Network Meta-analysis to Synthesize Evidence for Decision Making in Cardiovascular Research

Can botulinum toxin injection alleviate the pain of bruxism? A Bayesian network analysis and a single-arm analysis

Background/purpose

There is inconsistent evidence regarding whether the botulinum toxin A (BTA) injection can relieve pain caused by bruxism. This study aimed to estimate the efficiency of BTA injection in relieving pain caused by bruxism at different follow-up periods.

Materials and methods

Five electronic databases were searched from 2005 to 2022 using search terms related to botulinum toxin and bruxism. Only controlled clinical trials were included. Two investigators reviewed each article and discussed any disagreements until a consensus was reached. Pain outcomes as evaluated by the visual analogue scale (VAS) were subjected to single-arm and Bayesian network meta-analyses. Pooling data were measured by a random-effects model.

Results

Eleven studies with a total of 365 bruxism patients were included. According to the single-arm analyses of the pooled data, the reduction in bruxism-related pain after BTA injection measured 4.06 points (95% CI = 3.37 to 4.75) on the VAS, and the pain relief was significant in the first 6 months after treatment (P < 0.01). According to the Bayesian analysis, BTA also resulted in significantly greater pain relief than oral splinting (mean difference (MD), -1.5; 95% credible interval (CrI) = -2.7 to -0.19) or saline injection (MD, -3.3; 95% CrI = -6.2 to -0.32).

Conclusion

BTA significantly relieves the pain of bruxism for 6 months after injection, and its therapeutic efficacy was higher than that of oral splinting. Nevertheless, further long-term follow-up randomized controlled trials comparing BTA with other management or drugs are warranted.

Postoperative Application of Dexmedetomidine is the Optimal Strategy to Reduce the Incidence of Postoperative Delirium After Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Previous pairwise meta-analyses demonstrated the efficacy and safety of dexmedetomidine in preventing postoperative delirium (POD) after cardiac surgery; however, the optimal time of applying dexmedetomidine remains unclear.

OBJECTIVE

This network meta-analysis aimed to determine the optimal time of using dexmedetomidine to reduce the incidence of POD following cardiac surgery.

METHODS

We first retrieved eligible randomized controlled trials (RCTs) from previous meta-analyses, and then an updated search was performed to identify additional RCTs in PubMed, Embase, and the Cochrane library from January 1, 2021 to October 31, 2021. Two authors screened literature, collected data, and evaluated bias risk of eligible studies. Finally, we performed Bayesian network analysis using R version 3.6.1 with the "gemtc" and "rjags" package.

RESULTS

Eighteen studies with 2636 patients were included, and all studies were identified from previous meta-analyses. Results showed that postoperative dexmedetomidine reduced the risk of POD compared with normal saline (NS) (odds ratio [OR], 0.13; 95% credible interval [CrI], 0.03-0.35) and propofol (PRO) (OR, 0.19; 95%CrI, 0.04-0.66). Postoperative dexmedetomidine was associated with a lower incidence of POD compared with perioperative dexmedetomidine (OR, 0.21; 95% CrI, 0.04-0.82). Moreover, postoperative dexmedetomidine had the highest probability of ranking best (90.98%), followed by intraoperative dexmedetomidine (46.83%), PRO (36.94%), perioperative dexmedetomidine (30.85%), and NS (60.02%).

CONCLUSION AND RELEVANCE

Dexmedetomidine reduces the incidence of POD compared with PRO and NS in patients undergoing cardiac surgery, and postoperative application of dexmedetomidine is the optimal time.

Addition of Capecitabine to Adjuvant Chemotherapy May be the Most Effective Strategy for Patients With Early-Stage Triple-Negative Breast Cancer: A Network Meta-Analysis of 9 Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Previous studies determined the therapeutic effects of capecitabine-based chemotherapy regimens on early-stage triple-negative breast cancer (TNBC). However, the optimal strategy of capecitabine-based chemotherapy remains uncertain. We conducted this network meta-analysis to address this issue.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Registry of Controlled Trials (CENTRAL) to retrieve eligible studies published before September 2021. Two independent reviewers extracted information from eligible studies using a pre-designed data extraction sheet. The primary outcome included disease-free survival, and the second outcome showed overall survival and adverse events. Direct meta-analysis was performed using RevMan 5.4, and Bayesian network analysis was performed using R version 3.6.1 with the "gemtc" and "rjags" packages.

RESULTS

Nine studies involving 3661 TNBC patients met the selection criteria. The network meta-analysis suggested that the addition of capecitabine to adjuvant chemotherapy achieved a significantly longer disease-free (HR = 0.66, 95% CrI = 0.49 to 0.86) and overall survival time (HR = 0.60, 95% CrI = 0.43 to 0.83) than standard chemotherapy. All comparisons did not achieve statistical significance. The addition of capecitabine to adjuvant chemotherapy was the most effective treatment for improving disease-free (81.24%) and overall survival (78.46%) times, and the replacement of capecitabine to adjuvant chemotherapy was the safest regime.

CONCLUSIONS

Based on available evidence, capecitabine-based chemotherapy benefits TNBC patients, and the addition of capecitabine with adjuvant chemotherapy was the most effective regime. In contrast, the replacement of capecitabine to adjuvant chemotherapy was the safest regime. More studies of high quality and large scale are needed to confirm our findings.

Comparative efficacy of amitriptyline, duloxetine and pregabalin for treating fibromyalgia in adults: an overview with network meta-analysis

Treatment recommendations for fibromyalgia (FM) include a range of predominantly pharmacological treatment options designed to ensure the maintenance of symptoms and improvement in the quality of life of these patients. Our aim is to identify and compare the efficacy of amitriptyline (AMT), duloxetine (DLX), and pregabalin (PGB) for reducing pain intensity by 30% (R30%) and 50% (R50%) in adult patients with fibromyalgia. The review was conducted in the Medline/PubMed, Cochrane Library, and Embase databases up to February 2022. This study included systematic reviews (SR) of randomized clinical trials (RCTs) targeting adult patients over 18 years of age diagnosed with fibromyalgia according to the criteria of scientific societies, which include the basic clinical diagnosis characterized by the presence of pressure sensitivity in at least 11 of the 18 tender points, in addition to the presence of widespread musculoskeletal pain for a period longer than 3 months and a general assessment of the patient's health status. Pregnant women and children or adolescents were excluded. The Rob 2.0 tool from the Cochrane Collaboration was used to assess the risk of bias in RCTs. The quality of evidence of the reviews included was assessed according to the Grading of Recommendations Assessment, Development and Evaluation-GRADE. A meta-analysis for the evidence network was performed using the Bayesian approach, which allows simultaneous comparison of all treatment options (medication and dose). The different treatments were ranked according to the response rate according to the surface under the curve (SUCRA), which was expressed as a percentage. The results were presented in tables and figures. The protocol with the detailed methods was registered in PROSPERO (CRD42021229264). Eight systematic reviews were identified, and, from these, 15 clinical trials comparing AMT (n = 273), DLX (n = 2595), and PGB (n = 3,506) against placebo were selected. For the outcome R30%, PGB 450 mg was superior to DLX 30 mg and PGB 150 mg, while DLX 20 mg and 30 mg were not superior to placebo. For the outcome R50%, AMT 25 mg was superior to all other alternatives evaluated. The calculation of the SUCRA indicated that PGB 450 mg was the best performance option for R30% and AMT 25 mg for R50%. PGB 150 mg was the drug with the worst performance in the two outcomes evaluated. The drugs evaluated showed benefits for pain reduction in patients with fibromyalgia. In the absence of direct comparison studies, indirect comparison meta-analyses are an important resource for assisting in clinical decision-making. Our data only provide an indicator of the effectiveness of the three drugs evaluated, but as with other health conditions, tolerability and safety are important for the decision-making process and clinical management. In this regard, we encourage caution in interpreting our data.

Removal of accumulated hard tissue debris from mesial root of mandibular molars evaluated using micro-CT - a systematic review and network meta-analysis

Aim The aim of this systematic review and network meta-analysis was to identify the best irrigant activation technique (IAT) for the removal of accumulated hard tissue debris (AHTD) from the mesial root of mandibular molars evaluated using micro-CT studies.Methods The research question was based on the PICO format. Four electronic databases - PubMed, Scopus, Embase and Web of Science - were searched for articles up to June 2020. Selected articles were assessed for bias using the Joanna Briggs Institute Critical appraisal tool. The network meta-analysis using a fixed-effects model and SUCRA ranking were performed. The quality of the evidence was assessed using the CINeMA framework.Results Eleven studies were included for qualitative synthesis while seven were included for quantitative synthesis. The risk of bias of all included articles was low. The results based on SUCRA values revealed the IAT shock wave-enhanced emission photoacoustic streaming (100%) resulted in the greatest reduction of the volume of AHTD from mesial roots of mandibular molars. Ranking of the other IATs was as follows: photon-induced photoacoustic streaming (87%), laser-activated irrigation (79.3%), XP EndoFinisher (71.2%), ultrasonically activated irrigation (59.6%), apical negative pressure (42.3%), EasyClean (37.4%), EDDY (26.2%), EndoActivator (24.2%), self-adjusting file (11.6%) and needle irrigation (11.3%).Conclusion None of the IATs rendered the root canals completely free of AHTD. The laser-activated irrigation groups fared better than all other interventions in reducing AHTD from the mesial roots of mandibular molars. The confidence rating ranged from low to high for indirect evidence and moderate to high for mixed evidence. Results must be interpreted with caution due to the laboratory nature of the included studies.

Repetitive transcranial magnetic stimulation for lower extremity motor function in patients with stroke: a systematic review and network meta-analysis

Transcranial magnetic stimulation, a type of noninvasive brain stimulation, has become an ancillary therapy for motor function rehabilitation. Most previous studies have focused on the effects of repetitive transcranial magnetic stimulation (rTMS) on motor function in stroke patients. There have been relatively few studies on the effects of different modalities of rTMS on lower extremity motor function and corticospinal excitability in patients with stroke. The MEDLINE, Embase, Cochrane Library, ISI Science Citation Index, Physiotherapy Evidence Database, China National Knowledge Infrastructure Library, and ClinicalTrials.gov databases were searched. Parallel or crossover randomized controlled trials that addressed the effectiveness of rTMS in patients with stroke, published from inception to November 28, 2019, were included. Standard pairwise meta-analysis was conducted using R version 3.6.1 with the “meta” package. Bayesian network analysis using the Markov chain Monte Carlo algorithm was conducted to investigate the effectiveness of different rTMS protocol interventions. Network meta-analysis results of 18 randomized controlled trials regarding lower extremity motor function recovery revealed that low-frequency rTMS had better efficacy in promoting lower extremity motor function recovery than sham stimulation. Network meta-analysis results of five randomized controlled trials demonstrated that high-frequency rTMS led to higher amplitudes of motor evoked potentials than low-frequency rTMS or sham stimulation. These findings suggest that rTMS can improve motor function in patients with stroke, and that low-frequency rTMS mainly affects motor function, whereas high-frequency rTMS increases the amplitudes of motor evoked potentials. More high-quality randomized controlled trials are needed to validate this conclusion. The work was registered in PROSPERO (registration No. CRD42020147055) on April 28, 2020.