low amounts of research have been afforded to undisplaced fractures. For this fracture type, surgery is the standard of care. Despite a higher risk of reoperation, internal fixation is the preferred option for all age groups. Further study is required to identify the difference between internal fixation and THA, in particular, for unstable fracture patterns in elderly patients.

The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: A systematic review with network meta-analyses of randomised trials

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed psychiatric disorders in childhood. A wide variety of treatments have been used for the management of ADHD. We aimed to compare the efficacy and safety of pharmacological, psychological and complementary and alternative medicine interventions for the treatment of ADHD in children and adolescents.

METHODS AND FINDINGS

We performed a systematic review with network meta-analyses. Randomised controlled trials (≥ 3 weeks follow-up) were identified from published and unpublished sources through searches in PubMed and the Cochrane Library (up to April 7, 2016). Interventions of interest were pharmacological (stimulants, non-stimulants, antidepressants, antipsychotics, and other unlicensed drugs), psychological (behavioural, cognitive training and neurofeedback) and complementary and alternative medicine (dietary therapy, fatty acids, amino acids, minerals, herbal therapy, homeopathy, and physical activity). The primary outcomes were efficacy (treatment response) and acceptability (all-cause discontinuation). Secondary outcomes included discontinuation due to adverse events (tolerability), as well as serious adverse events and specific adverse events. Random-effects Bayesian network meta-analyses were conducted to obtain estimates as odds ratios (ORs) with 95% credibility intervals. We analysed interventions by class and individually. 190 randomised trials (52 different interventions grouped in 32 therapeutic classes) that enrolled 26114 participants with ADHD were included in complex networks. At the class level, behavioural therapy (alone or in combination with stimulants), stimulants, and non-stimulant seemed significantly more efficacious than placebo. Behavioural therapy in combination with stimulants seemed superior to stimulants or non-stimulants. Stimulants seemed superior to behavioural therapy, cognitive training and non-stimulants. Behavioural therapy, stimulants and their combination showed the best profile of acceptability. Stimulants and non-stimulants seemed well tolerated. Among medications, methylphenidate, amphetamine, atomoxetine, guanfacine and clonidine seemed significantly more efficacious than placebo. Methylphenidate and amphetamine seemed more efficacious than atomoxetine and guanfacine. Methylphenidate and clonidine seemed better accepted than placebo and atomoxetine. Most of the efficacious pharmacological treatments were associated with harms (anorexia, weight loss and insomnia), but an increased risk of serious adverse events was not observed. There is lack of evidence for cognitive training, neurofeedback, antidepressants, antipsychotics, dietary therapy, fatty acids, and other complementary and alternative medicine. Overall findings were limited by the clinical and methodological heterogeneity, small sample sizes of trials, short-term follow-up, and the absence of high-quality evidence; consequently, results should be interpreted with caution.

CONCLUSIONS

Clinical differences may exist between the pharmacological and non-pharmacological treatment used for the management of ADHD. Uncertainties about therapies and the balance between benefits, costs and potential harms should be considered before starting treatment. There is an urgent need for high-quality randomised trials of the multiple treatments for ADHD in children and adolescents. PROSPERO, number CRD42014015008.

Additional considerations are required when preparing a protocol for a systematic review with multiple interventions

OBJECTIVES

The number of systematic reviews that aim to compare multiple interventions using network meta-analysis is increasing. In this study, we highlight aspects of a standard systematic review protocol that may need modification when multiple interventions are to be compared.

STUDY DESIGN AND SETTING

We take the protocol format suggested by Cochrane for a standard systematic review as our reference and compare the considerations for a pairwise review with those required for a valid comparison of multiple interventions. We suggest new sections for protocols of systematic reviews including network meta-analyses with a focus on how to evaluate their assumptions. We provide example text from published protocols to exemplify the considerations.

CONCLUSION

Standard systematic review protocols for pairwise meta-analyses need extensions to accommodate the increased complexity of network meta-analysis. Our suggested modifications are widely applicable to both Cochrane and non-Cochrane systematic reviews involving network meta-analyses.

Live cumulative network meta-analysis: protocol for second-line treatments in advanced non-small-cell lung cancer with wild-type or unknown status for epidermal growth factor receptor

INTRODUCTION

Many second-line treatments for advanced non-small-cell lung cancer (NSCLC) have been assessed in randomised controlled trials, but which treatments work the best remains unclear. Novel treatments are being rapidly developed. We need a comprehensive up-to-date evidence synthesis of all these treatments. We present the protocol for a live cumulative network meta-analysis (NMA) to address this need.

METHODS AND ANALYSIS

We will consider trials of second-line treatments in patients with advanced NSCLC with wild-type or unknown epidermal growth factor receptor status. We will consider any single agent of cytotoxic chemotherapy, targeted therapy, combination of cytotoxic chemotherapy and targeted therapy and any combination of targeted therapies. The primary outcomes will be overall survival and progression-free survival. The live cumulative NMA will be initiated with a NMA and then iterations will be repeated at regular intervals to keep the NMA up-to-date over time. We have defined the update frequency as 4 months, based on an assessment of the pace of evidence production on this topic. Each iteration will consist of six methodological steps: adaptive search for treatments and trials, screening of reports and selection of trials, data extraction, assessment of risk of bias, update of the network of trials and synthesis, and dissemination. We will set up a research community in lung cancer, with different groups of contributors of different skills. We will distribute tasks through online crowdsourcing. This proof-of-concept study in second-line treatments of advanced NSCLC will allow one for assessing the feasibility of live cumulative NMA and opening the path for this new form of synthesis.

ETHICS AND DISSEMINATION

Ethical approval is not required because our study will not include confidential participant data and interventions. The description of all the steps and the results of this live cumulative NMA will be available online.

TRIAL REGISTRATION NUMBER

CRD42015017592.