Grading quality of evidence and strength of recommendations

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Vitamin D lacks efficacy: A re-analysis of a systematic review using the REB method

BACKGROUND

The results of randomized controlled trials (RCTs) evaluating the effect of vitamin D on the prevention of acute respiratory tract infections (RTIs) are conflicting. The aim of this study was to assess the level of evidence for the efficacy of vitamin D in preventing acute RTIs by performing a sensitivity analysis of the meta-analysis carried out by Jolliffe and al., using the Rebuild the Evidence Base (REB) method.

METHODS

The main inclusion criteria were double-blind, placebo-controlled, open-label RCTs. The exclusion criteria were RCTs in which vitamin D was associated with other nutrients and unpublished RCTs. The primary outcome was the number of people who had at least one RTI, including upper and lower RTIs. A bias analysis was performed of the included RCTs, followed by a hypothetico-deductive analysis to determine whether they were confirmatory or exploratory. Then, we used the REB method to determine the level of evidence for the effectiveness of vitamin D in preventing RTIs.

RESULTS

The main meta-analysis included 25 RCTs with a low risk of bias, involving 41 847 people. There was no significant difference between groups in the number of patients who had at least one RTI. According to the REB, there was a lack of evidence when assessing the effectiveness of vitamin D in preventing RTI.

CONCLUSION

According to the REB, the analysis of the RCTs, considering the risk of bias, showed that there is a lack of evidence to justify the prescription of vitamin D for the preventing of RTIs.

Effects of Malnutrition on Perioperative Outcomes of Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background

Malnutrition can play a significant role in wound healing, immune response, and conditioning. The purpose of this review is to characterize definitions of malnutrition in total hip arthroplasty (THA) and analyze its effects on postoperative outcomes.

Methods

A systematic search was conducted using iterations of the key terms "total hip arthroplasty" and "malnutrition." Human studies describing malnutrition in patients undergoing primary THA for either traumatic or elective indications were included. Using the SPSS meta-analysis binary and continuous model function, the mean effect size estimate (MSE) or Cohen's d (Cd) statistic with 95% confidence interval was reported.

Results

This search yielded a total of 555 studies, of which 9 articles comprising 495,657 patients undergoing primary THA were included, characterizing 16,895 patients (3.4%) as malnourished. Studies characterized malnutrition as albumin <3.5 g/dL (n = 7) and total lymphocyte count <1500 (n = 1). Malnutrition was associated with an increased rate of nonhome discharge (MSE = 0.81, [0.55-1.07]) and likelihood of readmission (MSE = 0.86, [0.75-0.97]). Malnutrition at the time of surgery was also associated with increased rates of any complication (MSE = 1.01, [0.46-1.57]), wound complications (MSE = 1.04, [0.72-1.36]), pulmonary complications (MSE = 1.54, [1.29-1.78]), need for transfusion (MSE = 0.75, [0.54-0.96]), periprosthetic fracture (MSE = 0.65, [0.47-0.82]), reoperation (MSE = 0.72, [0.58-0.86]), and perioperative mortality (MSE = 2.05, [1.76-2.33]).

Conclusions

Malnutrition was found to have significant associations with complications and disposition following THA. The findings from this meta-analysis provide support for further investigation into perioperative nutritional supplementation strategies for surgeons to optimize at-risk patients prior to THA.

Level of Evidence

III.

Intravenous lidocaine with propofol-based sedation for colonoscopy: a systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Intravenous lidocaine is a promising complementary strategy for sedation during surgical procedures. We performed a systematic review and meta-analysis to compare intravenous lidocaine with placebo as an adjuvant to propofol-based sedation in patients undergoing colonoscopy.

METHODS

We searched MEDLINE, Embase and Cochrane databases for randomised controlled trials comparing sedation with propofol and lidocaine vs. propofol and placebo in patients undergoing colonoscopy. The primary outcome was total propofol dose. A random-effects model was used to estimate the mean differences and risk ratios.

RESULTS

We included eight trials with 520 patients. Compared with placebo, intravenous lidocaine reduced propofol consumption during the procedure (mean difference (95%CI): -42.93 mg (-62.89 to -22.97)); shortened awakening time (mean difference (95%CI): -3.38 minutes (-5.92 to -0.84)); reduced post-procedural pain scores (mean difference (95%CI): -1.38 (-2.72 to -0.04)); and increased patient satisfaction scores (mean difference (95%CI): 0.50 (0.30 to 0.70)). There were no significant differences between the groups in procedure duration; endoscopist satisfaction scores; and risk of hypoxia or hypotension.

DISCUSSION

In patients undergoing colonoscopy, the addition of intravenous lidocaine to propofol-based sedation reduced propofol consumption, shortened awakening time, mitigated post-procedural pain and enhanced patient satisfaction compared with placebo. Although the findings are statistically significant, clinical relevance and cost-effectiveness are unclear.

Fenestrated endovascular repair for abdominal aortic aneurysms

BACKGROUND

Abdominal aortic aneurysms (AAAs) are abnormal dilatations of the aorta that most commonly affect its infrarenal segment, but can become more difficult to repair when they are close to or next to the renal arteries. The optimum treatment for these complex AAAs is unknown. One option is fenestrated endovascular aneurysm repair (FEVAR), which involves using fenestrations or scallops in the graft to facilitate access to the visceral arteries.

OBJECTIVES

To assess the benefits and harms of complex stent-graft fenestrated endovascular aneurysm repair (FEVAR) versus open surgical repair (OSR) or conservative (non-operative) management for people with complex AAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov without language, publication year or publication status restrictions (published, unpublished, in press or in progress) on 28 March 2023.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) and quasi-RCTs, comparing treatment of complex AAA with FEVAR versus open surgical repair or conservative management in adults undergoing primary repair of complex AAA.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies obtained from the search for potential inclusion in the review, in accordance with the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes were all-cause mortality (30 days and one year), aneurysm-related mortality at one year and length of hospital stay. Secondary outcomes were renal dysfunction at one year, reintervention rate at one year, visceral vessel patency at 30 days and one year, participant-reported health-related quality of life at one year, adverse events at one year and aneurysm-related mortality at 30 days.

MAIN RESULTS

We found no studies fulfilling the inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify eligible RCTs or quasi-RCTs that compared treatment of complex AAAs with FEVAR versus open surgical repair or conservative management. This is a difficult area in which to conduct research due to low incidence rates and aneurysm heterogeneity. Future studies could consider commissioning agreements mandating patient inclusion in studies to make the generation of high-quality evidence in this area feasible.

American Society of Hematology/International Society on Thrombosis and Haemostasis 2024 updated guidelines for treatment of venous thromboembolism in pediatric patients

BACKGROUND

The American Society of Hematology (ASH) guidelines on treatment of pediatric venous thromboembolism (VTE) were published in 2018. In the last 6 years, there has been a 10-fold increase in the number of children involved in VTE treatment trials.

OBJECTIVE

The ASH Committee on Quality and Guidelines agreed to update the pediatric guidelines in conjunction with the International Society on Thrombosis and Haemostasis (ISTH). These ASH/ISTH evidence-based guidelines are intended to support patients, clinicians, and other health care professionals in the management of pediatric patients with VTE.

METHODS

ASH/ISTH formed a multidisciplinary guideline panel to minimize potential bias from conflicts of interest. An unconflicted patient representative was not identified. The University of Kansas Health System supported the guideline development process, updating or performing systematic evidence reviews up to 2024. The panel focused specifically on the 2018 questions for which there was the greatest amount of interim data. The panel used the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 20 recommendations and also provided implementation guidance on the optimal use of anticoagulants in pediatric patients. Key recommendations of these guidelines include the role of DOACs in the treatment of a variety of pediatric VTEs.

CONCLUSIONS

Further research is required. Key priorities are understanding the natural history of clinically unsuspected thrombosis across a range of patient subpopulations and obtaining real-world data on the use of DOACs in children.

Nephrotoxicity Surveillance for Childhood and Young Adult Survivors of Cancer: Recommendations From the International Late Effects of Childhood Cancer Guideline Harmonization Group

PURPOSE

Childhood, adolescent, and young adult (CAYA) survivors of cancer are at risk of nephrotoxicity. Surveillance guidelines are important for timely diagnosis and treatment of these survivors, which could slow the progression to higher stages of kidney dysfunction.

METHODS

The International Late Effects of Childhood Cancer Guideline Harmonization Group established a multidisciplinary panel of 34 experts from 11 countries. The panel performed systematic literature reviews for articles published between 1990 and June 2023, graded the evidence using Grading of Recommendations Assessment, Development, and Evaluation methodology, and formulated recommendations based on evidence, clinical judgment, and consideration of benefits and harms of surveillance. Recommendations were critically appraised by two independent external experts and patient representatives.

RESULTS

Glomerular dysfunction surveillance is recommended every 2-5 years for survivors treated with ifosfamide, cisplatin, abdominal radiotherapy, total body irradiation, or nephrectomy and is reasonable after carboplatin treatment. We recommend screening for glomerular dysfunction using an estimated glomerular filtration rate (eGFR) equation that includes serum creatinine, preferably combined with serum cystatin C if available. Tubular dysfunction surveillance is recommended once at entry into long-term follow-up and with follow-up as clinically indicated for survivors treated with ifosfamide and is reasonable after cisplatin treatment.

CONCLUSION

These recommendations inform routine, uniform long-term follow-up care for CAYA survivors of cancer at risk of nephrotoxicity.

Towards Precision Medicine in Obesity: Genetic Copy Number Variations Profiling Linked to Specific Metabolic Dysregulation Patterns

This study aimed to identify and analyse the copy number variations (CNVs) in the genes involved in the pathophysiology of obesity and correlate these findings with the phenotypic manifestations. Genetic screening of 59 apparently healthy individuals with elevated adipose tissue percentages was performed, assessing the duplications and deletions of obesity-related genes through the MLPA (Multiplex Ligation-dependent Probe Amplification) technique. Clinical and metabolic parameters, including insulin, HOMA-IR, leptin, and adiponectin levels, were measured to better describe the obesity profiles of the participants in this study. In our research, 11.86% of the subjects presented with genetic alterations in obesity-associated genes, with 16% of these modifications involving concurrent duplications in SEZ6L2-1 and SH2B1-2, linked to doubled insulin and tripled HOMA-IR levels. However, the same duplications were associated with a reduced trunk adipose tissue percentage (but not BMI), suggesting leptin signalling modulation. Duplications were more frequent in the metabolically unhealthy obese patients, resulting in a higher relative risk of an obese metabolically unhealthy diagnosis (1.85-fold increased risk in subjects with SEZ6L2-1/SH2B1-2 duplications, p = 0.52). No duplications or deletions were reported in the non-obese patient groups, defined according to the BMI criteria. A partial LEPR deletion was identified in one patient, associated with severe insulin resistance (second-highest HOMA-IR in the cohort). Another subject presented with 11 duplications (7 in LEPR) and reported the lowest adiponectin and second-highest leptin levels among the genetically altered subjects. The genetic profiles revealed complex associations between the CNVs and obesity phenotypes, highlighting the potential for early risk stratification. Despite the interpretative challenges, identifying the genetic predispositions could significantly predict cardiometabolic risk and be used to map personalised interventions to possibly modulate phenotypic expression.

Electromechanical-assisted training for walking after stroke

RATIONALE

Walking difficulties are common after a stroke. During rehabilitation, electromechanical and robotic gait-training devices can help improve walking. As the evidence and certainty of the evidence may have changed since our last update in 2020, we aimed to update the scientific evidence on the benefits and acceptability of these technologies to ensure they remain a viable option for stroke rehabilitation.

OBJECTIVES

Primary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) improves walking in adults after stroke. Secondary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases. We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors to identify further published, unpublished, and ongoing trials. The date of the latest search was December 2023.

ELIGIBILITY CRITERIA

We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus physiotherapy (or usual care).

OUTCOMES

Our critical outcome was the ability to walk independently, measured with the Functional Ambulation Category (FAC). An FAC score of 4 or 5 indicated independent walking over a 15-metre surface, irrespective of aids used, such as a cane. An FAC score less than 4 indicates dependency in walking (supervision or assistance, or both, must be given in performing walking). Important outcomes included walking velocity and capacity, as well as dropouts.

RISK OF BIAS

We used Cochrane's RoB 1 tool.

SYNTHESIS METHODS

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We used random-effects models for the meta-analysis. We assessed the certainty of evidence using the GRADE approach.

INCLUDED STUDIES

We included 101 studies (39 new studies plus 62 studies from previous versions) with a total of 4224 participants after stroke in our review update.

SYNTHESIS OF RESULTS

Electromechanical-assisted gait training in combination with physiotherapy probably increases the odds of participants becoming independent in walking (odds ratio (OR) 1.65, 95% confidence interval (CI) 1.21 to 2.25; P = 0.001; I² = 31%; 51 studies, 2148 participants; moderate-certainty evidence); probably does not increase mean walking velocity (mean difference (MD) 0.05 m/s, 95% CI 0.02 to 0.08; P < 0.001; I² = 58%; 73 studies, 3043 participants; moderate-certainty evidence); and does not increase mean walking capacity (MD 11 metres walked in 6 minutes, 95% CI 1.8 to 20.3; P = 0.02; I² = 43%; 42 studies, 1966 participants; high-certainty evidence). Electromechanical-assisted gait training does not increase or decrease the risk of loss to the study during the intervention or the risk of death from all causes (high-certainty evidence). At follow-up after study end, electromechanical-assisted gait training in combination with physiotherapy may not increase the odds of participants becoming independent in walking (OR 1.64, 95% CI 0.77 to 3.48; P = 0.20; I² = 69%; 8 studies, 569 participants; low-certainty evidence), and probably does not increase mean walking velocity (MD 0.05 m/s, 95% CI -0.03 to 0.13; P = 0.22; I² = 66%; 17 studies, 857 participants; moderate-certainty evidence) or mean walking capacity (MD 9.6 metres walked in 6 minutes, 95% CI -14.6 to 33.7; P = 0.44; I² = 53%; 15 studies, 736 participants; moderate-certainty evidence). Our results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study; and (2) there was variation between trials with respect to the devices used and duration and frequency of treatment.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that people who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are probably more likely to achieve independent walking than people who receive gait training without these devices.We concluded that nine patients need to be treated to prevent one dependency in walking. Further research should consist of large, definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time poststroke in their trial design.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol (2006): doi:10.1002/14651858.CD006185 Original review (2007): doi:10.1002/14651858.CD006185.pub2 Review update (2013): doi:10.1002/14651858.CD006185.pub3 Review update (2017): doi:10.1002/14651858.CD006185.pub4 Review update (2020): doi:10.1002/14651858.CD006185.pub5.

Identification of Online Health Information Using Large Pretrained Language Models: Mixed Methods Study

BACKGROUND

Online health information is widely available, but a substantial portion of it is inaccurate or misleading, including exaggerated, incomplete, or unverified claims. Such misinformation can significantly influence public health decisions and pose serious challenges to health care systems. With advances in artificial intelligence and natural language processing, pretrained large language models (LLMs) have shown promise in identifying and distinguishing misleading health information, although their effectiveness in this area remains underexplored.

OBJECTIVE

This study aimed to evaluate the performance of 4 mainstream LLMs (ChatGPT-3.5, ChatGPT-4, Ernie Bot, and iFLYTEK Spark) in the identification of online health information, providing empirical evidence for their practical application in this field.

METHODS

Web scraping was used to collect data from rumor-refuting websites, resulting in 2708 samples of online health information, including both true and false claims. The 4 LLMs' application programming interfaces were used for authenticity verification, with expert results as benchmarks. Model performance was evaluated using semantic similarity, accuracy, recall, F1-score, content analysis, and credibility.

RESULTS

This study found that the 4 models performed well in identifying online health information. Among them, ChatGPT-4 achieved the highest accuracy at 87.27%, followed by Ernie Bot at 87.25%, iFLYTEK Spark at 87%, and ChatGPT-3.5 at 81.82%. Furthermore, text length and semantic similarity analysis showed that Ernie Bot had the highest similarity to expert texts, whereas ChatGPT-4 showed good overall consistency in its explanations. In addition, the credibility assessment results indicated that ChatGPT-4 provided the most reliable evaluations. Further analysis suggested that the highest misjudgment probabilities with respect to the LLMs occurred within the topics of food and maternal-infant nutrition management and nutritional science and food controversies. Overall, the research suggests that LLMs have potential in online health information identification; however, their understanding of certain specialized health topics may require further improvement.

CONCLUSIONS

The results demonstrate that, while these models show potential in providing assistance, their performance varies significantly in terms of accuracy, semantic understanding, and cultural adaptability. The principal findings highlight the models' ability to generate accessible and context-aware explanations; however, they fall short in areas requiring specialized medical knowledge or updated data, particularly for emerging health issues and context-sensitive scenarios. Significant discrepancies were observed in the models' ability to distinguish scientifically verified knowledge from popular misconceptions and in their stability when processing complex linguistic and cultural contexts. These challenges reveal the importance of refining training methodologies to improve the models' reliability and adaptability. Future research should focus on enhancing the models' capability to manage nuanced health topics and diverse cultural and linguistic nuances, thereby facilitating their broader adoption as reliable tools for online health information identification.

Acceptability of human papillomavirus self-sampling among women living with HIV in sub-Saharan Africa: A systematic review and meta-analysis

HPV self-sampling has the potential to improve early detection of cervical cancer among women living with HIV (WLHIV), but its acceptability varies, creating implementation challenges, especially in sub-Saharan Africa. This study aims to assess the acceptability of HPV self-sampling among WLHIV. We searched PubMed, Web of Science, CINAHL, Academic Medical Ultimate, Cochrane databases, and Google Scholar. The review protocol was registered with PROSPERO (CRD42022299781). Inclusion criteria were based on population, intervention, comparison, and outcome. Statistical analysis was done with R Studio version 4.3.2, and data abstraction was performed in Microsoft Excel. The analysis included 14 studies on the acceptability of HPV self-sampling among WLHIV. The overall acceptability rate was 73%. The pooled data showed that 94% felt comfortable with self-sampling, 72% found it easy to use, 10% reported pain, 14% felt embarrassed, and 41% felt confident about the process. The study found that a majority of WLHIV accepted HPV self-sampling, a higher rate than in the general female population. Many participants had concerns about the method's efficacy. This indicates that while WLHIV generally views self-sampling positively, additional education and support are needed to improve their confidence in its accuracy and reliability.

Effect of perioperative lidocaine infusion on the subjective quality of recovery after surgery: Protocol for an updated systematic review and meta-analysis

BACKGROUND

Lidocaine is increasingly used for surgical patients requiring general anesthesia. However, its clinical benefits on postoperative recovery quality are not well established. Our main objective aims to summarize the evidence regarding the effectiveness of perioperative lidocaine infusion on postoperative subjective quality of recovery (QoR).

METHODS AND ANALYSIS

This protocol will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guideline. This systematic review will include randomized controlled trials (RCTs) from their inception until December 31st, 2024 with no language restrictions. The major databases including PubMed, Embase, and the Cochrane library will be comprehensively searched and supplemented by a hand searching reference lists of all included articles. Searches will involve studies assessing the efficacy of the perioperative lidocaine infusion for improving postoperative QoR, in comparison to placebo, or on treatment. The two authors will independently screen studies, extract study data and assess bias risk of the studies. The subjective QoR (QoR-15, QoR-40) on postoperative day 1-3 will be defined as primary outcome, whereas secondary outcomes will include morphine consumption, incidence of postoperative nausea and vomiting, time to first bowel movement, time to first flatus, and length of hospital stay. A meta-analysis will be performed using Review Manager 5.3 software. Sensitivity analyses, subgroup analysis and publication bias will also be conducted. The evidence quality of pooled results will be assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

DISCUSSION

This review and meta-analysis is anticipated to provide the evidence for the role of intravenous lidocaine on the subjective quality of recovery after surgery. In addition, the findings from this review will help clinicians with developing effective and safe perioperative anesthetic management regimens for surgery patients.

STUDY REGISTRATION

PROSPERO registration number: CRD42024585866.

Efficacy of BCG vaccination against COVID-19 in health care workers and non-health care workers: A meta-analysis of randomized controlled trials

BACKGROUND

The Bacillus Calmette-Guérin (BCG) vaccine has shown potential non-specific protection against infectious diseases through "trained immunity", which may offer cross-protection against viral infections. However, there is no consensus on whether BCG vaccination could prevent COVID-19 or reduce its symptoms.

METHODS

PubMed, Cochrane Library, Embase and Web of Science were searched for randomized controlled trials on BCG vaccination and COVID-19 prevention, covering studies from the inception of each database to 2 May 2024. We included studies where participants, not infected with COVID-19, were vaccinated with BCG or placebo. We excluded non-randomized trials, studies without full texts, unrelated interventions, and those not reporting relevant outcomes. Clinical data on COVID-19 infection, severity, hospitalization, mortality, and other adverse events, were extracted and analyzed. The DerSimonian-Laird random-effects model and the Cochrane Collaboration's risk of Bias Tool were used for analysis and risk of bias assessment.

RESULTS

A total of 12 RCTs involving 18,086 patients were finally included. For the prophylactic effect of BCG on COVID-19, pooled results showed no statistically significant difference between BCG and placebo (pooled RR 1.02; 95%CI: 0.91-1.14). There was no statistically significant difference between non-health care workers (pooled RR 0.91; 95%CI: 0.67-1.24) and health care workers (pooled RR 1.03; 95%CI: 0.93-1.15). Regarding COVID-19 severity, no significant difference were found for asymptomatic (pooled RR 1.18; 95%CI: 0.81-1.72), mild to moderate (pooled RR 0.99; 95%CI: 0.84-1.17), severe COVID-19 (pooled RR 1.25; 95%CI: 0.92-1.70), hospitalization (pooled RR 0.93; 95%CI: 0.58-1.50) or all-cause mortality (pooled RR 0.60; 95%CI: 0.18-1.95) between BCG and placebo groups. Subgroup analysis also showed no significant difference between BCG and placebo in non-health care workers or health care workers.

CONCLUSIONS

Vaccination of BCG could not effectively prevent COVID-19 infection or decrease COVID-19 symptoms both in non-health care workers and health care workers.

Efficacy of CEUS-guided biopsy for thoracic and pulmonary lesions: a systematic review and meta-analysis

BACKGROUND

This study compares the success rate, diagnostic accuracy, and safety of contrast-enhanced ultrasound (CEUS)-guided biopsy versus conventional ultrasound (US)-guided biopsy for thoracic and pulmonary lesions.

METHODS

A systematic search of PubMed, EMBASE, Web of Science, and Cochrane Library was conducted. The primary outcomes included success rate and diagnostic accuracy, and the secondary outcome was the odds ratio of adverse effects. A random-effects meta-analysis pooled the data, with heterogeneity assessed by I² and publication bias evaluated using Egger's test and funnel plot analysis. Sensitivity analysis was performed to confirm result robustness. Subgroup analysis and meta-regression were conducted to explore the sources of heterogeneity.

RESULTS

Sixteen studies with 3,459 patients were included. CEUS-guided biopsy demonstrated higher success rate (99.18%, 95% CI: 98.00-99.90%) and diagnostic accuracy (95.96%, 95% CI: 94.84-96.96%) than US-guided biopsy (success rate: 97.26%, 95% CI: 95.45-98.68%; diagnostic accuracy: 85.87%, 95% CI: 82.05-89.31%). Complications were more frequent in the US-guided group, with an odds ratio of 1.65 (95% CI: 1.15-2.37). Heterogeneity was low, and publication bias was minimal, except for diagnostic accuracy in the US group. Sensitivity analysis confirmed result robustness.

CONCLUSION

Compared with conventional ultrasound, CEUS-guided biopsy demonstrates a comparable success rate, superior diagnostic accuracy, and a lower incidence of complications, underscoring its clinical value as a preferred approach for thoracic and pulmonary lesion assessment.

SYSTEMATIC REVIEW REGISTRATION

This study was registered with PROSPERO under the registration number CRD42024608627.

CLINICAL TRIAL NUMBER

Not applicable.

The effect of cognitive retraining after stroke on everyday living: A systematic review and meta-analysis

ObjectiveTo determine if the addition of cognitive retraining to rehabilitation following stroke results in better everyday living outcomes.Data sourcesElectronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, OT Seeker and Cochrane Library were searched until January 2025.Review methodsRandomised controlled trials were included if they measured change in function and investigated a cognitive retraining intervention aimed at restoration of impaired cognition in one or more specific cognitive domains in the adult stroke population. Papers were excluded if they exclusively provided interventions that were not restorative, such as compensatory approaches or direct task retraining. Two independent reviewers extracted data and assessed study quality.ResultsTwenty-one studies involving 1476 participants were included. There was very low-quality evidence that basic activity of daily living (ADL) was not improved by the addition of cognitive retraining (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) -0.04 to 1.01). There was moderate quality evidence that cognitive retraining had no effect on Instrumental ADL (IADL) (SMD -0.19, 95% CI -0.65 to 0.27) or other measures of functional performance (SMD -0.03, 95% CI -0.31 to 0.24).ConclusionsCognitive retraining focusing on restoration of one or more cognitive domains after stroke did not show an impact in basic ADL performance, IADL performance, or other measures of functional performance. Results were complicated by low-quality evidence and methodological factors including variations in study populations, interventions provided and outcome measures. Further research that includes suitable measures of everyday living is needed to provide more robust evidence and guide clinical practice.

Psychosocial Management of First-Episode Psychosis and Schizophrenia: Synopsis of the US Department of Veterans Affairs and US Department of Defense Clinical Practice Guidelines

BACKGROUND

Despite the large number of people treated for first-episode psychosis and schizophrenia within the Departments of Defense (DOD) and Veterans Affairs (VA), neither the DOD nor VA had established formal recommendations for the treatment of these conditions. This gap led Congress to require the development of clinical practice guidelines (CPG) for the treatment of schizophrenia. This paper reports on the psychosocial and rehabilitative recommendations presented in the VA/DOD Clinical Practice Guidelines for Management of First-Episode Psychosis and Schizophrenia.

STUDY DESIGN

The CPG was developed by an interdisciplinary panel of mental health and primary care providers from DOD and VA following methods specified by the VA/DOD Evidence-Based Practice Guideline Work Group. The panel formulated key questions and identified critical outcomes that guided a comprehensive search of the literature published from November 2011 to December 2021. The evidence considered was limited to systematic reviews, meta-analyses, and randomized clinical trials. Recommendations were based on the evaluation of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

STUDY RESULTS

The review process produced 4 psychosocial/rehabilitative treatment recommendations for first-episode psychosis (early intervention services, family interventions, individual placement and support (IPS), and cognitive behavioral therapy for psychosis) and 11 recommendations for schizophrenia (family and caregiver services, assertive community treatment, IPS, smoking cessation, skills training, cognitive training, psychotherapies, aerobic exercise, yoga, weight management, and telephone-based care management).

CONCLUSIONS

The VA/DOD CPG reflects the expansion of treatments for first-episode psychosis and schizophrenia and highlights the challenges in developing clinical practice guidelines.

Association of Dietary Advanced Glycation End Products with Overall and Site-Specific Cancer Risk and Mortality: A Systematic Review and Meta-Analysis

Background/Objectives: Dietary advanced glycation end products (dAGEs) have a pro-inflammatory effect and increase oxidative stress, potentially leading to cancer. The aim of this study was to estimate the association between dAGEs consumption and risk and mortality from overall cancer and according to its site. Methods: A systematic search was conducted in Medline, Scopus, Web of Science, and the Cochrane Library from inception to April 2025. The search strategy was conducted according to the PECO structure adapted to this study, as well as the inclusion criteria, in which the population (P) was the adult population, the exposure (E) was the highest level of dAGEs intake, the comparator (C) was the lowest level of dAGEs intake, and the outcomes (O) were the overall cancer risk, cancer risk by site, and cancer mortality. Results across studies were summarised using random effects and fixed effects. Results: Fourteen studies were included in the systematic review. In the random-effects meta-analysis, high dAGEs intake was associated with Hazard Ratio (HR) = 0.99 [95% Confidence Interval (95% CI): 0.98, 1.00] for overall cancer risk. However, although there was no association with breast cancer (BC), there was an association with invasive BC, with HR = 1.14 (95% CI: 1.05, 1.23). In contrast, in other tumours, there were opposite results depending on the site of the cancer. Conclusions: The reduction in cancer risk is not clinically significant. However, high consumption of dAGEs may increase the risk of BC, particularly the invasive BC, which is a challenge for cancer prevention and subsequent mortality. Due to the limited evidence, further studies are needed to confirm the potential impact of dAGEs, as well as other dietary factors that may play a larger role in cancer development.

Prevalence of Intolerance to Amines and Salicylates in Individuals with Atopic Dermatitis: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Elimination diets targeting amines and salicylates have been used since the 1980s to diagnose pharmacological food intolerance in individuals with atopic dermatitis (eczema), yet supporting evidence regarding relevance is limited. To our knowledge, this systematic review with meta-analysis is the first to examine the prevalence and association between atopic dermatitis flares and amine intolerance (including histamine intolerance) and salicylate intolerance in individuals with atopic dermatitis.

METHODS

Following the PRISMA guidelines, searches of PubMed, Embase, CINAHL, and Cochrane were conducted. Included studies involved children and adults with atopic dermatitis who underwent dietary elimination and double-blind placebo-controlled challenges involving histamine, other amines, or salicylates. Risk of bias was assessed using the Joanna Briggs Institute Checklist for Prevalence Studies. Meta-analysis of the prevalence of atopic dermatitis flare by food chemical type was performed using a random effects model in Stata/MP, version 16.1 for Windows. Heterogeneity was assessed using the I2 statistic and Cochrane's Q test.

RESULTS

A total of 2323 titles and abstracts were screened, with 46 full-text articles evaluated independently by two reviewers, resulting in the inclusion of four prevalence studies involving 188 participants. Meta-analysis of two trials showed histamine intolerance prevalence at 31% [95% CI, 20-41%] with no heterogeneity (I2 = 0.01%). Two trials showed amine intolerance prevalence at 32% [95% CI, 16-48%] with moderate heterogeneity (I2 = 34.91%). Two trials showed salicylate intolerance prevalence at 53% [95% CI, 44-62%] with no heterogeneity (I2 = 0.00%).

CONCLUSIONS

This review suggests there may be low-certainty evidence linking intolerance to histamine, amines, and salicylates to atopic dermatitis flare in a substantial proportion of individuals with atopic dermatitis. Further, well-designed studies are needed to confirm these findings and clarify the role of pharmacological food intolerance in atopic dermatitis.

Sustained-release naltrexone for opioid dependence

BACKGROUND

Opioid dependence is a severe and often lifelong disorder with a high risk of overdose and premature death, as well as severe psychosocial difficulties. Sustained-release naltrexone is a treatment option that works by blocking the euphoric and overdose effects of opioids. When injected intramuscularly, naltrexone provides blockade for one month, while the blocking effects with implants can last for up to six months.

OBJECTIVES

To assess the benefits and harms of sustained-release naltrexone for the treatment of opioid dependence.

SEARCH METHODS

For this update, we searched the following databases from 2007 up to 20 December 2023: the Cochrane Drugs and Alcohol Specialised Register of Trials, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, ISI Web of Science, LILACS, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We manually searched the reference lists of identified studies, published reviews and relevant websites.

SELECTION CRITERIA

Randomised controlled trials comparing the effects of injectable or implantable naltrexone with other treatment, no treatment or placebo in adults with opioid dependence.

DATA COLLECTION AND ANALYSIS

Primary outcomes were illicit opioid use, retention in treatment, treatment acceptability and adverse events. Secondary outcomes were opioid craving, recreational use of substances other than opioids, mental health, quality of life and criminal activity. We assessed the risk of bias using the Cochrane risk of bias tool (RoB 1). We combined the results of individual trials through meta-analysis where possible using a random-effects model. Two review authors independently assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified 22 studies (3416 participants) that met our inclusion criteria. Three studies compared sustained-release naltrexone with opioid agonist treatment, five with oral naltrexone, six with placebo, nine with treatment as usual and one with psychosocial intervention. Sustained-release naltrexone compared with opioid agonist treatment We found moderate-certainty evidence that sustained-release naltrexone probably increases in-treatment illicit opioid use slightly (risk ratio (RR) 1.15, 95% confidence interval (CI) 1.01 to 1.31; 1 study, 570 participants). The evidence is very uncertain about the effect of sustained-release naltrexone on retention in treatment (RR 1.17, 95% CI 0.78 to 1.76; 3 studies, 773 participants) and treatment acceptability (RR 0.92, 95% CI 0.73 to 1.16; 3 studies, 773 participants). There was low-certainty evidence that sustained-release naltrexone may increase serious adverse events slightly in comparison with opioid agonist treatment for serious adverse events (RR 1.40, 95% CI 0.92 to 2.11; 2 studies, 713 participants). Sustained-release naltrexone compared with oral naltrexone treatment We found low-certainty evidence that sustained-release naltrexone may reduce in-treatment illicit opioid use (RR 0.65, 95% CI 0.45 to 0.93; 1 study, 69 participants). The evidence is very uncertain about the effect of sustained-release naltrexone on retention in treatment (RR 2.40, 95% CI 1.64 to 3.52; 3 studies, 464 participants) and on serious adverse events (RR 1.25, 95% CI 0.46 to 3.36; 2 studies, 260 participants). There was low-certainty evidence that sustained-release naltrexone may result in little to no difference in treatment acceptability in comparison with oral naltrexone treatment (RR 1.00, 95% CI 0.99 to 1.01; 3 studies, 474 participants). Sustained-release naltrexone compared with placebo We found low-certainty evidence that sustained-release naltrexone may result in little to no difference in in-treatment illicit opioid use (RR 0.83, 95% CI 0.66 to 1.03; 3 studies, 443 participants), treatment acceptability (RR 1.00, 95% CI 0.98 to 1.02; 1 study, 204 participants) and serious adverse events (RR 0.74, 95% CI 0.17 to 3.23; 3 studies, 443 participants). The evidence is very uncertain about the effect of sustained-release naltrexone on retention in treatment in comparison with placebo (RR 2.10, 95% CI 1.23 to 3.60; 4 studies, 594 participants). Sustained-release naltrexone compared with treatment as usual We found high-certainty evidence that sustained-release naltrexone reduces in-treatment illicit opioid use (RR 0.72, 95% CI 0.57 to 0.90; 4 studies, 479 participants). There was low-certainty evidence that sustained-release naltrexone may result in little or no difference in retention in treatment (RR 1.20, 95% CI 0.79 to 1.82; 3 studies, 126 participants) and that it may result in a slight reduction in treatment acceptability (RR 0.79, 95% CI 0.69 to 0.90; 8 studies, 1094 participants). There was moderate-certainty evidence that sustained-release naltrexone probably reduces serious adverse events in comparison with treatment as usual (RR 0.59, 95% CI 0.36 to 0.95; 6 studies, 1009 participants). Our primary outcome measures were not reported for sustained-release naltrexone compared with psychosocial treatments. Amongst the most common methodological weaknesses were the risk of performance bias and imprecision due to few studies and small sample size for many outcomes.

AUTHORS' CONCLUSIONS

Sustained-release naltrexone may slightly increase illicit opioid use and serious adverse events compared to opioid agonists, with uncertain effects on retention and acceptability. It may reduce illicit opioid use compared to oral naltrexone but has uncertain effects on other outcomes. Compared to placebo, it may have little to no impact on key outcomes. Compared to treatment as usual, it reduces illicit opioid use and may reduce serious adverse events but has little effect on retention and slightly reduces acceptability. Significant gaps remain in the evidence on sustained-release naltrexone for opioid dependence. Future research should include comparisons with psychosocial treatments, larger and higher-quality studies, and analyses of differences between formulations and comparator treatments. Improved study designs are needed to reduce bias, and more inclusive research should address under-represented populations and synthetic opioid users. The lack of long-term outcome data limits understanding of sustained effects, highlighting the need for extended follow-up and exploration of diverse treatment settings and populations.

Localizing value of ictal hypersalivation/sialorrhea and ictal spitting: A systematic review

OBJECTIVE

We performed a systematic review on the localizing value of ictal hypersalivation and ictal spitting in focal epilepsy with the aim of summarizing the state-of-the-art anatomo-clinical correlations in the field and aiding the interpretation of ictal semiology within the framework of pre-surgical evaluation.

METHODS

We conducted a review and meta-analysis of the published evidence and reported the results according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. We searched in PubMed for relevant articles using the following key words: (hyper)salivation, sialorrhea, drooling, spitting, insular, opercular, epilepsy, seizure, ictal, EEG, and surgery. We evaluated the risk of bias and the diagnostic accuracy quality of each publication using the Quality of Diagnostic Accuracy Studies (QUADAS)-2-adapted tool. We assessed the level of confidence (very high, high, moderate, and low) in the reported epileptogenic zone (EZ) based on the availability of findings from MRI, intracerebral EEG, and postoperative outcomes.

RESULTS

We reviewed the full text of 65 articles that fulfilled the criteria for evidence synthesis. Thirty-two studies and 11 case reports (173 patients) on ictal hypersalivation and 15 studies and 13 case reports (54 patients) on ictal spitting were eligible. Ictal hypersalivation was reported in approximately 11% of (mesio)-temporal and approximately 23% of insular, opercular, and insulo-opercular epilepsies with >70% high-confidence cases due to seizure-free postsurgical outcomes. Ictal spitting was very rarely observed in focal epilepsies, including mesio-temporal epilepsies (incidence of 1% and 1.6%, respectively), but was significantly associated with a nondominant mesio-temporal EZ.

SIGNIFICANCE

There is strong evidence that ictal hypersalivation is more common in insular, opercular, and insulo-opercular seizures than in temporal lobe seizures, with the mid-insula and central operculum most consistently identified as symptomatogenic zones. Ictal spitting is a rare complex motor automatism pointing to seizures originating in nondominant mesio-temporal structures.

Matrix Metalloproteinase-9 and Postoperative Outcomes in Carotid Endarterectomy: A Systematic Review

Background/Objectives: Carotid endarterectomy (CEA) is the treatment of choice for severe symptomatic and asymptomatic carotid artery stenosis. Nonetheless, it carries risks and several complications, including stroke and death. Previous studies have indicated that elevated matrix metalloproteinase-9 (MMP-9) levels may serve as biomarkers for adverse outcomes after CEA. This systematic review investigates the association between plasma MMP-9 levels and adverse cardiovascular outcomes following CEA. Methods: PubMed/MedLine, Scopus and Web of Science were searched for studies assessing the relationship between plasma MMP-9 levels and postoperative outcomes after CEA. Assessment of studies' quality was performed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for observational cohorts and cross-sectional studies. Results: Five studies were included (n = 891 participants). All five were retrospective cohort studies. MMP-9 was significantly higher in patients who presented with a combination of amaurosis fugax, central retinal artery occlusion, TIA and minor/major stroke at follow-up. However, individual outcomes like TIA or stroke did not consistently correlate with MMP-9 levels. Additionally, increased MMP-9 levels were also associated with cognitive dysfunction post CEA. Conclusions: Despite the potential of MMP-9 levels to serve as a biomarker for predicting postoperative cerebrovascular complications, this review presents limitations, including a high risk of bias in included studies and variability in methodologies. There is a need for further research with larger cohorts to validate these findings and improve risk stratification and management strategies for patients undergoing CEA.

The roles and signalling pathways of lncMALAT1 in coronary artery disease: A protocol for systematic review of in vivo and in vitro studies

BACKGROUND

Coronary artery disease (CAD) is a major cardiovascular disease that affects global population health. Several studies have indicated the association between high expression level of a non-coding RNA, lncMALAT1 and an increased risk of CAD. In this study, we conducted a protocol of systematic review aims to evaluate the role and mechanism of lncMALAT1 that may contributed to CAD based on animal and in vitro studies. The roles of lncMALAT1 will be elucidated focusing on activating upstream signalling Klotho/FGF23 or regulate the downstream Wnt/β-catenin or extracellular signal-regulated kinase/mitogen-activated protein kinase(ERK/MAPK) and any other pathways with the vascular changes in term of proliferation, migration, lumen formation and apoptosis.

METHODS

A systematic review protocol with a reproducible strategy according to the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines and Population, Intervention, Comparison Outcome and Study (PICOS) framework were proposed to evaluate the existing literature on the roles and mechanisms of the lncMALAT1. A PRISMA-compliant electrical systematic research was performed in the databases including PubMed, Web of Science and Scopus for English publication from their inceptions until January 2024. Data for collection will include primary CAD animal models and any cardiomyocyte cell line with primary hypoxia model. The article title, authors, type of models, signaling pathways and biological changes (proliferation, migration, lumen formation and apoptosis) will be recorded.

CONCLUSION

This will provide a new approach in understanding molecular interactions on CAD for new perspective and target treatment for CAD patients in future, especially that intolerance of invasive coronary therapy.

REGISTRATION

Registered in PROSPERO on 10 April, 2024. (CRD42024504245) (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024504245).

Olanzapine for the Prevention of Postoperative Nausea and Vomiting: An Updated Meta-Analysis With Trial Sequential Analysis

BACKGROUND AND OBJECTIVES

Postoperative nausea and vomiting (PONV) notably affects up to 30% of surgical patients, resulting in elevated medical service costs, dehydration, discomfort, and delayed recovery. Although standard antiemetic medications are effective, but they may not completely prevent PONV due to complicated underlying pathophysiology involving various neurotransmitter systems. Therefore, this systematic review and meta-analysis evaluates the efficacy and safety of olanzapine, an atypical antipsychotic with wide-spectrum receptor antagonism, in PONV reduction.

METHODS

A comprehensive literature search was conducted to retrieve randomized controlled trials (RCTs) comparing prophylactic olanzapine to other traditional antiemetics or placebo in multiple electronic databases, including PubMed, Scopus, Cochrane Library, and Web of Science. However, the main outcome was the incidence rate of PONV within 24 hours postsurgical operations. Furthermore, risk differences (RD) and relative risks (RR) were calculated on Review Manager (RevMan), and trial sequential analysis (TSA) was established to precisely assess the evidence reliability of olanzapine.

RESULTS

Five RCTs with 793 patients were eligible for our inclusion criteria. Olanzapine potentially decreased PONV risk (RR = 0.67; 95% CI, 0.56, 0.80) and absolute risk reduction by 15% (RD = -0.15; 95% CI, -0.24, -0.06). Furthermore, subgroup analysis by dose revealed that the 10 mg dose of olanzapine had a strong effect in lowering PONV. However, only the 5 mg dose showed a statistically significant reduction in the use of rescue antiemetics (RR = 0.28; 95% CI, 0.10, 0.84). Moreover, TSA demonstrated and confirmed notable evidence supporting the efficacy of olanzapine.

CONCLUSION

Olanzapine potentially decreases PONV incidence rates, particularly when combined with traditional antiemetics, indicating its pivotal role in PONV prevention. There is a pressing need for further research to optimize dosing and assess its efficacy among different surgical populations and procedures.

Vitamin D Deficiency and Clinical Outcomes in Critically Ill Pediatric Patients: A Systematic Review and Meta-Analysis

Context

Vitamin D deficiency (VDD) is common in paediatric populations, and its relationship with critical care outcomes warrants further investigation.

Objective

The aim is to examine the association between VDD and clinical outcomes in children admitted to the Pediatric Intensive Care Unit (PICU).

Methods

This systematic review and meta-analysis investigated the impact of VDD on clinical outcomes in PICU patients. A comprehensive search of Embase, Web of Science, PubMed, and Cochrane databases was conducted. Our primary outcomes were mortality and sepsis incidence, while secondary outcomes included length of stay (LOS), need for inotropic support, and need for and duration of mechanical ventilation. Eligible studies included infants and children aged 1 month to 18 years admitted to the PICU, with baseline 25-hydroxyvitamin D levels measured on admission. Two independent reviewers screened studies, extracted data, and assessed quality. Pooled estimates were obtained using a random-effects model.

Results

Out of 2298 screened studies, 27 met the inclusion criteria, comprising 4682 patients. VDD was defined as 25-hydroxyvitamin D levels <20 ng/mL and <30 ng/mL in 22 and 5 studies, respectively. VDD was associated with increased mortality (odds ratio [OR] 2.05, 95% CI 1.21-3.48) and a greater need for inotropic support (OR 2.02, 95% CI 1.43-2.85) than children with vitamin D sufficiency (VDS). No differences were observed between VDD and VDS groups in terms of sepsis incidence postadmission, LOS, or the need for and duration of mechanical ventilation.

Conclusion

VDD in critically ill pediatric patients was associated with increased mortality and higher need for inotropic support. Further research is warranted to evaluate the potential benefits of vitamin D supplementation in this high-risk population.

Influence of Neuromuscular Training Interventions on Jump-Landing Biomechanics and Implications for ACL Injuries in Youth Females: A Systematic Review and Meta-analysis

BACKGROUND

Various exercise interventions are recommended to reduce the risk of anterior cruciate ligament (ACL) injury in females. However, the extent to which these training interventions influence lower-limb landing biomechanics in youth female remains unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to quantitatively summarise the effectiveness of various training interventions on jump-landing biomechanics in youth females.

METHODS

We systematically searched PubMed, SPORTDiscus, EMBASE and Scopus. Articles were included if they: (1) conducted research on uninjured youth females (reported mean age < 18 years) with no restriction on playing level/experience or physical activity level; (2) performed any form of training intervention for ≥ 4 weeks; (3) reported any lower-limb kinematic (flexion/extension, adduction/abduction or internal/external rotation angles) or kinetic (joint moments or vertical ground reaction forces) data during the landing phase of jump-landing tasks, pre- and post-training intervention for both experimental and control groups, using a two- or three-dimensional motion capture system; (4) were randomised- or non-randomised controlled trials. The quality of the randomised controlled trials was assessed using the Risk of Bias tool 2, whereas the Downs and Black checklist was used for assessing the quality of non-randomised controlled trials. A multi-level meta-analytical model was used for conducting the quantitative analysis.

RESULTS

Thirteen studies (7 randomised controlled, 6 non-randomised controlled studies) involving 648 female participants were included in the final analyses. With regards to the overall quality of the included studies, three studies had high risk of bias while ten studies had some concerns. As part of the meta-analysis, we were able to analyse seven kinematic variables and two kinetic variables in aggregate. Compared with controls, the experimental group had significantly increased peak knee flexion angle (g = 0.58, p = 0.05) and reduced knee valgus motion (g =  - 0.86, p = 0.05) post-intervention. The effects on other kinematic and kinetic variables ranged from trivial to moderate and were not significantly altered as a result of various training interventions.

CONCLUSION

The findings from the synthesised literature indicate that training interventions have small to moderate effects on peak knee flexion angle and knee valgus motion during jumping tasks. However, further research employing more consistent study designs and methodologies is required to better understand the changes in jump-landing biomechanics in the youth female population following training interventions.

Australian clinical practice guideline for physical rehabilitation and mobilisation in adult intensive care units

BACKGROUND

The evidence base for research on physical rehabilitation and mobilisation in the intensive care unit has led to uncertainty about best practice.

OBJECTIVE

The objective of this guideline was to develop evidence-based recommendations to support clinical decision-making for physical rehabilitation management of adults undergoing invasive mechanical ventilation in Australian intensive care units.

METHODS

The guideline development group, comprising national representation of clinical experts, methodologists, and consumers, followed a rigorous process, adhering to Australian National Health and Medical Research Council Guidelines for Guidelines, to create the recommendations. The guideline development group determined the scope of the guideline and defined the key clinical question. A systematic review was conducted to evaluate all available evidence based on the predefined outcomes. Meta-analyses were performed using a restricted maximum likelihood approach, and results were summarised in an evidence profile. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence, and the GRADE Evidence to Decision framework was used to formulate recommendations.

SUMMARY OF RECOMMENDATIONS

Based on the evidence profile and GRADE Evidence to Decision framework, the group developed three conditional recommendations and 14 Good Clinical Practice statements to guide practice. The guideline provides conditional recommendations in favour of undertaking physical rehabilitation and mobilisation in adults receiving invasive mechanical ventilation in the intensive care unit whilst acknowledging the uncertainty of evidence. It was endorsed by four key professional organisations.

CONCLUSION

The recommendations within this guideline were developed following best methodological practice. Despite the overall low certainty of evidence, the resulting guideline provides support to clinical decision-making, facilitates the translation of research into practice, and enhances the reach and impact of clinical research. Additionally, the guideline development group identified evidence gaps that could be addressed by future research.

TRIAL REGISTRATION

Not applicable.

The Impact of Domiciliary Dental Care and Oral Health Promotion in Nursing Homes of Older Adults: A Systematic Review

Background: The global increase in the population older than 80 years has led to a paradigm shift centered in the hospital environment, with the inclusion of domiciliary oral health actions improving quality of life. This review evaluates the effects of domiciliary dental care and oral health promotion in nursing homes of older adults. Methods: Seven databases were searched without date restrictions from 15 September to 21 November 2024. A manual search was also performed in the reference lists of the included articles. This research included studies evaluating older adults aged ≥80 years, regardless of sex, who received domiciliary dental care associated or not with oral health promotion, evaluating periodontal condition, dental caries, and the dental and denture plaque index. Regarding data collection and analysis, a risk of bias assessment was performed using RoB 2.0 and RoB 1.0, according to the study design. The level of evidence was assessed using the GRADE tool. Results: Of the 2415 studies found, 5 met the eligibility criteria. After quality assessment, one randomized clinical trial presented a moderate risk of bias, and one presented a low risk. Also, two non-randomized studies presented a high risk and one a low risk. The certainty of evidence was classified as low for all outcomes assessed. One study demonstrated a reduction in the caries level of participants. Regarding periodontal and gingival conditions, although the occurrence of deep pockets (greater than 3.5 mm) decreased over time, there was no significant difference between the control and intervention groups. The level of dental and denture plaque showed a slight reduction. Conclusion: There is limited evidence that domiciliary dental care in nursing homes for older adults can lead to a reduction in caries levels and that oral health programs can reduce dental and denture plaque in evaluations conducted over periods of up to two years. Although the results show a limited magnitude, this does not diminish the importance of promoting domiciliary oral health care.

Efficacy and safety of mirikizumab in the treatment of inflammatory bowel disease: A meta-analysis

BACKGROUND

This meta-analysis explores the efficacy and safety of mirikizumab in treating IBD.

METHODS

A comprehensive search was conducted encompassing randomized controlled trials examining the efficacy of mirikizumab in treating IBD across PubMed, Embase, Cochrane Library, and Web of Science, with a search deadline of November 1, 2023. Quality assessment leaned on the Cochrane manual risk-of-bias evaluation, while Stata 15 undertook the data analysis.

RESULTS

Three randomized controlled studies involving 1602 individuals were finally included. Our meta-analysis suggested that mirikizumab can improve clinical remission (RR = 2.11, 95% CI [1.74, 2.55]), clinical response (RR = 1.68, 95% CI [1.50, 1.89]), endoscopic remission (RR = 1.95, 95% CI [1.65, 2.31]), histologic-endoscopic mucosal improvement (RR = 1.92, 95% CI [1.60, 2.32]) in inflammatory bowel disease (IBD).

CONCLUSION

According to our meta-analysis, mirikizumab is a promising drug in the treatment of IBD.

Muscle strengthening in individuals with Amyotrophic Lateral Sclerosis: a systematic review with meta-analyses

Despite the observed benefits of properly prescribed exercises for people with Amyotrophic Lateral Sclerosis (ALS), the scarcity of studies and lack of consensus on the effects of muscle-strengthening exercises on this population has a negative impact on their rehabilitation. This study aimed to evaluate the effects of muscle-strengthening interventions in individuals with ALS. This systematic review of intervention studies included clinical trials that performed non-respiratory muscle strengthening in people with ALS compared to non-strengthening interventions, usual care, or placebo. Such studies were obtained from the MEDLINE, EMBASE, Cochrane Library, SPORTDiscus, and Physiotherapy Evidence Database databases, with no language or publication date restrictions. The outcomes considered were peripheral muscle strength, functionality, fatigue, and adverse events. The Physiotherapy Evidence Database scale was used to analyze the risk of bias, while the Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of the evidence. Searches were conducted in October 2023 and eight studies were included, totaling 296 individuals. Seven of the eight studies showed superiority of the experimental intervention over the control, but this was not supported in the meta-analyses. Small sample size and high heterogeneity in the primary studies contributed significantly to the low quality of the evidence. There was no evidence of the superiority of interventions for muscle strengthening compared to interventions not aimed at strengthening, usual care, or placebo in terms of the outcomes analyzed immediately after the intervention. The quality of the evidence ranged from low to very low. Five of the studies evaluated adverse events, without reporting serious events. Interventions for muscle strengthening did not prove to be more effective when compared to the control group in the short term nor seem to produce serious adverse events. The low quality of the evidence indicates the need for studies with greater methodological rigor in this population, to more assertively assess the impacts of this intervention over the short, medium, and long term.

Prevention of infection in aortic or aortoiliac peripheral arterial reconstruction

BACKGROUND

Peripheral arterial disease (PAD) results from the narrowing of arteries. Aortic aneurysms - abnormal dilatations in artery walls - are a related concern. For severe cases, arterial reconstruction surgery is the treatment option. Surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

OBJECTIVES

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, for the prevention of infection in people undergoing any open or hybrid aortic or aortoiliac peripheral arterial reconstruction.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform, LILACS, and ClinicalTrials.gov up to 11 November 2024.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) or split-body design, and quasi-RCTs, which assessed any intervention to reduce or prevent infection following aortic or aortoiliac procedures for the treatment of aneurysm or PAD. There were no limitations regarding age and sex.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third review author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 21 RCTs with 4952 participants. Fifteen studies were assessed as having a high risk of bias in at least one domain, and 19 studies had an unclear risk of bias in at least one domain. We analysed 10 different comparisons for eight different outcomes. The comparisons were antibiotic versus placebo or no treatment; short-duration antibiotics (≤ 24 hours) versus long-duration antibiotics (> 24 hours); different types of systemic antibiotics (one versus another); antibiotic-bonded implant versus standard implant; Dacron graft versus stretch polytetrafluoroethylene graft; prophylactic closed suction drainage versus undrained wound; individualised goal-directed therapy (IGDT) versus fluid therapy based on losses, standard haemodynamic parameters and arterial blood gas values (standard care); comprehensive geriatric assessment versus standard preoperative care; percutaneous versus open-access technique; and negative pressure wound therapy (NPWT) versus standard dressing. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes included all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the intervention, and adverse events resulting from the interventions to prevent infection. We did not assess all the outcomes across the different comparisons. The main findings are presented below. Antibiotic versus placebo or no treatment (five studies) Very low-certainty evidence from five included studies suggests that antibiotic prophylaxis reduces SSI (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.71; 5 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNT) 9). With very low- to low-certainty evidence, there was little or no difference between the groups in the other assessed outcomes (graft infection rate, all-cause mortality, re-intervention rate, and amputation rate). We did not quantitatively assess other outcomes in this comparison. Short duration antibiotics (≤ 24 hours) versus long duration antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no difference in graft infection rate (RR 2.74, 95% CI 0.11 to 65.59; 1 study, 88 participants) or SSI rate (RR 3.65, 95% CI 0.59 to 7.71; 1 study, 88 participants) between short- and long-duration antibiotic prophylaxis. We did not quantitatively assess other outcomes in this comparison. Different types of systemic antibiotics (one versus another) (seven studies) We grouped seven studies comparing one antibiotic to another into three subgroups that compared different classes of antibiotics amongst themselves. We found little or no difference between the groups analysed. Graft infection rate: beta-lactams versus cephalosporins (RR 0.36, 95% CI 0.02 to 8.71; 1 study, 88 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 5.00, 95% CI 0.24 to 103.05; 1 study, 238 participants; low-certainty evidence); one cephalosporin versus another (RR not estimable, CI not estimable; 1 study; 69 participants; very low-certainty evidence); SSI rate: beta-lactams and cephalosporins (RR 0.27, 95% CI 0.03 to 2.53; 2 studies, 229 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 2.17, 95% CI 0.65 to 7.23; 2 studies, 312 participants; very low-certainty evidence); and one cephalosporin versus another (RR 1.26, 95% CI 0.21 to 7.45; 3 studies, 625 participants; very low-certainty evidence). We could extract all-cause mortality data for the glycopeptide versus cephalosporin comparison; there was little or no difference between groups (RR 1.33, 95% CI 0.30 to 5.83; 1 study, 238 participants; low-certainty evidence). We did not quantitatively assess other outcomes in this comparison.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that the use of prophylactic antibiotics may prevent SSIs in aortic or aortoiliac peripheral arterial reconstruction. We found no superiority amongst specific antibiotics or differences in extended antibiotic use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no difference across various outcomes. We advise interpreting these conclusions with caution due to the limited number of events in all groups and comparisons.

Assessing Omega-3 Therapy and Its Cardiovascular Benefits: What About Icosapent Ethyl? A Systematic Review and Meta-Analysis

Background: Lipid-lowering therapies are an option for stabilizing lipid levels. Icosapent ethyl (IPE) is a highly purified formulation of eicosapentaenoic acid, which can reduce lipid action, improve plaque stabilization, reduce platelet aggregation, lower TG, and prevent cardiovascular events. IPE is frequently used with statins to manage elevated TG levels. However, the evidence on IPE as a lipid-lowering agent is limited, and no updated systematic review and meta-analysis have been published considering the recent advancements in the field and newly published studies. Therefore, we aim to fill this gap. Methods: We used the PRISMA guidelines and the PICO (Population, Intervention, Comparison, and Outcome) framework to conduct this review, aiming to answer the question, "Can IPE benefit patients at cardiovascular risk?" GRADE was used to evaluate evidence levels to adhere to the highest criteria. Results: Predominantly, the evaluated population presented TG levels between ≥135 mg/dL and 500 mg/dL and LDL-C levels between >40 mg/dL and ≤100 mg/dL. The included studies showed a reduction in TG and LDL-C and a decrease in cardiovascular events. It means that, according to our systematic review evidence analysis, IPE has been effective in lowering blood lipid levels, including TG, and reducing cardiovascular death and events, such as non-fatal stroke or hospitalization for unstable angina. However, it is worth noting that these results were primarily from patients undergoing statin therapy. According to our meta-analysis, IPE may not be considered a lipid-lowering drug, as limited action associated with its use was evident in the quantitative results. However, caution is necessary, as only two studies were suitable for inclusion due to the differing outcomes in the analyzed samples. Conclusions: Despite the quantitative synthesis, IPE possesses anti-inflammatory, anti-thrombotic, and anti-atherogenic properties, highly related to cardiovascular protection. Based on our included studies, IPE was considered a promising therapy for atherosclerotic cardiovascular disease in conjunction with other lipid-lowering therapies, particularly statins, for patients with extremely high TG levels. The limitations of the reviewed studies may include small sample sizes, varying outcomes, and a small duration of interventions. Future clinical trials with similar outcomes, sample sizes, and intervention durations must be designed, and updated meta-analyses must be published in the following years to fully assess the effects of IPE as a lipid-lowering and cardiovascular protector drug.

Obeticholic Acid vs Fibrates as Second-Line Therapy for Primary Biliary Cholangitis: Systematic Review and Meta-Analysis

BACKGROUND

Around 40% of patients diagnosed with Primary Biliary Cholangitis (PBC) experience a suboptimal biochemical response to ursodeoxycholic acid (UDCA).

AIMS

We aimed to compare fibrates and obeticholic acid (OCA) as add-on second-line therapy and evaluate whether these drugs hold superiority over each other.

METHODS

We systematically searched Embase, MEDLINE, and Cochrane CENTRAL for studies comparing fibrates and OCA published by May 6, 2024. A pooled analysis was conducted to evaluate changes in liver biochemistry and response rates based on validated criteria. Data were expressed as mean difference (MD) for continuous outcomes and as Odds Ratio (OR) when binary.

RESULTS

We included 883 patients from 4 studies, 468 (53.0%) under UDCA + OCA. Follow-up time ranged from 6 to 12 months. Patients treated with fibrates have similar mean bilirubin post-intervention values (MD 0.11 × upper limit of normal [ULN]; 95% CI - 0.26 to 0.49) compared to OCA. However, fibrates demonstrated superiority over OCA for percentual reduction in ALP compared to baseline (MD 20.13%; 95% CI 11.84-28.41), ALP post-intervention values (MD - 0.59 xULN; 95% CI - 1.02 to - 0.15), and rate of ALP normalization (OR 32.34; 95% CI 14.54-71.92). Patients treated with fibrates also more frequently met Barcelona (OR 4.28; 95% CI 2.26-8.11), POISE (OR 5.48; 95% CI 2.70-11.13), and Paris II (OR 5.88; 95% CI 3.96-8.74) response criteria.

CONCLUSION

In patients with PBC and an incomplete response to UDCA, fibrates seem to be associated with greater ALP reduction and achievement of response criteria compared to OCA.

Maternal and neonatal outcomes after delayed vs early cord clamping at cesarean delivery: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically review maternal and neonatal outcomes after delayed cord clamping compared with early cord clamping at the time of cesarean delivery.

DATA SOURCES

MEDLINE, Embase, and ClinicalTrials.gov were searched from inception through October 5, 2023.

STUDY ELIGIBILITY CRITERIA

Our population included childbearing people undergoing cesarean delivery, and neonates delivered via cesarean delivery after 23 weeks of gestation. Our intervention was delayed cord clamping (>30 seconds after birth) compared with early cord clamping. Randomized controlled trials and prospective and retrospective comparative studies were included.

METHODS

Abstracts and potentially relevant full-text articles were doubly screened, and accepted articles were doubly extracted. Of the 736 abstracts screened, 222 full-text articles were assessed, and 25 studies were included. Fifteen studies reported maternal outcomes, 20 reported neonatal outcomes, and 10 assessed both neonatal and maternal outcomes. Data were extracted by 9 reviewers, and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Random-effects meta-analyses of pooled proportions were conducted. Maternal outcomes included were estimated blood loss, postoperative hematocrit reduction, total surgical time, postpartum hemorrhage, blood transfusion, uterotonic administration, postoperative hemoglobin reduction, and incidence of hysterectomy. Neonatal outcomes included bilirubin levels, hematocrit change, phototherapy, neonatal intensive care unit admissions, Apgar scores at 1 and 5 minutes, mean hemoglobin, cord pH, mortality, need for resuscitation, and blood transfusion.

RESULTS

No difference was noted between delayed and early cord clamping at cesarean delivery for any maternal outcome, including estimated blood loss, postpartum hemorrhage, blood transfusion, surgical time, additional uterotonic administration, change in hemoglobin/hematocrit, and incidence of hysterectomy. Delayed cord clamping was favored for neonatal hematocrit change and bilirubin levels. No difference was noted in the need for phototherapy, neonatal intensive care unit admissions, and Apgar scores.

CONCLUSION

In agreement with robust physiological evidence, our data suggest that delayed cord clamping improves some neonatal outcomes (including hematocrit and bilirubin levels) for both term and preterm infants born via cesarean delivery compared with early cord clamping, without increasing the risk of adverse maternal outcomes, including maternal bleeding.

The effects of methyl nutrients on cognition and one carbon metabolism in older adults with mild cognitive impairment, A systematic review and meta-analysis

BACKGROUND

Methyl nutrients can influence the one-carbon metabolic cycle and are important for cognitive function in older adults. We aimed to evaluate the effects of methyl nutrient supplementation, including the combination of folate and vitamin B12, and folate or vitamin B12 alone, on cognitive function and one-carbon metabolism in older adults with mild cognitive impairment.

METHODS

Data were retrieved and collected from six electronic databases. Two authors independently appraised the methodological quality of included studies. Network meta-analysis was performed using the Bayesian method, R software.

RESULTS

The combined intervention of folate and vitamin B12 is an effective type of nutrient intervention to slow cognitive decline in the elderly with MCI, reduce serum homocysteine concentration, and elevate serum folate and vitamin B12 concentrations.

CONCLUSION

Combining vitamin B12 plus folate supplementation is the best option for improving cognitive function in older adults with MCI.

Psychological interventions for treatment of inflammatory bowel disease

BACKGROUND

Persons with inflammatory bowel disease (IBD) have an increased risk of suffering from psychological problems. The association is assumed to be bi-directional. Psychological treatment is expected to improve quality of life (QoL), psychological issues and, possibly, disease activity. Many trials have tested various psychotherapy approaches, often in combination with educational modules or relaxation techniques, with inconsistent results.

OBJECTIVES

To assess the effects of psychological interventions on quality of life, emotional state and disease activity in persons of any age with IBD.

SEARCH METHODS

We searched Web of Science Core Collection, KCI-Korean Journal Database, Russian Science Citation Index, MEDLINE, Psyndex, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, and LILACS from inception to May 2023. We also searched trial registries and major gastroenterological and selected other IBD-related conferences from 2019 until 2023.

SELECTION CRITERIA

Randomized controlled trials of psychological interventions in children or adults with IBD compared to no therapy, sham (i.e. simulated intervention), or other active treatment, with a minimum follow-up time of two months, were eligible for inclusion, irrespective of publication status and language of publication. Interventions included psychotherapy and other non-pharmacological interventions addressing cognitive or emotional processing, patient education, or relaxation techniques to improve individual health status.

DATA COLLECTION AND ANALYSIS

Two raters independently extracted data and assessed the study quality using the Risk of Bias 2 Tool. Pooled standardized mean differences (SMD) for continuous outcomes and relative risks (RR) for event data were calculated with 95% confidence intervals (CI), based on separate random-effects models by age group, type of therapy and type of control. An SMD of 0.2 was considered a minimally relevant difference. SMD ≥ 0.4 was considered a moderate effect. Group analyses were planned to examine differential effects by type of IBD, disease activity, psychological comorbidity, therapy subtype, and treatment intensity. Statistical heterogeneity was determined by calculating the I2 statistic. Publication bias was assessed by presenting a funnel plot and calculating the Eggers Test. GRADE Profiling was used to describe the certainty of the evidence for relevant results.

MAIN RESULTS

Sixty-eight studies were eligible. Of these, 48 had results reported in sufficient detail for inclusion in the meta-analyses (6111 adults, 294 children and adolescents). Two trials were excluded from the meta-analysis following sensitivity analysis and tests for asymmetry because of implausible results. Most studies used multimodular approaches. The risk of bias was moderate for most outcomes, and high for some. The most common problems in individual trials were the inability to blind participants and investigators and outcome measures susceptible to measurement bias. The main issues leading to downgrading of the certainty of the evidence were heterogeneity of results, low precision and high or moderate risk of bias in the included trials. Publication bias could not be shown for any of the inspected analyses. In adults, psychotherapy was slightly more effective than care-as-usual (CAU) in improving short-term QoL (SMD 0.23, 95% CI 0.12 to 0.34; I2 = 13%; 20 trials, 1572 participants; moderate-certainty), depression (SMD -0.27, 95% CI -0.39 to -0.16; I2 = 0%; 16 trials, 1232 participants; moderate-certainty), and anxiety (SMD -0.29, 95% CI -0.40 to -0.17; I2 = 1%; 15 studies, 1135 participants; moderate-certainty). The results for disease activity were not pooled due to high heterogeneity (I2 = 72%). Interventions which used patient education may also have small positive short-term effects on QoL (SMD 0.19, 95% CI 0.06 to 0.32; I2 = 11%; 12 trials, 1058 participants; moderate-certainty), depression (SMD -0.22, 95% CI -0.37 to -0.07; I2 = 11%; 7 studies, 765 participants; moderate-certainty) and anxiety (SMD -0.16, 95% CI -0.32 to 0.00; I2 = 10%; 6 studies, 668 participants; moderate-certainty). We did not find an effect of education on disease activity (SMD -0.09, 95% CI -0.28 to 0.10; I2 = 38%; 7 studies, 755 participants; low-certainty). Pooled results on the effects of relaxation techniques showed small effects on QoL (SMD 0.25, 95% CI 0.08 to 0.41; I2 = 30%; 12 studies, 916 participants; moderate-certainty), depression (SMD -0.18, 95% CI -0.35 to -0.02; I2 = 0%; 7 studies, 576 participants; moderate-certainty), and anxiety (SMD -0.26, 95% CI -0.43 to -0.09; I2 = 13%; 8 studies, 627 participants; moderate-certainty). Results for disease activity were not pooled due to high heterogeneity (I2 = 72%). In children and adolescents, multimodular psychotherapy increased quality of life (SMD 0.54, 95% CI 0.06 to 1.02; I2 = 19%; 3 studies, 91 participants; moderate-certainty). The results for anxiety were inconclusive (SMD -0.09; 95% CI 0.-64 to 0.46; 2 trials, 51 patients, very low-certainty). Pooled effects were not calculated for depressive symptoms. Disease activity was not assessed in any of the trials compared to CAU. In education, based on one study, there might be a positive effect of the intervention on quality of life (MD 7.1, 95% CI 2.18 to 12.02; 40 patients; low-certainty evidence) but possibly not on depression (MD -6, 95% CI -12.01 to 0.01; 41 patients; very low-certainty). Anxiety and disease activity were not assessed for this comparison. Regarding the effects of relaxation techniques on children and adolescents, all results were inconclusive (very low-certainty).

AUTHORS' CONCLUSIONS

Psychological interventions in adults are likely to improve the quality of life, depression and anxiety slightly. Psychotherapy is probably also effective for improving the quality of life in children and adolescents. The evidence suggests that psychological interventions may have little to no effect on disease activity. The interpretation of these results presents a challenge due to the clinical heterogeneity of the included trials, particularly concerning the type and various components of the common multimodular interventions. This complexity underscores the need for further research and exploration in this area.

Effects of Selenium Administration on Blood Lipids: A Systematic Review and Dose-Response Meta-Analysis of Experimental Human Studies

CONTEXT

Overexposure to the essential trace element selenium has been associated with adverse metabolic and cardiovascular outcomes, hypertension, and diabetes. However, dose-response meta-analyses analyzing the effects of selenium administration on the lipid profile in experimental human studies are lacking.

OBJECTIVE

Through a restricted cubic spline regression meta-analysis, the dose-response relation between the dose of selenium administered or blood selenium concentrations at the end of the trials and changes over time in blood lipids, ie, total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglycerides was assessed.

DATA SOURCES

Searches were performed on PubMed, Web of Science, Embase, and the Cochrane Library from inception up to January 11, 2025 to identify randomized controlled trials (RCTs) investigating the impact of selenium supplementation on blood lipid profiles among adults.

DATA EXTRACTION

A total of 27 eligible RCTs that enrolled healthy individuals, pregnant individuals, and participants with specific health conditions were identified and the relevant data was extracted.

DATA ANALYSIS

Dose-response analysis indicated that selenium administration at and above 200 µg/day decreased HDL and LDL cholesterol and increased triglyceride levels. Blood selenium concentrations at the end of the trial above approximately 150 µg/L were positively associated with triglyceride and LDL cholesterol concentrations, and inversely associated with HDL cholesterol. Inorganic selenium supplementation showed stronger associations than organic selenium. At the lowest levels of baseline intake, selenium supplementation appeared instead to have beneficial effects on the lipid profile, with an overall indication of U-shaped curves, apart from HDL-cholesterol. The adverse effects of selenium were stronger in studies involving healthy participants as compared with unhealthy participants and pregnant females, in those having a longer duration of the intervention, particularly more than 3 months, and in European populations at selenium intake levels of above 300 µg/day.

CONCLUSIONS

In this dose-response meta-analysis of experimental human studies, an adverse effect of selenium administration on blood lipids at levels around or above the current upper level of intake was observed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022380432.

The optimal adjunctive therapies for microfracture treatment of osteochondral lesions of the talus: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

This study systematically compares the efficacy of different adjunctive therapies in enhancing microfracture (MF) treatment for osteochondral lesions of the talus (OLT) through a network meta-analysis, aiming to identify the optimal adjunctive therapy for microfracture.

METHODS

A systematic search of PubMed, Embase, Web of Science, Cochrane, and Scopus databases was conducted for relevant literature until October 1, 2024. Two researchers independently screened, extracted data, and assessed quality. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of six randomized controlled trials were included, comprising 295 OLT patients and involving four adjunctive therapies: MF combined with platelet-rich plasma (MF_PRP), hyaluronic acid (MF_HA), collagen scaffold (MF_CS), and pulsed electromagnetic fields (MF_PEMF). The results of the network meta-analysis indicated that while HA is the most commonly used adjunctive therapy, PRP-assisted MF demonstrated the best improvement in AOFAS and VAS scores for OLT. The surface under the cumulative ranking curve (SUCRA) predictions also revealed that PRP has the greatest potential among the four adjunctive therapies, followed by HA. Conversely, MF_PEMF showed the least effectiveness in improving AOFAS and VAS scores. Additionally, only one study reported complications associated with MF_PEMF and MF, with no statistically significant differences between the two.

CONCLUSION

Among the MF adjunctive therapies validated by RCTs, HA is the most widely used; however, PRP-assisted MF provides the best outcomes for OLT patients, suggesting that its application should be emphasized in clinical practice.

PROSPERO

Registration No: CRD42024546984.

CLINICAL TRIAL DETAILS

Not applicable.

Emotion regulation and mental health across cultures: a systematic review and meta-analysis

Emotion regulation (ER) plays a central role in mental health, but the effect differs across cultures. Here, expanding from extant literature's focus on Western-Eastern dichotomy or individualism-collectivism, this meta-analysis synthesized evidence on the associations between the two most-studied ER strategies (cognitive reappraisal and expressive suppression) and two mental health outcomes (psychopathology and positive functioning) and investigated the moderating roles of several cultural dimensions: Hofstede's national cultures dimensions, education, industrialization, richness and democracy (EIRDness), and sample demographics. A comprehensive literature search was conducted using electronic databases (CINAHL, Scopus, Web of Science, PsycINFO and MEDLINE) to identify eligible studies reporting relationships between ER and mental health outcomes (PROSPERO: CRD42021258190, 249 articles, n = 150,474, 861 effect sizes, 37 countries/regions). For Hofstede's national cultures and EIRDness, multimodel inference revealed that greater reappraisal propensity was more adaptive in more short-term-oriented, uncertainty-tolerant and competition-driven cultures, whereas greater suppression propensity was more maladaptive in more indulgent and competition-driven cultures. For demographics, greater reappraisal propensity was more adaptive for samples with more female (B = -0.19, 95% confidence interval (CI) -0.29 to -0.09) and more racial minority participants (B = -0.32, 95% CI -0.51 to -0.13), whereas greater suppression propensity was more maladaptive in younger samples (B = -0.004, 95% CI -0.005 to -0.002). These findings elucidate how cultures are associated with the function of ER and suggests ways in which future studies can integrate cultural characteristics when examining ER and psychological adjustment.

Pregnancy Complications and Risk of Autoimmune Disease in Women: A Systematic Review and Meta-Analysis

Background: Autoimmune diseases disproportionately impact women, and pregnancy-related events could play an underlying role. We summarized literature on the association between pregnancy complications and future risk of autoimmune disease. Materials and Methods: We systematically searched Medline, EMBASE, CINAHL Plus, and Web of Science from database inception to January 2024 for observational studies that reported on history of pregnancy complications (exposure), risk of newly diagnosed autoimmune disease (outcome), and included a comparison group of unaffected women. Two reviewers independently assessed study eligibility, extracted data, and rated risk of bias. We estimated pooled risk ratios (RRs) or odds ratios (ORs) and 95% confidence intervals (CIs) for pregnancy complications with ≥3 identified studies using DerSimonian and Laird random effects models and otherwise summarized findings following synthesis without meta-analysis (SWiM). Results: We screened 7,763 citations and included 25 studies (12 cohort, 13 case-control). Most studies were from Denmark (n = 10) or the United Kingdom (n = 5), with sample sizes ranging from 138 to >1.5 million women (median = 1,304 women). Risk of bias was moderate, serious, and critical in 10, 13, and 2 studies, respectively, with quality adversely impacted by potential unmeasured confounding. Meta-analyses indicated an elevated risk of autoimmune disease following preeclampsia (adjusted RR: 1.61, 95% CI: 0.98-2.65, I2 = 90.0%) and small fetal/infant size (adjusted OR: 2.02, 95% CI: 1.16-3.52, I2 = 28.4%), and possibly spontaneous pregnancy loss (adjusted RR: 1.58, 95% CI: 0.66-3.79, I2 = 99.4%) and stillbirth (adjusted RR: 2.18, 95% CI: 0.65-7.34, I2 = 99.2%), although estimates were often imprecise. SWiM findings generally supported a positive association between pregnancy complications and autoimmune disease; there were insufficient studies for gestational diabetes, placental disorders, and preterm birth. Conclusions: History of certain pregnancy complications may be a novel risk factor for autoimmune disease in women. Additional high-quality research with geographically diverse data sources would be valuable.

Impact of pre-Omicron COVID-19 vaccine boosters on the risk of Omicron variant infections: A systematic review and meta-regression

BACKGROUND

An argument against COVID-19 vaccine boosters is that immune imprinting may impair immune responses to new SARS-CoV-2 variants, as some epidemiological studies found a paradoxical increase in Omicron variant infections correlated with the number of prior pre-Omicron vaccine doses. However, substantial variability between studies has left the true impact of boosters uncertain, warranting further investigation.

METHODS

We systematically reviewed available data and applied meta-regression to identify sources of heterogeneity among studies that examined the impact of pre-Omicron COVID-19 vaccine boosters-compared with primary vaccination series without boosters-on the risk of Omicron variant infections and severe diseases.

RESULTS

We screened 1703 articles and included 35 eligible studies. Heterogeneities in the impact of pre-Omicron boosters on the risk of Omicron infections and severe diseases are attributable to differences in time after boosters, age, and vaccine products (meta-regression R2: 70.4 % and 67.7 %, respectively). During the first month post-vaccination, pre-Omicron mRNA boosters decrease-rather than increase-the risk of Omicron infections and severe diseases by 58 % (95 % CI: 54 %-62 %) and 80 % (95 % CI: 68 %-87 %). This effectiveness declines to 9 % (95 % CI: 7 %-23 %) and 55 % (95 % CI: 49 %-60 %) by the sixth and fifth month, respectively. The certainty for evidence is moderate for protection against infections and high for protection against severe diseases.

CONCLUSION

Our findings refute the immune imprinting hypothesis that COVID-19 boosters impair immunity against new SARS-CoV-2 variants and support current recommendations to stay protected through updated booster vaccination once or twice a year.

Preparing medical students to incorporate scientific evidence into patient care: A cross-sectional study

OBJECTIVE

To explore teaching- and assessment-related factors that predict medical students' perceived attainment of sufficient skills to incorporate scientific evidence into patient care.

METHODS

An anonymous questionnaire was distributed to final-semester students in six medical programs in Sweden. The students were asked to rate statements concerning the extent to which 11 national degree outcomes related to the scientific basis of medicine (scholarly degree outcomes) had been adequately assessed during the program; their perceived preparedness for evidence-based patient care; and training during the program regarding the components of a systematic review/health technology assessment (HTA).

RESULTS

In total, 433 students (median age: 25 years [interquartile range: 24‒28], 59% female) participated in the study (response rate: 68%). A multivariate analysis indicated that experienced adequate assessment on a single scholarly degree outcome (i.e., "Demonstrate knowledge of the scientific foundation of medicine and insight into current research as well as knowledge of the link between science and proven experience") predicted the students' perception of having developed sufficient skills in incorporating scientific evidence into patient care (odds ratio: 6.17 [95% confidence interval: 3.10; 12.3]). The educational content predictors of this perception included the teaching of HTA (11.3 [1.44; 89.5]) and training regarding two components of a systematic review/HTA: appraising scientific articles using checklists (2.46 [1.23; 4.90]) and assessing organizational aspects related to the introduction/withdrawal of a health technology (2.65 [1.05; 6.67]). The presence of hands-on, credit-bearing, evidence-based medicine (EBM)-related learning activities during clinical courses was also predictive (4.68 [1.69; 13.0]).

CONCLUSIONS

This study highlights important educational activities that prepare medical students to incorporate scientific evidence into patient care: (i) adequate assessment of key content regarding scholarly outcomes, including the scientific foundation of medicine; (ii) learning activities about HTA and the systematic review process; and (iii) hands-on application of EBM-related learning activities integrated into clinical courses.

Telemedicine interventions for improving antibiotic stewardship and prescribing: A systematic review

The global antibiotic resistance crisis necessitates optimized stewardship programs, with telemedicine emerging as a promising delivery strategy. This systematic review evaluated the effectiveness of telemedicine interventions in improving antibiotic stewardship across clinical settings. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched seven databases from January 2010 to July 2024. Two independent reviewers assessed studies using Risk of Bias in Non-randomized Studies (ROBINS-I) and Cochrane Risk of Bias 2.0 tools, with evidence certainty evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Twenty-one studies met inclusion criteria (10 observational, 8 quasi-experimental, 2 Randomized Controlled Trials [RCTs], 1 mixed-methods), predominantly from the United States (57.0%, n = 12). Among studies reporting antibiotic use outcomes (52.4%, n = 11), 90.9% demonstrated significant reductions ranging from 5.3% to 62.7%, with the highest-quality evidence showing a 28% reduction (95% Confidence Interval [CI]: 22-34%). Guideline adherence studies (57.1%, n = 12) showed acceptance rates of 67.7% to 98%, with comparable effectiveness between telemedicine and in-person consultation (79.1% vs 80.4%, p = 0.36). Prescribing rate outcomes (38.1%, n = 8) revealed setting-dependent variations: inpatient implementations demonstrated significant reductions (Relative Risk [RR] 0.68; 95% CI: 0.63-0.75), while outpatient findings showed mixed results. Quality assessment revealed predominantly low risk of bias [ROB] (66.7%, n = 14). These findings suggest that telemedicine effectively improves antibiotic stewardship compared to traditional care models, particularly in hospital settings, while outpatient applications demonstrated variable effectiveness. This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023454663).

The PACE Trial's GET Manual for Therapists Exposes the Fixed Incremental Nature of Graded Exercise Therapy for ME/CFS

The British National Institute for Health and Care Excellence (NICE) published its updated guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in October 2021. NICE concluded, after an extensive review of the literature, that graded exercise therapy (GET) is harmful and should not be used, and that cognitive behavioural therapy (CBT) is only an adjunctive and not a curative treatment. An article by White et al., which is written by 51 researchers, claims that there are eight anomalies in the review process and the interpretation of the evidence by NICE. In this article, we reviewed the evidence they used to support their claims. Their three most important claims are that NICE redefined the disease, that CBT and GET are effective, and that fixed incremental increases are not part of GET. However, our analysis shows that the disease was not redefined by NICE. Instead, it was redefined in the 1990s by a group of doctors, including a number of authors of White et al., when they erased the main characteristic of the disease (an abnormally delayed muscle recovery after trivial exertion, which, over the years, has evolved into post-exertional malaise) and replaced it with chronic disabling severe fatigue. Their own studies show that CBT and GET do not lead to a substantial improvement of the quality-of-life scores or a reduction in CFS symptom count, nor do they lead to objective improvement. Also, both treatments have a negative instead of a positive effect on work and disability status. Moreover, a recent systematic review, which included one of the authors of White et al., showed that ME/CFS patients remain severely disabled after treatment with CBT. Our analysis of, for example, the PACE trial's GET manual for therapists exposes the fixed incremental nature of GET. Why the authors are not aware of that is unclear because eight of them were involved in the PACE trial. Three of them were centre leaders and its principal investigators, four others were also centre leaders, and another one was one of the three independent safety assessors of the trial. Moreover, many of these eight authors wrote, or were involved in writing, this manual. In conclusion, our analysis shows that the arguments that are used to claim that there are eight anomalies in the review process and the interpretation of the evidence by NICE are anomalous and highlight the absence of evidence for the claims that are made. Furthermore, our analysis not only exposes the fixed incremental nature of GET, but also of CBT for ME/CFS.

Transcatheter versus surgical aortic valve replacement for severe aortic valve stenosis: Meta-analysis with trial sequential analysis

OBJECTIVES

Randomized controlled trials comparing transcatheter aortic valve implantation with surgical aortic valve replacement demonstrate conflicting evidence, particularly in low-risk patients. We aim to reevaluate the evidence using trial sequential analysis, balancing type I and II errors, and compare with conventional meta-analysis.

METHODS

Databases were searched for randomized controlled trials, which were divided into higher-risk and lower-risk randomized controlled trials according to a pragmatic risk classification. Primary outcomes were death and a composite end point of death or disabling stroke assessed at 1 year and maximum follow-up. Conventional meta-analysis and trial sequential analysis were performed, and the required information size was calculated considering a type I error of 5% and a power of 90%.

RESULTS

Eight randomized controlled trials (n = 5274 higher-risk and 3661 lower-risk patients) were included. Higher-risk trials showed no significant reduction in death at 1 year with transcatheter aortic valve implantation (relative risk, 0.93, 95% CI, 0.81-1.08, P = .345). Lower-risk trials suggested lower death risk on conventional meta-analysis (relative risk, 0.67, 95% CI, 0.47-0.96, P = .031), but trial sequential analysis indicated potential spurious evidence (P = .116), necessitating more data for conclusive benefit (required information size = 5944 [59.8%]). For death or disabling stroke at 1 year, higher-risk trials lacked evidence (relative risk, 0.90, 95% CI, 0.79-1.02, P = .108). In lower-risk trials, transcatheter aortic valve implantation indicated lower risk in conventional meta-analysis (relative risk, 0.68, 95% CI, 0.50-0.93, P = .014), but trial sequential analysis suggested potential spurious evidence (P = .053), necessitating more data for conclusive benefit (required information size = 5122 [69.4%]). Follow-up results provided inconclusive evidence for both primary outcomes across risk categories.

CONCLUSIONS

Conventional meta-analysis methods may have prematurely declared an early reduction of negative outcomes after transcatheter aortic valve implantation when compared with surgical aortic valve replacement.

Effects of Photobiomodulation on Burning Mouth Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this research is to evaluate the effectiveness and safety of photobiomodulation or low-level laser therapy on burning mouth syndrome compared to placebo, no-laser, clonazepam and alpha-lipoic acid.

METHODS

A systematic review of randomised clinical trials was performed. The databases consulted were MEDLINE, CENTRAL, LILACS, EMBASE and clinical trial registries ClincalTrial.org and WHO-ICTRP, to retrieve citations published until April 4, 2023. In addition, we consulted the grey literature for unpublished studies. There were no restrictions on language, publication status and publication date. Outcomes included pain relief, change in oral health quality of life, adverse effects and change in the quality of life concerning anxiety and depression. Two independent authors performed the study selection, and the risk of bias was assessed using the Cochrane collaboration tool. The random effect was calculated with a 95% confidence interval to calculate the relative risk. We performed heterogeneity by I2 and subgroup analysis. For all calculations, we used Review Manager 5.4.1 software.

RESULTS

In total, 528 references were located, and 13 studies were included, with 503 participants. Seven studies were evaluated qualitatively, and six were grouped for data meta-analysis according to the type of laser used, red or infrared. The following comparisons were evaluated: laser versus placebo, laser versus clonazepam and laser versus alpha-lipoic acid. Less pain was reported with the use of a laser, with low quality of evidence, in the comparisons: red laser versus placebo with a weighted mean difference (WMD) of -1.18; 95% CI [-2.16 to -0.19]; I2 = 61%; N = 58; 2 RCTs; infrared laser versus placebo with WMD = -1.34; 95% CI [-1.86 to -0.82]; I2 = 14%; N = 87; 3 RCTs; laser versus clonazepam with mean difference (MD) of -1.66; 95% CI [-3.17 to -0.15]; I2 = 0%; N = 33; 1 RCT. Oral health quality of life was better with the use of the laser, with very low quality of evidence, in the comparisons: red laser versus placebo with WMD = -1.08; 95% CI [-1.49 to -0.66]; I2 = 0%; N = 105; 2 RCTs; infrared laser versus placebo with WMD = -0.46; 95% CI [-1.70 to 0.78]; I2 = 86%; N = 85; 3 RCTs; laser versus clonazepam with MD = -19.65; 95% CI [-45.97 to 6.67]; N = 33; 1 RCT. For anxiety and depression, there was no significant difference between the groups, with very low quality of evidence, in the comparisons: infrared laser versus placebo, for anxiety with MD = 0.11; 95% CI [-2.64 to 2.86]; N = 28; 1 RCT; and for depression with MD = -0.66; 95% CI [-3.56 to 3.44]; N = 28; 1 RCT. Likewise, the comparison of laser versus clonazepam for anxiety and depression with MD = 1.05; 95% CI [-2.83 to 4.93]; N = 33; 1 RCT.

CONCLUSION

Pain was less common, and quality of life was better when using a low-level laser than placebo and clonazepam. The certainty of the evidence obtained was low and very low, respectively, meaning that the true effect may differ substantially from the effect estimate. Further well-conducted RCTs are needed to increase the degree of certainty of the evidence obtained.

Remimazolam vs. propofol for induction and maintenance of general anesthesia: A systematic review and meta-analysis of emergence agitation risk in surgical populations

INTRODUCTION

The association between remimazolam and emergence agitation (EA) remains unclear. This meta-analysis aimed to compare the relative risk of developing EA when using remimazolam vs. propofol in induction and maintenance of general anesthesia.

METHOD

We searched PubMed, clinicaltrials.gov, Web of Science, Cochrane Library, and Embase databases to identify studies meeting the inclusion criteria. The primary outcome was the incidence of EA. Secondary outcomes included the incidence of postoperative delirium (POD) within 7 days after surgery, emergence time, extubation time, length of post-anesthesia care unit (PACU) stay, and adverse events.

RESULTS

A total of 19 randomized controlled trials with 3031 patients were included in the meta-analysis. There was no statistically significant difference in the incidence of EA (RR = 0.82; 95 % confidence interval [CI], 0.41-1.65; p = 0.585) between remimazolam and propofol. Likewise, there were no significant intergroup differences in POD incidence, extubation time, emergence time, or length of PACU stay. Remimazolam exhibited superior hemodynamic stability, with a significantly reduced incidence of postinduction hypotension and intraoperative hypotension compared with propofol, while maintaining comparable safety profiles in terms of postoperative nausea and vomiting (PONV), intraoperative awareness, and hypoxemia. Subgroup analysis revealed that without routine postoperative antagonist administration, remimazolam was associated with prolonged extubation and length of PACU stay relative to propofol. In contrast, following antagonizing with flumazenil, the extubation and emergence times of the remimazolam group were shorter than those of the propofol group, while comparable PACU discharge time was maintained.

CONCLUSION

The use of remimazolam for the induction and maintenance of general anesthesia does not lead to a higher occurrence of EA in adult patients undergoing surgery, relative to propofol. However, in patients with ASA III-IV, remimazolam may be linked to a greater risk of POD than propofol.

Home-based prehabilitation: a systematic review and meta-analysis of randomised trials

BACKGROUND

Prehabilitation aims to enhance preoperative functional capacity through exercise, nutrition, and psychological programs. Home-based prehabilitation represents an alternative to hospital prehabilitation, with the advantage of not utilising hospital resources. This review aims to evaluate adherence and clinical effectiveness of home-based prehabilitation.

METHODS

We searched PubMed, Cochrane, and Embase up to October 1, 2024 for randomised controlled trials comparing home-based prehabilitation with standard care. The primary outcome was the proportion of patients with postoperative complications. Secondary outcomes included protocol adherence, and 6-min walking test. We used risk ratios (RR) and mean differences to summarise the results. The risk of bias was assessed using RoB 2 tool.

RESULTS

We included 29 randomised trials for a total of 3508 patients. Median adherence to home-based prehabilitation programs was 82%. Home-based prehabilitation reduced the proportion of patients with postoperative complications (508/1322 [38.4%] vs 578/1335 [43.3%], risk ratio 0.84, 95% confidence interval [CI] 0.72-0.98, P=0.02, I2=44%, low certainty). After home-based prehabilitation, 6-min walking test performance was better compared with control (MD 28.2 m (95% CI 9.5-46.9; P<0.01, I2=48). Preoperative depression (MD -0.65, 95% CI -0.87 to -0.43; P<0.001, I2=0%), postoperative anxiety (MD -0.50, 95% CI -0.75 to -0.25; P<0.001, I2=0%, low certainty) and length of hospital stays (MD -0.32 days, 95% CI -0.61 to -0.03; P=0.03, I2=45%, low certainty) were lower with home-based prehabilitation.

CONCLUSIONS

Home-based prehabilitation reduced the proportion of patients with postoperative complications, but with low certainty of evidence. It also improved preoperative functional capacity, reduced hospital stays, depression and anxiety scores, with good adherence to the intervention.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42024591208).

Effect of Exercise Intensity, Duration, and Volume on Protein Oxidation During Endurance Exercise in Humans: A Systematic Review With Meta-Analysis

Proteins are degraded and amino acids are metabolized in different quantities during endurance exercise. However, a clear consensus on protein oxidation during exercise has yet to be established. The main objective was to calculate estimates of protein oxidation during endurance exercise using available data. Additionally, we aimed to investigate the effects of exercise intensity, duration, and volume on protein oxidation. We systematically searched for research studies published in English in the online databases PubMed and Google Scholar in March 2023. The inclusion criteria were: (1) measurement of protein metabolism with nitrogen excretion, leucine oxidation, or indicator amino acid utilization method; (2) inclusion of an endurance exercise condition and a control condition without exercise; (3) inclusion of a description of the endurance exercise protocol (duration, intensity); and (4) inclusion of healthy participants over the age of 18. Endurance exercises were defined as exercise periods of at least 60 min' duration of running, cycling, or cross-country skiing. We included 30 articles (n = 286 participants). Protein oxidation increased by 1.02 ± 0.06 mg∙kg-1∙min-1 (95% CI [0.91, 1.14]) during endurance exercise, from the level of 0.81 ± 0.38 mg∙kg-1∙min-1 measured without exercise. Protein contributed 3.28% ± 0.15% (95% CI [2.97, 3.58]) of the total energy expenditure during exercise. Protein oxidation normalized by exercise duration significantly increased with exercise intensity. This review is the first to aggregate data on protein oxidation during endurance exercise, measured using different methods. Endurance exercise consistently increased protein oxidation, with protein metabolism more than doubling during exercise compared to rest. Protein oxidation increased with exercise intensity, but neither exercise duration nor volume augmented the rate of protein oxidation.

Nebulized Dexmedetomidine for Postoperative Sore Throat: A Systematic Review and Meta-analysis

Postoperative sore throat (POST) is common following general anesthesia, and the effects of preoperative nebulized dexmedetomidine on reducing the incidence of POST is uncertain. We aimed to clarify the efficacy of preoperative nebulized dexmedetomidine compared to nebulized ketamine and placebo on the incidence of POST. A systematic review and meta-analysis was performed from the PubMed, EMBASE, Web of Science, CENTRAL, Google Scholar databases (inception to May 2024). Trials involving adult patients (> 18 years) undergoing surgery under general anesthesia with tracheal intubation, with one group receiving preoperative nebulized dexmedetomidine, and the other receiving either preoperative nebulized ketamine or normal saline placebo were included. The primary outcome was the incidence of POST at 2-, 12- and 24-h. Eight randomized controlled trials (n = 686) were included in the final analysis. Preoperative nebulized dexmedetomidine did not reduce the incidence of POST at 2-, 12- and 24-h compared to ketamine [OR(95% CI) 0.89(0.38-2.07), p = 0.79; 0.86(0.40-1.85), p = 0.70; 0.67(0.25-1.77), p = 0.42, respectively]. Preoperative nebulized dexmedetomidine significantly reduced the incidence of POST at 2-, 12- and 24-h compared to normal saline placebo [OR(95% CI) 0.16(0.04-0.60), p = 0.007; 0.13(0.02-0.80), p = 0.03; 0.07(0.01-0.35), p = 0.001, respectively]. Preoperative dexmedetomidine nebulization is superior to nebulization with normal saline placebo and comparable to nebulized ketamine in terms of the incidence of POST. The quality of evidence is, however, low.