Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy. A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work. Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach

OBJECTIVES

We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery.

METHODS

PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data.

RESULTS

Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93).

CONCLUSIONS

The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT.

Cognitive Behavioral Therapy Reduces Unhelpful Thinking Among People with Musculoskeletal Symptoms: A Meta-Analysis

Background

Greater unhelpful thinking is associated with greater musculoskeletal discomfort and incapability. Cognitive-behavioral therapy (CBT) fosters healthy thinking to help alleviate symptoms.

Questions

In a meta-analysis of randomized control trials (RCT) of CBT for unhelpful thinking among people with musculoskeletal symptoms, we asked: 1) Does CBT reduce unhelpful thinking and feelings of distress, and improve capability, in individuals with musculoskeletal symptoms? 2) Are outcomes affected by CBT delivery methods?

Methods

Following QUOROM guidelines, we searched databases using keywords of pain catastrophizing, kinesiophobia, cognitive-behavioral therapy, musculoskeletal and variations. Inclusion criteria were RCT's testing CBT among people with musculoskeletal symptoms. Study quality was assessed with Cochrane Review of Bias 2. Meta-analysis of means and standard deviations was performed.

Results

CBT led to modest reductions in catastrophic thinking (-0.44 CI: -0.76 to -0.12; P = .01, kinesiophobia (-0.60 CI: -1.07 to -0.14; P = .01) and anxiety symptoms (-0.23 CI: -0.36 to -0.09; P < .01) over six months compared to usual care. There were no improvements in levels capability (-0.28 CI: -0.56 to 0.01; P = .05). CBT led by mental health professionals reduced catastrophic thinking more than CBT led by other clinicians (QB Test = 4.73 P = .03). There were no differences between online and in-person sessions, group versus individual therapy, or surgical versus non-surgical interventions.

Conclusion

The evidence that CBT delivered by various clinicians in various settings fosters healthier thinking in people presenting for care of musculoskeletal symptoms, supports comprehensive care of musculoskeletal illness. More research is needed to develop indications and interventions that also improve levels of capability. Level-I, meta-analysis of RCT's.

Impact of antibiotic-coated sutures on surgical site infections: a second-order meta-analysis

BACKGROUND

Surgical site infections (SSIs) pose a global challenge, impacting patients and healthcare expenditures. This second-order meta-analysis endeavors to assess the efficacy of antibiotic sutures in averting SSIs by amalgamating data from various meta-studies.

MATERIALS AND METHODS

This research adhered to the PRISMA 2020 guidelines. The quality and comprehensiveness of the encompassed meta-analyses were assessed through the QUOROM checklist and AMSTAR techniques. The primary study overlap was evaluated via measures such as pairwise intersection heat maps, corrected covered area, and the citation matrix of evidence. The statistical power at the study-level was determined utilizing the meta-meta package. Data synthesis employed random and fixed effects models at a 95% CI. A meta-regression analysis was conducted to explore potential correlations between the CDC classification of SSIs, trial types, and the observed effect sizes in the studies.

RESULTS

This investigation revealed a significant reduction in SSI rates due to antimicrobial-coated sutures, evidenced by a relative risk (RR) of 0.68 (95% CI: 0.59-0.76), with a prediction interval of 0.38-1.19. The analysis encompassed 18 studies with 22 meta-analyses, demonstrating a median QUOROM score of 13.6 out of 18 and an AMSTAR score of 9.1 out of 11. The presence of moderate heterogeneity was noted ( Q =106.611, I2 =54.038%), with nonrandomized controlled trials exhibiting an RR of 0.56 (95% CI: 0.39-0.80), and RCTs displaying an RR of 0.71 (95% CI: 0.63-0.81). Subgroup analysis unveiled variable RR reductions for specific surgical procedures.

CONCLUSION

Antimicrobial-coated sutures offer a promising approach to mitigating SSIs risk. However, their efficacy is optimally realized when employed in conjunction with other robust practices.

Preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO): a minimum requirements

BACKGROUND

A bibliometric review of the biomedical literature could be essential in synthesizing evidence if thoroughly conducted and documented. Although very similar to review papers in nature, it slightly differs in synthesizing the data when it comes to providing a pile of evidence from different studies into a single document. This paper provides a preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO).

METHODS

The BIBLIO was developed through two major processes: literature review and the consensus process. The BIBLIO started with a comprehensive review of publications on the conduct and reporting of bibliometric studies. The databases searched included PubMed, Scopus, Web of Sciences, and Cochrane Library. The process followed the general recommendations of the EQUATOR Network on how to develop a reporting guideline, of which one fundamental part is a consensus process. A panel of experts was invited to identify additional items and was asked to choose preferred options or suggest another item that should be included in the checklist. Finally, the checklist was completed based on the comments and responses of the panel members in four rounds.

RESULTS

The BIBLIO includes 20 items as follows: title (2 items), abstract (1 item), introduction/background (2 items), methods (7 items), results (4 items), discussion (4 items). These should be described as a minimum requirements in reporting a bibliometric review.

CONCLUSIONS

The BIBLIO for the first time provides a preliminary guideline of its own kind. It is hoped that it could contribute to the transparent reporting of bibliometric reviews. The quality and utility of BIBILO remain to be investigated further.

A statistical method for removing unbalanced trials with multiple covariates in meta-analysis

In meta-analysis literature, there are several checklists describing the procedures necessary to evaluate studies from a qualitative point of view, whereas preliminary quantitative and statistical investigations on the "combinability" of trials have been neglected. Covariate balance is an important prerequisite to conduct meta-analysis. We propose a method to identify unbalanced trials with respect to a set of covariates, in presence of covariate imbalance, namely when the randomized controlled trials generate a meta-sample that cannot satisfy the requisite of randomization/combinability in meta-analysis. The method is able to identify the unbalanced trials, through four stages aimed at achieving combinability. The studies responsible for the imbalance are identified, and then they can be eliminated. The proposed procedure is simple and relies on the combined Anderson-Darling test applied to the Empirical Cumulative Distribution Functions of both experimental and control meta-arms. To illustrate the method in practice, two datasets from well-known meta-analyses in the literature are used.

Effect of PRISMA 2009 on reporting quality in systematic reviews and meta-analyses in high-impact dental medicine journals between 1993-2018

INTRODUCTION

The PRISMA guidelines were published in 2009 to address inadequate reporting of key methodological details in systematic reviews and meta-analyses (SRs/MAs). This study sought to assess the impact of PRISMA on the quality of reporting in the full text of dental medicine journals.

METHODS

This study assessed the impact of PRISMA (2009) on thirteen methodological details in SRs/MAs published in the highest-impact dental medicine journals between 1993-2009 (n = 211) and 2012-2018 (n = 618). The study further examined the rate of described use of PRISMA in the abstract or full text of included studies published post- PRISMA and the impact of described use of PRISMA on level of reporting. This study also examined potential effects of inclusion of PRISMA in Instructions for Authors, along with study team characteristics.

RESULTS

The number of items reported in SRs/MAs increased following the publication of PRISMA (pre-PRISMA: M = 7.83, SD = 3.267; post-PRISMA: M = 10.55, SD = 1.4). Post-PRISMA, authors rarely mention PRISMA in abstracts (8.9%) and describe the use of PRISMA in the full text in 59.87% of SRs/MAs. The described use of PRISMA within the full text indicates that its intent (guidance for reporting) is not well understood, with over a third of SRs/MAs (35.6%) describing PRISMA as guiding the conduct of the review. However, any described use of PRISMA was associated with improved reporting. Among author team characteristics examined, only author team size had a positive relationship with improved reporting.

CONCLUSION

Following the 2009 publication of PRISMA, the level of reporting of key methodological details improved for systematic reviews/meta-analyses published in the highest-impact dental medicine journals. The positive relationship between reference to PRISMA in the full text and level of reporting provides further evidence of the impact of PRISMA on improving transparent reporting in dental medicine SRs/MAs.

Completeness of reporting in systematic reviews and meta-analyses in vascular surgery

OBJECTIVE

Systematic reviews (SRs) and meta-analyses are essential in informing clinical guidelines and decision-making. Complete reporting of SRs through compliance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines promotes transparency, reproducibility, and consistency across the literature. The purpose of this meta-epidemiological study is to assess the completeness of reporting of SRs in the vascular surgery literature.

METHODS

MEDLINE and Embase were used to search through four major vascular surgery journals and four high impact general medical journals for SRs published between 2018 and October 2022 evaluating clinical treatments for any pathology treated by a vascular surgeon. Data screening and extraction were conducted in duplicate. The reporting completeness of each included SR was measured with reference to the 27-item PRISMA checklist, and methodological quality was evaluated using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) tool. Parametric tests were used to evaluate for associations between PRISMA score and study funding, protocol registration, publication in a higher impact factor journal, and AMSTAR 2 score. The protocol is available online: 10.17605/OSF.IO/VBC5N.

RESULTS

Of 1653 articles captured in the initial search, 162 SRs were included in the final analysis. All SRs had more than one incomplete PRISMA item. The mean PRISMA score was 21.2/27 (standard deviation: 2.9, 78.5% compliance), and the mean AMSTAR 2 score was 11.7/16 (standard deviation: 1.9, 73%). SRs that had a prospectively registered protocol had a higher PRISMA score (22.9 vs 20.6, P < .001) as did those that were published in higher impact factor journals (23.3 vs 21.0, P = .017). There was a large positive correlation between an SR's PRISMA and AMSTAR 2 scores (Pearson r = 0.655, 95% confidence interval: 0.55-0.74). There were no associations between the PRISMA score and publication year (P = .067) or funding status (P = .076).

CONCLUSIONS

Overall, the reporting of SRs and meta-analyses in vascular surgery is less than ideal, with several key items being consistently under-reported. Prospective registration and methodological quality as measured by AMSTAR 2 scores are positively associated with improved reporting. Authors, reviewers, and journal editors should consider these findings moving forward to encourage completeness of SR reporting. Raising awareness surrounding the value of complete reporting of SRs can aid in enhancing the quality of evidence, and journals should consider these findings in methods used to promote SR reporting.

Probiotic management and inflammatory factors as a novel treatment in cirrhosis: A systematic review and meta-analysis

The interaction between intestinal microecological dysregulation, altered inflammatory factors, and cirrhosis is unclear. The aim of this systematic review and meta-analysis was to synthesize the results of previous studies to assess the efficacy of probiotics in the treatment of cirrhosis and their effect on inflammatory factors, as well as to explore the relationship between gut microecological dysregulation and liver disease to gain a deeper understanding of this interaction. Up to December 2022, eligible studies were identified by searching the following databases: National Knowledge Infrastructure (CNKI), Wanfang Data, Web of Science, PubMed, Embase, Medline, and the Cochrane Library. Statistical analysis was performed using software RevMan Version 5.4. A total of 33 eligible randomized controlled trials were included in the study, and data on probiotic strains, duration of intervention, measures in the control group, and outcomes were extracted and evaluated. Compared to the control group, the experimental group had significant improvements in overall efficacy. The results of the meta-analysis revealed that probiotic use significantly decreased biochemical parameters for liver function, including aspartate transaminase, alanine aminotransferase, and total bilirubin. Similar result was obtained in interleukin-6, tumor necrosis factor-α, and endotoxin. However, probiotic intervention did not significantly affect interleukin-2 and interleukin-10. The current meta-analysis illustrates that probiotic supplementation reduces inflammatory markers and biochemical parameters for liver function in patients with cirrhosis, suggesting that probiotic management may be a novel treatment for cirrhosis. Furthermore, the interaction of the gut microbiota, associated metabolites, and inflammation factors with cirrhosis may provide a promising therapeutic target for the pharmacological and clinical treatment of cirrhosis.

Clinical Benefit of Bempedoic Acid in Randomized Clinical Trials

Bempedoic acid is a selective inhibitor of the adenosine triphosphate citrate lyase that reduces low-density lipoprotein cholesterol (LDLc) levels by 17% to 28%. Although the Evaluation of Major Cardiovascular Events in Patients With, or at High Risk for, Cardiovascular Disease Who Are Statin Intolerant Treated With Bempedoic Acid (CLEAR-OUTCOMES) trials demonstrated the efficacy on cardiovascular outcomes there is a controversy related to the possible net clinical benefit. Thereafter, we performed an intention-to-treat meta-analysis in line with recommendations from the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary outcome of the metanalysis was the incidence of major adverse cardiovascular events, defined by each study protocol. Secondary outcomes for the analyses were myocardial infarction, stroke, myocardial revascularization, cardiovascular death, and all-cause death. Results of 4 clinical trials evaluated contained a total of 17,324 patients; 9,236 received bempedoic acid for a median of 46.6 months. The mean baseline LDLc was 129.4 (22.8) mg/100 ml and treatment was associated with a mean LDLc reduction of 26.0 (12.6) mg/100 ml. Treatment with bempedoic acid significantly reduced the incidence of major adverse cardiovascular events (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.81 to 0.96), myocardial infarction (HR 0.76, 95% CI 0.66 to 0.89) and myocardial revascularization (HR 0.82, 95% CI 0.73 to 0.92); the crude incidence of stroke, cardiovascular or all-cause mortality were lower in patients in the bempedoic acid groups although no significant risk reduction was observed. No heterogeneity was observed in any of the end points. In conclusion, the metanalysis of the 4 clinical trials currently available with bempedoic acid provides reliable evidence of its clinical benefit with no signs of heterogeneity or harm.

Heterogeneity of placebo effects on urinary incontinence in overactive bladder syndrome: A meta-analysis of Japanese placebo-controlled clinical trials

OBJECTIVES

The effect sizes, changes over time, and heterogeneity of placebo effects on frequency of urination for voiding disorders in Japanese clinical trials have been published. This study evaluated the characteristics of placebo effects on overall and urge incontinence in overactive bladder patients.

METHODS

A meta-analysis of Japanese placebo-controlled clinical trials was conducted to determine placebo effects on the daily frequency of overall (n = 16) and urge (n = 11) incontinence and identify factors that should be considered in clinical trials.

RESULTS

The between-study heterogeneity variance of placebo effects for overall and urge incontinence at 8 weeks was estimated as I2  = 70.3% and 64.2%, and the prediction interval for the ratio of means ranged from g = 0.31-0.91 and 0.32-0.81, respectively. Subgroup analysis using the random-effects model showed placebo effects in overall incontinence (p = 0.08) and urge incontinence (p < 0.0001). The ratio of means (95% confidence interval) of urge incontinence frequency from baseline to 4 (n = 10), 8 (n = 10), and 12 (n = 7) weeks were 0.65 (0.57, 0.74), 0.51 (0.42, 0.62), and 0.48 (0.36, 0.64), respectively, for the random-effects model. Regression analysis did not reveal any significant factors that influenced placebo effects.

CONCLUSIONS

This meta-analysis confirmed the characterization of placebo effects on overall and urge incontinence, which demonstrates heterogeneity between trials. The impact of population, follow-up period, and endpoints on placebo effects should be considered when designing clinical trials for overactive bladder syndrome.

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy. A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work. Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Patella alta and increased TT-TG distance do not adversely affect patient-reported outcomes following isolated MPFL reconstruction: A systematic review

OBJECTIVES

To analyze the effect of patellofemoral anatomical variations (patella alta, increased tibial tubercle-trochlear groove [TT-TG] distance, and trochlear dysplasia) on clinical outcomes after isolated medial patellofemoral ligament (MPFL) reconstruction.

METHODS

A comprehensive search from PubMed, Embase, and the Cochrane Library databases was conducted to identify studies that compared outcomes based on the presence or absence of patella alta, elevated tibial tubercle-trochlear groove (TT-TG) distance, and/or trochlear dysplasia. Exclusion criteria included reviews and meta-analyses, studies that included patients who underwent associated bony procedures, and those reporting outcomes after isolated MPFL reconstruction with no comparison between varying anatomical groups.

RESULTS

After application of selection criteria, 19 studies were included. Patella alta was not predictive of failure or poorer outcomes among 13 studies; however, 2 studies demonstrated poorer patient-reported outcome scores and/or higher failure rates with increasing patellar height. Increasing TT-TG distance demonstrated a statistically significant correlation with poorer outcomes in only one study, whereas 12 other studies showed no association. Trochlear dysplasia resulted in worse outcomes and greater failure rates in 6 studies, while 10 studies showed no statistically significant correlation between trochlear dysplasia and postoperative outcomes.

CONCLUSION

Patella alta and increased TT-TG distance did not adversely affect outcomes following isolated MPFL reconstruction in the preponderance of reviewed studies. Data are mixed regarding the impact of trochlear dysplasia on the outcomes of isolated MPFL reconstruction.

LEVEL OF EVIDENCE

IV.

Effect of Antecedent Hypertension on Mortality After Acute Coronary Syndromes in the Coronary Intervention Era: A Meta-analysis

BACKGROUND

The effect of antecedent hypertension on mortality after acute coronary syndromes (ACS) in the percutaneous coronary intervention era is unclear. Therefore, this meta-analysis aimed to assess the effect of antecedent hypertension on short-term and long-term mortality after ACS in the coronary intervention era.

METHODS

PubMed, Medline, EMBASE, and the Cochrane library were systematically searched up to July 2023. Ten studies with a total of 64,989 of patients met the inclusion criteria. The outcomes of interest were all-cause in-hospital mortality and long-term all-cause mortality.

RESULTS

No significant difference was observed in in-hospital mortality between the antecedent hypertension and non-antecedent hypertension groups in the ACS patients (pooled OR 1.07; 95% CI 0.79-1.45; I2=82%), which was the same as the ST elevation myocardial infarction group (pooled OR 1.01; 95% CI 0.73-1.39; I2=66%). However, the result was statistically significant for non-ST elevation myocardial infarction patients (pooled OR 0.67; 95% CI 0.55-0.82; p=0.0001; I2=0%). Antecedent hypertension was related to increased long-term mortality in patients with ACS (pooled OR 1.28; 95% CI 1.16-1.40; p=0.0001; I2=0%), which was the same as the ST elevation myocardial infarction subgroup.

CONCLUSION

In the percutaneous coronary intervention era, antecedent hypertension is associated with higher long-term mortality in ACS patients. This meta-analysis found no significant difference in in-hospital mortality between the hypertension and non-hypertension groups. However, antecedent hypertension may be a protective factor related to in-hospital mortality for non-ST elevation myocardial infarction patients.

Mortality across treatment strategies in intermediate-to-high risk pulmonary embolism in the modern era: A meta-analysis of observational studies and RCTs

INTRODUCTION

Pulmonary embolism (PE) represents one of the leading causes of death worldwide and mainly treated with medical management, although the utility of more invasive approaches has emerged more recently. This meta-analysis aims to evaluate the 30-day mortality of intermediate-to-high risk PE across different treatment strategies.

METHODS

A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting 30-day mortality rates in intermediate-to-high-risk PE were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, 30-day mortality, and secondary endpoints (RV/LV ratio, mPAP, and long-term mortality, any bleeding events).

RESULTS

Of the 2390 studies published between 2000 and 2022, 76 studies (74 observational and 2 RCTs for a total of 1,194,285 patients in the medical cohort and 3007 in the interventional cohort) were included. The median age was 71.4 (IQR 62.8-77.3) years, 53.6% were women. 30-day mortality in the patients treated with medical management was 9.1% (6.6-12.6). In the interventional cohort, 30-day mortality was 2.1% (1.5-3.1) while the pre- vs post-procedure change in mean difference was -6.1 mmHg (-11.2 to -1.1) for mPAP and - 0.41 (-0.51 to - 0.31) for RV/LV ratio. The overall bleeding rate in the interventional cohort was 4.9% (CI 2.6-8.9), without differences between the two strategies (RR 1.26 CI 0.89-1.78).

CONCLUSION

Intermediate-high-risk mortality in pulmonary embolisms treated with medical management remains high in the modern era. Despite the absence of comparative studies, an interventional approach may have a lower 30-day mortality rate and a good safety profile.

Clinical Outcomes of Unicompartmental Knee Arthroplasty in Patients with Full-versus Partial-Thickness Cartilage Loss: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of the study was to compare postoperative patient-reported outcomes and reoperation rates following unicompartmental knee arthroplasty (UKA) between patients with full-thickness cartilage loss (FTCL) and partial-thickness cartilage loss (PTCL).

DESIGN

Multiple databases, including PubMed, Embase, Cochrane Library, and CNKI, were searched until October 2019 for studies comparing the Oxford Knee Score (OKS), American Knee Society (AKS) score, and reoperation rates between patients with FTCL and PTCL following UKA. Data analysis was performed using Review Manager software.

RESULTS

A total of 613 UKA cases from 5 retrospective cohort studies were included. The mean difference in postoperative OKSs was significantly higher by 2.92 in FTCL group than in PTCL group (95% confidence interval [CI] = -5.29 to -0.55; P = 0.02). Improvement in OKS was significantly higher by 2.69 in FTCL group than in PTCL group (95% CI = -4.79 to -0.60; P = 0.01). However, the differences in OKSs were not clinically significant. The mean difference in AKS knee scores was similar between the 2 groups (95% CI = -9.14 to -3.34; P = 0.36), whereas the pooled mean difference in AKS function scores was higher by 5.63 in FTCL group than in PTCL group (95% CI = -9.27 to -1.98; P = 0.002), which was clinically relevant. The reoperation rates were statistically higher in PTCL group than in FTCL group (odds ratio = 2.24; 95% CI = 1.15 to 4.38; P = 0.02).

CONCLUSIONS

Patients with FTCL achieved superior postoperative patient-reported outcomes and lower reoperation rates following UKA compared with those with PTCL. Thus, we believe this procedure should only be applied to end-stage medial osteoarthritis of the knee joint.

The efficacy of intensive lipid-lowering therapies on the reduction of LDLc and of major cardiovascular events

BACKGROUND

Statins are the cornerstone of lipid-lowering therapy (LLT) for reduction of low-density lipoprotein cholesterol (LDLc) levels and high percentage of patients require LLT combinations or alternative treatments for adequate LDLc control.

METHODS

We performed an intention-to-treat meta-analysis of published data of phase III trials evaluating LLT efficacy on major adverse cardiovascular events (MACE). The primary endpoint was MACE incidence, as reported in each trial, and secondary analyses included myocardial infarction, stroke and mortality.

RESULTS

Eleven clinical trials and 135,688 patients were included; seven trials tested high intensity LLT and 4 LLT combinations. Intensive LLT reduced MACE risk by 15% (12.03% vs. 13.79%, HR: 0.85 95% CI 0.80-0.90; p<0.001). The number needed to treat was 56 patients. Meta-regression analyses showed a linear correlation between absolute LDLc reductions and the risk of MACE. Significant reductions in myocardial infarction (HR: 0.83, 95% CI 0.80-0.86) and stroke (HR: 0.81, 95% CI 0.75-0.87) were observed. Cardiovascular death rate was 3.32% in LLT treatment arm vs. 3.56% in controls, resulting in a HR: 0.94 (95% CI 0.88-0.99; p = 0.03); no effect on all-cause mortality was observed (HR: 0.97 95% CI 0.93-1.01; p = 0.09). The sensitivity analyses verified the lack of heterogeneity, except for MACE that was mainly driven by the divergent results of the 2 trials. Small study effect was detected for the assessment of mortality.

CONCLUSIONS

Current evidence consistently supports the efficacy of available intensity LLT for LDLc decrease on MACE and cardiovascular mortality reduction.

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy. A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work. Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

The global effect of digital health technologies on health workers' competencies and health workplace: an umbrella review of systematic reviews and lexical-based and sentence-based meta-analysis

Systematic reviews have quantified the effectiveness, feasibility, acceptability, and cost-effectiveness of digital health technologies (DHTs) used by health-care workers. We aimed to collate available evidence on technologies' effect on health-care workers' competencies and performance. We searched the Cochrane Database of Systematic Reviews, Embase, MEDLINE, Epistemonikos, and Scopus for reviews published from database inception to March 1, 2023. Studies assessing the effects of DHTs on the organisational, socioeconomic, clinical, and epidemiological levels within the workplace, and on health-care workers' performance parameters, were included. Data were extracted and clustered into 25 domains using vote counting based on the direction of effect. The relative frequency of occurrence (RFO) of each domain was estimated using R software. AMSTAR-2 tool was used to appraise the quality of reporting, and the Confidence in the Evidence from Reviews of Qualitative research approach developed by Grading of Recommendations Assessment, Development and Evaluation was used to analyse the certainty of evidence among included studies. The 12 794 screened reviews generated 132 eligible records for assessment. Top-ranked RFO identifiers showed associations of DHT with the enhancement of health-care workers' performance (10·9% [95% CI 5·3-22·5]), improvement of clinical practice and management (9·8% [3·9-24·2]), and improvement of care delivery and access to care (9·2% [4·1-20·9]). Our overview found that DHTs positively influence the daily practice of health-care workers in various medical specialties. However, poor reporting in crucial domains is widely prevalent in reviews of DHT, hindering our findings' generalisability and interpretation. Likewise, most of the included reviews reported substantially more data from high-income countries. Improving the reporting of future studies and focusing on low-income and middle-income countries might elucidate and answer current knowledge gaps.

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.

Association of Successful Percutaneous Revascularization of Chronic Total Occlusions With Quality of Life: A Systematic Review and Meta-Analysis

Importance

Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is not usually offered because of skepticism about long-term clinical benefits.

Objective

To assess the association of successful CTO-PCI with quality of life by analyzing the relevant domains of the Seattle Angina Questionnaire (SAQ).

Data Sources

PubMed, EMBASE, Web of Science, Google Scholar, and Cochrane databases were searched to identify randomized trials and observational studies specifically addressing quality of life domains of SAQ from January 2010 to June 2022.

Study Selection

Studies included reporting SAQ metrics such as angina frequency, physical limitation, and quality of life, before and after CTO-PCI.

Data Extraction and Synthesis

The present study was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements, in which fixed-effect or random-effect models with generic inverse-variance weighting depending on statistical homogeneity were applied. Data were extracted by 3 independent reviewers.

Outcomes and Measures

The primary outcome was angina frequency; physical limitation and quality of life were assessed as secondary outcomes.

Results

Seven prospective randomized or observational studies (2500 patients) were included, with a mean (SD) participant age of 61.2 (2.1) years. CTO-PCI was associated with significantly improved quality-of-life metrics during a mean (SD) follow-up of 14.8 (16.3) months. In patients with successful procedures, angina episodes became less frequent (mean [SD] difference for SAQ angina frequency of 12.9 [3.1] survey points [95% CI, 7.1-19.8 survey points]; standardized mean difference was 0.54 [95% CI, 0.21-0.92]; P = .002; I2 = 86.4%) and they experienced less physical activity limitation (mean [SD] difference for SAQ physical limitation of 9.7 [6.2] survey points [95% CI, 3.5-16.2 survey points]; standardized mean difference was 0.42 [95% CI, 0.24-0.55]; P < .001; I2 = 20.9%), and greater quality-of-life domain (mean [SD] difference for SAQ quality of life of 14.9 [3.5] survey points [95% CI, 7.7-22.5 survey points]; standardized mean difference was 0.41 [95% CI, 0.25-0.61]; P < .001; I2 = 58.8%) compared with patients with optimal medical therapy or failed procedure. Furthermore, follow-up duration (point estimate, 0.03; 95% CI, 0.01-0.04; P = .01) was associated with a significant decrease in angina frequency in meta-regression analysis.

Conclusions and Relevance

In this systematic review and meta-analysis examining quality of life following CTO-PCI, successful procedures were associated with improved quality-of-life parameters compared with patients on optimal medical therapy or after failed CTO-PCI. These findings suggest support for using PCI to treat CTOs in symptomatic patients unresponsive to medical treatment.

The role of NF-κB in breast cancer initiation, growth, metastasis, and resistance to chemotherapy

Breast cancer (BC) is the second most fatal disease and is the prime cause of cancer allied female deaths. BC is caused by aberrant tumor suppressor genes and oncogenes regulated by transcription factors (TFs) like NF-κB. NF-κB is a pro-inflammatory TF that crucially alters the expressions of various genes associated with inflammation, cell progression, metastasis, and apoptosis and modulates a network of genes that underlie tumorigenesis. Herein, we focus on NF-κB signaling pathways, its regulators, and the rationale for targeting NF-κB. This review also includes TFs that maintain NF-κB crosstalk and their roles in promoting angiogenesis and metastasis. In addition, we discuss the importance of combination therapies, resistance to treatment, and potential novel therapeutic strategies including nanomedicine that targets NF-κB.

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy.A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work.Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Guidance to best tools and practices for systematic reviews

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy.A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work.Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Guidance to Best Tools and Practices for Systematic Reviews

» Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy.» A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work.» Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

Effect of n-3 PUFA on left ventricular remodelling in chronic heart failure: a systematic review and meta-analysis

Accumulating evidence suggests that supplementation of n-3 PUFA was associated with reduction in risk of major cardiovascular events. This meta-analysis was to systematically evaluate whether daily supplementation and accumulated intake of n-3 PUFA are associated with improved left ventricular (LV) remodelling in patients with chronic heart failure (CHF). Articles were obtained from Pubmed, Clinical key and Web of Science from inception to January 1 in 2021, and a total of twelve trials involving 2162 participants were eligible for inclusion. The sources of study heterogeneity were explained by I2 statistic and subgroup analysis. Compared with placebo groups, n-3 PUFA supplementation improved LV ejection fraction (LVEF) (eleven trials, 2112 participants, weighted mean difference (WMD) = 2·52, 95 % CI 1·25, 3·80, I2 = 87·8 %) and decreased LV end systolic volume (five studies, 905 participants, WMD = -3·22, 95 % CI 3·67, -2·77, I2 = 0·0 %) using the continuous variables analysis. Notably, the high accumulated n-3 PUFA dosage groups (≥ 600 g) presented a prominent improvement in LVEF, while the low and middle accumulated dosage (≤ 300 and 300-600 g) showed no effects on LVEF. In addition, n-3 PUFA supplementation decreased the levels of pro-inflammatory mediators including TNF-α, IL-6 (IL-6) and hypersensitive c-reactive protein. Therefore, the present meta-analysis demonstrated that n-3 PUFA consumption was associated with a substantial improvement of LV function and remodelling in patients subjected to CHF. The accumulated dosage of n-3 PUFA intake is vital for its cardiac protective role.

A meta-analysis on the characteristics of placebo effects on urinary function in placebo-controlled clinical trials among Japanese patients

OBJECTIVES

This study aimed to assess the effect sizes, changes over time, and ethnic differences in placebo effects on urinary function among Japanese patients participating in clinical trials.

METHODS

A meta-analysis of 30 Japanese placebo-controlled clinical trials was conducted to determine the placebo effects on three functions: daily urinary frequency, nocturnal urinary frequency, and average urine volume per void.

RESULTS

The I-square heterogeneity values for the basic values of the three functions ranged from 84.5% to 97.9%, with differences among trials. Longitudinal analysis (1 to 12 weeks) indicated an enhanced placebo effect for up to 8 weeks and no consistency among trials on nocturnal urinary frequency (p < 0.01), unlike those on daily urinary frequency and average urine volume per void (p = 1.0). Based on the random-effects model, the mean differences in urinary frequency at 4, 8, and 12 weeks were -0.70 (-0.80; -0.60), -1.06 (-1.16; -0.96), and -1.18 (-1.34; -1.01), respectively. Furthermore, the mean difference (95% confidence interval) in nocturnal urinary frequency and volume of urination per void at 12 weeks was -0.63 (-0.94; -0.31) and 9.67 (7.25; 12.1), respectively.

CONCLUSIONS

My findings suggest an increase in the strength of placebo effects over time (up to 8 weeks). A comparison of my results to those published in previous global reports showed no meaningful differences in placebo effects among ethnic groups. The consistent placebo effect size on urinary function could be an external indicator in clinical trials.

Psoriasis Patients Treated With Methotrexate Have an Increased Risk of Nonmelanoma Skin Cancer: A Systematic Review and Meta-Analysis

Both psoriasis and methotrexate are associated with an increased risk of nonmelanoma skin cancer. The effect of methotrexate on the development of nonmelanoma skin cancer in patients with psoriasis is currently unknown. To evaluate this relationship, a systematic review of the literature was conducted using databases including Ovid Medline (from 1946), Scopus (from 1970), and Embase (from 1974) through June 2019. Observational comparative and case-control studies comparing psoriasis patients treated with methotrexate to those not treated with methotrexate with data on the subsequent development of nonmelanoma skin cancer in both cohorts were included based on prespecified criteria. Two reviewers analyzed all studies for relevant data, which were analyzed using OpenMeta-Analyst statistical software. Quality was assessed with the Newcastle-Ottawa method. Nine cohort and case-control comparative studies of 1,486 screened abstracts met the inclusion criteria. Of 11,875 reported patients with psoriasis, 2,192 were taking methotrexate. A meta-analysis demonstrated an odds ratio of 2.8 (95% confidence interval = 1.47-5.39; p = 0.002) for nonmelanoma skin cancer development in patients with psoriasis taking methotrexate compared with those not taking methotrexate. Based on these findings, psoriasis patients treated with methotrexate are at a significantly increased (2.8 times higher) risk of developing nonmelanoma skin cancer. Risk counseling can improve healthcare outcomes in patients with psoriasis.

Restricted Versus Liberal Versus Goal-Directed Fluid Therapy for Non-vascular Abdominal Surgery: A Network Meta-Analysis and Systematic Review

Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.

Is There an Inflammatory Profile of Perinatal Depression?

PURPOSE OF REVIEW

To synthesize and critically examine recent evidence regarding associations between immune system activity and perinatal depression.

RECENT FINDINGS

Despite a significant number of studies assessing potential immunological markers of perinatal depression, it does not appear that levels of any individual pro- or anti-inflammatory marker is a useful predictor of perinatal depression. Some recent studies have observed differences in overall immune system functioning and adaptation across this period, taking into account multiple pro- and anti- inflammatory markers. Furthermore, there is evidence for interactions between depression and maternal psychosocial factors. Immune system functioning may be a mechanism through which social determinants of health contribute to risk for perinatal depression. There is substantial evidence implicating dysregulated immune activity in perinatal depression, yet little clarity regarding a consistent immune profile, especially based on analysis of circulating peripheral cytokines.

One-Third of Systematic Reviews in Rehabilitation Applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) System to Evaluate Certainty of Evidence: A Meta-Research Study

OBJECTIVE

To determine how many systematic reviews (SRs) of the literature in rehabilitation assess the certainty of evidence (CoE) and how many apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to do this.

DATA SOURCES

For this meta-research study, we searched PubMed and Cochrane Database of Systematic Reviews databases for SRs on rehabilitation published in 2020.

STUDY SELECTION AND DATA EXTRACTION

Two reviewers independently selected the SRs and extracted the data. Reporting characteristics and appropriate use of the GRADE system were assessed.

DATA SYNTHESIS

The search retrieved 827 records: 29% (239/827) SRs evaluated CoE, 68% (163/239) of which applied the GRADE system. GRADE was used by SRs of randomized controlled trials (RCTs, 88%; 144/163), non-randomized intervention studies (NRIS, 2%; 3/163), and both RCT and NRIS (10%; 16/163). In the latter case, a separate GRADE assessment according to the study design was not provided in 75% (12/16). The reasons for GRADE judgment were reported in 82% (134/163) of SRs.

CONCLUSIONS

One-third of SRs in rehabilitation assessed CoE with the GRADE system. GRADE assessment was presented transparently by most SRs. Journal editors and funders should encourage the uptake of the GRADE system when considering SRs in rehabilitation for publication. The authors should pre-define GRADE assessment in a registered and/or published protocol.

Study design methodology in neurosurgical research

Background

Medical research has evolved from individual expert-described opinions and techniques to scientifically designed methodology-based studies. There are different study designs, and selecting an appropriate study design is critical to appropriately answer the research question being investigated.

Main body

A research question may be addressed using different approaches that can be descriptive, analytical, or experimental. The choice of study design is influenced by features as that related to exposure (intervention) and disease (outcome); considerations related to time, resources, ethics and gaps in scientific knowledge that remain to be filled. The purpose of this review is to provide an overview of the basic study designs as it is the foundation of neurosurgical research to provide valid scientific evidence.

Conclusion

Quality in scientific research begins with a clear hypothesis and a well-formulated design. This entails a thorough understanding of the different study designs to choose the best suited to answer the investigated research question.

Cemented vs Uncemented hemiarthroplasties for femoral neck fractures: An overlapping systematic review and evidence appraisal

BACKGROUND

The purpose of our study is to assess the methodology of overlapping systematic reviews related to cemented vs uncemented hip hemiarthroplasties for the treatment of femoral neck fractures to find the study with the best evidence. Also, we assess the gaps in methodology and information to help with direction of future studies.

METHODS

A systematic search was conducted in September 2022 using Pubmed, Embase, and Cochrane Library. Clinical outcome data and characteristics of each study were extracted to see which treatment had better favorability. The outcomes and characteristics extracted from each study includes, first author, search date, publication journal and date, number of studies included, databases, level of evidence, software used, subgroup analyses that were conducted, and heterogeneity with the use of I2 statistics Methodological quality information was extracted from each study using four different methodologic scores (Oxford Levels of Evidence; Assessment of Multiple Systematic Reviews (AMSTAR); Quality of reporting of meta-analyses (QUROM); Oxman and Guyatt. After that, the Jadad decision algorithm was used to identify which studies in our sample contained the best available evidence. Finally, overlap of each systematic review was assessed using Corrected Covered Area (CCA) to look at redundancy and research waste among the systematic reviews published on the topic.

RESULTS

After screening, 12 studies were included in our sample. For the Oxford Levels of Evidence, we found that all the studies were Level I evidence. For the QUORUM assessment, we had 1 study with the highest score of 18. Additionally, we did the Oxman and Guyatt assessment, where we found 4 studies with a maximum score of 6. Finally, we did an AMSTAR assessment and found 2 studies with a score of 9. After conducting the methodological scores; the authors determined that Li. L et al 2021 had the highest quality. In addition, it was found that the CCA found among the primary studies in each systematic review calculated to .22. Any CCA above .15 is considered "very high overlap".

CONCLUSIONS

The best available evidence suggests that Cemented HAs are better at preventing Prosthesis-related complications. Conversely, the best evidence also suggests that Cemented HA also results in longer operative time and increased intraoperative blood loss. When conducting future systematic reviews related to the topic, we ask that authors restrict conducting another systematic review until new evidence emerges so as not to confuse the clinical decision-making of physicians.

Methodological, reporting, and evidence quality of systematic reviews of traditional Chinese medicine for ischemic stroke

Objective: The aim of this study is to critically appraise whether published systematic reviews/meta-analyses of traditional Chinese medicine for adults with ischemic stroke are of sufficient quality and to rate the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Method: A literature search was performed in the Cochrane Library, PubMed, Chinese National Knowledge Infrastructure, and SinoMed databases by March 2022. The inclusion criteria were systematic reviews/meta-analyses of traditional Chinese medicine in adults who suffered from ischemic stroke. A Measurement Tool to Access Systematic Reviews 2 (AMSTAR-2) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Abstract (PRISMA-A) statements were used to assess the methodological and reporting quality of the included reviews. The Grading of Recommendations, Assessment, Development, and Evaluation system was utilized to assess each report's evidence level. Results: Of the 1,908 titles and abstracts, 83 reviews met the inclusion criteria. These studies were published between 2005 and 2022. The results of AMSTAR-2 showed that 51.4% of the items were reported, but the registration, reasons for the inclusion of study design, the list of excluded studies, and funding information were ignored in the majority of the reviews. The results of PRISMA-A showed that 33.9% of items were reported, and the information on registration, limitation, and funding was not available in many publications. The assessment of the evidence with the Grading of Recommendations, Assessment, Development, and Evaluation showed that more than half (52/83) of the included studies had either low or very low levels of evidence. Conclusion: The reporting quality in the abstract of systematic reviews/meta-analyses on traditional Chinese medicine for ischemic stroke is poor and does not facilitate timely access to valid information for clinical practitioners. Although the methodological quality is of a medium level, this evidence lacks certainty, especially with a high risk of bias in individual studies.

Measurement studies of personal exposure to radiofrequency electromagnetic fields: A systematic review

The last 25 years have seen an increase in the number of radiofrequency sources with the global adoption of smartphones as primary connectivity devices. The objective of this work was to review and evaluate the measured studies of personal exposure to Radiofrequency Electromagnetic Fields (RF-RMF) and meet the basic quality criteria eligible for inclusion in this Review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, following the eligibility criteria of the PECO (Population, Exposure, Comparator, and Outcome) methodology, and the instrument for critical reading Critical Appraisal Skills Programme Español (CASPe). We systematically reviewed the works published between January 1, 1998, and December 31, 2021, yielding 56 publications. Of the different types of studies in which personal exposure to RF-EMF has been measured with two measurement methodologies can be highlighted: Personal measurements with volunteers and Personal measurements with a trained researcher (touring a specific area, one or several microenvironments, an entire city, walking or in some means of transport). Personal exposimeters were used in 83% of the studies. The lowest mean was measured in Egypt with a value of 0.00100 μW/m² (1.00 nW/m²) in 2007 and the highest mean was measured in Belgium with a value of 285000 μW/m² (0.285 W/m²) in 2019. The results of our study confirm that RF-EMF exposure levels are well below the maximum levels established by the ICNIRP guidelines.

Cannabinoids versus placebo for pain: A systematic review with meta-analysis and Trial Sequential Analysis

OBJECTIVES

To assess the benefits and harms of cannabinoids in participants with pain.

DESIGN

Systematic review of randomised clinical trials with meta-analysis, Trial Sequential Analysis, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

The Cochrane Library, MEDLINE, Embase, Science Citation Index, and BIOSIS.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Published and unpublished randomised clinical trials comparing cannabinoids versus placebo in participants with any type of pain.

MAIN OUTCOME MEASURES

All-cause mortality, pain, adverse events, quality of life, cannabinoid dependence, psychosis, and quality of sleep.

RESULTS

We included 65 randomised placebo-controlled clinical trials enrolling 7017 participants. Fifty-nine of the trials and all outcome results were at high risk of bias. Meta-analysis and Trial Sequential Analysis showed no evidence of a difference between cannabinoids versus placebo on all-cause mortality (RR 1.20; 98% CI 0.85 to 1.67; P = 0.22). Meta-analyses and Trial Sequential Analysis showed that cannabinoids neither reduced acute pain (mean difference numerical rating scale (NRS) 0.52; 98% CI -0.40 to 1.43; P = 0.19) or cancer pain (mean difference NRS -0.13; 98% CI -0.33 to 0.06; P = 0.1) nor improved quality of life (mean difference -1.38; 98% CI -11.81 to 9.04; P = 0.33). Meta-analyses and Trial Sequential Analysis showed that cannabinoids reduced chronic pain (mean difference NRS -0.43; 98% CI -0.72 to -0.15; P = 0.0004) and improved quality of sleep (mean difference -0.42; 95% CI -0.65 to -0.20; P = 0.0003). However, both effect sizes were below our predefined minimal important differences. Meta-analysis and Trial Sequential Analysis indicated that cannabinoids increased the risk of non-serious adverse events (RR 1.20; 95% CI 1.15 to 1.25; P < 0.001) but not serious adverse events (RR 1.18; 98% CI 0.95 to 1.45; P = 0.07). None of the included trials reported on cannabinoid dependence or psychosis.

CONCLUSIONS

Cannabinoids reduced chronic pain and improved quality of sleep, but the effect sizes are of questionable importance. Cannabinoids had no effects on acute pain or cancer pain and increased the risks of non-serious adverse events. The harmful effects of cannabinoids for pain seem to outweigh the potential benefits.

Efficacy of Probiotics Compared to Chlorhexidine Mouthwash in Improving Periodontal Status: A Systematic Review and Meta-Analysis

Purpose

To critically evaluate the available literature and conduct a systematic review of recent randomized controlled trials to assess the effectiveness of probiotics compared to chlorhexidine mouthwash in enhancing periodontal health.

Methods

Five databases were searched electronically, as well as the gray literature. Using the Cochrane risk-of-bias tool for randomized clinical trials, the risk of bias was examined. The weighted mean difference (WMD) method was used to calculate the effect sizes. Heterogeneity was assessed using I ² and τ ² statistics. The GRADE approach was adopted to assess the certainty of the evidence. To assess the robustness of the findings, sensitivity analysis and publication bias assessment were undertaken.

Results

A total of 1850 studies were initially identified. Sixteen clinical trials were eligible for qualitative synthesis, and ten were included in the meta-analysis. In terms of the gingival index, in total, no statistically significant difference was observed between chlorhexidine and probiotics within 4 weeks (WMD -0.03, 95% CI: -0.09∼0.04, P = 0.3885). Similar to GI, no statistically significant difference was observed between chlorhexidine and probiotics regarding the plaque index within 4 weeks (WMD 0.11, 95% CI: -0.05∼0.28, P = 0.1726). No statistically significant difference was observed between chlorhexidine and probiotics in all time intervals regarding oral hygiene index-simplified (WMD -0.01, 95% CI: -0.05∼0.04, P = 0.7508). The robustness of these findings was confirmed by sensitivity analysis and publication bias assessments.

Conclusions

Based on the findings, probiotics were an acceptable alternative to conventional chlorhexidine in improving periodontal health. High-quality studies with rigorous methodology should be conducted to assess the optimum doses of probiotics for clinical implications.

A Review of Machine Learning and Deep Learning Approaches on Mental Health Diagnosis

Combating mental illnesses such as depression and anxiety has become a global concern. As a result of the necessity for finding effective ways to battle these problems, machine learning approaches have been included in healthcare systems for the diagnosis and probable prediction of the treatment outcomes of mental health conditions. With the growing interest in machine and deep learning methods, analysis of existing work to guide future research directions is necessary. In this study, 33 articles on the diagnosis of schizophrenia, depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), anorexia nervosa, and attention deficit hyperactivity disorder (ADHD) were retrieved from various search databases using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) review methodology. These publications were chosen based on their use of machine learning and deep learning technologies, individually assessed, and their recommended methodologies were then classified into the various disorders included in this study. In addition, the difficulties encountered by the researchers are discussed, and a list of some public datasets is provided.

What Are the Determinants of the Quality of Systematic Reviews in the International Journals of Occupational Medicine? A Methodological Study Review of Published Literature

Objective: The aim of this study was to evaluate the methodological quality of systematic reviews published in occupational medicine journals from 2014 to 2021. Methods: Papers edited between 2014 and 2021 in the 14 open access journals with the highest impact were assessed for their quality. Studies were included if they were systematic reviews and meta-analyses, and if they were published in English. Results: The study included 335 studies. Among these, 149 were meta-analyses and 186 were systematic reviews. The values of the AMSTAR-2 score range between three and fourteen with a mean value of 9.85 (SD = 2.37). The factors that significantly and directly associate to a higher AMSTAR-2 score were impact factor (p = 0.003), number of consulted research databases (p = 0.011), declaration of PRISMA statement (p = 0.003), year of publication (p < 0.001) and performing a meta-analysis (p < 0.001).The R² values from the multivariate analysis showed that the AMSTAR-2 score could be predicted by the inclusion of these parameters by up to 23%. Conclusions: This study suggests a quality assessment methodology that could help readers in a fast identification of good systematic reviews or meta-analyses. Future studies should analyze more journals without applying language restrictions and consider a wider range of years of publication in order to give a more robust evidence for results.

Guidance to best tools and practices for systematic reviews1

Data continue to accumulate indicating that many systematic reviews are methodologically flawed, biased, redundant, or uninformative. Some improvements have occurred in recent years based on empirical methods research and standardization of appraisal tools; however, many authors do not routinely or consistently apply these updated methods. In addition, guideline developers, peer reviewers, and journal editors often disregard current methodological standards. Although extensively acknowledged and explored in the methodological literature, most clinicians seem unaware of these issues and may automatically accept evidence syntheses (and clinical practice guidelines based on their conclusions) as trustworthy.A plethora of methods and tools are recommended for the development and evaluation of evidence syntheses. It is important to understand what these are intended to do (and cannot do) and how they can be utilized. Our objective is to distill this sprawling information into a format that is understandable and readily accessible to authors, peer reviewers, and editors. In doing so, we aim to promote appreciation and understanding of the demanding science of evidence synthesis among stakeholders. We focus on well-documented deficiencies in key components of evidence syntheses to elucidate the rationale for current standards. The constructs underlying the tools developed to assess reporting, risk of bias, and methodological quality of evidence syntheses are distinguished from those involved in determining overall certainty of a body of evidence. Another important distinction is made between those tools used by authors to develop their syntheses as opposed to those used to ultimately judge their work.Exemplar methods and research practices are described, complemented by novel pragmatic strategies to improve evidence syntheses. The latter include preferred terminology and a scheme to characterize types of research evidence. We organize best practice resources in a Concise Guide that can be widely adopted and adapted for routine implementation by authors and journals. Appropriate, informed use of these is encouraged, but we caution against their superficial application and emphasize their endorsement does not substitute for in-depth methodological training. By highlighting best practices with their rationale, we hope this guidance will inspire further evolution of methods and tools that can advance the field.

The impact of funding on the quality and interpretation of systematic reviews of mechanical thrombectomy in stroke patients

BACKGROUND

Funding may impact the quality and findings of systematic reviews (SRs). We aimed to compare the methodological quality of funded and non-funded SRs that investigated the outcomes in ischemic stroke patients undergoing mechanical thrombectomy.

METHODS

We conducted a comprehensive search strategy in different databases, including Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline (including epub ahead of print, in-process & other non-indexed citations), PubMed, Scopus and Web of Science Core Collection to retrieve all relevant SRs. Random sequence generation matched each funded SR with a non-funded one. A Measurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool was used to assess the bias and quality of the included SRs. We also used uni- and multivariate analysis to perform our analysis, and results were expressed in odds ratio (OR) and 95% confidence interval (CI).

RESULTS

We retrieved 150 articles, which were randomized and matched into 100 SRs, including 50 funded and 50 non-funded studies. By multivariate analysis, we found that including randomized clinical trials (RCTs) (OR: 5.7; 95% CI: 1.8-17.8; p = 0.003) and reporting conflict of interests (OR: 5.2; 95 CI: 1.1-24; p = 0.036) were the only significant differences between funded and non-funded SRs. No significant differences were found regarding the overall confidence for low-quality (OR: 0.54; 95% CI: 0.09-3.2; p = 0.49) and moderate/high-quality SRs (OR: 0.17; 95% CI: 0.02-1.87; p = 0.14).

CONCLUSION

Funded studies tend to include RCTs more often and report conflict of interests with no significant impact on overall confidence.

Prebriefing for high-fidelity simulation in nursing education: A meta-analysis

BACKGROUND

Briefing, scenario development, and debriefing of high-fidelity simulation (HFS) have been widely discussed in the past, but less attention is given to prebriefing, and its role in learning outcomes. The prebriefing engages students and equips them with the knowledge and skills they need for a successful simulation.

OBJECTIVES

To identify the effectiveness of prebriefing of HFS in Bachelor of Science in Nursing (BSN) students.

DESIGN

A meta-analysis of randomized controlled trials and quasi-experiment.

DATA SOURCES

The Web of Science, PubMed, Embase, Cochrane Library, WANFANG, and CNKI were for randomized controlled and quasi-experimental studies published in English or Chinese up to June 26, 2022.

REVIEW METHODS

Two authors independently screened the literature, extracted data and evaluated the quality of the included studies. The standardized mean difference with a 95 % confidence interval was used to facilitate direct comparisons between studies. All statistical tests were conducted with Review Manager 5.4 software.

RESULTS

This meta-analysis included 17 randomized controlled studies and 25 quasi-experimental studies involving 4926 BSN students. No significant differences in knowledge (p = 0.58), skill (p = 0.67), satisfaction (p = 0.84), critical thinking (p = 0.56), caring (p = 0.11), learning interest (p = 0.85), and self-confidence (p = 0.21) between HFS with and without prebriefing were found in subgroup analyses. HFS with prebriefing generated larger effect for collaboration (0.82 vs 0.27, p = 0.004).

CONCLUSION

HFS with prebriefing facilitates collaboration of BSN students more effectively, and it has an equivalent effect to HFS without prebriefing on fostering BSN students' knowledge, skills, critical thinking, caring, learning interest, and self-confidence.

PROTOCOL: Critical appraisal of methodological quality and reporting items of systematic reviews with meta-analysis in evidence-based social science in China: A systematic review

This is the protocol for a Campbell systematic review. The objectives are as follows: (1) To evaluate the reporting quality of systematic reviews published in Chinese social science journals against the PRISMA and MOOSE standards; (2) To evaluate the methodology quality of systematic reviews published in Chinese social science journals against the AMSTAR-2 and DART standards; and (3) To analyze other characteristics of systematic reviews published in Chinese social science journals using content analysis.

Synthesizing genome regulation data with vote-counting

The increasing availability of high-throughput datasets allows amalgamating research information across a large body of genome regulation studies. Given the recent success of meta-analyses on transcriptional regulators, epigenetic marks, and enhancer:gene associations, we expect that such surveys will continue to provide novel and reproducible insights. However, meta-analyses are severely hampered by the diversity of available data, concurring protocols, an eclectic amount of bioinformatics tools, and myriads of conceivable parameter combinations. Such factors can easily bar life scientists from synthesizing omics data and substantially curb their interpretability. Despite statistical challenges of the method, we would like to emphasize the advantages of joining data from different sources through vote-counting and showcase examples that achieve a simple but highly intuitive data integration.

A methodological review with meta-epidemiological analysis of preclinical systematic reviews with meta-analyses

Systematic reviews and meta-analyses have been proposed as an approach to synthesize the literature and counteract the lack of power of small preclinical studies. We aimed to evaluate (1) the methodology of these reviews, (2) the methodological quality of the studies they included and (3) whether study methodological characteristics affect effect size. We searched MEDLINE to retrieve 212 systematic reviews with meta-analyses of preclinical studies published from January, 2018 to March, 2020. Less than 15% explored the grey literature. Selection, data extraction and risk of bias assessment were performed in duplicate in less than two thirds of reviews. Most of them assessed the methodological quality of included studies and reported the meta-analysis model. The risk of bias of included studies was mostly rated unclear. In meta-epidemiological analysis, none of the study methodological characteristics was associated with effect size. The methodological characteristics of systematic reviews with meta-analyses of recently published preclinical studies seem to have improved as compared with previous assessments, but the methodological quality of included studies remains poor, thus limiting the validity of their results. Our meta-epidemiological analysis did not show any evidence of a potential association between methodological characteristics of included studies and effect size.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

C-reactive protein and coronary atheroma regression following statin therapy: A meta-regression of randomized controlled trials

OBJECTIVE

Several clinical trials have indicated that statins stabilize and reverse atherosclerotic plaque. However, different studies have provided inconsistent findings regarding mechanisms and influencing factors of plaque regression under statin therapy. Apart from lipid-lowering effect, statins have pleiotropic effects including anti inflammation in humans. In this study, meta-analysis and meta-regression were used to determine the effects of statin medications on coronary plaque volume. Meanwhile, to assess whether statins promote plaque regression effect was related to their anti-inflammatory ability, the impact of CRP/hsCRP reduction during statin therapy on plaque regression was investigated.

METHODS

Up to June 15, 2022, a systematic PubMed, EMBASE, and Cochrane search was performed for randomized controlled trials that assessed treatment effect using total atheroma volume (TAV), percent atheroma volume (PAV), or plaque volume (PV). Only CRP/hsCRP and LDL-C values reported before and after treatment were considered.

RESULTS

12 studies (2,812 patients with heart and/or vascular disease) fulfilled the inclusion criteria and were included in the systematic review. A meta-analysis of 15 statin-treated arms reported a significant reduction in change of TAV/PV [standardized mean difference (SMD): -0.27, 95% confidence intervals (-CI): -0.42, -0.12, p < 0.001], compared with the control arms. Another meta-analysis of 7 trials also found that patients in the intervention group had a significant reduction in change of PAV (SMD: -0.16, 95% CI: -0.29, -0.03, p = 0.019), compared with those in the control group. Meta-regressionanalysis revealed that the percent change of CRP/hsCRP was significantly associated with SMD in change of TAV/PV after adjusting for percent change of LDL-C, age, gender and study duration. Meta-regression analysis showed that percent change of CRP/hsCRP statistically influenced SMD in change of PAV, when percent change of CRP/hsCRP was included separately. However, the percent change of CRP/hsCRP was not significantly associated with SMD of PAV change after adjusting for all covariates.

CONCLUSION

In conclusion, statin therapy is beneficial for plaque regression. Statins promote plaque regression, which might be associated to their anti-inflammatory ability.