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Chen C, Chuang YC, Chan ESY, Chen JH, Hou WH, Kang E. Beading plot: a novel graphics for ranking interventions in network evidence. BMC Med Res Methodol 2024; 24:235. [PMID: 39385093 PMCID: PMC11462909 DOI: 10.1186/s12874-024-02355-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/27/2024] [Indexed: 10/11/2024] Open
Abstract
BACKGROUND Network meta-analysis is developed to compare all available treatments; therefore it enriches evidence for clinical decision-making, offering insights into treatment effectiveness and safety when faced with multiple options. However, the complexity and numerous treatment comparisons in network meta-analysis can challenge healthcare providers and patients. The purpose of this study aimed to introduce a graphic design to present complex rankings of multiple interventions comprehensively. METHODS Our team members developed a "beading plot" to summary probability of achieving the best treatment (P-best) and global metrics including surface under the cumulative ranking curve (SUCRA) and P-score. Implemented via the "rankinma" R package, this tool summarizes rankings across diverse outcomes in network meta-analyses, and the package received an official release on the Comprehensive R Archive Network (CRAN). It includes the `PlotBead()` function for generating beading plots, which represent treatment rankings among various outcomes. RESULTS Beading plot has been designed based on number line plot, which effectively displays collective metrics for each treatment across various outcomes. Order on the -axis is derived from ranking metrics like P-best, SUCRA, and P-score. Continuous lines represent outcomes, and color-coded beads signify treatments. CONCLUSION The beading plot is a valuable graphic that intuitively displays treatment rankings across diverse outcomes, enhancing reader-friendliness and aiding decision-making in complex network evidence scenarios. While empowering clinicians and patients to identify optimal treatments, it should be used cautiously, alongside an assessment of the overall evidence certainty.
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Affiliation(s)
- Chiehfeng Chen
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, No. 111, Section 3, Xinglong Road, Taipei, 116, Taiwan
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chieh Chuang
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei 10341, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Edwin Shih-Yen Chan
- Cochrane Singapore, Singapore, Singapore
- Singapore Clinical Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jin-Hua Chen
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, 110, Taiwan
- Research Center of Biostatistics Center, College of Management, Taipei Medical University, Taipei, 110, Taiwan
- Biostatistics Center, Wan Fang Hospital, Taipei Medical University, Taipei, 116, Taiwan
| | - Wen-Hsuan Hou
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Enoch Kang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, No. 111, Section 3, Xinglong Road, Taipei, 116, Taiwan.
- Institute of Health Policy & Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Vinatier C, Palpacuer C, Scanff A, Naudet F. Vibration of effects resulting from treatment selection in mixed-treatment comparisons: a multiverse analysis on network meta-analyses of antidepressants in major depressive disorder. BMJ Evid Based Med 2024; 29:324-332. [PMID: 38769000 DOI: 10.1136/bmjebm-2024-112848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE It is frequent to find overlapping network meta-analyses (NMAs) on the same topic with differences in terms of both treatments included and effect estimates. We aimed to evaluate the impact on effect estimates of selecting different treatment combinations (ie, network geometries) for inclusion in NMAs. DESIGN Multiverse analysis, covering all possible NMAs on different combinations of treatments. SETTING Data from a previously published NMA exploring the comparative effectiveness of 22 treatments (21 antidepressants and a placebo) for the treatment of acute major depressive disorder. PARTICIPANTS Cipriani et al explored a dataset of 116 477 patients included in 522 randomised controlled trials. MAIN OUTCOME MEASURES For each possible treatment selection, we performed an NMA to estimate comparative effectiveness on treatment response and treatment discontinuation for the treatments included (231 between-treatment comparisons). The distribution of effect estimates of between-treatment comparisons across NMAs was computed, and the direction, magnitude and statistical significance of the 1st and 99th percentiles were compared. RESULTS 4 116 254 different NMAs concerned treatment response. Among possible network geometries, 172/231 (74%) pairwise comparisons exhibited opposite effects between the 1st and 99th percentiles, 57/231 (25%) comparisons exhibited statistically significant results in opposite directions, 118 of 231 (51%) comparisons derived results that were both significant and non-significant at 5% risk and 56/231 (24%) treatment pairs obtained consistent results with only significant differences (or only non-significant differences) at 5% risk. Comparisons based on indirect evidence only were associated with greater variability in effect estimates. Comparisons with small absolute values observed in the complete NMA more frequently obtained statistically significant results in opposite directions. Similar results were observed for treatment discontinuation. CONCLUSION In this multiverse analysis, we observed that the selection of treatments to be included in an NMA could have considerable consequences on treatment effect estimations. TRIAL REGISTRATION https://osf.io/mb5dy.
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Affiliation(s)
- Constant Vinatier
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Centre d'investigation clinique de Rennes (CIC1414), F-35000, Rennes, France
| | - Clement Palpacuer
- Groupe Hospitalier de la Region de Mulhouse et Sud Alsace, Mulhouse, France
| | - Alexandre Scanff
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Centre d'investigation clinique de Rennes (CIC1414), F-35000, Rennes, France
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Centre d'investigation clinique de Rennes (CIC1414), F-35000, Rennes, France
- Institut Universitaire de France, Paris, France
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Bhat AM, Marrero-Gonzalez AR, Nguyen SA, Scharner M, Meenan K, Sataloff RT. Photoangiolytic Lasers for Treatment of Benign Laryngeal Lesions: A Systematic Review and Meta-Analysis. Laryngoscope 2024. [PMID: 39119758 DOI: 10.1002/lary.31658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 06/24/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES To compare the efficacy of the 445-nm blue laser to the 585-nm pulsed dye laser (PDL) and 532-nm potassium-titanyl-phosphate (KTP) laser in the treatment of benign laryngeal lesions. DATA SOURCES Cochrane Library, PubMed, Scopus, and CINAHL. REVIEW METHODS Following PRISMA guidelines, databases were searched from inception through January 29, 2024, for studies reporting the use of photoangiolytic lasers for treatment of benign laryngeal lesions, including the 585-nm PDL, 532-nm KTP laser, and 445-nm blue laser. Outcome measures included lesion resolution (%), mean differences (Δ) in Voice Handicap Index (VHI-10), and summed dysphonia grade, roughness, and breathiness (GRB) scale. RESULTS A total of 45 studies were included for meta-analysis, consisting of 348 patients treated with PDL, 550 patients with KTP laser, and 338 patients with blue laser. Treatment with blue laser resulted in the greatest lesion resolution (94.0%; 95% confidence interval [CI]: 90.2%-96.7%), followed by KTP laser (90.4%; 95% CI: 84.1%-95.2%), and PDL (86.9%; 95% CI: 62.9%-99.2%). VHI-10 improved significantly in patients following treatment with blue laser (Δ13.3; 95% CI: 10.7-16.0; p < 0.0001), KTP laser (Δ10.3; 95% CI: 7.4-13.3; p < 0.0001), and PDL (Δ7.4; 95% CI: 4.8-10.1; p < 0.0001). GRB improved significantly in patients following treatment with blue laser (Δ4.1; 95% CI: 2.9-5.2; p < 0.0001), KTP laser (Δ3.0; 95% CI: 2.0-4.0; p < 0.0001), and PDL (Δ2.5; 95% CI: 0.8-4.2; p = 0.005). CONCLUSIONS Photoangiolytic lasers are effective in treating benign laryngeal lesions. Blue lasers are promising for laryngeal laser surgery. Laryngoscope, 2024.
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Affiliation(s)
- Akash M Bhat
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Alejandro R Marrero-Gonzalez
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Shaun A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Megan Scharner
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Kirsten Meenan
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, U.S.A
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Guelimi R, Afach S, Bettuzzi T, Meyer A, Padern G, Yiu Z, Naudet F, Sbidian E, Le-Cleach L. Funding and conclusions of network meta-analyses on targeted therapies in inflammatory diseases: an overview. J Clin Epidemiol 2024; 172:111411. [PMID: 38852893 DOI: 10.1016/j.jclinepi.2024.111411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/08/2024] [Accepted: 06/03/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES To explore the association between industry funding and network meta-analyses' (NMAs) conclusion, and the use in Clinical Practice Guidelines (CPGs) of NMAs. STUDY DESIGN AND SETTING This was an overview of NMAs and CPGs. We searched PubMed/MEDLINE, Epistemonikos, and several guideline databases up to February 18th 2023. We included CPGs from the last 5 years and NMAs of randomized controlled trials that evaluated targeted therapies in immune-mediated inflammatory diseases. Data extraction and outcome assessments were done in duplicate by independent authors. RESULTS We included 216 NMAs and 99 CPGs. 31% (67/216) were industry-funded. The proportion of industry-funded NMAs that cited one treatment as being best was 44% (25/57) compared to 26% (30/116) for nonindustry-funded (OR = 2.24 [1.15-4.39]; aOR = 1.76 [0.81-3.81]). The abstract's conclusion of 39/67 (58%) industry-funded and 69/149 (46%) nonindustry-funded NMAs were considered unsupported by the results (OR = 1.61 [0.90-2.89]; aOR = 1.40 [0.71-2.78]). All industry-funded NMAs that cited one treatment as best cited their own sponsored drug. 59/99 (60%) CPGs included at least one NMA, with 23/59 (39%) of them citing industry-funded NMAs. CONCLUSIONS We did not find evidence that industry-funded NMAs were more likely to have unsupported conclusions or to cite only one treatment as being best in their conclusions compared to non-industry-funded NMAs. However, almost all industry-funded NMAs favored their own treatments. Even though 40% of the CPGs did not rely on NMA, over a third of those who did used industry-funded NMAs. Limitations include the possible misclassification due to undisclosed funding and potential confounders that have not been accounted for.
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Affiliation(s)
- Robin Guelimi
- EpiDermE EA 7379, Université Paris Est Créteil, Créteil, F-94010, France; Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, F-94010, France.
| | - Sivem Afach
- EpiDermE EA 7379, Université Paris Est Créteil, Créteil, F-94010, France
| | - Thomas Bettuzzi
- EpiDermE EA 7379, Université Paris Est Créteil, Créteil, F-94010, France; Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, F-94010, France
| | - Antoine Meyer
- Department of Gastroenterology, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris and Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Guillaume Padern
- IRMB, University of Montpellier, Inserm U1183, CHU Montpellier, Montpellier, France
| | - Zenas Yiu
- Faculty of Biology, Medicine and Health, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom; Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M6 8HD, United Kingdom
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], F-35000, Rennes, France; Institut Universitaire de France (IUF), Paris, France
| | - Emilie Sbidian
- EpiDermE EA 7379, Université Paris Est Créteil, Créteil, F-94010, France; Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, F-94010, France
| | - Laurence Le-Cleach
- EpiDermE EA 7379, Université Paris Est Créteil, Créteil, F-94010, France; Department of Dermatology, Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Créteil, F-94010, France
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Garcia C, Rehman N, Matos-Silva J, Deng J, Ghandour S, Huang Z, Mbuagbaw L. Interventions to Improve Adherence to Oral Pre-exposure Prophylaxis: A Systematic Review and Network Meta-analysis. AIDS Behav 2024; 28:2534-2546. [PMID: 38814406 DOI: 10.1007/s10461-024-04365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
For people at risk of HIV infection, pre-exposure prophylaxis (PrEP) can reduce the risk of infection in anticipation of exposure to HIV. The effectiveness of PrEP relies upon a user's adherence to their PrEP regimen. We sought to assess the effect of PrEP adherence interventions compared to usual care or another intervention for people at risk of HIV. We searched electronic databases from 2010 onwards for randomized controlled trials (RCTs) involving persons at risk of HIV randomized to an adherence promoting intervention vs usual care or another intervention. We used network meta-analyses to compare PrEP adherence for all participant populations. Certainty of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). 21 trials (N = 4917) were included in qualitative analysis (19 in network meta-analyses (N = 4101)). HIV self-testing interventions with adherence feedback elements improved adherence compared to usual care (risk ratio (RR): 1.83, 95%CI 1.19, 2.82). In contrast, HIV self-testing alone was inferior to HIV self-testing with adherence feedback (RR: 0.58, 95%CI 0.37-0.92). Reminders alone also were inferior to HIV self-testing with adherence feedback on adherence (RR: 0.53, 95%CI 0.34-0.84) and had similar effects on adherence as usual care (RR: 0.98, 95%CI: 0.86-1.11). Interventions with only one component were inferior for adherence than those with two components (RR: 0.74, 95%CI 0.62-0.88) and those with three components (RR: 0.78, 95%CI 0.65-0.93). The certainty of evidence was moderate for HIV self-testing plus adherence feedback and interventions with two or three components. When designing future PrEP adherence interventions, we recommend strategies with more than one but no more than three components.
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Affiliation(s)
- Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Nadia Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jéssyca Matos-Silva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara Ghandour
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Zhongyu Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Løvsletten PO, Wang X, Pitre T, Ødegaard M, Veroniki AA, Lunny C, Tricco AC, Agoritsas T, Vandvik PO. A systematic survey of 200 systematic reviews with network meta-analysis (published 2020-2021) reveals that few reviews report structured evidence summaries. J Clin Epidemiol 2024; 173:111445. [PMID: 38942177 DOI: 10.1016/j.jclinepi.2024.111445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVES To map whether and how systematic reviews (SRs) with network meta-analysis (NMA) use presentation formats to report (a) structured evidence summaries - here defined as reporting of effects estimates in absolute effects with certainty ratings and with a method to rate interventions across one or more outcome(s) - and (b) NMA results in general. STUDY DESIGN AND SETTING We conducted a systematic survey, searching MEDLINE (Ovid) for SRs with NMA published between January 1, 2020, and December 31, 2021. We planned to include a random sample of publications, with predefined mechanisms in place for saturation, and included SRs that met prespecified quality criteria and extracted data on presentation formats that reported: (a) estimates of effects, (b) certainty of the evidence, or (c) rating of interventions. RESULTS The 200 eligible SRs, from 158 unique Journals, utilized 1133 presentation formats. We found structured evidence summaries in 10 publications (5.0%), with 3 (1.5%) reporting structured evidence summaries across all outcomes, including benefits and harms. Sixteen of the 133 SRs (11.7%) reporting dichotomous outcomes included estimates of absolute effects. Seventy-six SRs (38.0%) reported both benefits and harms and 26 SRs (13.0%) reported certainty ratings in presentation formats, 20 (76.9%) used Grading of Recommendations Assessment, Development and Evaluation and 6 (23.1%) used Confidence In Network Meta-analysis. Surface Under the Cumulative Ranking Curve was the most common method to rate interventions (69 SRs, 34.5%). NMA results were most often reported using forest plots (108 SRs, 54.0%) and league tables (93 SRs, 46.5%). CONCLUSION Most SRs with NMA do not report structured evidence summaries and only rarely do such summaries include reporting of both benefits and harms; those that do offer effective user-friendly communication and provide models for optimal NMA presentation practice.
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Affiliation(s)
- Per Olav Løvsletten
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Xiaoqin Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; University of Ottawa Heart Institute Research Corporation, Ottawa, Ontario, Canada
| | - Tyler Pitre
- Department of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Marte Ødegaard
- Library of Medicine and Science, University of Oslo Library, University of Oslo, Oslo, Norway
| | - Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Toronto, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Toronto, Canada; Cochrane Hypertension Group and the Therapeutics Initiative, University of British Columbia, Vancouver, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Toronto, Canada; Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's School of Nursing. Queen's University, Kingston, Ontario, Canada; Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Agoritsas
- Department of Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; MAGIC Evidence Ecosystem Foundation, Oslo, Norway
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway; Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway; MAGIC Evidence Ecosystem Foundation, Oslo, Norway
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Wang L, Huang J, Chang X, Xia F. Effects of different neuraxial analgesia modalities on the need for physician interventions in labour: A network meta-analysis. Eur J Anaesthesiol 2024; 41:411-420. [PMID: 38546832 DOI: 10.1097/eja.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Neuraxial labour analgesia can be initiated with epidural (EPL), combined spinal epidural (CSE) or dural puncture epidural (DPE) and maintained with continuous epidural infusion (CEI), patient-controlled epidural analgesia (PCEA) or programmed intermittent epidural bolus (PIEB), but the optimal analgesia modality is still controversial. OBJECTIVE To compare the effects of commonly used neuraxial analgesia modalities on the proportion of women needing physician interventions, as defined by the need for physician-administered epidural top-ups for inadequate analgesia in labour. DESIGN Bayesian network meta-analysis. DATA SOURCES PubMed, Embase, CENTRAL, Web of Science and Wanfang Data were searched from January 1988 to August 2023 without language restriction. ELIGIBILITY CRITERIA Randomised controlled trials comparing two or more modalities of the following six neuraxial analgesia modalities in healthy labouring women: EPL+CEI+PCEA, EPL+PIEB+PCEA, CSE+CEI+PCEA, CSE+PIEB+PCEA, DPE+CEI+PCEA and DPE+PIEB+PCEA. RESULTS Thirty studies with 8188 women were included. Compared with EPL+CEI+PCEA, EPL+PIEB+PCEA [odds ratio (OR) = 0.44; 95% credible interval (CrI), 0.22 to 0.86], CSE+PIEB+PCEA (OR = 0.29; 95% CrI, 0.12 to 0.71) and DPE+PIEB+PCEA (OR = 0.19; 95% CrI, 0.08 to 0.42) significantly reduced the proportion of women needing physician interventions. DPE+PIEB+PCEA had fewer women needing physician interventions than all other modalities, except for CSE+PIEB+PCEA (OR = 0.63; 95% CrI, 0.25 to 1.62). There were no significant differences in local anaesthetic consumption, maximum pain score, and the incidence of instrumental delivery between the different neuraxial modalities. CONCLUSIONS PIEB+PCEA is associated with a lower risk of physician interventions in labour than CEI+PCEA. DPE or CSE and PIEB+PCEA may be associated with a lower likelihood of physician interventions than other neuraxial modalities. Otherwise, the new neuraxial analgesia techniques do not appear to offer significant advantages over traditional techniques. However, these results should be interpreted with caution due to limited data and methodological limitations. TRIAL REGISTRATION PROSPERO (CRD42023402540).
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Affiliation(s)
- Lizhong Wang
- From the Department of Anesthesiology, Jiaxing Maternity and Children Healthcare Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China (LW, JH, XC, FX)
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Wang L, Huang J, Hu H, Chang X, Xia F. Commonly used antiemetics for prophylaxis of postoperative nausea and vomiting after Caesarean delivery with neuraxial morphine: a network meta-analysis. Br J Anaesth 2024; 132:1274-1284. [PMID: 38627136 DOI: 10.1016/j.bja.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Dopamine antagonists, 5-HT3 antagonists, and dexamethasone are frequently used in obstetrics to prevent postoperative nausea and vomiting (PONV). However, the superiority of any drug class is yet to be established. This network meta-analysis aimed to compare the efficacy of these antiemetics for PONV prophylaxis in women receiving neuraxial morphine for Caesarean delivery. METHODS We searched PubMed, Embase, CENTRAL, Web of Science, and Wanfang Data for eligible randomised controlled trials. Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) within 24 h after surgery. We used a Bayesian random-effects model and calculated odds ratios with 95% credible intervals for dichotomous data. We performed sensitivity and subgroup analyses for primary outcomes. RESULTS A total of 33 studies with 4238 women were included. In the primary analyses of all women, 5-HT3 antagonists, dopamine antagonists, dexamethasone, and 5-HT3 antagonists plus dexamethasone significantly reduced PON and POV compared with placebo, and 5-HT3 antagonists plus dexamethasone were more effective than monotherapy. In the subgroup analyses, similar results were seen in women receiving epidural morphine or intrathecal morphine alone but not in women receiving intrathecal morphine with fentanyl or sufentanil. However, most included studies had some concerns or a high risk of bias, and the overall certainty of the evidence was low or very low. CONCLUSIONS Combined 5-HT3 antagonists plus dexamethasone are more effective than monotherapy in preventing PONV associated with neuraxial morphine after Caesarean delivery. Future studies are needed to determine the role of prophylactic antiemetics in women receiving intrathecal morphine and lipophilic opioids. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023454602.
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Affiliation(s)
- Lizhong Wang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
| | - Jiayue Huang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Huijing Hu
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Xiangyang Chang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Feng Xia
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
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Giok KC, Veettil SK, Menon RK. Comparative effectiveness of interventions for the treatment of peri-implantitis: A systematic review with network meta-analysis. J Prosthet Dent 2024:S0022-3913(24)00219-1. [PMID: 38632026 DOI: 10.1016/j.prosdent.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 04/19/2024]
Abstract
STATEMENT OF PROBLEM Extensive research has been carried out on the various aspects of diagnosing and treating peri-implantitis. However, clinical guidelines for the management of peri-implantitis based on high quality evidence are lacking. PURPOSE The purpose of this systematic review with network meta-analysis was to analyze the current evidence on nonsurgical and surgical interventions for the treatment of peri-implantitis and synthesize clinical guidelines based on high quality evidence. MATERIAL AND METHODS A search was conducted for trials published in Medline, Scopus, PubMed, and Cochrane Central Register of Controlled Trials from inception until July 2023. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023451056). A network meta-analysis was performed on data from randomized controlled trials that assessed nonsurgical and surgical interventions for the treatment of peri-implantitis. The interventions were ranked according to their efficacy using surface under the cumulative ranking (SUCRA) system. The grading of recommendations, assessment, development, and evaluations (GRADE) approach was used to assess the level of certainty of evidence. RESULTS A total of 45 articles were included in the quantitative analysis. The GRADE approach determined a moderate to high level of certainty of evidence. Among the nonsurgical interventions, mechanical debridement with adjunctive systemic antibiotics was significant in improving probing depth at 3 months and beyond 6 months, clinical attachment loss at 3 months, and clinical attachment loss beyond 6 months. Mechanical debridement with adjunctive topical antibiotics was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive photodynamic therapy was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive systemic antibiotics and photodynamic therapy was significant in improving probing depth beyond 6 months. Among surgical interventions, open flap debridement with implant surface decontamination and open flap debridement with decontamination and adjunctive photodynamic therapy were significant in improving probing depth at 3 months. CONCLUSIONS Mechanical debridement with adjunctive systemic antibiotics or photodynamic therapy results in improved clinical outcomes.
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Affiliation(s)
- Koay Chun Giok
- Predoctoral student, School of Dentistry, International Medical University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Sajesh K Veettil
- Associate Professor, Department of Pharmacy Practice, School of Pharmacy, College of Pharmacy, International Medical University, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Rohit Kunnath Menon
- Assistant Professor, Prosthodontics, College of Dentistry, Ajman University, Ajman, United Arab Emirates.
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10
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Ades AE, Welton NJ, Dias S, Phillippo DM, Caldwell DM. Twenty years of network meta-analysis: Continuing controversies and recent developments. Res Synth Methods 2024. [PMID: 38234221 DOI: 10.1002/jrsm.1700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
Network meta-analysis (NMA) is an extension of pairwise meta-analysis (PMA) which combines evidence from trials on multiple treatments in connected networks. NMA delivers internally consistent estimates of relative treatment efficacy, needed for rational decision making. Over its first 20 years NMA's use has grown exponentially, with applications in both health technology assessment (HTA), primarily re-imbursement decisions and clinical guideline development, and clinical research publications. This has been a period of transition in meta-analysis, first from its roots in educational and social psychology, where large heterogeneous datasets could be explored to find effect modifiers, to smaller pairwise meta-analyses in clinical medicine on average with less than six studies. This has been followed by narrowly-focused estimation of the effects of specific treatments at specific doses in specific populations in sparse networks, where direct comparisons are unavailable or informed by only one or two studies. NMA is a powerful and well-established technique but, in spite of the exponential increase in applications, doubts about the reliability and validity of NMA persist. Here we outline the continuing controversies, and review some recent developments. We suggest that heterogeneity should be minimized, as it poses a threat to the reliability of NMA which has not been fully appreciated, perhaps because it has not been seen as a problem in PMA. More research is needed on the extent of heterogeneity and inconsistency in datasets used for decision making, on formal methods for making recommendations based on NMA, and on the further development of multi-level network meta-regression.
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Affiliation(s)
- A E Ades
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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11
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Rohwer A, Ngah V, Mavridis D, Young T, McCaul M. Building capacity for network meta-analysis in Sub-Saharan Africa: reflections and future direction. Syst Rev 2024; 13:7. [PMID: 38167514 PMCID: PMC10759577 DOI: 10.1186/s13643-023-02418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Robust, relevant, comprehensive, and up-to-date evidence syntheses are the cornerstone for evidence-informed healthcare decisions. When considering multiple treatment options, network meta-analysis (NMA) systematic reviews play a key role in informing impactful decisions and clinical practice guidelines. However, the capacity and literacy to conduct NMA systematic reviews and interpret its results remains out of reach for many clinicians and review authors, especially in low-to-middle-income countries. Despite ample resources and guides, NMA capacity and training opportunities remain limited to non-existent in Sub-Saharan Africa. Towards solutions and strengthening evidence synthesis and NMA capacity in the Sub-Saharan African region, we describe and reflect on two courses that build NMA capacity and aim to address NMA literacy in Sub-Saharan Africa.The Primer in NMA systematic reviews aimed for participants to be able to find, appraise, interpret, and consider the use of NMA SRs of intervention effects. It is a 6-week online course for clinicians, policy-makers, and researchers wanting to learn more about using NMA systematic reviews. The Global NMA Masterclass workshop aimed for participants to be able to understand and apply pairwise and NMA in STATA and R, evaluate NMA assumptions and confidence in NMA results, and appropriately report NMA results. This course was offered over 5 weeks to clinicians, biostatisticians, and researchers with basic knowledge of epidemiology and biostatics. Although the bulk of learning occurred through self-study, we had weekly, synchronous question-and-answer sessions for both courses. Using relevant examples throughout the courses helped to enable an authentic learning environment.This was the first NMA training developed in Africa for Africa. Development of the courses was a collaborative effort from a multi-disciplinary team. Both NMA courses were well received and attended by a diverse group of participants spread across Sub-Saharan African countries. Participants felt the courses were applicable to their setting. Although most participants appreciated the benefits of online learning, we also experienced some challenges. There is great potential to conduct NMA systematic reviews in Sub-Saharan Africa. The NMA Primer and NMA workshop can play an essential role in expanding and developing NMA SR capacity and literacy in SSA.
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Affiliation(s)
- Anke Rohwer
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Veranyuy Ngah
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- South African GRADE Network, Stellenbosch University, Cape Town, South Africa
| | - Michael McCaul
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- South African GRADE Network, Stellenbosch University, Cape Town, South Africa.
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12
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Williams MJ, Vogel JP, Gallos ID, Ramson JA, Chou D, Oladapo OT. The use of network meta-analysis in updating WHO living maternal and perinatal health recommendations. BMJ Glob Health 2023; 8:e013109. [PMID: 38084476 PMCID: PMC10711830 DOI: 10.1136/bmjgh-2023-013109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023] Open
Abstract
Drawing on two recent examples of WHO living guidelines in maternal and perinatal health, this paper elucidates a pragmatic, stepwise approach to using network meta-analysis (NMA) in guideline development in the presence of multiple treatment options. NMA has important advantages. These include the ability to compare multiple interventions in a single coherent analysis, provide direct estimates of the relative effects of all available interventions, infer indirect effect estimates for interventions not directly compared and generate rankings of the available treatment options. It can be difficult to harness these advantages in the face of a lack of current guidance on using NMA evidence in guideline development, with several challenges emerging. Challenges include the choice of conceptual approach, the volume and complexity of the evidence, the contribution of treatment rankings, and the fact that the preferable treatment is not always obvious. This paper describes a layered approach to resolving these challenges, which supports systematic guideline decision-making and development of trustworthy clinical guidelines when multiple treatment options are available.
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Affiliation(s)
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Ioannis D Gallos
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jenny A Ramson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Doris Chou
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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13
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Tramacere I, Virgili G, Perduca V, Lucenteforte E, Benedetti MD, Capobussi M, Castellini G, Frau S, Gonzalez-Lorenzo M, Featherstone R, Filippini G. Adverse effects of immunotherapies for multiple sclerosis: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012186. [PMID: 38032059 PMCID: PMC10687854 DOI: 10.1002/14651858.cd012186.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic disease of the central nervous system that affects mainly young adults (two to three times more frequently in women than in men) and causes significant disability after onset. Although it is accepted that immunotherapies for people with MS decrease disease activity, uncertainty regarding their relative safety remains. OBJECTIVES To compare adverse effects of immunotherapies for people with MS or clinically isolated syndrome (CIS), and to rank these treatments according to their relative risks of adverse effects through network meta-analyses (NMAs). SEARCH METHODS We searched CENTRAL, PubMed, Embase, two other databases and trials registers up to March 2022, together with reference checking and citation searching to identify additional studies. SELECTION CRITERIA We included participants 18 years of age or older with a diagnosis of MS or CIS, according to any accepted diagnostic criteria, who were included in randomized controlled trials (RCTs) that examined one or more of the agents used in MS or CIS, and compared them versus placebo or another active agent. We excluded RCTs in which a drug regimen was compared with a different regimen of the same drug without another active agent or placebo as a control arm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for data extraction and pairwise meta-analyses. For NMAs, we used the netmeta suite of commands in R to fit random-effects NMAs assuming a common between-study variance. We used the CINeMA platform to GRADE the certainty of the body of evidence in NMAs. We considered a relative risk (RR) of 1.5 as a non-inferiority safety threshold compared to placebo. We assessed the certainty of evidence for primary outcomes within the NMA according to GRADE, as very low, low, moderate or high. MAIN RESULTS This NMA included 123 trials with 57,682 participants. Serious adverse events (SAEs) Reporting of SAEs was available from 84 studies including 5696 (11%) events in 51,833 (89.9%) participants out of 57,682 participants in all studies. Based on the absolute frequency of SAEs, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 18 additional people would have a SAE compared to placebo. Low-certainty evidence suggested that three drugs may decrease SAEs compared to placebo (relative risk [RR], 95% confidence interval [CI]): interferon beta-1a (Avonex) (0.78, 0.66 to 0.94); dimethyl fumarate (0.79, 0.67 to 0.93), and glatiramer acetate (0.84, 0.72 to 0.98). Several drugs met our non-inferiority criterion versus placebo: moderate-certainty evidence for teriflunomide (1.08, 0.88 to 1.31); low-certainty evidence for ocrelizumab (0.85, 0.67 to 1.07), ozanimod (0.88, 0.59 to 1.33), interferon beta-1b (0.94, 0.78 to 1.12), interferon beta-1a (Rebif) (0.96, 0.80 to 1.15), natalizumab (0.97, 0.79 to 1.19), fingolimod (1.05, 0.92 to 1.20) and laquinimod (1.06, 0.83 to 1.34); very low-certainty evidence for daclizumab (0.83, 0.68 to 1.02). Non-inferiority with placebo was not met due to imprecision for the other drugs: low-certainty evidence for cladribine (1.10, 0.79 to 1.52), siponimod (1.20, 0.95 to 1.51), ofatumumab (1.26, 0.88 to 1.79) and rituximab (1.01, 0.67 to 1.52); very low-certainty evidence for immunoglobulins (1.05, 0.33 to 3.32), diroximel fumarate (1.05, 0.23 to 4.69), peg-interferon beta-1a (1.07, 0.66 to 1.74), alemtuzumab (1.16, 0.85 to 1.60), interferons (1.62, 0.21 to 12.72) and azathioprine (3.62, 0.76 to 17.19). Withdrawals due to adverse events Reporting of withdrawals due to AEs was available from 105 studies (85.4%) including 3537 (6.39%) events in 55,320 (95.9%) patients out of 57,682 patients in all studies. Based on the absolute frequency of withdrawals, our non-inferiority threshold (up to a 50% increased risk) meant that no more than 1 in 31 additional people would withdraw compared to placebo. No drug reduced withdrawals due to adverse events when compared with placebo. There was very low-certainty evidence (meaning that estimates are not reliable) that two drugs met our non-inferiority criterion versus placebo, assuming an upper 95% CI RR limit of 1.5: diroximel fumarate (0.38, 0.11 to 1.27) and alemtuzumab (0.63, 0.33 to 1.19). Non-inferiority with placebo was not met due to imprecision for the following drugs: low-certainty evidence for ofatumumab (1.50, 0.87 to 2.59); very low-certainty evidence for methotrexate (0.94, 0.02 to 46.70), corticosteroids (1.05, 0.16 to 7.14), ozanimod (1.06, 0.58 to 1.93), natalizumab (1.20, 0.77 to 1.85), ocrelizumab (1.32, 0.81 to 2.14), dimethyl fumarate (1.34, 0.96 to 1.86), siponimod (1.63, 0.96 to 2.79), rituximab (1.63, 0.53 to 5.00), cladribine (1.80, 0.89 to 3.62), mitoxantrone (2.11, 0.50 to 8.87), interferons (3.47, 0.95 to 12.72), and cyclophosphamide (3.86, 0.45 to 33.50). Eleven drugs may have increased withdrawals due to adverse events compared with placebo: low-certainty evidence for teriflunomide (1.37, 1.01 to 1.85), glatiramer acetate (1.76, 1.36 to 2.26), fingolimod (1.79, 1.40 to 2.28), interferon beta-1a (Rebif) (2.15, 1.58 to 2.93), daclizumab (2.19, 1.31 to 3.65) and interferon beta-1b (2.59, 1.87 to 3.77); very low-certainty evidence for laquinimod (1.42, 1.01 to 2.00), interferon beta-1a (Avonex) (1.54, 1.13 to 2.10), immunoglobulins (1.87, 1.01 to 3.45), peg-interferon beta-1a (3.46, 1.44 to 8.33) and azathioprine (6.95, 2.57 to 18.78); however, very low-certainty evidence is unreliable. Sensitivity analyses including only studies with low attrition bias, drug dose above the group median, or only patients with relapsing remitting MS or CIS, and subgroup analyses by prior disease-modifying treatments did not change these figures. Rankings No drug yielded consistent P scores in the upper quartile of the probability of being better than others for primary and secondary outcomes. AUTHORS' CONCLUSIONS We found mostly low and very low-certainty evidence that drugs used to treat MS may not increase SAEs, but may increase withdrawals compared with placebo. The results suggest that there is no important difference in the occurrence of SAEs between first- and second-line drugs and between oral, injectable, or infused drugs, compared with placebo. Our review, along with other work in the literature, confirms poor-quality reporting of adverse events from RCTs of interventions. At the least, future studies should follow the CONSORT recommendations about reporting harm-related issues. To address adverse effects, future systematic reviews should also include non-randomized studies.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Ophthalmology, IRCCS - Fondazione Bietti, Rome, Italy
| | - Vittorio Perduca
- Université Paris Cité, CNRS, MAP5, F-75006 Paris, France
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Maria Donata Benedetti
- UOC Neurologia B - Policlinico Borgo Roma, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Matteo Capobussi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | | | - Marien Gonzalez-Lorenzo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Oncology, Laboratory of Clinical Research Methodology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | - Graziella Filippini
- Scientific Director's Office, Carlo Besta Foundation and Neurological Institute, Milan, Italy
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Yunitri N, Chu H, Kang XL, Wiratama BS, Lee TY, Chang LF, Liu D, Kustanti CY, Chiang KJ, Chen R, Tseng P, Chou KR. Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: a network meta-analysis of randomised controlled trials. Psychol Med 2023; 53:6376-6388. [PMID: 36628572 DOI: 10.1017/s0033291722003737] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Evidence on the long-term comparative effectiveness of posttraumatic stress disorder (PTSD) psychotherapies in adults remains unknown. Therefore, we performed an extensive network meta-analysis of randomised controlled trials (RCTs) to determine the comparative effectiveness of psychotherapies for people diagnosed with PTSD. METHODS A comprehensive search was conducted in Cochrane library, Embase, Medline-OVID, PubMed, Scopus, and Psych-Info until March 2021. Studies on the effectiveness of cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation reprocessing (EMDR), narrative exposure therapy (NET), prolonged exposure (PE), cognitive behavioural therapy (CBT), present-centred therapy (PCT), brief eclectic psychotherapies (BEP), psychodynamic therapy (PDT) or combination therapies compared to no treatment (NT) or treatment as usual (TAU) in adults with PTSD were included. Frequentist and Bayesian approaches were used for analysis in R-software. RESULTS We included 98 RCTs with 5567 participants from 18 897 studies. CPT, EMDR, CT, NET, PE, CBT, and PCT were significant to reduce PTSD symptoms (SMD range: -1.53 to -0.75; Certainty: very low to high) at immediate post-treatment and ranked accordingly. Longitudinal analysis found EMDR (1.02) and CPT (0.85) as the significant therapies with large effect size in short-term and long-term follow-up, respectively. NET and CPT showed higher proportion of loss of PTSD diagnosis (RR range: 5.51-3.45) while there were no significant psychotherapies for retention rate compared to NT. CONCLUSIONS Our findings provide evidence for improving current guidelines and informing clinical decision-making for PTSD management. However, the best PTSD treatment plan should be tailored to patients' needs, characteristics, and clinician expertise. REGISTRATION PROSPERO CRD42020162143.
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Affiliation(s)
- Ninik Yunitri
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Mental Health and Psychiatric Nursing Department, Faculty of Nursing, Universitas Muhammadiyah Jakarta, Indonesia
| | - Hsin Chu
- Institute of Aerospace and Undersea Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Xiao Linda Kang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Bayu Satria Wiratama
- Department of Biostatistics, Epidemiology and Population Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Tso-Ying Lee
- Nursing Research Center, Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Fang Chang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Medical Education & Emergency and Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Doresses Liu
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Christina Yeni Kustanti
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Sekolah Tinggi Ilmu Kesehatan Bethesda Yakkum Yogyakarta, Indonesia
| | - Kai-Jo Chiang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Ruey Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Philip Tseng
- Graduate Institute of Mind, Brain and Consciousness, Taipei Medical University, Taipei, Taiwan
- Brain and Consciousness Research Center, TMU - Shuang Ho Hospital, New Taipei, Taiwan
- Research Center for Mind, Brain & Learning, National Chengchi University, Taipei, Taiwan
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Neuroscience Research Center, Taipei Medical University, Taipei, Taiwan
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Sehmbi H, Retter S, Shah UJ, Nguyen D, Martin J, Uppal V. Methodological and reporting quality assessment of network meta-analyses in anesthesiology: a systematic review and meta-epidemiological study. Can J Anaesth 2023; 70:1461-1473. [PMID: 37420161 DOI: 10.1007/s12630-023-02510-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 07/09/2023] Open
Abstract
PURPOSE The scientific rigour of the conduct and reporting of anesthesiology network meta-analyses (NMAs) is unknown. This systematic review and meta-epidemiological study assessed the methodological and reporting quality of NMAs in anesthesiology. METHODS We searched four databases, including MEDLINE, PubMed, Embase, and the Cochrane Systematic Reviews Database, for anesthesiology NMAs published from inception to October 2020. We assessed the compliance of NMAs against A Measurement Tool to Assess Systematic Reviews (AMSTAR-2), Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Network Meta-Analyses (PRISMA-NMA), and PRISMA checklists. We measured the compliance across various items in AMSTAR-2 and PRISMA checklists and provided recommendations to improve quality. RESULTS Using the AMSTAR-2 rating method, 84% (52/62) of NMAs were rated "critically low." Quantitatively, the median [interquartile range] AMSTAR-2 score was 55 [44-69]%, while the PRISMA score was 70 [61-81]%. Methodological and reporting scores showed a strong correlation (R = 0.78). Anesthesiology NMAs had a higher AMSTAR-2 score and PRISMA score if they were published in higher impact factor journals (P = 0.006 and P = 0.01, respectively) or followed PRISMA-NMA reporting guidelines (P = 0.001 and P = 0.002, respectively). Network meta-analyses from China had lower scores (P < 0.001 and P < 0.001, respectively). Neither score improved over time (P = 0.69 and P = 0.67, respectively). CONCLUSION The current study highlights numerous methodological and reporting deficiencies in anesthesiology NMAs. Although the AMSTAR tool has been used to assess the methodological quality of NMAs, dedicated tools for conducting and assessing the methodological quality of NMAs are urgently required. STUDY REGISTRATION PROSPERO (CRD42021227997); first submitted 23 January 2021.
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Affiliation(s)
- Herman Sehmbi
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
| | - Susanne Retter
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, 10W Victoria Building, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
- Nova Scotia Health Authority, Halifax, NS, Canada
| | - Ushma J Shah
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Derek Nguyen
- Schulich School of Medicine & Dentistry, London, ON, Canada
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Epidemiology & Biostatistics, London Health Sciences Centre, Western University, London, ON, Canada
| | - Vishal Uppal
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, 10W Victoria Building, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada.
- Nova Scotia Health Authority, Halifax, NS, Canada.
- IWK Health Centre, Halifax, NS, Canada.
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Türk S, Korfmacher AK, Gerger H, van der Oord S, Christiansen H. Interventions for ADHD in childhood and adolescence: A systematic umbrella review and meta-meta-analysis. Clin Psychol Rev 2023; 102:102271. [PMID: 37030086 DOI: 10.1016/j.cpr.2023.102271] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 03/03/2023] [Accepted: 03/24/2023] [Indexed: 03/28/2023]
Abstract
There are several meta-analyses of treatment effects for children and adolescents with attention deficit hyperactivity disorder (ADHD). The conclusions of these meta-analyses vary considerably. Our aim was to synthesize the latest evidence of the effectiveness of psychological, pharmacological treatment options and their combination in a systematic overview and meta-meta-analyses. A systematic literature search until July 2022 to identify meta-analyses investigating effects of treatments for children and adolescents with ADHD and ADHD symptom severity as primary outcome (parent and teacher rated) yielded 16 meta-analyses for quantitative analyses. Meta-meta-analyses of pre-post data showed significant effects for pharmacological treatment options for parent (SMD = 0.67, 95% CI 0.60 to 0.74) and teacher ADHD symptom ratings (SMD = 0.68, 95% CI 0.54 to 0.82) as well as for psychological interventions for parent (SMD = 0.42, 95% CI 0.33 to 0.51) and teacher rated symptoms (SMD = 0.25, 95% CI 0.12 to 0.38). We were unable to calculate effect sizes for combined treatments due to the lack of meta-analyses. Our analyses revealed that there is a lack of research on combined treatments and for therapy options for adolescents. Finally, future research efforts should adhere to scientific standards as this allows comparison of effects across meta-analyses.
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Affiliation(s)
- Selina Türk
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Gutenbergstraße 18, 35032 Marburg, Germany.
| | - Ann-Kathrin Korfmacher
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Gutenbergstraße 18, 35032 Marburg, Germany.
| | - Heike Gerger
- Family Medicine, Faculty of Health, Medicine and Life Sciences, Maastricht University, Universiteitssingel 60, 6229, ER, Maastricht, Netherlands
| | | | - Hanna Christiansen
- Clinical Child and Adolescent Psychology, Department of Psychology, Philipps-University Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
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Veroniki AA, Wong EKC, Lunny C, Martinez Molina JC, Florez ID, Tricco AC, Straus SE. Does type of funding affect reporting in network meta-analysis? A scoping review of network meta-analyses. Syst Rev 2023; 12:81. [PMID: 37149700 PMCID: PMC10163730 DOI: 10.1186/s13643-023-02235-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/06/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Evidence has shown that private industry-sponsored randomized controlled trials (RCTs) and meta-analyses are more likely to report intervention-favourable results compared with other sources of funding. However, this has not been assessed in network meta-analyses (NMAs). OBJECTIVES To (a) explore the recommendation rate of industry-sponsored NMAs on their company's intervention, and (b) assess reporting in NMAs of pharmacologic interventions according to their funding type. METHODS Design: Scoping review of published NMAs with RCTs. INFORMATION SOURCES We used a pre-existing NMA database including 1,144 articles from MEDLINE, EMBASE and Cochrane Database of Systematic Reviews, published between January 2013 and July 2018. STUDY SELECTION NMAs with transparent funding information and comparing pharmacologic interventions with/without placebo. SYNTHESIS We captured whether NMAs recommended their own or another company's intervention, classified NMAs according to their primary outcome findings (i.e., statistical significance and direction of effect), and according to the overall reported conclusion. We assessed reporting using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension to NMA (PRISMA-NMA) 32-item checklist. We matched and compared industry with non-industry NMAs having the same research question, disease, primary outcome, and pharmacologic intervention against placebo/control. RESULTS We retrieved 658 NMAs, which reported a median of 23 items in the PRISMA-NMA checklist (interquartile range [IQR]: 21-26). NMAs were categorized as 314 publicly-sponsored (PRISMA-NMA median 24.5, IQR 22-27), 208 non-sponsored (PRISMA-NMA median 23, IQR 20-25), and 136 industry/mixed-sponsored NMAs (PRISMA-NMA median 21, IQR 19-24). Most industry-sponsored NMAs recommended their own manufactured drug (92%), suggested a statistically significant positive treatment-effect for their drug (82%), and reported an overall positive conclusion (92%). Our matched NMAs (25 industry vs 25 non-industry) indicated that industry-sponsored NMAs had favourable conclusions more often (100% vs 80%) and were associated with larger (but not statistically significantly different) efficacy effect sizes (in 61% of NMAs) compared with non-industry-sponsored NMAs. CONCLUSIONS Differences in completeness of reporting and author characteristics were apparent among NMAs with different types of funding. Publicly-sponsored NMAs had the best reporting and published their findings in higher impact-factor journals. Knowledge users should be mindful of this potential funding bias in NMAs.
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Affiliation(s)
- Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Eric Kai Chung Wong
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Medical Research Institute, School of Medicine, University of Antioquia, Medellín, Colombia
| | - Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Cochrane Hypertension Review Group and the Therapeutics Initiative, University of British Columbia, Vancouver, Canada
| | | | - Ivan D Florez
- Paediatric Intensive Care Unit, Clinica Las Américas, Medellin, Colombia
- Department of Pediatrics, University of Antioquia, Medellín, Colombia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Epidemiology Division & Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, ON, Canada
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18
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Li Y, Liang X, Li H, Chen X. Comparative efficacy and safety of immune checkpoint inhibitors for unresectable advanced melanoma: A systematic review and network meta-analysis. Int Immunopharmacol 2023; 115:109657. [PMID: 36608446 DOI: 10.1016/j.intimp.2022.109657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have entered the treatment paradigm for unresectable advanced melanoma, but there is a lack of evidence regarding its relative efficacy and safety. This study aim to compare the efficacy and safety of ICIs in patients with advanced unresectable melanoma. METHODS Studies included randomized clinical trials (RCTs) that compared ICIs, or combination therapy of ICIs, or with chemotherapy drugs, different ICIs, or one of the ICIs at different dosing schedules. Random-effects models of Bayesian network meta-analysis were performed following the PRISMA reporting guideline. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Secondary outcomes included objective response rate (ORR), disease control rate (DCR), and adverse events. PROSPERO CRD42021229086. RESULTS Twenty-four RCTs with 18 different treatment regimens for advanced melanoma involving 10,090 patients were included. Overall, nivolumab 1 mg/kg plus ipilimumab 3 mg/kg treatment regimen were associated with the highest beneficial effect on OS, PFS, and DCR. Closely followed by nivolumab 3 mg/kg plus ipilimumab 1 mg/kg, and nivolumab plus relatlimab treatment regimens. However, three regimens had less favorable safety profiles. Although ipilimumab 0.3 mg/kg was ranked as the best options with the lowest risk of grade ≥ 3 treatment or immune-related adverse events, less therapeutic benefit was performed. The pembrolizumab 10 mg/kg regimen may be the preferred treatment with relative higher efficiency and safety among the ICIs regimens reported, as well as the nivolumab 3 mg/kg regimen. Head-to-head trials showed similar results. CONCLUSIONS This study shown the preferred treatment regimens with relatively higher efficiency and safety among the reported ICI regimens. Our results may complement the current standard of care, while its direct drug comparisons will aid future trials.
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Affiliation(s)
- Yan Li
- Department of Pharmacy, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Xueyan Liang
- Phase 1 Clinical Trial Laboratory, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Huijuan Li
- Phase 1 Clinical Trial Laboratory, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Xiaoyu Chen
- Department of Pharmacy, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China; Phase 1 Clinical Trial Laboratory, Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China.
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Bryant A, Johnson E, Grayling M, Hiu S, Elattar A, Gajjar K, Craig D, Vale L, Naik R. Residual Disease Threshold After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 1: A Systematic Review and Network Meta-Analysis. Am J Ther 2023; 30:e36-e55. [PMID: 36608071 PMCID: PMC9812425 DOI: 10.1097/mjt.0000000000001584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We present a systematic review and network meta-analysis (NMA) that is the precursor underpinning the Bayesian analyses that adjust for publication bias, presented in the same edition in AJT. The review assesses optimal cytoreduction for women undergoing primary advanced epithelial ovarian cancer (EOC) surgery. AREAS OF UNCERTAINTY To assess the impact of residual disease (RD) after primary debulking surgery in women with advanced EOC. This review explores the impact of leaving varying levels of primary debulking surgery. DATA SOURCES We conducted a systematic review and random-effects NMA for overall survival (OS) to incorporate direct and indirect estimates of RD thresholds, including concurrent comparative, retrospective studies of ≥100 adult women (18+ years) with surgically staged advanced EOC (FIGO stage III/IV) who had confirmed histological diagnoses of ovarian cancer. Pairwise meta-analyses of all directly compared RD thresholds was previously performed before conducting this NMA, and the statistical heterogeneity of studies within each comparison was evaluated using recommended methods. THERAPEUTIC ADVANCES Twenty-five studies (n = 20,927) were included. Analyses demonstrated the prognostic importance of complete cytoreduction to no macroscopic residual disease (NMRD), with a hazard ratio for OS of 2.0 (95% confidence interval, 1.8-2.2) for <1 cm RD threshold versus NMRD. NMRD was associated with prolonged survival across all RD thresholds. Leaving NMRD was predicted to provide longest survival (probability of being best = 99%). The results were robust to sensitivity analysis including only those studies that adjusted for extent of disease at primary surgery (hazard ratio 2.3, 95% confidence interval, 1.9-2.6). The overall certainty of evidence was moderate and statistical adjustment of effect estimates in included studies minimized bias. CONCLUSIONS The results confirm a strong association between complete cytoreduction to NMRD and improved OS. The NMA approach forms part of the methods guidance underpinning policy making in many jurisdictions. Our analyses present an extension to the previous work in this area.
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eugenie Johnson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael Grayling
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ahmed Elattar
- Pan-Birmingham Gynaecological Oncology Cancer Centre, Birmingham, United Kingdom
| | - Ketankumar Gajjar
- Nottingham City hospital, Obstetrics and Gynaecology, Nottingham, United Kingdom; and
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Gateshead, United Kingdom
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Fundaun J, Thomas ET, Schmid AB, Baskozos G. The power of integrating data: advancing pain research using meta-analysis. Pain Rep 2022; 7:e1038. [PMID: 36213594 PMCID: PMC9534369 DOI: 10.1097/pr9.0000000000001038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/21/2022] [Accepted: 07/30/2022] [Indexed: 12/03/2022] Open
Abstract
Publications related to pain research have increased significantly in recent years. The abundance of new evidence creates challenges staying up to date with the latest information. A comprehensive understanding of the literature is important for both clinicians and investigators involved in pain research. One commonly used method to combine and analyse data in health care research is meta-analysis. The primary aim of a meta-analysis is to quantitatively synthesise the results of multiple studies focused on the same research question. Meta-analysis is a powerful tool that can be used to advance pain research. However, there are inherent challenges when combining data from multiple sources. There are also numerous models and statistical considerations when undertaking a meta-analysis. This review aims to discuss the planning and preparation for completing a meta-analysis, review commonly used meta-analysis models, and evaluate the clinical implications of meta-analysis in pain research.
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Affiliation(s)
- Joel Fundaun
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Elizabeth T. Thomas
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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21
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Castellini G, Pillastrini P, Vanti C, Bargeri S, Giagio S, Bordignon E, Fasciani F, Marzioni F, Innocenti T, Chiarotto A, Gianola S, Bertozzi L. Some conservative interventions are more effective than others for people with chronic non-specific neck pain: a systematic review and network meta-analysis. J Physiother 2022; 68:244-254. [PMID: 36266185 DOI: 10.1016/j.jphys.2022.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/08/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023] Open
Abstract
QUESTION Which is the most effective conservative intervention for patients with non-specific chronic neck pain (CNSNP)? DESIGN A systematic review and network meta-analysis of randomised clinical trials. PARTICIPANTS Adults with CNSNP of at least 3 months duration. INTERVENTIONS All available pharmacological and non-pharmacological interventions. OUTCOME MEASURES The primary outcomes were pain intensity and disability. The secondary outcome was adverse events. RESULTS Overall, 119 RCTs (12,496 patients; 32 interventions) were included. Risk of bias was low in 50.4% of trials, unclear in 22.7% and high in 26.9%. Compared with inert treatment, a combination of active and/or passive multimodal non-pharmacological inventions (eg, exercise and manual therapy) were effective for pain on a 0-to-10 scale at 1 month (MD range 0.84 to 3.74) and at 3 to 6 months (MD range 1.06 to 1.49), and effective on disability on a 0-to-100 scale at 1 month (MD range 10.26 to 14.09) and 3 to 6 months (MD range 5.60 to 16.46). These effects ranged from possible to definite clinical relevance. Compared with inert treatment, anti-inflammatory drugs alone or in combination with another non-pharmacological treatment did not reduce pain at 1 month or 3 to 6 months. At 12 months, no superiority was found over inert treatment on both outcomes. Most mild adverse events were experienced following acupuncture/dry needling intervention. On average, the evidence varied from low to very low certainty. CONCLUSIONS While multimodal non-pharmacological interventions may reduce pain and disability for up to 3 to 6 months of follow-up when compared with inert treatment, the evidence was very uncertain about their effects. Better quality and larger trials are needed to improve the certainty of evidence. REGISTRATION PROSPERO CRD42019124501.
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Affiliation(s)
- Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences (DIBINEM) - University of Bologna, Italy
| | - Carla Vanti
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Bargeri
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Giagio
- Department of Biomedical and Neuromotor Sciences (DIBINEM) - University of Bologna, Italy
| | | | - Francesco Fasciani
- Department of Biomedical and Neuromotor Sciences (DIBINEM) - University of Bologna, Italy
| | - Francesco Marzioni
- Department of Biomedical and Neuromotor Sciences (DIBINEM) - University of Bologna, Italy
| | - Tiziano Innocenti
- Department of Health Science - Faculty of Science - Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands; GIMBE Foundation, Bologna, Italy
| | - Alessandro Chiarotto
- Department of Health Science - Faculty of Science - Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands; Department of General Practice - Erasmus MC - University Medical Center Rotterdam, The Netherlands
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Lucia Bertozzi
- Division of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
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22
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Hwang SH, Kim SW, Kim DH. Efficacy of Imaging Methods in the Detection and Diagnosis of Cerebrospinal Fluid Rhinorrhea. Laryngoscope 2022; 133:1281-1287. [PMID: 36125276 DOI: 10.1002/lary.30388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea. DATA SOURCES The PubMed, EMBASE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar databases were searched up to December 2021. REVIEW METHODS Diagnostic accuracy was compared among seven radiological methods: computed tomography (CT), CT cisternography (CTC), magnetic resonance imaging (MRI), magnetic resonance cisternography (MRC), CT + MRI, radionuclide cisternography, and intrathecal gadolinium (Gd)-MRC. Sensitivity, specificity, and accuracy were used as outcomes of the analysis. Both a traditional pairwise meta-analysis and a network meta-analysis were performed. RESULTS Twenty-three trials were included in the analysis. The results of a network meta-analysis performed on a network consisting of seven diagnostic methods showed that all imaging modalities had greater diagnostic accuracy than CT, with the exception of CTC, which had lower sensitivity. Only intrathecal Gd-MRC was significantly superior to other imaging methods with regard to sensitivity and accuracy. Gd-MRC also showed the greatest surface under the cumulative ranking curve values for all of the outcomes (sensitivity: 0.9200; specificity: 0.8364; accuracy: 0.8920). CONCLUSION This network meta-analysis demonstrates that intrathecal Gd-MRC is the most useful diagnostic method to detect CSF rhinorrhea. Laryngoscope, 2022.
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Affiliation(s)
- Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sun Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Papakonstantinou T, Salanti G, Mavridis D, Rücker G, Schwarzer G, Nikolakopoulou A. Answering complex hierarchy questions in network meta-analysis. BMC Med Res Methodol 2022; 22:47. [PMID: 35176997 PMCID: PMC8855601 DOI: 10.1186/s12874-021-01488-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Network meta-analysis estimates all relative effects between competing treatments and can produce a treatment hierarchy from the most to the least desirable option according to a health outcome. While about half of the published network meta-analyses present such a hierarchy, it is rarely the case that it is related to a clinically relevant decision question. METHODS We first define treatment hierarchy and treatment ranking in a network meta-analysis and suggest a simulation method to estimate the probability of each possible hierarchy to occur. We then propose a stepwise approach to express clinically relevant decision questions as hierarchy questions and quantify the uncertainty of the criteria that constitute them. The steps of the approach are summarized as follows: a) a question of clinical relevance is defined, b) the hierarchies that satisfy the defined question are collected and c) the frequencies of the respective hierarchies are added; the resulted sum expresses the certainty of the defined set of criteria to hold. We then show how the frequencies of all possible hierarchies relate to common ranking metrics. RESULTS We exemplify the method and its implementation using two networks. The first is a network of four treatments for chronic obstructive pulmonary disease where the most probable hierarchy has a frequency of 28%. The second is a network of 18 antidepressants, among which Vortioxetine, Bupropion and Escitalopram occupy the first three ranks with frequency 19%. CONCLUSIONS The developed method offers a generalised approach of producing treatment hierarchies in network meta-analysis, which moves towards attaching treatment ranking to a clear decision question, relevant to all or a subset of competing treatments.
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Affiliation(s)
- Theodoros Papakonstantinou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre-University of Freiburg, Freiburg, Germany
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre-University of Freiburg, Freiburg, Germany
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre-University of Freiburg, Freiburg, Germany
| | - Adriani Nikolakopoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre-University of Freiburg, Freiburg, Germany.
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
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Kwon M, Cheong MJ, Leem J, Kim TH. Effect of Acupuncture on Movement Function in Patients with Parkinson's Disease: Network Meta-Analysis of Randomized Controlled Trials. Healthcare (Basel) 2021; 9:healthcare9111502. [PMID: 34828548 PMCID: PMC8619200 DOI: 10.3390/healthcare9111502] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to compare the effectiveness of some different acupuncture modalities on motor function using the unified Parkinson disease rating scale (UPDRS)-III scores of idiopathic Parkinson’s disease (PD) via pairwise and network meta-analyses (NMA) of randomized controlled trials (RCTs). The Cochrane risk of bias assessment tool was used to assess the methodological quality of the included RCTs. A frequentist approach-based random effect model NMA was performed. Seventeen RCTs with 1071 participants were included. The five following modalities were identified: combination of conventional medication (levodopa) with (1) electroacupuncture (ELEC), (2) manual acupuncture (MANU), (3) bee venom acupuncture (BEEV), (4) sham acupuncture (SHAM), and (5) conventional medication alone (CONV). In NMA on UPDRS-III, BEEV was the best modality compared to CONV (mean difference [MD]) −7.37, 95% confidence interval [−11.97, −2.77]). The comparative ranking assessed through NMA was suggested to be BEEV, MANU, ELEC, SHAM, and CONV. Regarding daily activity assessment (UPDRS-II), the magnitude of effectiveness was in the order of BEEV, ELEC, MANU, SHAM, and CONV. Combination treatment with BEEV (MANU or ELEC) and CONV can be recommended to improve motor function in PD patients. Due to the limited number of included RCTs, further NMA with more rigorous RCTs are warranted.
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Affiliation(s)
- Miri Kwon
- Department of Clinical Korean Medicine, College of Korean Medicine, Graduate School, Kyung Hee University, Seoul 02447, Korea;
| | - Moon Joo Cheong
- Rare Diseases Integrative Treatment Research Institute, Wonkwang University, Jangheung Integrative Medical Hospital, Iksan 59338, Korea;
| | - Jungtae Leem
- Research Center of Traditional Korean Medicine, Wonkwang University, Iksan 54538, Korea
- Correspondence: (J.L.); (T.-h.K.); Tel.: +82-063-850-5114 (J.L.); +82-02-958-9194 (T.-h.K.)
| | - Tae-hun Kim
- Department of Clinical Korean Medicine, College of Korean Medicine, Graduate School, Kyung Hee University, Seoul 02447, Korea;
- Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University Medical Center, Seoul 02447, Korea
- Correspondence: (J.L.); (T.-h.K.); Tel.: +82-063-850-5114 (J.L.); +82-02-958-9194 (T.-h.K.)
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25
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The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). Eur Child Adolesc Psychiatry 2021:10.1007/s00787-021-01871-x. [PMID: 34677682 PMCID: PMC8532460 DOI: 10.1007/s00787-021-01871-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/01/2021] [Indexed: 11/24/2022]
Abstract
ADHD is the most common neurodevelopmental disorder presenting to child and adolescent mental health, paediatric, and primary care services. Timely and effective interventions to address core ADHD symptoms and co-occurring problems are a high priority for healthcare and society more widely. While much research has reported on the benefits and adverse effects of different interventions for ADHD, these individual research reports and the reviews, meta-analyses and guidelines summarizing their findings are sometimes inconsistent and difficult to interpret. We have summarized the current evidence and identified several methodological issues and gaps in the current evidence that we believe are important for clinicians to consider when evaluating the evidence and making treatment decisions. These include understanding potential impact of bias such as inadequate blinding and selection bias on study outcomes; the relative lack of high-quality data comparing different treatments and assessing long-term effectiveness, adverse effects and safety for both pharmacological and non-pharmacological treatments; and the problems associated with observational studies, including those based on large national registries and comparing treatments with each other. We highlight key similarities across current international clinical guidelines and discuss the reasons for divergence where these occur. We discuss the integration of these different perspective into a framework for person/family-centered evidence-based practice approach to care that aims to achieve optimal outcomes that prioritize individual strengths and impairments, as well as the personal treatment targets of children and their families. Finally, we consider how access to care for this common and impairing disorder can be improved in different healthcare systems.
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Al-Moraissi EA, Conti PCR, Alyahya A, Alkebsi K, Elsharkawy A, Christidis N. The hierarchy of different treatments for myogenous temporomandibular disorders: a systematic review and network meta-analysis of randomized clinical trials. Oral Maxillofac Surg 2021; 26:519-533. [PMID: 34674093 DOI: 10.1007/s10006-021-01009-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/23/2021] [Indexed: 02/08/2023]
Abstract
The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo. At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling therapy (71.2%, moderate quality), and occlusal appliances (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments. This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.
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Affiliation(s)
- Essam Ahmed Al-Moraissi
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Thamar, Yemen.
| | | | - Abdulmalik Alyahya
- Oral and Maxillofacial Surgery Department, King Abdulaziz Medical City - National Guard, Riyadh, Saudi Arabia
| | - Khaled Alkebsi
- Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Ahmed Elsharkawy
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Nikolaos Christidis
- Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, and Scandinavian Center for Orofacial Neurosciences, SE-141 04, Huddinge, Sweden
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MacDonald L, Zanjir M, Laghapour Lighvan N, da Costa BR, Suri S, Azarpazhooh A. Efficacy and safety of different interventions to accelerate maxillary canine retraction following premolar extraction: A systematic review and network meta-analysis. Orthod Craniofac Res 2021; 24:17-38. [PMID: 34643019 DOI: 10.1111/ocr.12409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/03/2023]
Abstract
Decreasing orthodontic treatment duration is at the forefront of innovation for clinical orthodontics. This network meta-analysis aimed to determine the relative efficacy and safety of treatments for accelerated orthodontic tooth movement (OTM) in patients undergoing extraction of maxillary first premolars followed by canine retraction in any orthodontic setting. MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL and SCOPUS were searched (from inception to 20 April 2020). Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials (RCTs) were meta-analysed to estimate the rate of tooth movement, 95% credible interval and surface under the cumulative ranking curve (SUCRA) in the first 3 months following the application of the adjunctive accelerative method. Eligible RCTs were assessed by Cochrane risk of bias tool, and quality of evidence was assessed by GRADE approach, obtained from CINeMA web application. Interventions were ranked for efficacy and reviewed for safety. Nineteen studies pertaining to eight interventions, with data from 415 patients were included. Quality of evidence was very low to moderate. Very low-to low-quality evidence suggests that corticotomy is an efficacious and safe adjunctive treatment to accelerate OTM in comparison with conventional treatment in the first 2 months of treatment. Low-quality evidence suggests that piezocision and micro-osteoperforations (MOP) are efficacious and safe adjunctive treatments only in the first month of treatment. Frequent MOP in conjunction with low-level laser therapy appeared to be an efficacious and safe adjunctive treatment only in the first month following its initial application but not thereafter.
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Affiliation(s)
- Laura MacDonald
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Maryam Zanjir
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | | | - Bruno R da Costa
- Clinical Epidemiology & Health Care Research, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sunjay Suri
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.,Department of Dentistry, The Hospital for Sick Children, Toronto, ON, Canada
| | - Amir Azarpazhooh
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada.,Clinical Epidemiology & Health Care Research, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Dentistry, Mount Sinai Hospital, Toronto, ON, Canada
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Del Giovane C, Boncoraglio GB, Bertù L, Banzi R, Tramacere I. Antiplatelet drugs for secondary prevention in patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis. BMC Neurol 2021; 21:319. [PMID: 34399713 PMCID: PMC8365925 DOI: 10.1186/s12883-021-02341-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antiplatelet drugs may prevent recurrent ischemic events after ischemic stroke but their relative effectiveness and harms still need to be clarified. Within this network meta-analysis we aimed to summarize the current evidence for using antiplatelet drugs for secondary stroke prevention. METHODS We searched MEDLINE, EMBASE and CENTRAL up to September 2020. Randomized controlled trials (RCTs) assessing antiplatelet drugs for secondary stroke prevention were included. We did pairwise meta-analyses and network meta-analyses using random-effects models. Primary outcomes were all strokes (ischemic or hemorrhagic) and all-cause mortality. RESULTS The review included 57 RCTs, 50 (n = 165,533 participants) provided data for the meta-analyses. Compared to placebo/no treatment, moderate to high-confidence evidence indicated that cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day significantly reduced the risk of all strokes (odds ratios, ORs and absolute risk difference, ARD): cilostazol 0.51 (95 % confidence interval, CI, 0.37 to 0.71; 3.6 % fewer), clopidogrel 0.63 (95 % CI, 0.49 to 0.79; 2.7 % fewer), dipyridamole + aspirin 0.65 (95 % CI, 0.55 to 0.78; 2.5 % fewer), ticagrelor 0.68 (95 % CI, 0.50 to 0.93; 2.3 % fewer), ticlopidine 0.74 (95 % CI 0.59 to 0.93; 1.9 % fewer), aspirin ≤ 150 mg/day 0.79 (95 % CI, 0.66 to 0.95; 1.5 % fewer). Aspirin > 150 mg/day and the combinations clopidogrel/aspirin, ticagrelor/aspirin, also decrease all strokes but increase the risk of hemorrhagic events. Only aspirin > 150 mg/day significantly reduced all-cause mortality (OR 0.86, 95 % CI 0.76 to 0.97; ARD 0.9 %, 95 %CI 1.5-0.2 % fewer, moderate confidence). Compared to aspirin ≤ 150 mg/day, clopidogrel significantly reduced the risk of all strokes, cardiovascular events, and intracranial hemorrhage outcomes. Cilostazol also appeared to provide advantages but data are limited to the Asian population. CONCLUSIONS Considering the benefits and harms ratio, cilostazol, clopidogrel, dipyridamole + aspirin, ticagrelor, ticlopidine, and aspirin ≤ 150 mg/day appear to be the best choices as antiplatelet drugs for secondary prevention of patients with ischemic stroke or TIA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020159896 .
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Affiliation(s)
- Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,Population Health Laboratory, University of Fribourg, Fribourg, Switzerland
| | - Giorgio B Boncoraglio
- Department of Cerebrovascular Disease, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Lorenza Bertù
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rita Banzi
- Center for Health Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Irene Tramacere
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
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Lunny C, Tricco AC, Veroniki AA, Dias S, Hutton B, Salanti G, Wright JM, White I, Whiting P. Methodological review to develop a list of bias items used to assess reviews incorporating network meta-analysis: protocol and rationale. BMJ Open 2021; 11:e045987. [PMID: 34168027 PMCID: PMC8231030 DOI: 10.1136/bmjopen-2020-045987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 06/07/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Systematic reviews with network meta-analysis (NMA; ie, multiple treatment comparisons, indirect comparisons) have gained popularity and grown in number due to their ability to provide comparative effectiveness of multiple treatments for the same condition. The methodological review aims to develop a list of items relating to biases in reviews with NMA. Such a list will inform a new tool to assess the risk of bias in NMAs, and potentially other reporting or quality checklists for NMAs which are being updated. METHODS AND ANALYSIS We will include articles that present items related to bias, reporting or methodological quality, articles assessing the methodological quality of reviews with NMA, or papers presenting methods for NMAs. We will search Ovid MEDLINE, the Cochrane library and difficult to locate/unpublished literature. Once all items have been extracted, we will combine conceptually similar items, classifying them as referring to bias or to other aspects of quality (eg, reporting). When relevant, reporting items will be reworded into items related to bias in NMA review conclusions, and then reworded as signalling questions. ETHICS AND DISSEMINATION No ethics approval was required. We plan to publish the full study open access in a peer-reviewed journal, and disseminate the findings via social media (Twitter, Facebook and author affiliated websites). Patients, healthcare providers and policy-makers need the highest quality evidence to make decisions about which treatments should be used in healthcare practice. Being able to critically appraise the findings of systematic reviews that include NMA is central to informed decision-making in patient care.
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Affiliation(s)
- Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health & Institute of Health Policy, Management, and Evaluation, University of Toronto, University of Toronto, Toronto, Ontario, Canada
- Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Ontario, Canada
| | | | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Ottawa University, Ottawa, Ontario, Canada
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - James M Wright
- Anesthesiology, Pharmacology & Therapeutics, Cochrane Hypertension Review Group and the Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
| | - Ian White
- MRC Clinical Trials Unit, University College London, London, UK
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Light A, Jabarkhyl D, Gilling P, George G, Van Hemelrijck M, Challacombe B, Malde S, Popert R, Dasgupta P, Elhage O. Erectile Function Following Surgery for Benign Prostatic Obstruction: A Systematic Review and Network Meta-analysis of Randomised Controlled Trials. Eur Urol 2021; 80:174-187. [PMID: 34127315 DOI: 10.1016/j.eururo.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 04/12/2021] [Indexed: 12/21/2022]
Abstract
CONTEXT Benign prostatic obstruction (BPO) is associated with sexual dysfunction. Furthermore, numerous BPO interventions may themselves impact sexual function. OBJECTIVE To perform a systematic review with network meta-analysis to evaluate how BPO interventions affect erectile function. EVIDENCE ACQUISITION Three databases were searched for randomised controlled trials (RCTs) comparing surgical interventions for BPO. The primary outcome was postoperative International Index of Erectile Function-5 (IIEF-5) score at ten time points up to 72 mo. A random-effects Bayesian network meta-analysis with meta-regression was performed. In comparison to monopolar transurethral resection (mTURP), the mean difference (MD) with 95% credible interval (CrI) and rank probability (rank p) were calculated for interventions. The mean baseline score was studied in meta-regression. τ2 values were used to quantify heterogeneity. EVIDENCE SYNTHESIS A total of 48 papers (33 RCTs, 5159 patients, 16 interventions) were included. Prostatic urethral lift (PUL) ranked highest at 1 mo (MD 3.88, 95% CrI -0.47 to 8.25; rank p = 0.742), 6 mo (MD 2.43, 95% CrI -0.72 to 5.62; rank p = 0.581), 12 mo (MD 2.94, 95% CrI -0.26 to 6.12, rank p = 0.782), and 24 mo (MD 3.63, 95% CrI 0.14 to 7.11; rank p = 0.948), at which point statistical significance was reached. At time points up to 60 mo, there were no statistically significant comparisons for other interventions. Analyses were not possible at 18, 48, or 72 mo. β did not reach statistical significance in meta-regression. τ2 was highest at 1 mo (0.56) and 60 mo (0.55). CONCLUSIONS PUL ranked highly and resulted in erectile function improvement at 24 mo compared to mTURP, but direct evidence is lacking. We did not observe significant differences in erectile function following other interventions up to 60 mo. Owing to heterogeneity, our conclusions are weakest at 1 and 60 mo. Further RCTs comparing sexual function outcomes are recommended, such as PUL versus holmium laser or bipolar enucleation. PATIENT SUMMARY Different surgical treatments can be used to treat benign enlargement of the prostate causing urinary problems. We compared the effects of various treatments on erectile function at time points up to 5 years after surgery. Compared to surgical removal of some of the prostate gland (transurethral resection of the prostate, TURP), a technique called prostatic urethral lift resulted in better erectile function scores at 24 months. However, other treatments did not differ in their effect on erectile function.
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Affiliation(s)
- Alexander Light
- Department of Surgery, University of Cambridge, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dost Jabarkhyl
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter Gilling
- Department of Urology, Tauranga Hospital, Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Gincy George
- Translational Oncology & Urology Research, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Mieke Van Hemelrijck
- Translational Oncology & Urology Research, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Ben Challacombe
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rick Popert
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Prokar Dasgupta
- Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Oussama Elhage
- Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Bourdin A, Molinari N, Ferguson GT, Singh B, Siddiqui MK, Holmgren U, Ouwens M, Jenkins M, De Nigris E. Efficacy and Safety of Budesonide/Glycopyrronium/Formoterol Fumarate versus Other Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2021; 38:3089-3112. [PMID: 33929661 PMCID: PMC8189959 DOI: 10.1007/s12325-021-01703-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/10/2021] [Indexed: 11/30/2022]
Abstract
In patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations or symptoms, despite being prescribed dual long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) or inhaled corticosteroid (ICS)/LABA therapies, triple ICS/LAMA/LABA therapy is recommended. A previous network meta-analysis showed comparable efficacy of the ICS/LAMA/LABA, budesonide/glycopyrronium bromide/formoterol fumarate (BUD/GLY/FOR) 320/18/9.6 µg, to other fixed-dose and open combination triple therapies at 24 weeks in COPD. Subsequently, the ETHOS study was published, including data for 8509 patients, assessing the efficacy and safety of BUD/GLY/FOR over 52 weeks. This network meta-analysis (NMA) was conducted to compare the relative efficacy, safety, and tolerability of BUD/GLY/FOR 320/18/9.6 µg with other fixed-dose and open combination triple therapies in COPD over 52 weeks, including data from ETHOS. A systematic literature review was conducted to identify ≥ 10-week randomized controlled trials, including ≥ 1 fixed-dose or open combination triple-therapy arm, in patients with moderate-to-very severe COPD. The methodologic quality and risk of bias of included studies were assessed. Study results were combined using a three-level hierarchical Bayesian NMA model to assess efficacy and safety outcomes at or over 24 and 52 weeks. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. Nineteen studies (n = 37,741 patients) met the inclusion criteria of the review; 15 contributed to the base case network. LAMA/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes for exacerbations, lung function, symptoms, health-related quality of life, safety, and tolerability, the efficacy and safety of BUD/GLY/FOR were comparable to those of other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium bromide/formoterol fumarate) and open combinations at or over 24 and 52 weeks. Sensitivity analyses and meta-regression results for exacerbation outcomes were broadly in line with the base case NMA. In this NMA, BUD/GLY/FOR 320/18/9.6 μg showed comparable efficacy versus other ICS/LAMA/LABA fixed-dose or open combination therapies in terms of reducing exacerbation rates and improving lung function, symptoms and health-related quality of life in patients with moderate-to-very-severe COPD, in line with previously published meta-analysis results of triple combinations in COPD. The safety and tolerability profile of BUD/GLY/FOR was also found to be comparable to other triple combination therapies.
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Affiliation(s)
- Arnaud Bourdin
- Department of Respiratory Diseases, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France.
- Département Pneumologie et Addictologie, CHU de Montpellier-Hôpital Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud, 34295, Montpellier Cedex 5, France.
| | - Nicolas Molinari
- IMAG, CNRS, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
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Park JJH, Mogg R, Smith GE, Nakimuli-Mpungu E, Jehan F, Rayner CR, Condo J, Decloedt EH, Nachega JB, Reis G, Mills EJ. How COVID-19 has fundamentally changed clinical research in global health. Lancet Glob Health 2021; 9:e711-e720. [PMID: 33865476 PMCID: PMC8049590 DOI: 10.1016/s2214-109x(20)30542-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 01/07/2023]
Abstract
COVID-19 has had negative repercussions on the entire global population. Despite there being a common goal that should have unified resources and efforts, there have been an overwhelmingly large number of clinical trials that have been registered that are of questionable methodological quality. As the final paper of this Series, we discuss how the medical research community has responded to COVID-19. We recognise the incredible pressure that this pandemic has put on researchers, regulators, and policy makers, all of whom were doing their best to move quickly but safely in a time of tremendous uncertainty. However, the research community's response to the COVID-19 pandemic has prominently highlighted many fundamental issues that exist in clinical trial research under the current system and its incentive structures. The COVID-19 pandemic has not only re-emphasised the importance of well designed randomised clinical trials but also highlighted the need for large-scale clinical trials structured according to a master protocol in a coordinated and collaborative manner. There is also a need for structures and incentives to enable faster data sharing of anonymised datasets, and a need to provide similar opportunities to those in high-income countries for clinical trial research in low-resource regions where clinical trial research receives considerably less research funding.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robin Mogg
- Bill & Melinda Gates Medical Research Institute, Boston, MA, USA
| | - Gerald E Smith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Craig R Rayner
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Certara, Princeton, NJ, USA
| | - Jeanine Condo
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Cape Town, South Africa
| | - Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Department of Epidemiology and Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gilmar Reis
- Departamento de Medicina, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Cytel, Vancouver, BC, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda.
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Wu YC, Shih MC, Tu YK. Using Normalized Entropy to Measure Uncertainty of Rankings for Network Meta-analyses. Med Decis Making 2021; 41:706-713. [PMID: 33754893 DOI: 10.1177/0272989x21999023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ranking of treatments offers a straightforward interpretation of results derived from network meta-analysis. However, some published network meta-analyses have overemphasized treatment ranking without paying attention to its uncertainty. According to a review of 91 network meta-analyses, 52 reported treatment ranking, but 43 of them did not report the uncertainty of ranking. Without reporting the uncertainty, small differences in the ranking of treatments may be overinterpreted. Rankograms, cumulative rankograms, the credible/confidence interval of mean rank, the surface under the cumulative ranking curve (SUCRA), and the interquartile range of median rank have been used to show the uncertainty of rankings. However, it is not always straightforward to compare the differences in the distribution of probabilities by inspecting rankograms or to compare the intervals or ranges of treatment ranks. We therefore proposed normalized entropy, which transforms the distribution of ranking probabilities into a single quantitative measure, to facilitate a refined interpretation of uncertainty of treatment ranking. We used 4 real examples to demonstrate the uncertainty of ranking quantified by ranking probabilities, 95% confidence interval of SUCRA, and normalized entropy. We showed that as normalized entropy ranges from 0 to 1 and is independent of the number of treatments, it can be used to compare the uncertainty of treatment ranking within a network meta-analysis (NMA) and between different NMAs. Normalized entropy is an alternative tool for measuring the uncertainty of treatment ranking by improving the translation of results from NMAs to clinical practice and avoiding naïve interpretation of treatment ranking. We therefore recommend normalized entropy to be included in the presentation and interpretation of results from NMAs.
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Affiliation(s)
- Yun-Chun Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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Kim MG, Yang I, Lee HS, Lee JY, Kim K. Lipid-modifying effects of krill oil vs fish oil: a network meta-analysis. Nutr Rev 2021; 78:699-708. [PMID: 32073633 DOI: 10.1093/nutrit/nuz102] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
CONTEXT Krill oil is a good source of n-3 phospholipids and has greater bioavailability than fish oil, which contains n-3 triglycerides. However, it is unclear whether krill oil affects circulating lipid concentrations more beneficially than fish oil. OBJECTIVE A network meta-analysis was conducted to compare the lipid-modifying effects of krill oil and fish oil. DATA SOURCES PubMed and Embase databases were searched. STUDY SELECTION A total of 64 randomized controlled trials that determined the lipid-modifying effects of krill oil or fish oil were selected. DATA EXTRACTION The MetaXL program was used for meta-analysis. A subgroup analysis and a network meta-regression were conducted to investigate the dose-response effect of the n-3 fatty acid content of fish oil and krill oil. RESULTS Krill oil was associated with significantly lower triglyceride levels than control supplements (weighted mean difference [WMD] -23.26 [95%CI, -38.84 to -7.69]). However, the net differences in triglycerides (WMD -4.07 [95%CI, -15.22 to 7.08]), low-density lipoprotein cholesterol (WMD 3.01 [95%CI, -5.49 to 11.51]), high-density lipoprotein cholesterol (WMD 1.37 [95%CI, -3.73 to 6.48]), and total cholesterol (WMD 1.69 [95%CI, -6.62 to 10.01]) were not significantly different between the krill oil and fish oil groups. One gram of n-3 fatty acids contained in fish oil and krill oil lowered median triglycerides by 8.971 mg/dL (95% credible interval [CrI], 2.27 to 14.04) and 9.838 mg/dL (95%CrI, 0.72 to 19.40), respectively. CONCLUSIONS The lipid-modifying effects of krill oil and fish oil do not differ. The reduction in triglycerides depends on the dose of n-3 fatty acids consumed.
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Affiliation(s)
- Myeong Gyu Kim
- Graduate School of Clinical Pharmacy, CHA University, Pocheon, Republic of Korea
| | - Inkyou Yang
- Graduate School of Clinical Pharmacy, CHA University, Pocheon, Republic of Korea
| | - Han Sol Lee
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Jae-Young Lee
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Kyungim Kim
- College of Pharmacy, Korea University, Seoul, Republic of Korea
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Giglio V, Schneider P, Madden K, Lin B, Multani I, Baldawi H, Thornley P, Naji L, Levin M, Wang P, Bozzo A, Wilson D, Ghert M. Published randomized controlled trials of surveillance in cancer patients - a systematic review. Oncol Rev 2021; 15:522. [PMID: 34267889 PMCID: PMC8256375 DOI: 10.4081/oncol.2021.522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 04/09/2021] [Indexed: 01/14/2023] Open
Abstract
With solid tumor cancer survivorship increasing, the number of patients requiring post-treatment surveillance also continues to increase. This highlights the need for evidence-based cancer surveillance guidelines. Ideally, these guidelines would be based on combined high-quality data from randomized controlled trials (RCTs). We present a systematic review of published cancer surveillance RCTs in which we sought to determine the feasibility of data pooling for guideline development. We carried out a systematic search of medical databases for RCTs in which adult patients with solid tumors that had undergone surgical resection with curative intent and had no metastatic disease at presentation, were randomized to different surveillance regimens that assessed effectiveness on overall survival (OS). We extracted study characteristics and primary and secondary outcomes, and assessed risk of bias and validity of evidence with standardized checklist tools. Our search yielded 32,216 articles for review and 18 distinct RCTs were included in the systematic review. The 18 trials resulted in 23 comparisons of surveillance regimens. There was a highlevel of variation between RCTs, including the study populations evaluated, interventions assessed and follow-up periods for the primary outcome. Most studies evaluated colorectal cancer patients (11/18, [61%]). The risk of bias and validity of evidence were variable and inconsistent across studies. This review demonstrated that there is tremendous heterogeneity among RCTs that evaluate effectiveness of different postoperative surveillance regimens in cancer patients, rendering the consolidation of data to inform high-quality cancer surveillance guidelines unfeasible. Future RCTs in the field should focus on consistent methodology and primary outcome definition.
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Affiliation(s)
- Victoria Giglio
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Patricia Schneider
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kim Madden
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Bill Lin
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Hassan Baldawi
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Patrick Thornley
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Leen Naji
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Marc Levin
- Michael DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Peiyao Wang
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Anthony Bozzo
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - David Wilson
- Hamilton Health Sciences, Juravinski Hospital and Cancer Center, Hamilton, ON, Canada
| | - Michelle Ghert
- Hamilton Health Sciences, Juravinski Hospital and Cancer Center, Hamilton, ON, Canada
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Kwon CY, Lee B, Cheong MJ, Kim TH, Jang BH, Chung SY, Kim JW. Non-pharmacological Treatment for Elderly Individuals With Insomnia: A Systematic Review and Network Meta-Analysis. Front Psychiatry 2021; 11:608896. [PMID: 33584374 PMCID: PMC7876437 DOI: 10.3389/fpsyt.2020.608896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/07/2020] [Indexed: 01/25/2023] Open
Abstract
Background: Insomnia causes a huge socioeconomic burden among the elderly, and is not simply a health problem. This study aimed to determine the comparative advantage of the effectiveness and acceptability of non-pharmacological interventions available for elderly individuals with insomnia. Methods: Comprehensive searches in 13 medical databases were performed to find relevant randomized controlled trials (RCTs) up to August 2019. Two independent reviewers performed study selection, data extraction, and quality assessment of included RCTs using the Cochrane Collaboration's risk of bias. A network meta-analysis within the frequentist model was performed by combining direct and indirect evidence from all available RCTs. The primary outcomes were effectiveness as measured by the Pittsburgh Sleep Quality Index (PSQI) total score and acceptability by the incidence of all-cause drop-out. Results: Twenty-eight RCTs involving 2,391 participants were included. Compared to wait-list, acupuncture (standardized mean difference -4.37, 95% confidence interval -8.53 to -0.12), acupuncture combined with benzodiazepines (-5.20, -9.82 to -0.57), behavioral therapy (-10.44, -17.31 to -3.58), benzodiazepines (-4.28, -8.45 to -0.11), benzodiazepines combined with cognitive behavioral therapy (CBT) (-7.18, -12.17 to -2.19), and CBT (-4.93, -8.63 to -1.22) showed significant superiority in their effectiveness. No significant comparative superiority or inferiority was found in terms of acceptability. Conclusions: In terms of effectiveness as indicated by the PSQI total score, compared to wait-list, superior benefits were observed for acupuncture, acupuncture combined with benzodiazepines, behavioral treatment, benzodiazepines, benzodiazepines combined with CBT, and CBT. Importantly, combined treatments, including benzodiazepines combined with CBT or with acupuncture, were generally superior to other monotherapies. In terms of acceptability, there was not enough data to draw conclusions. However, most RCTs included had methodological problems related to the lack of blinding procedure, suggesting a risk of effect size overestimation. Registration: CRD42019145518.
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Affiliation(s)
- Chan-Young Kwon
- Department of Oriental Neuropsychiatry, Dong-eui University College of Korean Medicine, Busan, South Korea
| | - Boram Lee
- Clinical Medicine Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Moon Joo Cheong
- Education Graduate of Wonkwang University, Iksan-si, South Korea
| | - Tae-Hun Kim
- Korean Medicine Clinical Trial Center, Korean Medicine Hospital, Kyung Hee University, Seoul, South Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, South Korea
| | - Sun Yong Chung
- Department of Neuropsychiatry, Kyung Hee University Korean Medicine Hospital at Gangdong, Seoul, South Korea
| | - Jong Woo Kim
- Department of Neuropsychiatry, Kyung Hee University Korean Medicine Hospital at Gangdong, Seoul, South Korea
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Nikolakopoulou A, Mavridis D, Chiocchia V, Papakonstantinou T, Furukawa TA, Salanti G. Network meta-analysis results against a fictional treatment of average performance: Treatment effects and ranking metric. Res Synth Methods 2020; 12:161-175. [PMID: 33070439 DOI: 10.1002/jrsm.1463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Network meta-analysis (NMA) produces complex outputs as many comparisons between interventions are of interest. The estimated relative treatment effects are usually displayed in a forest plot or in a league table and several ranking metrics are calculated and presented. METHODS In this article, we estimate relative treatment effects of each competing treatment against a fictional treatment of average performance using the "deviation from the means" coding that has been used to parametrize categorical covariates in regression models. We then use this alternative parametrization of the NMA model to present a ranking metric (PreTA: Preferable Than Average) interpreted as the probability that a treatment is better than a fictional treatment of average performance. RESULTS We illustrate the alternative parametrization of the NMA model using two networks of interventions, a network of 18 antidepressants for acute depression and a network of four interventions for heavy menstrual bleeding. We also use these two networks to highlight differences among PreTA and existing ranking metrics. We further examine the agreement between PreTA and existing ranking metrics in 232 networks of interventions and conclude that their agreement depends on the precision with which relative effects are estimated. CONCLUSIONS A forest plot with NMA relative treatment effects using "deviation from means" coding could complement presentation of NMA results in large networks and in absence of an obvious reference treatment. PreTA is a viable alternative to existing probabilistic ranking metrics that naturally incorporates uncertainty.
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Affiliation(s)
- Adriani Nikolakopoulou
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.,Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center-University of Freiburg, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Virginia Chiocchia
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | | | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Kanters S, Vitoria M, Zoratti M, Doherty M, Penazzato M, Rangaraj A, Ford N, Thorlund K, Anis PAH, Karim ME, Mofenson L, Zash R, Calmy A, Kredo T, Bansback N. Comparative efficacy, tolerability and safety of dolutegravir and efavirenz 400mg among antiretroviral therapies for first-line HIV treatment: A systematic literature review and network meta-analysis. EClinicalMedicine 2020; 28:100573. [PMID: 33294805 PMCID: PMC7700905 DOI: 10.1016/j.eclinm.2020.100573] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To inform World Health Organization (WHO) global guidelines, we updated and expanded the evidence base to assess the comparative efficacy, tolerability, and safety of first-line antiretroviral therapy (ART) regimens. METHODS We searched Embase, Medline and CENTRAL on 28 February 2020 to update the systematic literature review of clinical trials comparing recommended first-line ART that informed previous WHO guidelines. Outcomes included viral suppression, change in CD4 cell counts, mortality, serious and overall adverse events (AEs), discontinuation, discontinuations due to AEs (DAEs); and new outcomes: drug-resistance, neuropsychiatric AEs, early viral suppression, weight gain and birth outcomes. Comparative effects were assessed through network meta-analyses and certainty in the evidence was assessed using the GRADE framework. FINDINGS We identified 156 publications pertaining to 68 trials for the primary population. Relative to efavirenz, dolutegravir had improved odds of viral suppression across all time points (odds ratio [OR]: 1·94; 95% credible interval [CrI]: 1·48-2·56 at 96 weeks); was protective of drug-resistance (OR: 0·13; 95%CrI: 0·04-0·48); and led to fewer discontinuations (OR: 0·58; 95%CrI: 0·48-0·70). Evidence supported dolutegravir use among TB-HIV co-infected persons and pregnant women. Adverse birth outcomes were observed in 33.2% of dolutegravir-managed pregnancies and 35.0% of efavirenz-managed pregnancies. Low-dose efavirenz had comparable efficacy and safety to standard-dose efavirenz, but led to fewer DAEs (OR: 0·70; 95%CrI: 0·50-0·92). INTERPRETATION The evidence supports choosing dolutegravir in combination with lamivudine/emtricitabine and tenofovir disoproxil fumarate as the preferred first-line regimen and low-dose efavirenz-based regimens as an alternative. Dolutegravir can be considered to be effective, safe and tolerable. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michael Zoratti
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | | | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Kristian Thorlund
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Prof. Aslam H. Anis
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, USA
- Botswana–Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland
| | - Tamara Kredo
- South African Medical Research Council, Cape Town, South Africa
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
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Hird AE, Magee DE, Bhindi B, Ye XY, Chandrasekar T, Goldberg H, Klotz L, Fleshner N, Satkunasivam R, Klaassen Z, Wallis CJ. A Systematic Review and Network Meta-analysis of Novel Androgen Receptor Inhibitors in Non-metastatic Castration-resistant Prostate Cancer. Clin Genitourin Cancer 2020; 18:343-350. [DOI: 10.1016/j.clgc.2020.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 12/22/2022]
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Park JJH, Harari O, Siden E, Dron L, Zannat NE, Singer J, Lester RT, Thorlund K, Mills EJ. Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2020; 3:1660. [PMID: 32259047 PMCID: PMC7096089 DOI: 10.12688/gatesopenres.13083.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Ellie Siden
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | | | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, Vancouver, BC, V6Z 1Y6, Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Kristian Thorlund
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Edward J. Mills
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
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Park JJH, Harari O, Siden E, Zoratti M, Dron L, Zannat NE, Lester RT, Thorlund K, Mills EJ. Interventions to improve birth outcomes of pregnant women living in low- and middle-income countries: a systematic review and network meta-analysis. Gates Open Res 2020; 3:1657. [PMID: 33134854 PMCID: PMC7520556 DOI: 10.12688/gatesopenres.13081.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/14/2023] Open
Abstract
Background: Improving the health of pregnant women is important to prevent adverse birth outcomes, such as preterm birth and low birthweight. We evaluated the comparative effectiveness of interventions under the domains of micronutrient, balanced energy protein, deworming, maternal education, and water sanitation and hygiene (WASH) for their effects on these adverse birth outcomes. Methods: For this network meta-analysis, we searched for randomized clinical trials (RCTs) of interventions provided to pregnant women in low- and middle-income countries (LMICs). We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We extracted data from eligible studies for study characteristics, interventions, participants' characteristics at baseline, and birth outcomes. We compared effects on preterm birth (<37 gestational week), low birthweight (LBW; <2500 g), and birthweight (continuous) using studies conducted in LMICs. Results: Our network meta-analyses were based on 101 RCTs (132 papers) pertaining to 206,531 participants. Several micronutrients and balanced energy food supplement interventions demonstrated effectiveness over standard-of-care. For instance, versus standard-of-care, micronutrient supplements for pregnant women, such as iron and calcium, decreased risks of preterm birth (iron: RR=0.70, 95% credible interval [Crl] 0.47, 1.01; calcium: RR=0.76, 95%Crl 0.56, 0.99). Daily intake of 1500kcal of local food decreased the risks of preterm birth (RR=0.36, 95%Crl 0.16, 0.77) and LBW (RR=0.17, 95%Crl 0.09, 0.29), respectively when compared to standard-of-care. Educational and deworming interventions did not show improvements in birth outcomes, and no WASH intervention trials reported on these adverse birth outcomes. Conclusion: We found several pregnancy interventions that improve birth outcomes. However, most clinical trials have only evaluated interventions under a single domain (e.g. micronutrients) even though the causes of adverse birth outcomes are multi-faceted. There is a need to combine interventions that of different domains as packages and test for their effectiveness. Registration: PROSPERO CRD42018110446; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
| | - Ellie Siden
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Michael Zoratti
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
| | | | - Richard T. Lester
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Kristian Thorlund
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, BC, V5Z 1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
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Park JJH, Siden E, Harari O, Dron L, Mazoub R, Jeziorska V, Zannat NE, Gadalla H, Thorlund K, Mills EJ. Interventions to improve linear growth during exclusive breastfeeding life-stage for children aged 0-6 months living in low- and middle-income countries: a systematic review with network and pairwise meta-analyses. Gates Open Res 2020; 3:1720. [PMID: 33062941 PMCID: PMC7536351 DOI: 10.12688/gatesopenres.13082.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Exclusive breastfeeding (EBF) during the first six months of life is critical for child's linear growth. While there is strong evidence in favor of EBF, the evidence with regards to other interventions for linear growth is unclear. We evaluated intervention domains of micronutrients, food supplements, deworming, maternal education, water sanitation and hygiene (WASH), and kangaroo care, for their comparative effectiveness on linear growth. Methods: For this review, we searched for randomized clinical trials (RCTs) of the interventions provided to infants aged 0-6 months and/or their breastfeeding mothers in low- and middle-income countries reporting on length-for-age z-score (LAZ), stunting, length, and head circumference. We searched for reports published until September 17 th, 2019 and hand-searched bibliographies of existing reviews. For LAZ and stunting, we used network meta-analysis (NMA) to compare the effects of all interventions except for kangaroo care, where we used pairwise meta-analysis to compare its effects versus standard-of-care. For length and head circumference, we qualitatively summarized our findings. Results: We found 29 RCTs (40 papers) involving 35,119 mother and infant pairs reporting on the effects of aforementioned interventions on linear growth outcomes. Our NMA on LAZ found that compared to standard-of-care, multiple micronutrients administered to infants (MMN-C) improved LAZ (mean difference: 0.20; 95% credible interval [CrI]: 0.03,0.35), whereas supplementing breastfeeding mothers with MMN did not (MMN-M, mean difference: -0.02, 95%CrI: -0.18,0.13). No interventions including MMN-C (relative risk: 0.74; 95%CrI: 0.36,1.44) reduced risk for stunting compared to standard-of-care. Kangaroo care, on the other hand, improved head circumference (mean difference: 0.20 cm/week; 95% confidence intervals [CI]: 0.09,0.31 cm/week) and length (mean difference: 0.23 cm/week; 95%CI: 0.10,0.35 cm/week) compared to standard-of-care. Conclusion: Our study found important improvements for kangaroo care, but we did not find sufficient evidence for other interventions. Registration: PROSPERO CRD42018110450; registered on 17 October 2018.
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Affiliation(s)
- Jay J. H. Park
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ellie Siden
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada
| | - Ofir Harari
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Louis Dron
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
| | - Reham Mazoub
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | | | | | | | - Kristian Thorlund
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
| | - Edward J. Mills
- MTEK Sciences, Vancouver, BC, V5Z1J5, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, L8S4K1, Canada
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Kim DH, Lee J, Kim SW, Hwang SH. The Efficacy of Hypotensive Agents on Intraoperative Bleeding and Recovery Following General Anesthesia for Nasal Surgery: A Network Meta-Analysis. Clin Exp Otorhinolaryngol 2020; 14:200-209. [PMID: 32847341 PMCID: PMC8111392 DOI: 10.21053/ceo.2020.00584] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES A systematic review of the literature was conducted to evaluate hypotensive agents in terms of their adverse effects and associations with perioperative morbidity in patients undergoing nasal surgery. METHODS Two authors independently searched databases (Medline, Scopus, and Cochrane databases) up to February 2020 for randomized controlled trials comparing the perioperative administration of a hypotensive agent with a placebo or other agent. The outcomes of interest for this analysis were intraoperative morbidity, operative time, intraoperative bleeding, hypotension, postoperative nausea/vomiting, and postoperative pain. Both a standard pairwise meta-analysis and network meta-analysis were conducted. RESULTS Our analysis was based on 37 trials. Treatment networks consisting of six interventions (placebo, clonidine, dexmedetomidine, beta-blockers, opioids, and nitroglycerine) were defined for the network meta-analysis. Dexmedetomidine resulted in the greatest differences in intraoperative bleeding (-0.971; 95% confidence interval [CI], -1.161 to -0.781), intraoperative fentanyl administration (-3.683; 95% CI, -4.848 to -2.518), and postoperative pain (-2.065; 95% CI, -3.170 to -0.960) compared with placebo. The greatest difference in operative time compared with placebo was achieved with clonidine (-0.699; 95% CI, -0.977 to -0.421). All other agents also had beneficial effects on the measured outcomes. Dexmedetomidine was less likely than other agents to cause adverse effects. CONCLUSION This study demonstrated the superiority of the systemic use of dexmedetomidine as a perioperative hypotensive agent compared with the other five tested agents. However, the other agents were also superior to placebo in improving operative time, intraoperative bleeding, and postoperative pain.
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Affiliation(s)
- Do Hyun Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Junuk Lee
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Won Kim
- Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se Hwan Hwang
- Department of Otolaryngology-Head and Neck Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Pulmonary Recruitment Maneuver for Reducing Shoulder Pain after Laparoscopic Gynecologic Surgery: A Network Meta-Analysis of Randomized Controlled Trials. Minim Invasive Surg 2020; 2020:7154612. [PMID: 32765908 PMCID: PMC7387971 DOI: 10.1155/2020/7154612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 06/26/2020] [Indexed: 12/29/2022] Open
Abstract
Background Shoulder pain is a common symptom following laparoscopic surgery. This systematic review was undertaken to assess updated evidence regarding the effectiveness and complications of the pulmonary recruitment maneuver (PRM) for reducing shoulder pain after laparoscopic gynecologic surgery. Methods A number of databases for randomized controlled trials (RCTs) investigating PRM for reducing shoulder pain were searched up to June 2019. Two authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, and compared results. Network meta-analyses were employed to simultaneously compare multiple interventions. Effect measures were presented as pooled mean difference (MD) or risk ratio (RR) with corresponding 95% confidence intervals (CI). Results Of the 44 records that we identified as a result of the search (excluding duplicates), eleven RCTs involving 1111 participants were included. Three studies had an unclear risk of selection bias. PRM with a maximum pressure of 40 cm H2O was most likely to result in the lowest shoulder pain intensity at 24 hours (MD −1.91; 95% CI −2.06 to −1.76) while PRM with a maximum pressure of 40 cm H2O plus intraperitoneal saline (IPS) appeared to be the most efficient at 48 hours (MD −2.09; 95% CI −2.97 to −1.21). The estimated RRs for analgesia requirement, nausea/vomiting, and cardiopulmonary events were similar across the competing interventions. Conclusion PRM with 40 cm H2O performed either alone or accompanied by IPS is a promising intervention for alleviating shoulder pain within 48 hours following gynecologic laparoscopy.
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Pease A, Lo C, Earnest A, Kiriakova V, Liew D, Zoungas S. Time in Range for Multiple Technologies in Type 1 Diabetes: A Systematic Review and Network Meta-analysis. Diabetes Care 2020; 43:1967-1975. [PMID: 32669412 DOI: 10.2337/dc19-1785] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 04/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Time in range is a key glycemic metric, and comparisons of management technologies for this outcome are critical to guide device selection. PURPOSE We conducted a systematic review and network meta-analysis to compare and rank technologies for time in glycemic ranges. DATA SOURCES We searched Evidenced-Based Medicine Reviews, CINAHL, Embase, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PROSPERO, PsycInfo, PubMed, and Web of Science until 24 April 2019. STUDY SELECTION We included randomized controlled trials ≥2 weeks' duration comparing technologies for management of type 1 diabetes in adults (≥18 years of age), excluding pregnant women. DATA EXTRACTION Data were extracted using a predefined template. Outcomes were percent time with sensor glucose levels 3.9-10.0 mmol/L (70-180 mg/dL), >10.0 mmol/L (180 mg/dL), and <3.9 mmol/L (70 mg/dL). DATA SYNTHESIS We identified 16,772 publications, of which 14 eligible studies compared eight technologies comprising 1,043 participants. Closed-loop systems led to greater percent time in range than any other management strategy, and mean percent time in range was 17.85 (95% predictive interval 7.56-28.14) longer than with usual care of multiple daily injections with capillary glucose testing. Closed-loop systems ranked best for percent time in range or above range with use of Surface Under the Cumulative RAnking curve (SUCRA) (98.5% and 93.5%, respectively). Closed-loop systems also ranked highly for time below range (SUCRA 62.2%). LIMITATIONS Overall risk of bias ratings were moderate for all outcomes. Certainty of evidence was very low. CONCLUSIONS In the first integrated comparison of multiple management strategies considering time in range, we found that the efficacy of closed-loop systems appeared better than all other approaches.
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Affiliation(s)
- Anthony Pease
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Clement Lo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia .,Monash Health, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
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Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. PLoS Med 2020; 17:e1003262. [PMID: 32813696 PMCID: PMC7446790 DOI: 10.1371/journal.pmed.1003262] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events. METHODS AND FINDINGS We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis. CONCLUSIONS In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.
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Rhim HC, Kim MS, Choi S, Tenforde AS. Comparative Efficacy and Tolerability of Nonsurgical Therapies for the Treatment of Midportion Achilles Tendinopathy: A Systematic Review With Network Meta-analysis. Orthop J Sports Med 2020; 8:2325967120930567. [PMID: 32728589 PMCID: PMC7366412 DOI: 10.1177/2325967120930567] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/10/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Achilles tendinopathy (AT) is a common cause of overuse injury in both
athletes and nonactive individuals, especially at older ages. Due to the
limited number of direct comparisons among interventions, determining the
best treatment option can be difficult. Purpose: To evaluate the comparative efficacy and tolerability of nonsurgical
therapies for midportion AT. Study Design: Systematic review; Level of evidence, 1. Methods: PubMed, MEDLINE, EMBASE, and Google Scholar were searched from database
inception through June 20, 2019. Randomized controlled trials investigating
the effect of nonsurgical therapies for midportion AT using the Victorian
Institute of Sports Assessment–Achilles (VISA-A) assessment were eligible
for inclusion. Primary outcome was mean change in VISA-A score from
baseline. Comparisons between interventions were made through use of
random-effects network meta-analysis over the short term (≤3 months) and
longer term (>3 to <12 months). A safety profile was defined for each
intervention by rate of all-cause discontinuation (dropout) during
follow-up. Relative ranking of therapies was assessed by the
surface-under-the–cumulative ranking possibilities. Results: A total of 22 studies with 978 patients met the inclusion criteria. In
short-term studies, high-volume injection with corticosteroid (HVI+C) along
with eccentric exercise (ECC) significantly improved the change of VISA-A
score compared with that of ECC alone (standardized mean difference [SMD],
1.08; 95% CI, 0.58-1.58). Compared with ECC, acupuncture showed benefits
over both the short term (SMD, 1.57; 95% CI, 1.00-2.13) and longer term
(SMD, 1.23; 95% CI, 0.69-1.76). In longer-term studies, the wait-and-see
approach resulted in unfavorable outcomes compared with ECC (SMD, −1.51; 95%
CI, −2.02 to −1.01). Improvement was higher when ECC was combined with HVI+C
(SMD, 0.53; 95% CI, 0.05-1.02) and extracorporeal shockwave therapy (ESWT)
(SMD, 0.99; 95% CI, 0.48-1.49). All interventions had a similar safety
profile. Conclusion: From available high-level studies, HVI+C and ESWT may be possible
interventions to add along with ECC to improve longer-term outcomes.
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Affiliation(s)
- Hye Chang Rhim
- Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Seo Kim
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Seungil Choi
- Department of Biostatistics, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
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Datta NR, Kok HP, Crezee H, Gaipl US, Bodis S. Integrating Loco-Regional Hyperthermia Into the Current Oncology Practice: SWOT and TOWS Analyses. Front Oncol 2020; 10:819. [PMID: 32596144 PMCID: PMC7303270 DOI: 10.3389/fonc.2020.00819] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Moderate hyperthermia at temperatures between 40 and 44°C is a multifaceted therapeutic modality. It is a potent radiosensitizer, interacts favorably with a host of chemotherapeutic agents, and, in combination with radiotherapy, enforces immunomodulation akin to “in situ tumor vaccination.” By sensitizing hypoxic tumor cells and inhibiting repair of radiotherapy-induced DNA damage, the properties of hyperthermia delivered together with photons might provide a tumor-selective therapeutic advantage analogous to high linear energy transfer (LET) neutrons, but with less normal tissue toxicity. Furthermore, the high LET attributes of hyperthermia thermoradiobiologically are likely to enhance low LET protons; thus, proton thermoradiotherapy would mimic 12C ion therapy. Hyperthermia with radiotherapy and/or chemotherapy substantially improves therapeutic outcomes without enhancing normal tissue morbidities, yielding level I evidence reported in several randomized clinical trials, systematic reviews, and meta-analyses for various tumor sites. Technological advancements in hyperthermia delivery, advancements in hyperthermia treatment planning, online invasive and non-invasive MR-guided thermometry, and adherence to quality assurance guidelines have ensured safe and effective delivery of hyperthermia to the target region. Novel biological modeling permits integration of hyperthermia and radiotherapy treatment plans. Further, hyperthermia along with immune checkpoint inhibitors and DNA damage repair inhibitors could further augment the therapeutic efficacy resulting in synthetic lethality. Additionally, hyperthermia induced by magnetic nanoparticles coupled to selective payloads, namely, tumor-specific radiotheranostics (for both tumor imaging and radionuclide therapy), chemotherapeutic drugs, immunotherapeutic agents, and gene silencing, could provide a comprehensive tumor-specific theranostic modality akin to “magic (nano)bullets.” To get a realistic overview of the strength (S), weakness (W), opportunities (O), and threats (T) of hyperthermia, a SWOT analysis has been undertaken. Additionally, a TOWS analysis categorizes future strategies to facilitate further integration of hyperthermia with the current treatment modalities. These could gainfully accomplish a safe, versatile, and cost-effective enhancement of the existing therapeutic armamentarium to improve outcomes in clinical oncology.
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Affiliation(s)
- Niloy R Datta
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - H Petra Kok
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hans Crezee
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Bodis
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
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Efficacy of Budesonide/Glycopyrronium/Formoterol Fumarate Metered Dose Inhaler (BGF MDI) Versus Other Inhaled Corticosteroid/Long-Acting Muscarinic Antagonist/Long-Acting β 2-Agonist (ICS/LAMA/LABA) Triple Combinations in COPD: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2020; 37:2956-2975. [PMID: 32335859 PMCID: PMC7467454 DOI: 10.1007/s12325-020-01311-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Triple inhaled corticosteroid/long-acting muscarinic antagonist/long-acting β2-agonist (ICS/LAMA/LABA) combination therapy is recommended for patients with chronic obstructive pulmonary disease (COPD) who experience further exacerbations/symptoms on dual LAMA/LABA or ICS/LABA therapy. The relative efficacy of budesonide/glycopyrronium/formoterol fumarate metered dose inhaler 320/18/9.6 µg (BGF MDI) in COPD was compared with other ICS/LAMA/LABA fixed-dose and open combination therapies in a network meta-analysis (NMA). METHODS A systematic literature review was conducted to identify randomized controlled trials of at least 10-week duration, including at least one fixed-dose or open combination triple therapy arm, in patients with moderate to very severe COPD. Studies were assessed for methodological quality and risk of bias. A three-level hierarchical Bayesian NMA model was used to determine the exacerbation rate per patient per year as well as the following outcomes at week 24: changes from baseline in pre-dose trough forced expiratory volume in 1 s (FEV1), post-dose peak FEV1, and St. George's Respiratory Questionnaire (SGRQ) total score; proportion of SGRQ responders; and Transition Dyspnea Index focal score. Change from baseline in rescue medication use over weeks 12-24 was also analyzed. Meta-regression and sensitivity analyses were used to assess heterogeneity across studies. RESULTS Eighteen studies (n = 29,232 patients) contributed to the NMA. ICS/LABA dual combinations were combined as a single treatment group to create a connected network. Across all outcomes, there were no statistically significant differences between BGF MDI and other triple ICS/LAMA/LABA fixed-dose (fluticasone furoate/umeclidinium/vilanterol and beclomethasone dipropionate/glycopyrronium/formoterol fumarate) and open combinations with data available within the network. Results from sensitivity analyses and meta-regression were consistent with the base-case scenario. CONCLUSION This NMA suggested that BGF MDI has comparable efficacy to other ICS/LAMA/LABA fixed-dose and open triple combination therapies in reducing exacerbations and improving lung function and symptoms in patients with moderate to very severe COPD. Further research is warranted as additional evidence regarding triple therapies, especially fixed-dose combinations, becomes available.
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Geng J, Bao H, Chen Y, Shi L, Geng J, Wang Q, Yu H. Nucleos(t)ide analogues for the treatment of chronic hepatitis B: a systematic review with network meta-analysis. Expert Rev Anti Infect Ther 2020; 18:823-834. [PMID: 32329638 DOI: 10.1080/14787210.2020.1760843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Chronic hepatitis B (CHB) is a major global health problem caused by hepatitis B virus (HBV) infection, and can put patients at high risk of death from cirrhosis and liver cancer. However, CHB can be treated with nucleos(t)ide analogues. We aimed to evaluate the effectiveness and safety of nucleos(t)ide analogues for the treatment of CHB patients. METHODS A systematic literature search was performed. Direct comparison meta-analyses and network meta-analysis (NMA) were carried out. RESULTS Thirty-six randomized controlled trials (RCTs) met inclusion criteria. Compared with placebo, the nucleos(t)ide analogues were all effective in HBeAg seroconversion, HBeAg loss, and achieving undetectable HBV DNA. Telbivudine was associated with higher HBeAg seroconversion compared with entecavir. For HBeAg loss rate and proportion of achieving undetectable HBV DNA, tenofovir ranked as the best. Entecavir might be the most potent in the normalization of alanine aminotransferase (ALT). The nucleos(t)ide analogues did not have higher serious adverse events rate as compared with placebo. CONCLUSION The nucleos(t)ide analogues are all effective for HBeAg seroconversion, HBeAg loss, undetectable HBV DNA, and most are effective for ALT normalization in adults with CHB. RCTs of multi-center, low risk of bias, and long-term follow-up are still needed.
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Affiliation(s)
- JinSong Geng
- Evidence-based Medicine Center, Medical School of Nantong University , Jiangsu, China
| | - HaiNi Bao
- Evidence-based Medicine Center, Medical School of Nantong University , Jiangsu, China
| | - YaLan Chen
- Evidence-based Medicine Center, Medical School of Nantong University , Jiangsu, China
| | - LiLi Shi
- Evidence-based Medicine Center, Medical School of Nantong University , Jiangsu, China
| | - Jing Geng
- Department of Gastroenterology, Lianyungang No 1 People's Hospital , Jiangsu, China
| | - Qing Wang
- Department of Infectious Disease, Ningxiang People's Hospital , Hunan, China
| | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute , Boston, MA, USA
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