The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations

Comparative effectiveness of pharmacological and non-pharmacological interventions for dyspnea management in advanced cancer: A systematic review and network meta-analysis

Objective

This study aimed to evaluate and rank the effectiveness of pharmacological and non-pharmacological interventions for managing dyspnea severity, anxiety, exercise capacity, and health-related quality of life (HRQoL) in patients with advanced cancer.

Methods

A comprehensive search of PUBMED, HINARI, CENTRAL, and ResearchGate was conducted to identify randomized controlled trials (RCTs) published up to March 2024. Network meta-analysis was performed to compare interventions, calculating mean differences (MD) and standardized mean differences (SMD) with 95% confidence intervals (CI). P-scores were used to rank the interventions. Risk of bias was assessed using the Cochrane tool, and the quality of evidence (QOE) was evaluated using the GRADE framework.

Results

A total of 42 RCTs, encompassing 3,832 patients, were included in the analysis. Among the evaluated interventions, high-flow nasal cannula (HFNC) demonstrated the most significant improvement in dyspnea relief (SMD = -1.91; 95% CI: -3.32 to -0.49; QOE: moderate), followed by acupressure/reflexology (SMD = -1.04; 95% CI: -2.02 to -0.06; QOE: very low). Activity rehabilitation was the only intervention that significantly reduced anxiety compared to the control group (SMD = -0.64; 95% CI: -0.97 to -0.32; QOE: very low). While all interventions showed trends of improving exercise capacity, none reached statistical significance. Notably, acupressure/reflexology significantly enhanced HRQoL (SMD = 1.55; 95% CI: 0.22 to 2.88; QOE: moderate).

Conclusions

Non-pharmacological interventions, particularly HFNC and acupressure/reflexology, were more effective than pharmacological approaches in improving dyspnea relief and HRQoL. However, the low quality of evidence underscores the need for high-quality, large-scale trials to confirm these findings and refine treatment strategies for dyspnea management in advanced cancer patients.

Systematic review registration

PROSPERO CRD42023479041.

Biologic Therapies for Chronic Obstructive Pulmonary Disease: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite limited breakthroughs in COPD pharmacotherapy, recent trials have shown promising results for biologics in COPD patients. However, robust evidence synthesis in this area is currently lacking.

METHODS

We conducted a systematic review of MEDLINE, EMBASE, and Cochrane CENTRAL from inception to July 17, 2024, to identify randomized trials of biologic medications in patients with COPD. We performed a random effects frequentist network meta-analysis and present the results using relative risk (RR) and 95% confidence intervals (CI). We used the GRADE framework to rate the certainty of the evidence. Outcomes of interest included exacerbations, change in FEV1, change in quality of life, and serious adverse events.

RESULTS

Dupilumab reduced exacerbations as compared to placebo (RR 0.68 [95% CI 0.59 to 0.79]) (high certainty). Benralizumab (RR 0.89 [95% CI 0.78 to 1]), itepekimab (RR 0.81 [95% CI 0.61 to 1.07]) and tezepelumab (RR 0.83 [95% CI 0.61 to 1.12]) may reduce exacerbations as compared to placebo (all low certainty). Dupilumab probably reduced exacerbations more than mepolizumab (RR 0.74 [95% CI 0.62 to 0.89]) (moderate certainty). Dupilumab may reduce exacerbations more than tezepelumab (RR 0.82 [95% CI 1.14]) (low certainty). For all patients, no treatment improved FEV1 above the pre-specified minimal clinically important difference (MCID) of 0.1 L. Dupilumab probably has no meaningful effect on FEV1 compared to placebo (MD 0.07 [95% CI 0.02 to 0.13]) (moderate certainty). However, in the subgroup of patients with blood eosinophils ≥300/mcL, both tezepelumab (MD 0.15 [95% CI 0.05 to 0.26]) and dupilumab (MD 0.13 [95% CI 0.06 to 0.19]) probably improved FEV1 above the MCID.

CONCLUSION

Dupilumab is effective at improving patient-relevant outcomes in COPD with higher eosinophil levels. Other biological therapies, including tezepelumab, have no important effect on patient-relevant outcomes.

Comparative effectiveness of Omicron XBB 1.5-adapted COVID-19 vaccines: a systematic literature review and network meta-analysis

INTRODUCTION

Comparative effectiveness data of COVID-19 vaccines remain limited. We conducted a systematic review and network meta-analysis (NMA) feasibility assessment of effectiveness studies of Omicron-adapted COVID-19 vaccines.

RESEARCH DESIGN AND METHODS

Searches in MEDLINE and Embase up to February 2025 identified studies comparing the effectiveness of Omicron-adapted COVID-19 vaccines, either directly or against no recent vaccine. Two investigators independently selected articles reporting adjusted vaccine effectiveness (VE). A feasibility assessment determined the appropriateness of a common comparator and evaluated effect modifiers (EMs). Data extraction and risk-of-bias assessment were performed by one investigator and validated by a second investigator. Bayesian NMAs using random-effects models were performed for base-case analyses, data permitting.

RESULTS

The review identified 25 studies for Omicron-adapted COVID-19 vaccines: 16 for XBB formulations, eight of which were included in NMAs, all for mRNA formulations, representing 29.9 million participants. BNT162b2 had the largest evidence base. Comparisons between XBB.1.5-adapted BNT162b2 (Comirnaty) and mRNA-1273 (Spikevax) found that both vaccines are effective and comparable against XBB-related hospitalizations, infections, and medically attended visits in adults Among elderly, the estimated effectiveness against XBB-related hospitalizations favored BNT162b2.

CONCLUSIONS

Findings of this NMA of observational studies support the effectiveness of XBB.1.5-adapted mRNA vaccines. Limitations included assumptions on EMs and sparse evidence networks.

Hormone therapy with different administration routes for patients with perimenopausal syndrome: a systematic review and network meta-analysis

PURPOSE

To comprehensively compare and rank hormone therapy for patients with perimenopausal syndrome.

METHODS

A comprehensive search was conducted on PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, and Wanfang databases from inception to August 20, 2024. The quality of the included randomized controlled trials (RCTs) were measured by the Cochrane risk of bias tool. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was applied to grade the quality of evidence in this network meta-analysis. Network plots were depicted to show direct and indirect comparisons of hormone therapy for each outcome. The influences of different hormone therapy on the outcomes were illustrated via forest plots and league tables. Rank probabilities showed the ranking of different administration routes.

RESULTS

Seven studies involving 704 perimenopausal syndrome patients were included. The rank probabilities suggested that oral estradiol (E2) combined with medroxyprogesterone and general health guidance had the highest likelihood to be the optimal therapy for the severity of menopausal syndrome. General health guidance combined with oral E2 was less likely to have a nausea and vomiting, and breast pain.

CONCLUSION

Oral E2 and medroxyprogesterone or general health guidance combined with oral E2 may be the effective and safe option for the management of perimenopausal syndrome.

Comparative efficacy and safety of febuxostat and allopurinol in chronic kidney disease stage 3-5 patients with asymptomatic hyperuricemia: a network meta-analysis

OBJECTIVE

This study evaluates and compares the effectiveness and safety of febuxostat and allopurinol in chronic kidney disease (CKD) stages 3-5 patients with asymptomatic hyperuricemia using a network meta-analysis.

METHODS

A systematic review and network meta-analysis were conducted, adhering to PRISMA-NMA guidelines. Searches included PubMed, Embase, Cochrane Library, and Chinese databases up to June 2024. Randomized controlled trials (RCTs) and cohort studies were assessed for methodological rigor using GRADE.

RESULTS

A total of 12 RCTs and 4 cohort studies (n = 2,423 participants) were included. Febuxostat was associated with greater improvements in estimated glomerular filtration rate compared to allopurinol (MD, 4.99 mL/min/1.73 m2; 95%CI -0.65 to 10.78; certainty: low) and placebo (MD, 4.72 mL/min/1.73 m2; 95%CI 0.67 to 8.82; low). Serum uric acid reduction was also more pronounced with febuxostat (MD, -0.61 mg/dL; 95%CI -1.15 to -0.05; moderate). Safety outcomes, including major cardiovascular events and adverse events, showed no significant differences between febuxostat and allopurinol. Subgroup analyses revealed enhanced effectiveness of febuxostat at six months of treatment.

CONCLUSIONS

This analysis provides robust evidence that febuxostat might offers greater improvements in kidney function and uric acid levels compared to allopurinol or placebo in asymptomatic hyperuricemia with CKD stage 3-5 patients, without compromising safety. These findings can guide clinical decision-making and treatment optimization.

Comparison of the diagnostic accuracies of various biomarkers and scoring systems for sepsis: A systematic review and Bayesian diagnostic test accuracy network meta-analysis

PURPOSE

Sepsis affects approximately 50 million people worldwide, resulting in 11 million deaths annually. Conflicting results and insufficient evidence comparing performance biomarkers exist. The study aimed to comprehensively compare available biomarkers and clinical scores for detecting sepsis since its redefinition in 2016 with this systematic review and Bayesian diagnostic test accuracy network meta-analysis.

MATERIALS AND METHODS

We conducted searches in the PubMed, EMBASE, and Scopus databases between January 2016 and December 2023. Eligible studies assessed the diagnostic accuracies of biomarkers, the quick Sequential Organ Failure Assessment (qSOFA) score, or Systemic Inflammatory Response Syndrome (SIRS) criteria in detecting sepsis. Bivariate hierarchical random effects arm-based beta-binomial models were used for quantitative synthesis (PROSPERO Registration Number: CRD42018086545).

RESULTS

We included 78 studies representing 34,234 patients and compared qSOFA score, SIRS criteria alongside seven of the most studied biomarkers: procalcitonin, C-reactive protein (CRP), interleukin-6 (IL-6), presepsin (cluster of differentiation 14 subtypes), CD64, soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), and lipopolysaccharide-binding protein (LBP). CD64 demonstrated the highest superiority index, followed by sTREM-1 and presepsin (diagnostic odds ratio: 20.17 vs 18.73 and 10.04, 95 % credible interval [CrI]: 8.39-38.61 vs 1.31-83.98 and 6.71-14.24; quality of evidence: moderate vs low and low). Multivariable meta-regression analysis identified significant sources of heterogeneity, including study design, proportion of sepsis, sample size, and the risk of bias (patient selection).

CONCLUSIONS

The best diagnostic accuracy for sepsis was shown by CD64, with a moderate quality of evidence. Compared to CD64, sTREM-1 and presepsin provided suboptimal and low evidence. These biomarkers were more effective at identifying updated sepsis than clinical scores. We recommend re-considering the addition of biomarkers in screening for sepsis or sepsis-related conditions, as this could lead to more accurate and timely decisions for future clinical interventions.

Cognitive benefits of music in aerobic exercise: Evidence from a Bayesian network meta-analysis in adults with mild cognitive impairment

Aerobic exercise improves cognitive functions in older adults with mild cognitive impairment (MCI), while dance, combining music and synchronized movement, offers additional cognitive benefits. Despite music's potential role in enhancing cognitive outcomes, most research on aerobic exercise has not considered the impact of accompanying music. This review compared the effectiveness of aerobic exercise with music, aerobic exercise without music, and dance on cognitive function in adults with MCI. A total of 38 papers from 25 randomized controlled trials (N = 2048) were synthesized. The multilevel meta-analyses showed that compared to the control group, global cognition was improved by aerobic exercise with music (g = 1.2 [0.47, 1.94]), aerobic exercise without music (g = 0.48 [0.18, 0.79]), and dance (g = 0.55 [0.13, 0.96]). Dance also enhanced short-term memory (g = 0.41 [0.24, 0.59]), learning efficiency (g = 0.39 [0.14, 0.65]), and retrieval fluency (g = 0.7 [0.19, 1.22]). Bayesian network meta-analyses indicated that aerobic exercise with music had the highest probability of being the most effective for improving global cognition, executive function, and processing speed. Dance was likely to be the most beneficial for enhancing short-term memory, learning efficiency, and retrieval fluency. This study supports that incorporating music in exercise amplifies the cognitive benefits beyond exercise alone for individuals with MCI. The "Music Exercise Synergy Model" is proposed to explain the cognitive benefits of combining music with exercise. Dance strategically uses music for coordination, offering psychological, social, cognitive, and neurobiological benefits and contributing to the observed enhancements in memory functions.

Biologics for the Treatment of Moderate-to-Severe Plaque Psoriasis: A Systematic Review and Network Meta-analysis

INTRODUCTION

Moderate-to-severe plaque psoriasis is a chronic disease impacting quality of life (QoL). This network meta-analysis (NMA) compared efficacy and safety of all biologics approved for the treatment of moderate-to-severe plaque psoriasis to better inform providers on mid-term outcomes, with a focus on the interleukin-23 p19 inhibitor tildrakizumab.

METHODS

MEDLINE®, Embase, and CENTRAL were searched for randomized clinical trials (RCT) from inception through January 2024. RCTs comparing biologics against placebo or each other reporting Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA) 0/1, or Dermatology Life Quality Index (DLQI) 0/1 responses and safety outcomes (adverse events [AEs] or serious AEs [SAEs]) were sought. Bayesian NMAs were performed at week 28 as the primary time point of interest. Analyses were also performed at weeks 12 and 16. Findings were expressed as risk ratios (RR; efficacy outcomes), risk differences (RD; safety outcomes), and numbers needed to treat (NNT) with 95% credible intervals.

RESULTS

Of 7418 publications screened, 187 describing 124 RCTs of 12 biologics were included in the systematic literature review, and 103 RCTs were included for NMA. All treatments demonstrated improved efficacy and QoL vs. placebo at week 28. Tildrakizumab efficacy at week 28 was comparable to risankizumab and guselkumab, respectively, for PASI 75 (RR 8.74 vs. 8.92 and 8.91), PASI 90 (RR 14.09 vs. 14.81 and 14.77), and PGA 0/1 (RR 9.34 vs. 10.29 and 10.23). No biologics exhibited an increased risk of SAEs vs. placebo; tildrakizumab exhibited no increased risk vs. placebo for AEs.

CONCLUSIONS

The investigated biologics demonstrated improved efficacy and QoL relative to placebo at week 28, with no increased risk of SAEs vs. placebo through week 16. At week 28, efficacy of tildrakizumab, risankizumab, and guselkumab was comparable. Limitations include lack of placebo comparators after week 12 or 16, which could affect results.

Belantamab Mafodotin Plus Proteasome Inhibition Efficacy Versus Comparators in Early Relapsed Myeloma: A Systematic Review and Network Meta-Analysis

In the Phase 3 DREAMM-7 study of patients with relapsed/refractory multiple myeloma (RRMM) who received ≥ 1 prior therapy, belantamab mafodotin plus bortezomib and dexamethasone (BVd) demonstrated a progression-free survival (PFS) benefit versus daratumumab plus bortezomib and dexamethasone (DVd). This study aimed to indirectly compare the efficacy of BVd against alternative regimens in this patient population. A systematic literature review (SLR; December 2021-February 4, 2024) was performed to identify relevant efficacy data. Studies were selected based on the Population-Intervention-Comparators-Outcomes-Study design framework criteria and independently reviewed for inclusion in the network meta-analysis (NMA) if they had a connection to DREAMM-7 (approved in the US or EU, or likely to be a future DREAMM-7 comparator). Each trial had a common comparator arm, allowing for a connected network between the trials and linkage by shared treatments. The primary analysis was PFS in the intent-to-treat population from each study, and secondary analyses examined other endpoints. All endpoints were also evaluated in subgroups by lenalidomide-exposure, -refractoriness, and other patient characteristics. The SLR identified 12 comparator studies comprising 12 comparator regimens (each contained a proteasome inhibitor [bortezomib or carfilzomib] plus dexamethasone), all of which were included in the NMA with the DREAMM-7 study. BVd improved PFS versus all comparators, including daratumumab plus carfilzomib and dexamethasone, isatuximab plus carfilzomib and dexamethasone, and DVd. Overall survival was also improved by belantamab mafodotin plus bortezomib and dexamethasone over the other regimens. This study provides compelling evidence for belantamab mafodotin, plus bortezomib and dexamethasone, in early lines of treatment for RRMM.

Comparing the effects of different non-pharmacological traditional Chinese medicine therapies on cancer survivors: A Bayesian Network Meta-analysis

OBJECTIVES

Several studies have demonstrated the positive impact of non-pharmacological Traditional Chinese Medicine (TCM) therapies on pain, fatigue, sleep quality, and quality of life in cancer survivors. However, no research has compared the effectiveness of these therapies. This study aims to compare various interventions and identify the most effective non-pharmacological TCM therapies to provide evidence-based recommendations for cancer survivors.

METHODS

A systematic search was conducted in PubMed, Embase, Web of Science, CNKI, and Wanfang Data. RCTs investigating the effects of Taichi, Qigong, acupuncture, acupressure, TCM emotional therapy, and mixed therapies as interventions for cancer survivors were screened was conducted. Data from the creation of the database to February 2025 were included. Two independent reviewers evaluated the study quality. A Bayesian Network Meta-analysis was conducted to carry out a random effects model.

RESULTS

Seventy-one RCTs involving 6473 patients were included in the analysis. Network meta-analysis showed significance for all five intervention therapies in pain control in cancer patients. The best efficacy was observed for acupressure (SMD=-1.1 [-1.55, -0.66]) and Taichi/Qigong (SMD=-1.08[-1.64, -0.53]), followed by TCM emotional therapy (SMD=-0.93 [-1.42, -0.44]) and acupuncture (SMD=-0.54 [-0.93, -0.15]), with the latter showing comparatively lower efficacy. None of the interventions demonstrated superior efficacy in improving fatigue compared to the control group. Mixed therapies (SMD=-1.36[-2.56, -0.28]) demonstrated the greatest effect in improving sleep quality. Taichi/Qigong (SMD=1.87 [0.96, 2.83]) demonstrated certain advantages in improving quality of life. However, acupuncture and TCM emotional therapy had no significant effect on sleep quality or overall quality of life.

CONCLUSION

The evidence from this study suggests that acupressure and Taichi/Qigong are recommended as the most effective therapies for pain relief and quality of life improvement, respectively. The efficacy of these therapies for fatigue remains inconclusive. However, due to the limited number of included studies and the high risk of bias, these results should be interpreted with caution. Future studies should include more rigorously designed high-quality randomized controlled trials to confirm their long-term efficacy and safety.

REGISTRATION

PROSPERO CRD42024601976.

The effectiveness of behavioral modification interventions for managing weight gain in pregnant women with overweight or obesity: a systematic review and Bayesian network meta-analysis

BACKGROUND

Global obesity prevalence among pregnant women is associated with adverse health outcomes for both the mother and the infant.

OBJECTIVE

This study aims to evaluate the efficacy of a behavioural intervention management model for controlling gestational weight gain (GWG) in pregnant women with overweight or obesity.

METHODS

The quality of the evidence was assessed using the Confidence In Network Meta-Analysis technique. Moreover, a Bayesian network meta-analysis summarised the comparative efficacy of various intervention methods on GWG outcomes.

RESULTS

The analysis included 24 trials with 11,008 participants across three different management models: in-person, remote (electronic health (eHealth) or mobile health (mHealth)), and mixed. Evidence quality ranged from very low to high. The multi-behavioural intervention delivered via a blended in-person and mHealth model demonstrated the highest likelihood of being in the top ranks of intervention effectiveness compared to the other interventions included in the analysis, scoring 85.9%.

CONCLUSIONS

The multi-behavioural intervention delivered via a blended in-person and mHealth administration mode ranked highest in effectiveness for reducing GWG in pregnant women with overweight or obesity compared to the other interventions included in the analysis. Future studies may focus on addressing evidence gaps through more rigorous and direct comparative analyses.

Interventions used in control group against cupping therapy for chronic nonspecific low back pain: A systematic review and network meta-analysis

INTRODUCTION

The evidence for the effect of cupping therapy on chronic nonspecific low back pain (CLBP) remains controversial, and existing researches didn't consider outcomes influenced by factor of selection of interventions in control group. This review and network meta-analysis is to compare the effects of diverse interventions in cupping therapy control groups for CLBP, with the objective of identifying the suitable control intervention against cupping therapy for CLBP.

METHODS

Studies were identified by a comprehensive search of databases, such as PubMed, Embase, Cochrane Library, Web of Science and China National Knowledge Infrastructure (CNKI), up to June, 2024. A total of 10 randomized control trials (RCT) were included in this network meta-analysis (NMA).

RESULTS

The results showed that compared with cupping therapy, minimum negative pressure cupping therapy (MNPCT) (SMD = - 0.01; 95 %CI: - 0.92 to 0.89), air circulating cupping therapy (ACCT) (SMD = - 0.05; 95 %CI: - 0.63 to 0.54) and diclofenac (SMD = - 0.13; 95 %CI: - 1.13 to - 0.87) was no significantly different from improvement of pain intensity. But there was significant difference between cupping therapy and D-ibuprofen (SMD = - 1.11; 95 %CI: - 2.08 to - 0.13), paracetamol (SMD = - 1.12; 95 %CI: - 1.80 to - 0.43) or usual care (SMD = - 1.18; 95 %CI: - 2.56 to - 1.06). The order of intervention effect by SUCRA diagram was as follows: cupping therapy (77.7 %) > MNPCT (75.2 %) > ACCT (73.8 %) > diclofenac (68.8 %) > D-ibuprofen (26.3 %) > paracetamol (24.5 %) > usual care (3.8 %). The quality of evidence for network estimates was moderate to very low due to the risk of bias and imprecision.

CONCLUSIONS

The results of this study suggest that usual care was the least effective in alleviating the pain intensity of CLBP, which might serve as the most appropriate intervention in the control group in cupping-related RCTs. MNPCT and ACCT have similar effects with cupping therapy for CLBP. Future research may be based on some objective clinical outcomes and control interventions with physiological inertia to isolate the true effect of cupping therapy or SCT from psychological biases.

TRIAL REGISTRATION

The protocol was registered on the international prospective register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO), registration number: CRD42024527513.

The application of non-invasive brain stimulation techniques to reduce anger and violence proneness: Results of a systematic review and meta-analysis

Since the 1990s, there has been a rise in the number of publications assessing the effects of applying non-invasive brain stimulation (NIBS) to treat patients with drug-resistant depression. This involves applying magnetic fields or electrical currents to the surface of the skull to influence the superficial neurons in the cerebral cortex. Due to the evidence regarding symptom reduction in these types of patients, such as irritability or hostility, there was a rise in the use of this technique to reduce negative mood, including anger state. This decrease in anger state could also help reduce other problems such as violence proneness. In this sense, the anger state of individuals who are prone to violence might be affected by interfering with the excitability of the prefrontal cortex (PFC), a key brain region responsible for behavioral regulation. Thus, we conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. After initially identifying 2426 sources, we eventually included a total of 69 publications for the systematic review, from which 45 were employed for the meta-analysis. Only a few of them highlighted a significant contribution of using NIBS techniques on different regions of the PFC to reduce anger state or violence when compared to participants receiving sham stimulation in normative and clinical samples. Furthermore, the comparison of effect sizes between groups that received real stimulation on several regions of the PFC and those that received sham stimulation did not reveal a significant difference in reducing anger state or violence. In addition, despite most of the conclusions being consistent, considerable heterogeneity existed across studies regarding certain PFC regions, which could be explained by the type of NIBS employed. Therefore, using superficial stimulation over the PFC as a general tool for reducing violence proneness should be approached with caution, except in specific cases.

CADCAM Versus Conventional Denture Bases: Network Meta-Analysis of In Vitro Studies Comparing Accuracy and Surface Properties

INTRODUCTION

This systematic review with network meta-analysis (NMA) analysed the current evidence on in vitro studies comparing trueness of fit, surface roughness, colour stability, surface wettability, water sorption, water solubility, and microbial adhesion between conventional and digital denture bases.

METHODS

From inception until December 2023, a systematic search of published in-vitro studies from Scopus, PubMed, and the Cochrane Central Register of Controlled Studies was conducted. The protocol was registered in PROSPERO (CRD42024531416). NMA compared properties related to dimensional accuracy and surface properties between conventional and digital dentures. The ranking was performed using the surface area under the cumulative ranking guidelines.

RESULTS

A total of 6004 articles were initially identified, of which 342 duplicates were removed, and 5566 were excluded by screening the titles and abstracts. A total of 96 articles were assessed by full-text reading, and 43 were included in the quantitative synthesis. As per the NMA results, MIL demonstrated significantly higher trueness of fit when compared with conventional compression moulding (standardized mean differences [SMD] = -2.25 [95% CI: -4.09, -0.40]), P = .017 (<.05) and TDP (SMD = -1.57 [95%CI: -3.14, -0.01]) P < .05. MIL demonstrated significantly lower surface roughness when compared with conventional compression moulding (SMD = -0.99 [95% CI: -1.72, -0.26]), P = .008 (<.05), and TDP (SMD = -1.08 [95%CI: -1.95, -0.22]) P < .05.

CONCLUSIONS

There is conclusive evidence that milled digital denture bases demonstrate higher trueness of fit and lower surface roughness than 3D-printed denture bases and conventional denture bases, as demonstrated by the concurrent network and pairwise results.

CLINICAL RELEVANCE

In vitro studies show that milled digital dentures exhibit higher accuracy and lower surface roughness. The clinical performance of milled dentures in relation to these properties needs to be evaluated by high-quality randomized controlled clinical trials.

Comparison of the efficacy of different protocols of repetitive transcranial magnetic stimulation and transcranial direct current stimulation on motor function, activities of daily living, and neurological function in patients with early stroke: a systematic review and network meta-analysis

BACKGROUND

The application of transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in patients with early stroke has recently received considerable attention, but the optimal protocol remains inconclusive. This study intends to evaluate and compare the effects of different protocols of tDCS and rTMS on improving motor function, activities of daily living (ADL), and neurological function in patients with early stroke, and to comprehensively assess their efficacy and safety.

METHODS

MEDLINE, Embase, Cochrane Library, and Web of Science were searched. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2.0 tool, and Bayesian NMA was conducted using R4.3.1 and Stata16.

RESULTS

The results of NMA showed that after early intervention, bilateral application of high- and low-frequency rTMS (BL-rTMS) performed best in improving the upper extremity motor function at the end of intervention (SUCRA: 92.8%) and 3 months (SUCRA: 95.4%). Besides, low-frequency rTMS (LF-rTMS) performed best in improving the lower extremity motor function (SUCRA: 67.7%). BL-rTMS was the most effective in ameliorating the ADL at the end of intervention (SUCRA: 100%) and 3 months (SUCRA: 85.6%). In terms of the NIHSS scores, BL-rTMS had the highest probability of being the most effective measure at the end of intervention (SUCRA: 99.7%) and 3 months (SUCRA: 97.05%). Besides, LF-rTMS (0%), 5 Hz-rTMS (0%), and intermittent theta-burst stimulation (iTBS) (0%) all exhibited a good safety profile.

CONCLUSION

BL-rTMS is the optimal stimulation protocol for improving upper extremity motor function, ADL, and neurological function in early stroke, with long-term efficacy.

Updated meta‑analysis on the therapeutic effects of botanical extract interventions for chronic lower back pain

Chronic lower back pain (CLBP) severely affects an individual's quality of life and increases reliance on healthcare services. Previous meta-analyses have primarily examined the effects of essential oils and herbal remedies separately, without considering their combined therapeutic potential. The present meta-analysis integrated both treatment modalities to evaluate the efficacy of botanical extract-based therapies for CLBP management. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with data extracted from randomized controlled trials (RCTs) conducted up to July 2024. A comprehensive search of several databases identified 13 RCTs that met the inclusion criteria, focusing on interventions using plant extracts, including various herbal formulations and essential oils. The meta-analysis demonstrated that botanical extract-based treatments, whether applied topically, combined with massage or administered orally, were more effective compared with a placebo in reducing pain, enhancing lumbar flexibility and extending walking duration in patients with CLBP. These findings support the role of botanical extracts as viable therapeutic options for CLBP management, emphasizing their potential integration into comprehensive pain management strategies. However, further research is necessary to explore their long-term efficacy and underlying mechanisms. The present study is registered in PROSPERO (registration no. CRD42024554015).

Efficacy of Probiotics Compared With Pharmacological Treatments for Maintenance Therapy for Functional Constipation in Children: A Systematic Review and Network Meta-analysis

CONTEXT

There has been an increase in randomized controlled trials (RCTs) comparing probiotics with various maintenance therapies, such as polyethylene glycol, lactulose, and mineral oil, to treat functional constipation in children.

OBJECTIVE

The aim was to compare probiotics with all other oral maintenance therapies for functional constipation in children and rank all treatments in terms of effectiveness in a network meta-analysis.

METHODS

RCTs were identified through systematically searching the MEDLINE, Scopus, EMBASE, and Cochrane Library databases, trial registries, and forward and backward citation searching. Within-study risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and confidence in the estimates was assessed using the CINeMA (Confidence in Network Meta-Analysis) framework. Random-effects network meta-analyses were conducted.

RESULTS

Data were pooled from 41 and 29 RCTs for network meta-analysis of defecation frequency and treatment success, respectively. Probiotics did not significantly increase the number of bowel movements per week when compared with any conventional treatment or placebo. A combination of mineral oil and probiotics was the most effective treatment for increasing defecation frequency (mean difference: 3.13; 95% confidence interval [CI]: 0.64, 5.63). The most effective treatments for increasing the risk of treatment success as compared with placebo were mineral oil (relative risk [RR]: 2.41; 95% CI: 1.53, 3.81) and a combined treatment of polyethylene glycol and lactulose (RR: 2.45; 95% CI: 1.21, 4.97). Confidence in the estimates ranged from very low to moderate.

CONCLUSION

Currently, there is no evidence to suggest that probiotics should be used as a standalone treatment for functional constipation in children. More high-quality studies are needed to evaluate different strains of probiotics and their potential benefit as an additional treatment component to conventional treatments. Mineral oil and polyethylene glycol were the most effective treatments to increase defecation frequency and treatment success rates and should remain the first line of treatment for children with functional constipation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no.

CRD42022360977 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=360977).

PTH1 receptor agonists for fracture risk: a systematic review and network meta-analysis

Osteoporosis, defined by reduced bone mineral density and macro- and micro-architectural degradation, leads to increased fracture risk, particularly in aging populations. While randomized controlled trials (RCTs) demonstrate that PTH1 receptor agonists, teriparatide and abaloparatide, are effective at reducing fracture risk, real-world evidence (RWE) remains sparse. This study reviews and compares the anti-fracture efficacy of these agents, against each other and against other osteoporosis treatments using both RCTs and RWE. We systematically searched Medline, Embase, and Cochrane up to May 2024, focusing on RCTs and RWE studies reporting reduction in vertebral, non-vertebral, hip, or all fractures as primary endpoint. A network meta-analysis (NMA) was conducted, first through pairwise meta-analyses of teriparatide versus abaloparatide, then a Bayesian NMA comparing each to other treatments. Safety assessments included adverse events classified by MedDRA, with a particular attention to hypercalcemia and cardiac events. Seventeen studies (11 RCTs, 6 RWE) met inclusion criteria. Teriparatide and abaloparatide were effective in reducing vertebral and non-vertebral fractures in all pairwise meta-analyses versus placebo. Abaloparatide showed an advantage over teriparatide for non-vertebral fractures (OR: 0.87, 95% CI: 0.80-0.95) and hip fractures (OR: 0.81, 95% CI: 0.71-0.93). In the NMA model, teriparatide and abaloparatide were superior to placebo, raloxifene, and calcitonin in reducing vertebral fracture while teriparatide was further superior to denosumab and risedronate. For non-vertebral fracture, abaloparatide was better than any other treatment while teriparatide was only superior to alendronate or placebo. PTH1 analogs were better than placebo at reducing all fractures while no difference was observed for the risk of hip fracture. Both abaloparatide and teriparatide demonstrate comparable safety to other osteoporosis treatments, with no increased cardiovascular risk. This review highlights that PTH1 receptor agonists effectively reduce fracture risk, with abaloparatide offering enhanced benefits for non-vertebral and hip fractures compared to teriparatide. Both agents exhibit acceptable safety profiles, suggesting their valuable role in managing osteoporosis, particularly for high-risk patients.

Comparative efficacy and safety of SGLT2 inhibitor class members in patients with heart failure and type 2 diabetes: A systematic review and network meta-analysis of randomized controlled trials

We conducted a systematic review with pairwise (PMA) and network meta-analyses (NMA) to evaluate sodium-glucose transport protein 2 inhibitor (SGLT2i) effects in patients with both heart failure (HF) and type 2 diabetes mellitus (T2DM). Five databases were searched up to April 15, 2025. Primary outcomes were all-cause mortality (ACM), cardiovascular death (CVD), all-cause hospitalization (ACH), and hospitalization for heart failure (HHF). SGLT2i class effects versus control were assessed via PMA and individual SGLT2i comparative efficacy via NMA plus ranking using p-scores. Seventeen randomized controlled trials (n = 17,809) were included. Arms included canagliflozin (n = 2), dapagliflozin (n = 6), empagliflozin (n = 6), ertugliflozin (n = 1), ipragliflozin (n = 1), sotagliflozin (n = 1), placebo (n = 13), and standard of care (n = 4). Compared to control, SGLT2i significantly reduced ACM (HR 0.87, 95 %CI 0.78 to 0.98, low quality of evidence [QoE]), ACH (HR 0.74, 95 %CI 0.62 to 0.88, high QoE), and HHF (HR 0.70, 95 %CI 0.63 to 0.77, low QoE); but not CVD (HR 0.87, 95 %CI 0.76 to 1.00, very low QoE). Canagliflozin ranked highest in decreasing ACM (p-score = 0.86), CVD (p-score = 0.82), and HHF (p-score = 0.88). In patients with HF and T2DM, SGLT2i class effects include ACM, ACH, and HHF reduction. Among SGLT2i, canagliflozin showed greatest ACM, CVD, and HHF benefit.

Comparative Efficacy and Safety of Multiple Wake-Promoting Agents for the Treatment of Residual Sleepiness in Obstructive Sleep Apnea Despite Continuous Positive Airway Pressure: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

Residual sleepiness can occur in adult patients with obstructive sleep apnea (OSA) despite adequate treatment with continuous positive airway pressure (CPAP). Various wake-promoting agents (WPAs) have been shown to reduce residual sleepiness in CPAP-treated patients with OSA. This systematic review and network meta-analysis aimed to compare the efficacy and safety of WPAs in this setting.

METHODS

We searched MEDLINE, Scopus, and ClinicalTrials.gov up to 9 January 2025 for randomized controlled trials (RCTs) examining WPAs for treating sleepiness in patients with OSA. Included were all RCTs that explored the efficacy and/or safety of any approved WPAs (i.e., modafinil, armodafinil, solriamfetol, or pitolisant) in patients with OSA (aged ≥ 18 years) treated with CPAP but who are still sleepy [Epworth sleepiness scale (ESS) score ≥10]. Studies that were conducted in patients whose comorbidities cause daytime somnolence [i.e., psychiatric conditions (other than depression), other sleep disorders, medical or surgical conditions], open label extension studies, and studies published in a language other than English were excluded. The primary outcomes included ESS, maintenance of wakefulness test (MWT), and adverse events. Two authors independently assessed the risk of bias using the revised Cochrane risk-of-bias tool for randomized trials 2.0.

RESULTS

In total, 14 RCTs studying four WPAs (total N = 2969) including modafinil (six RCTs; 200-400 mg/day), armodafinil (four RCTs; 150-250mg/day), solriamfetol (two RCTs; 37.5-300 mg/day), and pitolisant (two RCTs; 5-40 mg/day) were included. Solriamfetol, modafinil, and armodafinil were efficacious in reducing subjective sleepiness as measured by ESS [mean difference (95% confidence interval) at ≤ 4 weeks: -3.84 (-5.60, -2.07), -2.44 (-3.38, -1.49), and -2.41 (-3.60, -1.21) for solriamfetol, modafinil, and armodafinil, respectively; at > 4 weeks: -4.11 (-6.14, -2.08), -2.88 (-3.85, -1.91), -2.46 (-3.68, -1.24) for solriamfetol, armodafinil, and modafinil, respectively] and clinical global impression of change, as well as the objective MWT [at ≤ 4 weeks: 11.66 min (9.70, 13.61), 3.61 min (2.48, 4.73), and 2.52 min (1.27, 3.76) for solriamfetol, modafinil, and armodafinil, respectively; at > 4 weeks: 10.34 min (4.16, 16.52) for solriamfetol]. Pitolisant showed later improvements in ESS [at > 4 weeks: -2.70 (-3.66, -1.73)], with limited data on MWT. Sensitivity analyses restricted to U.S. Food and Drug Administration-approved solriamfetol dosages (37.5-150 mg/day) still showed higher efficacy, but lower anxiety risk.

CONCLUSIONS

Among all WPAs, solriamfetol demonstrated the highest efficacy on ESS and MWT, with the latter being significant. Modafinil demonstrated the best clinician impression, albeit not statistically significant. All four WPAs were associated with a low risk of serious or adverse events.

REGISTRATION

PROSPERO registration number, CRD42022359237.

Efficacy of Hypoglycemic Agents in Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD): A Systematic Review and Network Meta-Analysis

AIMS

Metabolic dysfunction associated steatotic liver disease (MASLD) is a universal hepatic disease, and many recent randomized clinical trials (RCTs) have explored whether hypoglycemic agents may be beneficial for its treatment. This study aimed to assess the relative effectiveness of each hypoglycemic agent for MASLD.

METHODS

China National Knowledge Infrastructure（CNKI）, WanFang, Weipu, PubMed, Embase, The Cochrane Library, and Web of Science Core Collection were searched for RCTs on the efficacy of hypoglycemic agents in MASLD published up to December 31, 2024. All statistical analyses were performed using R version 4.3.3. The network meta-analysis was conducted using Bayesian statistical methods.

RESULTS

A total of 26 hypoglycemic agents for treating MASLD in 37 studies with 2406 participants were included. Empagliflozin was most effective in improving liver stiffness measurement (LSM), whereas liraglutide showed significant benefits in body weight, body mass index (BMI), and waist circumference. Both sodium-glucose co-transporter 2 (SGLT-2) inhibitors (e.g., empagliflozin) and glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide) improved liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST], gamma-glutamyltransferase [GGT]), glucose metabolism (fasting plasma glucose [FPG], and homeostasis model assessment of insulin resistance [HOMA-IR]), and lipid profiles. Pioglitazone had limited benefits in these outcomes. Secondary outcomes such as inflammatory markers and fibrosis showed minimal changes.

CONCLUSIONS

Several hypoglycemic agents can improve laboratory and imaging indicators in adult patients with MASLD. Liraglutide is more effective than other agents, whereas empagliflozin emerged as the most effective for reducing LSM. However, different agents have different effects on the indicators; therefore, the relevant agents must be selected according to the specific patient condition.

Efficacy and Safety of Tirzepatide Compared with GLP-1 RAs in Patients with Type 2 Diabetes Treated with Basal Insulin: A Network Meta-analysis

INTRODUCTION

The relative efficacy and safety of tirzepatide was compared with glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in patients with type 2 diabetes mellitus (T2DM) treated with basal insulin using a network meta-analysis (NMA).

METHODS

A systematic literature review was performed to identify randomized controlled trials of GLP-1 RAs in patients with T2DM treated with insulin and an antihyperglycaemic drug. For the NMA, studies included trials with 100% of patients treated with basal insulin background therapy with a titration scheme comparable to the SURPASS-5 trial. The following data were extracted for efficacy and safety assessment at the primary endpoint of each study: changes from baseline in glycated haemoglobin (HbA1c) and body weight and the incidence of nausea, vomiting or diarrhoea, hypoglycaemia, and patients discontinuing treatment because of adverse events. In this study, a comparative analysis of tirzepatide was performed with the GLP-1 RAs dulaglutide, exenatide, and lixisenatide in addition to placebo.

RESULTS

A total of six studies were included across the analyses. Tirzepatide 5, 10, and 15 mg showed statistically significant, greater reductions in HbA1c and body weight at the primary endpoint versus all GLP-1 RA comparators and placebo. Tirzepatide 5, 10, and 15 mg showed a statistically significant, higher likelihood of experiencing nausea compared with those who received placebo or exenatide 2 mg; no statistically significant differences were observed when compared with all other GLP-1 RA comparators. No statistically significant differences were observed in the proportions of patients who discontinued treatment because of adverse events when tirzepatide 5, 10, and 15 mg were compared with GLP-1 RA comparators, apart from tirzepatide 10 and 15 mg versus placebo.

CONCLUSION

Tirzepatide demonstrated statistically significantly greater reductions in HbA1c and body weight when compared with selected GLP-1 RAs and placebo in patients with T2DM treated with basal insulin. Overall, the safety profile of tirzepatide was similar to that of GLP-1RAs.

Comparison of video laryngoscopy and direct laryngoscopy for urgent intubation in newborn infants: A meta-analysis

BACKGROUND

Securing a stable airway is a critical component in neonatal resuscitation. Compared to direct laryngoscopy, video laryngoscopy provides improved visualization of the glottis, potentially enhancing the success rate of intubation. This systematic review and meta-analysis were conducted to assess and compare the efficacy and safety of video laryngoscopy versus direct laryngoscopy in neonatal intubation.

METHODS

A thorough search was performed across CENTRAL, Embase, and PubMed databases to identify relevant randomized controlled trials (RCTs) that evaluated the use of video laryngoscopy in comparison with direct laryngoscopy for neonatal intubation. The data extraction and analysis were conducted in alignment with Cochrane guidelines. The primary outcome of interest was the time required for intubation, while secondary outcomes included the number of intubation attempts and the success rate on the first attempt.

RESULTS

The meta-analysis included nine RCTs, encompassing a total of 719 neonates. The findings revealed that video laryngoscopy was associated with a longer intubation time (mean difference [MD] 3.23 s, 95 % confidence interval [CI] 2.42 to 4.04; I2 = 96 %). However, it also significantly improved the first-attempt success rate (risk ratio [RR] 1.31, 95 % CI 1.20 to 1.44; I2 = 76 %) and borderline reduced the total number of intubation attempts (MD -0.08, 95 % CI -0.15 to 0.00; I2 = 53 %).

CONCLUSIONS

While video laryngoscopy is associated with a modest increase in intubation time, it provides clear benefits by enhancing the success rate of first-attempt intubations and reducing the need for multiple attempts in neonatal intubation procedures.

Effects of cerebellar repetitive transcranial magnetic stimulation on stroke rehabilitation: A systematic review and meta-analysis

BACKGROUND

Cerebellum has been a emerging target for non-invasive brain stimulation (NIBS) on post-stroke patients in recent years. While research is emerging on the impact of cerebellar repetitive transcranial magnetic stimulation (rTMS) on post-stroke patients, and its integrated effect remain unclear.

OBJECTIVES

The objective of this review is to evaluate the efficacy of cerebellar rTMS on stroke rehabilitation.

METHODS

We searched PubMed, EMBASE, and Web of Science databases from inception to 31 March 2024 for randomized controlled trials (RCTs) and case studies reporting effects of cerebellar rTMS on patients with stroke.

RESULTS

This review included 18 studies (n = 638 participants), consisting of 14 RCTs and 4 case reports. A total of 6 studies focused on post-stroke dysphagia, while 12 studies investigated post-stroke motor dysfunction. Comparative analysis between treatment and control groups revealed statistically significant improvements in swallowing function, as measured by the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) (P = 0.02), the Penetration Aspiration Scale (PAS) (P < 0.001), and the Standardised Swallowing Assessment (SSA) (P < 0.001). Moreover, cerebellar rTMS treatment showed significant enhancements in balance abilities and activity of daily living among stroke patients, as indicated by significant increases in the Berg Balance Scale (BBS) (P = 0.003) and the Barthel Index (BI) (P = 0.04) compared to the control group.

CONCLUSIONS

Existing evidence suggests that cerebellar rTMS holds promise in mitigating post-stroke swallowing dysfunction and motor dysfunction. Stimulation by cerebellar rTMS appears to be an efficacious technique for enhancing stroke rehabilitation.

Measuring suicidal behavior in the era of rapid-acting antidepressants: A systematic review of ketamine studies

Assessment measures for suicidal behavior range from depression scales to longer suicide-specific instruments. In this review, we systematically summarize and discuss the currently used instruments for assessing suicidal behavior in the context of ketamine and its enantiomers. We searched Medline/PubMed, Embase, and PsycINFO databases for ketamine (and its enantiomers) human studies exploring this drug's antisuicidal effects on major depressive disorder patients, published from February 2000 to June 2023. Forty-six studies were included, identifying 16 assessment tools, mostly explicit and clinician-rated measures. Prominent tools included the Montgomery-Åsberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HAM-D), and both the clinician and patient-rated Beck Scales for Suicide Ideation (SSI and BSS). With the exception of the Suicide Ideation and Behavior Assessment Tool (SIBAT), to the best of our knowledge, no other instrument that assesses suicidality seems to be specifically developed for measuring treatment response in rapid-acting antidepressants trials. Most scales have been validated in conventional antidepressant or psychotherapy contexts, though, for MADRS, as well as for SSI, BDI, and HAM-D, efforts have been made towards investigating their psychometric properties in the field of rapid-acting antidepressants. The heterogeneity of suicidal behavior assessment in ketamine studies may hinder adequate comparisons between them. Although there does not seem to be a universally preferable instrument for measuring suicidal behavior to date, the MADRS potentially emerges as an adequately recommended choice.

Evaluating the Impact of Induction and Consolidation Total Neoadjuvant Therapies Compared to Conventional Chemoradiotherapy for Locally Advanced Rectal Cancer: A Systematic Review and Network Meta-analysis

BACKGROUND

Total neoadjuvant therapy has been introduced to enhance oncological outcomes and minimize toxicity in locally advanced rectal cancer, but the superiority between the induction and consolidation of therapy remain unclear.

OBJECTIVE

To evaluate oncological and postoperative outcomes by comparing induction chemotherapy and consolidation chemotherapy with conventional chemoradiotherapy in patients with locally advanced rectal cancer.

DATA SOURCES

Systematic searches of PubMed, Embase, and Cochrane databases wereperformed for studies published from the database's inception until June 2023.

STUDY SELECTION

The inclusion criteria were patients diagnosed with rectal cancer. Interventions included induction chemotherapy and consolidation chemotherapy, and comparisons were specified as conventional neoadjuvant chemoradiotherapy.

MAIN OUTCOME MEASURES

Primary outcomes were the rates of pathologic or clinical complete response, postoperative results, chemoradiotherapy-related toxicity, and survival outcomes.

RESULTS

Thirty-three studies, encompassing patients from 1991 to 2021, were eligible for analysis. In network meta-analysis, a significantly increased OR for a pathologic complete response was observed in both the induction therapy group at 1.65 (95% credible interval, 1.18-2.30) and the consolidation therapy group at 1.87 (95% credible interval, 1.40-2.47) compared to conventional chemoradiotherapy. However, no difference was observed in complete response rates, postoperative results, or chemoradiotherapy-related toxicity grade 3 or higher between the groups. There were no differences among the groups in local recurrence, distant metastasis, or disease-free survival, whereas the induction group showed a nonsignificant improvement in overall survival.

LIMITATIONS

There was significant heterogeneity among the studies, and the short follow-up period in most studies limited the assessment of long-term survival outcomes.

CONCLUSIONS

Both induction and consolidation total neoadjuvant therapy increase the pathologic complete response rate in locally advanced rectal cancer without compromising safety or postoperative outcomes. However, total neoadjuvant therapy was not associated with a significant improvement in survival outcomes. Although total neoadjuvant therapy strategies for locally advanced rectal cancer are considered safe, additional long-term studies are needed.

TRIAL REGISTRATION NO

CRD42023445348.

Evaluating the efficacy and acceptability of non-invasive brain stimulation for generalized anxiety disorder: a systematic review and network meta-analysis

Non-invasive brain stimulation (NIBS) has the potential to treat generalized anxiety disorder (GAD). To assess the efficacy (response/remission/post-treatment continuous anxiety severity scores) and acceptability (failure to complete treatment for any reason) of NIBS, we searched PubMed, Web of Science, and the Cochrane Library (as of April 2024) for articles on NIBS for GAD and conducted a network meta-analysis of eight randomized trials (20 treatment arms, 405 participants). Data were pooled using standardized mean difference (SMD) and odds ratio (OR) with 95 % confidence interval (CI). Repetitive transcranial magnetic stimulation (rTMS) was the most widely studied treatment for GAD. The right dorsolateral prefrontal cortex (DLPFC) was the most common treatment target for GAD. High-frequency rTMS showed higher response rates (OR 291.40, 95 % CI 13.08 to 6490.21) and remission rates (OR 182.14, 95 % CI 8.72 to 3805.76) compared with other active therapies. Continuous theta burst stimulation (cTBS) greatly improved continuous post-treatment anxiety severity scores (SMD -2.56, 95 % CI -3.16 to -1.96). No significant differences in acceptability were found between the treatment strategies and the sham stimulation group. These findings provide evidence to consider NIBS techniques as alternative or adjunctive treatments for GAD.

Nutritional interventions for preventing cognitive decline in patients with mild cognitive impairment and Alzheimer's disease: A comprehensive network meta-analysis and Mendelian Randomization study

BACKGROUND

As the population ages rapidly, cognitive impairment, especially in conditions like Alzheimer's disease (AD) and mild cognitive impairment (MCI), has become a crucial public health issue. Nutritional interventions have garnered attention as a promising non-pharmacological strategy for maintaining cognitive function and decelerating its decline.

OBJECTIVE

This study aimed to evaluate the effectiveness of various nutritional interventions in preventing cognitive impairment and elucidate intricate biological pathways linking nutritional interventions to cognitive function through a comprehensive approach involving systematic review, network meta-analysis (NMA), and Mendelian randomization (MR) analysis.

METHODS

We utilized pair-wise comparisons and NMA to evaluate the efficacy of different nutritional interventions on cognitive function in patients with decreased cognitive abilities. A systematic search in three biomedical databases was performed for double-blinded, randomized controlled trials (RCTs) or head-to-head comparisons up to December 31, 2024. The NMA has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022331173). Moreover, to clarify the biological mechanisms linking nutritional interventions to cognitive impairment, we conducted two-sample MR analyses to assess the potential causal relationships between 9 genetically predicted nutrient levels derived from extensive genome-wide association studies (GWASs) and 12 biomarkers linked to brain aging.

RESULTS

This study encompassed 52 trials with 8452 participants, 9 GWASs examining genetically predicted nutrient levels with a total of 603,996 participants, and 12 GWASs investigating brain aging biomarkers with a total of 2,405,530 participants. The NMA demonstrated that the multi-ingredient intervention outperformed other interventions significantly (standardized mean difference [SMD] = 2.03; 95 % credible interval [95 % CrI] = 0.97-3.09, P = 0.0002). In the MR analysis, the findings indicated that the multi-ingredient intervention was linked to reduced C-reactive protein (CRP) levels (odds ratios [OR] = 0.96, 95 % confidence interval [95 % CI] = 0.93-0.99, P = 0.014), suggesting that the multi-ingredient intervention may mitigate cognitive impairment by reducing inflammation.

CONCLUSIONS

Our NMA amalgamated evidence underscoring multi-ingredient interventions as the most efficacious strategy for attenuating cognitive decline in individuals with MCI and AD. Furthermore, the MR analysis unveiled the mechanisms underpinning the protective effects of multi-ingredient interventions, potentially offering benefits even in the early stages of neurodegeneration by mitigating oxidative stress and inflammation.

Comparative effectiveness of various exercise interventions on cardiorespiratory fitness in adults living with overweight or obesity: A systematic review and Bayesian network meta-analysis

This study evaluated how different exercise interventions affect maximal oxygen uptake (VO2max) in adults with overweight or obesity. We systematically searched five databases from inception to February 2025 to identify relevant randomized controlled trials (RCTs). We used the Cochrane risk of bias tool. A Bayesian network meta-analysis with a random-effects model was conducted. A total of 93 RCTs involving 4,446 participants were included. The network meta-analysis showed high-intensity interval training (HIIT) ranked highest (Surface Under the Cumulative Ranking Curve [SUCRA]: 82.5%; Standardized Mean Difference [SMD]: 4.85; 95%Credible Interval [CrI]: 3.90, 5.80), followed by high-intensity aerobic training (HAT) (SUCRA: 76.7%; SMD: 4.72; 95%CrI: 3.78, 5.68), and combined aerobic and resistance training (CT) (SUCRA: 69.1%; SMD: 4.52; 95%CrI: 3.48, 5.60), with resistance training (RT) least effective (SUCRA: 18.3%; SMD: 2.57; 95%CrI: 1.32, 3.86). All six interventions effectively improved VO2max in overweight or obese adults. Among them, HIIT was most beneficial. Coaches and fitness professionals should consider these findings to help adults with overweight or obesity achieve optimal outcomes.

Efficacy of digital therapeutic applications for cognitive training among older adults with mild cognitive impairment or dementia: A systematic review and network meta-analysis of randomized controlled trials

Various digital therapeutics (DTx), which utilize computerized cognitive training (CCT) to improve cognitive functioning, have been tested and released. However, the efficacy of these DTx approaches may be diverse. This study aims to meta-synthesize the associations between mobile applications and cognitive functioning outcomes in older adults with mild cognitive impairment (MCI) or dementia from randomized controlled trials (RCTs). We searched PubMed, EMBASE, Scopus, and Cochrane Library from the inception through the end of June 2024. We selected RCTs using mobile application interventions in older adults with MCI or dementia. Interventions and comparisons included: CCT, intensive CCT (CCT2x), computerized cognitive engagement, progressive resistance training (PRT), CCT plus medication, CCT plus PRT, and medications only. Outcomes of interest included cognitive functioning and other measures of functioning (e.g., activities of daily living [ADLs]). Network meta-analysis was conducted to estimate pooled standardized mean differences (SMDs) with corresponding 95 % confidence intervals (CIs). Of 1,189 studies extracted, 10 RCTs were included in our analysis. CCT2x demonstrated statistically significant improvements in global cognitive function (SMD, 1.21 [95 % CI, 0.69-1.73]), episodic memory (SMD, 0.87 [0.47-1.27]), and working memory (SMD, 0.93 [0.44-1.42]) when compared with controls. For ADLs, CCT significantly reduced functional impairment (SMD, -0.80 [-1.40 to -0.21]). In depressive symptoms, CCT2x was the most effective in reducing symptoms (SMD, -0.77 [-1.08 to -0.45]). Overall, the DTx may be effective in improving cognitive and other functioning outcomes in older adults with MCI or dementia.

The Cost-Effectiveness of Avatrombopag Versus Eltrombopag and Romiplostim in the Treatment of Patients with Immune Thrombocytopenia in the UK

BACKGROUND

Thrombopoietin receptor agonists-romiplostim, eltrombopag and avatrombopag-are commonly used as second-line treatments for immune thrombocytopenia (ITP).

METHODS

A Markov model was developed to estimate the cost effectiveness of the three TPO-RAs in adults with insufficient response to previous treatment from the perspective of the UK National Health Service (NHS). The model considered the effects of bleeding events, concomitant ITP medications, rescue therapies and treatment related adverse events over a lifetime horizon. Model inputs for effectiveness were based on a network meta-analysis and other published literature on ITP management. Other model inputs included costs (e.g., drug acquisition and administration) and healthcare resource utilisation.

RESULTS

Avatrombopag was associated with higher quality-adjusted life-years (QALYs) (10.979) than romiplostim (10.628) and eltrombopag (10.085), producing incremental QALYs of -0.351 and -0.894, respectively. Avatrombopag was associated with lower total costs (GBP £319,334) compared with romiplostim (GBP 406,361 [cost saving of GBP 87,027]) and higher total costs compared with eltrombopag (GBP 313,987 [incremental cost of GBP 5347]). Avatrombopag therefore dominated romiplostim (more effective and less expensive) and was cost-effective versus eltrombopag (incremental cost-effectiveness ratio of GBP 5982 per QALY).

CONCLUSIONS

Avatrombopag is a cost-effective treatment compared with romiplostim and eltrombopag for the second-line treatment of adults with ITP from the perspective of the UK NHS.

Diagnostic Potential of Complementation of MRI to Prenatal Ultrasound for Detecting Orofacial Clefts in High-Risk Fetuses: A Network Meta-Analysis

ObjectiveTo compare the complementation of magnetic resonance imaging (MRI) to prenatal ultrasound (US) with prenatal US alone in detecting orofacial clefts in high-risk fetuses.DesignA network meta-analysis.SettingLiterature retrieval in PubMed, EMBASE, and Cochrane library, and meta-analysis based on STATA 14.0.PatientsFetuses were at high-risk for orofacial clefts.InterventionsPrenatal US and the complementation of MRI to prenatal US.Main outcome measuresThe pooled sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and area under the curve (AUC).ResultsThirteen studies involving 776 patients were included. Direct meta-analysis showed that the complementation of MRI to prenatal US did not differ from prenatal US in detecting orofacial clefts if the type of orofacial clefts was not distinguished. Subgroup analysis showed that the specificity of prenatal US for the detection of isolated cleft palate (CP) was lower than that of the complementation of MRI to prenatal US. Furthermore, network meta-analysis consistently suggested a comparable diagnostic value between prenatal US and the complementation of MRI to prenatal US. Moreover, subgroup analysis showed that the specificity of prenatal US was significantly lower than that of complementation of MRI to prenatal US for the detection of isolated CP.ConclusionsMRI is more accurate than ultrasound in detecting cleft palate. Therefore, MRI should be offered if there is a fetus with a possible or ultrasound diagnosis of cleft palate, especially if the evaluation of cleft palate is deemed unsatisfactory after careful evaluation of the images.

Efficacy of dietary interventions in irritable bowel syndrome: a systematic review and network meta-analysis

BACKGROUND

Patients with irritable bowel syndrome (IBS) are often interested in dietary interventions as a means of managing their symptoms. However, the relative efficacy of available diets for the management of IBS is unclear. We aimed to examine the relative efficacy of various dietary interventions in IBS.

METHODS

For this systematic review and network meta-analysis we searched MEDLINE, EMBASE, EMBASE Classic, and the Cochrane Central Register of Controlled Trials from database inception to Feb 7, 2025, to identify randomised controlled trials comparing an active dietary intervention requiring changes to the intake of more than one food in IBS with either a control intervention, such as a habitual diet, sham diet, a high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, or alternative miscellaneous dietary advice, or any other active dietary intervention requiring changes to the intake of more than one food. We assessed efficacy using dichotomous assessments of improvement in global IBS symptoms or improvement in individual IBS symptoms, including abdominal pain, abdominal bloating or distension, and bowel habit. We pooled data using a random-effects model, with the efficacy of each intervention reported as pooled relative risks (RRs) with 95% CIs. We ranked interventions according to their P-score, which measures the mean extent of certainty that one intervention is better than another, averaged over all competing interventions.

FINDINGS

We identified 28 eligible randomised controlled trials (comprising 2338 patients) of 11 different dietary interventions compared with four control interventions, of which six (low FODMAP diet, British Dietetic Association/National Institute for Health and Care Excellence [BDA/NICE] diet, lactose-reduced diet, starch-reduced and sucrose-reduced diet, a personalised diet, and a Mediterranean diet) were studied in more than one trial. For global IBS symptoms, assessed in 28 randomised controlled trials and when considering only the dietary interventions studied in more than one trial, a starch-reduced and sucrose-reduced diet ranked first (RR of global IBS symptoms not improving 0·41 [95% CI 0·26-0·67]; P-score 0·84; two trials), a low FODMAP diet ranked fourth (0·51 [0·37-0·70]; P-score 0·71; 24 trials), and a BDA/NICE diet ranked tenth (0·62 [0·43-0·90]; P-score 0·44; eight trials), versus a habitual diet. For abdominal pain, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised controlled trial, a starch-reduced and sucrose-reduced diet ranked second (RR of abdominal pain not improving 0·54 [95% CI 0·33-0·90]; P-score 0·73; two trials), and a low FODMAP diet ranked fifth (0·61 [0·42-0·89]; P-score 0·64; 23 trials), versus a habitual diet. For abdominal bloating or distension, assessed in 26 trials and when considering only the dietary interventions studied in more than one randomised trial, only a low FODMAP diet (RR of abdominal bloating or distension not improving 0·55 [95% CI 0·37-0·80]; P-score 0·64; 23 trials) was superior to a habitual diet and ranked fourth. For bowel habit, assessed in 23 randomised trials, none of the dietary interventions was superior to any of the control interventions, but a low FODMAP diet was superior to a BDA/NICE diet (RR of bowel habit not improving 0·79 [95% CI 0·63-0·99]). All comparisons across the network were rated as low or very low confidence, except for direct comparisons between a low FODMAP diet or a starch-reduced and sucrose-reduced diet and habitual diet, both of which were rated as moderate confidence.

INTERPRETATION

In terms of dietary interventions for IBS, the most evidence exists for a low FODMAP diet, but other promising therapies are emerging and should be the subject of further study.

FUNDING

None.

Network meta-analysis based ranking of dry off interventions to cure or prevent intramammary infections in dairy cows

This study aimed to rank dry off interventions for the prevention of new intramammary infections (IMI) and the cure of existing IMI in quarters of dry cows using two network meta-analyses. Randomized controlled trials reported in 137 papers were assessed for inclusion eligibility. Network meta-analyses were performed separately for the incidence risk of IMI and cure risk of IMI. For cure of IMI, 29 trials with 10 dry off interventions were included. Both selective and blanket dry cow therapy, either in combination with an internal teat sealant or as a singular intervention, resulted in a better cure risk compared with the non-antimicrobial interventions. No differences were observed between the antimicrobial based interventions. For the incidence risk of IMI, 54 trials were included, representing 18 dry off interventions. The incidence risk of IMI was similar for the various selective dry cow treatments when antimicrobials were administered together with an internal teat sealant, either at quarter or cow level. Also, they did not differ from the evaluated blanket dry cow treatment interventions or when an internal teat sealant was applied alone. Selective dry cow therapy with internal teat sealant is therefore likely a suitable intervention option to simultaneously maintain a low incidence risk of IMI and a high cure risk of IMI, all the while lowering the antimicrobial use in dairy herds. Circumstances in the herd, including the distribution and prevalence of mastitis pathogens, should be evaluated before results are utilized in dairy practice given the heterogeneity of included studies.

Intrapolyp Steroid Injection for Nasal Polyposis: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To conduct a systematic review and network meta-analysis to evaluate the safety and efficacy of intrapolyp steroid injection compared with oral steroids, nasal steroid wash, nasal steroid spray, and a control group in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

DATA SOURCES

PubMed, Scopus, Web of Science, Embase, and CENTRAL.

REVIEW METHODS

Both randomized and non-randomized clinical trials were included. For risk of bias assessment, we used the RoB-2 and ROBINS-I tools. Our outcomes focused on safety and efficacy, including rates of visual disturbance and bleeding, as well as improvements in nasal polyps evaluated through three domains: endoscopic, radiologic, and patient-reported assessments. Safety data were pooled as events (%), while efficacy data were pooled as mean difference (MD) or standardized mean difference (SMD).

RESULTS

Eight clinical trials involving 579 patients were analyzed. The pooled analyses showed low event rates for visual disturbances (event rate = 0.64%, 95% CI [0.00%, 2.23%]) and bleeding (event rate = 0.61%, 95% CI [0.00%, 2.25%]). Additionally, intrapolyp steroid injections were found to be comparable with oral steroids, with no statistically significant differences. Moreover, intrapolyp steroid injections demonstrated some superiority over nasal sprays, nasal washes, and the control group.

CONCLUSION

This network meta-analysis confirms that intrapolyp steroid injections have a favorable safety and efficacy profile as a viable management option for CRSwNP. The injections showed comparable efficacy with oral steroids and demonstrated certain advantages over other treatments, such as nasal sprays and washes. Further research with larger sample sizes and standardized protocols are needed. Laryngoscope, 135:1872-1883, 2025.

Genetic polymorphisms on temporomandibular disorders: Network meta-analysis

OBJECTIVE

The aim of this systematic review and network meta-analysis (NMA) is to compare and rank the effects of different genetic polymorphisms on the susceptibility of temporomandibular disorders (TMDs) occurrence.

DESIGN

The central question formulated was: "Are genetic polymorphisms involved in the etiology of TMDs?" Following PROSPERO registration (CRD42024507886), electronic searches were conducted in five databases for publications up to November 2024.

RESULTS

Sixty-three studies were included in the systematic review and 7 composed the NMA. The qualitative analysis summarized the association between 120 genes (and 206 polymorphisms) and TMDs. Thirty-two polymorphisms (in 24 genes) were linked to overall TMDs, while 22 polymorphisms (in 22 genes) with degenerative bone changes in the temporomandibular joint (TMJ). Additionally, 17 polymorphisms were identified in cases of painful chronic TMD, while 12 polymorphisms in intra-articular disorders. These polymorphisms were in genes related to neurotransmission (COMT, ADRB2, DRD2, ANKK1, SLC6A4 and HTR2A), inflammatory mediators (TNFα, IL10 and MMP1), sex hormones (ESR1and ESRRB), oxidative stress (GSTM1) and bone metabolism (VDR). A protective effect for myalgia occurrence with the COMT_rs165774 polymorphism compared to the wild-type genotype was found in the pairwise meta-analysis (AG genotype: OR: 0.33; 95 %CI: 0.14, 0.76; p < 0.01 and GG genotype: OR: 0.32; 95 %CI: 0.14, 0.74; p < 0.01) and this polymorphism showed the highest probability of being associated with the myalgia (97 %) and arthralgia (93 %) conditions.

CONCLUSIONS

Genetic polymorphisms in genes related to neurotransmission, inflammatory response, and sex hormones seem to be risk factors related to the TMDs pathogenesis.

Effects of different types of exercise on inflammatory markers in cancer patients: A systematic review and Bayesian network meta-analysis

This systematic review and network meta-analysis (NMA) was to investigate the effects of different exercise modalities on inflammatory markers in cancer patients. Using the standardized mean difference (SMD) as the effect size, a Bayesian random-effects network meta-analysis and regression analysis were conducted. Searches were performed across five databases for randomized controlled trials (RCTs) involving cancer patients, with exercise as the intervention, reported outcomes related to inflammatory markers, and interventions lasting more than four weeks, up to June 2024. A total of 57 RCTs (3106 patients) were included. The Cochrane risk of Bias Tool was utilized to assess the RCTs, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was employed to evaluate the quality of evidence. NMA results indicate that regular exercise is effective in reducing inflammation in cancer patients, with combined high-intensity aerobic and resistance exercises proving to be the most beneficial. The type, intensity, and total volume of exercise are critical factors in achieving positive outcomes. It is recommended to design exercise programs for cancer patients that combine aerobic and resistance training, with a gradual increase in intensity to ensure safety.

Drug treatments for mild or moderate covid-19: systematic review and network meta-analysis

OBJECTIVE

To compare the effects of treatments for mild or moderate (that is, non-severe) coronavirus disease 2019 (covid-19).

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Covid-19 Living Overview of Evidence Repository (covid-19 L-OVE) by the Epistemonikos Foundation, a public, living repository of covid-19 articles, from 1 January 2023 to 19 May 2024. The search also included the WHO covid-19 database (up to 17 February 2023) and six Chinese databases (up to 20 February 2021). The analysis included studies identified between 1 December 2019 and 28 June 2023.

STUDY SELECTION

Randomised clinical trials in which people with suspected, probable, or confirmed mild or moderate covid-19 were allocated to drug treatment or to standard care or placebo. Pairs of reviewers independently screened potentially eligible articles.

METHODS

After duplicate data abstraction, a bayesian network meta-analysis was conducted. Risk of bias was assessed by use of a modification of the Cochrane risk of bias 2.0 tool, and the certainty of the evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. For each outcome, following GRADE guidance, drug treatments were classified in groups from the most to the least beneficial or harmful.

RESULTS

Of 259 trials enrolling 166 230 patients, 187 (72%) were included in the analysis. Compared with standard care, two drugs probably reduce hospital admission: nirmatrelvir-ritonavir (25 fewer per 1000 (95% confidence interval 28 fewer to 20 fewer), moderate certainty) and remdesivir (21 fewer per 1000 (28 fewer to 7 fewer), moderate certainty). Molnupiravir and systemic corticosteroids may reduce hospital admission (low certainty). Compared with standard care, azithromycin probably reduces time to symptom resolution (mean difference 4 days fewer (5 fewer to 3 fewer), moderate certainty) and systemic corticosteroids, favipiravir, molnupiravir, and umifenovir probably also reduce duration of symptoms (moderate to high certainty). Compared with standard care, only lopinavir-ritonavir increased adverse effects leading to discontinuation.

CONCLUSION

Nirmatrelvir-ritonavir and remdesivir probably reduce admission to hospital, and systemic corticosteroids and molnupiravir may reduce admission to hospital. Several medications including systemic corticosteroids and molnupiravir probably reduce time to symptom resolution.

SYSTEMATIC REVIEW REGISTRATION

This review was not registered. The protocol is publicly available in the supplementary material.

The efficacy of psychosocial interventions on anxiety and depression in cancer caregivers: a network meta-analysis

BACKGROUND

Cancer caregivers often face substantial psychosocial burdens, which can lead to significant anxiety and depression. This network meta-analysis aimed to evaluate the relative efficacy of various psychosocial interventions in alleviating these symptoms.

METHODS

Following PRISMA guidelines, we conducted a systematic literature search for randomized controlled trials (RCTs) that evaluated psychosocial interventions for cancer caregivers. Data were synthesized using a network meta-analysis to compare the effects of different interventions on anxiety and depression.

RESULTS

A total of 35 trials involving 7 types of psychosocial interventions were included. Three interventions-meaning-centered psychotherapy (anxiety: MD =  - 5.48, 95% CI: - 8.46 to - 2.49; depression: MD =  - 5.13, 95% CI: - 8.27 to - 1.96), psychoeducation (anxiety: MD =  - 9.38, 95% CI: - 13.76 to - 4.94), and supportive therapy (anxiety: MD =  - 7.05, 95% CI: - 11.12 to - 3.05; depression: MD =  - 5.59, 95% CI: - 9.83 to - 1.36), showed significant efficacy in reducing anxiety and depression. Network meta-analysis indicated that these interventions were superior to control conditions in alleviating symptoms.

CONCLUSION

Meaning-centered psychotherapy, psychoeducation, and supportive therapy are particularly effective in reducing anxiety and depression among cancer caregivers. Our findings support the implementation of these psychosocial interventions as part of routine care.

Community-based interventions for the prevention or management of dental caries in children

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To undertake network meta-analysis (NMA) and component network meta-analysis (CNMA) to explore the comparative effectiveness of different community-based interventions, and the components within the interventions used singly or in combination, for the prevention or management of dental caries in children.  .

Network Meta-Analysis of Pharmacological Therapies for Long-Term Prophylactic Treatment of Patients with Hereditary Angioedema

BACKGROUND AND OBJECTIVES

Several treatments for long-term prophylaxis (LTP) of hereditary angioedema (HAE) are in clinical use, such as garadacimab, lanadelumab, subcutaneous C1 esterase inhibitor (C1INH), and berotralstat. In the absence of head-to-head comparative evidence, indirect comparison methods are needed to compare LTP treatments in patients with HAE. The objective of this analysis was to estimate the comparative efficacy, safety, and impact on quality of life of LTP treatments for patients with HAE through NMAs.

METHODS

A systematic literature review was conducted to identify randomized controlled trials (RCTs) investigating LTP treatments in patients (at least 12 years old) with HAE (PROSPERO protocol #CRD42022359207). A network meta-analysis (NMA) feasibility assessment evaluated trial suitability and Bayesian NMAs were conducted for evaluable efficacy, safety, and quality of life (QoL) outcomes.

RESULTS

The results of these NMAs show improved efficacy, QoL, and reduced rate of adverse events with garadacimab (200 mg once monthly), lanadelumab (300 mg every two or four weeks), subcutaneous C1INH (60 IU/kg twice weekly), and berotralstat (150 mg once daily) compared to placebo in the treatment of patients with HAE. For the primary outcome of time-normalized number of HAE attacks, garadacimab statistically significantly reduced the rate of attacks compared to lanadelumab Q4W and berotralstat. A similar statistically significant reduction was shown for HAE attacks treated with on-demand treatment. Garadacimab showed statistically significant reduction in the rate of moderate and/or severe HAE attacks compared to lanadelumab Q2W. Garadacimab also showed statistical improvements in change from baseline in AE-QoL total score as compared to berotralstat.

CONCLUSIONS

Overall, garadacimab ranked as the most probable effective treatment among all comparators assessed, with lanadelumab Q2W or subcutaneous C1INH ranking second, across most outcomes.

Association between gut microbiota and allergic rhinitis: a systematic review and meta-analysis

Background

Many studies have shown that allergic rhinitis (AR) is closely related to intestinal flora, and probiotics are effective in treatment. However, the results of human observational studies on the correlation between intestinal flora and AR have been contradictory. The aim of this study was to determine the relationship between gut microbiota and allergic rhinitis and to provide a clinical reference.

Methods

PubMed, Web of Science, Medline, Embase, Cochrane Library, and Cinahl databases were searched, and the literature on the correlation between allergic rhinitis and the gut microbiota reported from database establishment to December 2023 was included. Literature meeting the inclusion criteria was screened, and meta-analysis of the included literature was performed using R software (4.3.3). Literature quality underwent assessment utilizing the Newcastle-Ottawa Quality Assessment Scale. Hedge's g standardized mean difference (SMD), confidence intervals (CIs), and heterogeneity (I2 ) for alpha diversity were calculated. Median interquartile range (IQR) were calculated as effect statistics for the abundance of bacteria. The Egger test determined publication bias in the literature.

Results

A total of 10 observational studies in humans were conducted, identifying 550 patients with AR and 385 healthy individuals. No statistically significant differences were observed in alpha diversity between two groups, including Shannon index (SMD = -0.3938, 95% CI [-0.9847-0.1972], I2 = 94%), Simpson index (SMD = -0.16, 95% CI [-1.12-0.80], I2 = 96%) and Chao1 index (SMD = -0.00, 95% CI [-1.32-1.32], I2 = 97%). We performed a meta-analysis for the following four phyla, but found no significant differences: Firmicutes (95% CI [-0.10-0.19], I2 = 75%), Bacteroidetes (95% CI [-0.42-0.19], I2 = 95%), Proteobacteria (95% CI [-0.06-0.03], I2 = 92%), Actinobacteria (95% CI [-0.09-0.03], I2 = 83%).

Conclusions

The currently available evidence does not suggest that patients with allergic rhinitis may have similar intestinal flora imbalances. Nevertheless, further corroboration is required with larger samples and higher-quality studies.

Expanding therapeutic horizons: glucagon-like peptide-1 receptor agonists and sodium glucose transporter-2 inhibitors in poly cystic ovarian syndrome: a comprehensive review including systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex endocrine characterized by hyperandrogenism, hormonal imbalances, and metabolic disruptions, leading to reproductive complications and increased risk of cardiometabolic diseases. While lifestyle modifications are the cornerstone of PCOS management, pharmacological interventions, including metformin, oral contraceptives, and anti-androgens, are commonly utilized. Recently, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) have shown promising results in PCOS management.

METHODS

This study conducted a comprehensive review of randomized clinical trials evaluating the effects of GLP-1 RAs and SGLT2is in women with PCOS. A systematic literature search was performed, and network meta-analysis using random-effects model that generated mixed treatment comparison estimates was employed to assess the comparative efficacy of these drug classes on clinical (menstrual frequency, pregnancy rate and proportion of patients with regular menstrual cycles), anthropometric, hormonal, and metabolic parameters. Additionally, a systematic review of preclinical studies investigating GLP-1 RAs and SGLT2is in animal models of PCOS was undertaken.

RESULTS

This comprehensive meta-analysis included 27 RCTs (1642 participants). GLP-1 RAs (alone and in combination with metformin) were observed to improve menstrual frequencies. GLP-1 RAs showed significant reductions in all anthropometric parameters, while SGLT2is was observed to improve wait hip ratio (WHR) and android gynoid fat (AGF) ratio (in addition to reduced body weight observed with SGLT2is/metformin combination). Reductions in WHR and AGF ratio were better with SGLT2is compared to GLP-1 RAs. The combination of GLP-1 RAs and SGLT2is was observed to have superior efficacy in reducing body weight, percent fat mass, and AGF ratio compared to GLP-1 RAs alone. Regarding hormonal parameters, GLP-1 RAs were observed with significant improvement in free androgen index (FAI), free testosterone, androstenedione, and sex hormone binding globulin levels. SGLT2is was observed with significant improvements in FAI and total testosterone, outperforming GLP-1 RAs in reducing these parameters. Regarding metabolic parameters, GLP-1 RAs significantly improved triglycerides, markers of insulin resistance and fasting and postprandial plasma glucose. SGLT2is was associated with significant improvements in homeostatic model assessment for insulin resistance (HOMA-IR) and fasting plasma glucose, and in combination with metformin, SGLT2is significantly improved triglycerides. SGLT2is outperformed GLP-1 RAs in reducing LDL cholesterol and HOMA-IR. The combination of SGLT2is and GLP-1 RAs was better than GLP-1 RAs in reducing triglycerides and fasting plasma glucose. However, the strength of evidence for these findings was very low. Systematic assessment of animal studies revealed a potential association of several molecular pathways, including AMPK-α, SIRT1, FDX, PI3K/AKT, endothelial adhesion molecules (VCAM, ICAM, and E-selectin), STAR, and CYP17A1, with the therapeutic effects of GLP-1 RAs and SGLT2is in PCOS. Both drug classes were associated with significant improvements in ovarian morphology in animal studies.

CONCLUSION

This systematic review and meta-analysis advance our understanding of GLP-1 RAs and SGLT2is in PCOS management. While both drug classes demonstrate efficacy in metabolic parameters, their distinct mechanisms offer unique therapeutic advantages. SGLT2is excel in improving hormonal profiles and insulin resistance, whereas GLP-1 RAs show consistent benefits in weight management. The enhanced efficacy of combination therapy suggests a potential paradigm shift in PCOS treatment strategies, moving beyond traditional monotherapy approaches. These findings support the therapeutic potential of both drug classes, individually or combined, in PCOS management, providing a foundation for more personalized treatment approaches.

Therapeutic Potential of Plant-Derived Small Extracellular Vesicles in Sepsis: A Network Meta-analysis

Sepsis is a life-threatening condition characterized by systemic inflammation and multi-organ dysfunction. Plant-derived small extracellular vesicles (sEVs) have emerged as promising therapeutic agents due to their antioxidant, anti-inflammatory, and immunomodulatory properties. This study conducted a network meta-analysis to identify the most effective plant-derived sEVs for reducing sepsis-induced inflammation and oxidative stress. The analysis included 13 studies evaluating 10 plant-derived sEVs in sepsis-mimicking conditions, with primary outcomes focused on cytokine levels and reactive oxygen species (ROS) production in vitro and in vivo. Secondary outcomes included nuclear factor erythroid 2-related factor 2 (Nrf2) expression and cell viability. The study protocol was registered with PROSPERO (CRD420251011005). Ginger-derived sEVs were identified as the most effective, significantly reducing pro-inflammatory cytokines (interleukin-6 and tumor necrosis factor-α), increasing the anti-inflammatory cytokine (interleukin-10), and suppressing ROS production. They also enhanced Nrf2 expression and improved cell viability, highlighting their role in antioxidant defense and cytoprotection. In conclusion, ginger-derived sEVs are the most effective plant-derived sEVs for mitigating sepsis-induced inflammation and oxidation in both in vitro and in vivo sepsis-mimicking models.

Pharmacological treatments for atypical depression: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

Atypical depression is a highly prevalent subtype that includes mood reactivity, hypersomnia, and leaden paralysis, necessitating different therapeutic approaches than melancholic depression. No network meta-analysis has been conducted on pharmacological treatments for atypical depression.

METHODS

We performed a PRISMA-compliant systematic review and network meta-analysis searching PubMed/Central, Clinicaltrials.gov, Embase, PsycINFO, Scopus, WebOfScience for randomized controlled trials (RCTs) testing pharmacological interventions for atypical depression until 04/24/24 (PROSPERO: CRD42024540262). Depressive symptom change (standardized mean difference/SMD), response, and all-cause discontinuation (acceptability) (risk ratio/RR) were co-primary outcomes; tolerability was the secondary outcome. Risk-of-bias and global/local inconsistencies were measured, and Confidence in Network Meta-Analysis (CINeMA) was used to assess the confidence in the evidence.

RESULTS

Out of 2214 hits, we included 21 eligible RCTs, 20 entering the NMA. For efficacy (k = 16, N = 903, treatments=12), only phenelzine outperformed placebo (SMD=-1.31, 95 %C.I.=[-2.14;-0.49]). Phenelzine, moclobemide, isocarboxazid, imipramine, selegiline, sertraline, and fluoxetine all outperformed nortriptyline (from SMD=-4.54, 95 %C.I.=[-8.02;-1.07] to SMD=-3.08, 95 %C.I.=[-5.42; -0.75]). Regarding response (k = 13, N = 1442, treatments=7), phenelzine (RR=2.58, 95 %C.I.=[2.02-3.31]), sertraline (RR=2.25, 95 %C.I.=[1.01-4.99]), moclobemide (RR=2.16, 95 %C.I.=[1.12-4.19]), fluoxetine (RR=1.89, 95 %C.I.=[1.30-2.76]) and imipramine (RR=1.76, 95 %C.I.=[1.35-2.28]) outperformed placebo, and phenelzine also outperformed imipramine (RR=1.56, 95 %C.I.=[1.25-1.96]). No treatment was significantly different from placebo for acceptability. No intervention outperformed placebo on any outcome in sensitivity analyses upon exclusion of high-risk-of-bias and intention-to-treat trials, likely due to a loss in power of the analysis, and overall CINeMA ratings were low/very low.

CONCLUSIONS

Phenelzine might perform better than other compounds, but several drugs outperformed placebo in response. Nortriptyline performed worse than other treatments. High-quality studies are needed.

The molecular basis of music-induced neuroplasticity in humans: A systematic review

Neuroscientific research on music-based activities has grown rapidly, shedding light on the health benefits of music across various domains. However, the molecular mechanisms by which music influences neuroplasticity in humans remain largely unexplored. This review aimed to synthesize and critically appraise existing research on molecular neuroplasticity in humans, with a specific focus on the effects of receptive and active music-based interventions (MBIs) and musical training. Following the PRISMA guidelines, a systematic search was conducted across four databases (MEDLINE, Embase, PsycINFO, and Scopus), for articles published between 2000 and December 2023. From an initial return of 3239 records, 15 studies met the inclusion criteria and were synthesized into three categories of music experiences: (1) receptive MBIs, (2) active MBIs, and (3) musical training. Both active and receptive MBIs were found to enhance neuroplasticity. Specifically, music listening was associated with relaxation and improved immune function, marked by the upregulation of genes related to neuroprotection and synaptic plasticity, while active MBIs consistently enhanced peripheral neurotrophic factors in both healthy and patient populations. Among musicians, neurogenetic alterations linked to music perception and production, neurogenesis, and neurotransmission were identified, with multiple studies highlighting the roles of Brain-Derived Neurotrophic Factor (BDNF), Alpha Synuclein (SNCA), and GATA2 (GATA Binding Protein 2) genes. Collectively, both MBIs and musical training induce neuroplastic changes by modulating neurogenetics, enhancing neurotrophins, altering hormonal levels, and reducing stress in humans. These findings highlight the need for further research to elucidate the molecular mechanisms underlying music's effects on the human brain, which could have implications for advancing therapeutic interventions for neuropsychological disorders.

Effects of electrical and magnetic stimulation on upper extremity function after stroke: A systematic review and network meta-analysis

OBJECTIVES

To pool and rank the efficacy of various stimulation therapies, including repetitive peripheral magnetic stimulation (rPMS), neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), transcranial magnetic stimulation (TMS), and combinations of these interventions on upper extremity function, activities of daily living (ADL), and spasticity after stroke relative to sham/conventional rehabilitation.

LITERATURE SURVEY

MEDLINE, Scopus, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Clinical Trials, and Google Scholar were searched from inception to July 2022.

METHODOLOGY

Randomized controlled trials comparing any of the interventions mentioned above (rPMS, NMES, FES, TMS, NMES+rPMS, NMES+TMS, FES+TMS, and conventional rehabilitation) on upper extremity function, ADL, or spasticity from five databases were systematically reviewed and collected. Two-stage network meta-analysis was applied.

SYNTHESIS

Thirty-four studies involving 1476 patients reporting upper extremity function with the Fugl-Meyer Assessment were pooled. NMES combined with rPMS, NMES, NMES combined with TMS, TMS, and FES showed significantly higher improvement than conventional rehabilitation, with pooled mean differences (95% confidence intervals) of 14.69 (9.94-19.45), 9.09 (6.01-12.18), 6.10 (2.51-9.69), 4.07 (0.33-7.81), and 3.61 (0.14-7.07) respectively. NMES combined with rPMS had the highest probability for improving upper extremity function. NMES plus TMS had the highest probability for improving ADL, but none of the interventions showed significant differences in spasticity.

CONCLUSIONS

NMES plus rPMS might be the best intervention to improve upper extremity functions, with NMES plus TMS most likely to lead to improved ADL but the quality of the evidence is low.

Impact of Periprocedural Statin Therapy on Mortality and Cardiovascular Outcomes in Transcatheter Aortic Valve Replacement: A Meta-Analysis and Meta-Regression

BACKGROUND

Transcatheter aortic valve replacement (TAVR) stands as a notable alternative to surgical valve replacement for severe aortic stenosis (AS). Despite the established benefits of statins in cardiovascular pathologies, their specific impact in patients with severe AS undergoing TAVR remains uncertain.

AIMS

Our meta-analysis aims to assess whether periprocedural statin therapy improves survival and outcomes post-TAVR, thus addressing this gap in literature.

METHODS

A comprehensive literature search using various databases with relevant keywords terms was conducted to identify studies on the impact of periprocedural statin therapy on TAVR outcomes. We assessed the primary outcome of all-cause mortality alongside various secondary outcomes including stroke/transient ischemic attack (TIA), myocardial infarction, acute kidney injury (AKI), 30-day mortality, in-hospital mortality, rehospitalization, cardiovascular complications, and pacemaker requirement. A random-effects model using Comprehensive Meta Analysis Software was employed to analyze the data for each outcome. Statistical significance was set at a p < 0.05.

RESULTS

Our analysis of 19 observational studies revealed that periprocedural statin therapy significantly reduces all-cause mortality following TAVR surgery (OR = 0.71, 95% CI: 0.61-0.83, p < 0.001). However, the influence of statins on other outcomes remains inconclusive. These outcomes include stroke/TIA (OR = 0.90, 95% CI: 0.68-1.19, p = 0.455), risk of MI (OR = 1.72, 95% CI: 0.73-4.04, p = 0.214), AKI (OR = 0.99, 95% CI: 0.75-1.31, p = 0.968), 30-day mortality (OR = 0.71, 95% CI: 0.46-1.10, p = 0.126), in-hospital mortality (OR = 0.42, 95% CI: 0.13-1.38, p = 0.151), rehospitalization (OR = 0.92, 95% CI: 0.66-1.29, p = 0.645), cardiovascular complications (OR = 1.12, 95% CI: 0.91-1.37, p = 0.297), and pacemaker requirement (OR = 0.83, 95% CI: 0.65-1.06, p = 0.133).

CONCLUSION

Our meta-analysis indicates a potentially promising role for periprocedural statin therapy in enhancing patient outcomes post-TAVR surgery. We found a notable association between statin therapy and a reduction in all-cause mortality. However, the effects on secondary outcomes did not reach statistical significance, which warrants further investigation through larger, well-designed, randomized controlled trials.

Comparison of initial empirical antibiotic regimens in severe community-acquired pneumonia: a network meta-analysis

BACKGROUND

Severe community-acquired pneumonia (SCAP) remains a leading cause of morbidity and mortality worldwide. Identifying the optimal antibiotic regimen for treating SCAP is crucial for improving patient outcomes.

METHODS

We searched the PubMed, Embase, and Cochrane Central Register of Controlled Clinical Trials databases to identify studies reporting initial empirical antibiotic regimens in patients with SCAP. We performed a network meta-analysis to compare the relative efficacy of different antibiotic regimens in treating SCAP. The primary outcome was overall mortality. The second outcomes were 30-day mortality and in-hospital mortality.

RESULTS

This network meta-analysis included 1 randomized clinical trial and 13 observational studies with 8142 patients, categorized into five treatment groups: β-lactam antibiotics, β-lactam antibiotics plus doxycycline, β-lactam antibiotics plus fluoroquinolones, β-lactam antibiotics plus macrolides, and fluoroquinolones monotherapy. β-lactam antibiotics plus macrolides was ranked as the most effective treatment (surface under the cumulative ranking curve, 92.0%; mean rank, 1.3). The β-lactam antibiotics plus macrolides combination significantly reduced overall mortality compared to β-lactam antibiotics alone (RR, 0.79; 95% CI, 0.64-0.96) and β-lactam antibiotics plus fluoroquinolones (RR, 0.67; 95% CI, 0.64-0.82).

CONCLUSION

Our findings suggest that β-lactam antibiotics plus macrolides may be the optimal treatment for SCAP. β-lactam antibiotics monotherapy and β-lactam antibiotics plus fluoroquinolones should not be recommended due to their inferior outcomes.

Antibiotic for community-acquired pneumonia in hospitalized adults: A systematic review and Bayesian network meta-analysis

BACKGROUND

Inconsistent results have been obtained with various antibiotics for community-acquired pneumonia (CAP) in hospitalized adults. We performed a Bayesian network meta-analysis to compare and rank the effectiveness of antibiotics for adult patients with CAP.

METHODS

The databases of PubMed, Embase, and the Cochrane library were systematically searched until May 2025, for randomized controlled trials (RCTs) comparing at least two antibiotics for hospitalized adults with CAP. The investigated outcomes included clinical failure, bacteriological failure, mortality, total adverse events, gastrointestinal events, and requiring discontinuation of treatment.

RESULTS

Forty RCTs involving 12,838 hospitalized adults with CAP were selected for the final meta-analysis. The surface under the cumulative ranking probabilities (Surface Under the Cumulative Ranking Area, SUCRA; higher values indicate a greater likelihood of a treatment being the most effective) found that trovafloxacin (SUCRA: 87 %) and teicoplanin (SUCRA: 85 %) provided relatively better effects on clinical failure. Clarythromycin-ceftriaxone (SUCRA: 77 %) had the best effect for risk of bacteriological failure. Amoxicillin-clavulanate provided the optimal effect for reducing the risk of mortality (SUCRA: 82 %). The risk of total adverse events was lowest on using doxycycline (SUCRA: 86 %). Doxycycline (SUCRA: 89 %) and omadacycline (SUCRA: 80 %) provided relatively lower risk of gastrointestinal events. Finally, the use of ciprofloxacin was associated with the lowest risk of requiring discontinuation of treatment (SUCRA: 77 %).

CONCLUSIONS

This study provided an overview of the optimal antibiotics in management of adult patients with CAP, based on treatment effectiveness and safety profiles.