Standardized mean differences cause funnel plot distortion in publication bias assessments

The role of neutrophils in pain: systematic review and meta-analysis of animal studies

ABSTRACT

The peripheral inflammatory response is an attractive therapeutic target for pain treatment. Neutrophils are the first circulating inflammatory cells recruited to sites of injury, but their contribution to pain outcomes is unclear. We performed a systematic review and meta-analysis of original preclinical studies, which evaluated the effect of preemptive neutrophil depletion on pain outcomes (PROSPERO registration number: CRD42022364004). Literature search (PubMed, January 19, 2023) identified 49 articles, which were meta-analyzed using a random-effects model. The risk of bias was evaluated using SYRCLE's tool. The pooled effect considering all studies showed that neutrophil depletion induced a consistent pain reduction. Inflammatory, joint, neuropathic, and visceral pain showed significant pain alleviation by neutrophil depletion with medium-large effect sizes. However, muscle and postoperative pain were not significantly alleviated by neutrophil depletion. Further analysis showed a differential contribution of neutrophils to pain outcomes. Neutrophils had a higher impact on mechanical hyperalgesia, followed by nociceptive behaviors and mechanical allodynia, with a smaller contribution to thermal hyperalgesia. Interspecies (mice or rats) differences were not appreciated. Analyses regarding intervention unveiled a lower pain reduction for some commonly used methods for neutrophil depletion, such as injection of antineutrophil serum or an anti-Gr-1 antibody, than for other agents such as administration of an anti-Ly6G antibody, fucoidan, vinblastine, CXCR1/2 inhibitors, and etanercept. In conclusion, the contribution of neutrophils to pain depends on pain etiology (experimental model), pain outcome, and the neutrophil depletion strategy. Further research is needed to improve our understanding on the mechanisms of these differences.

Effects of resistance training on breast cancer-related arm lymphedema: a systematic review and dose-response meta-analysis

PURPOSES

This meta-analysis aims to (1) examine how resistance training affects lymphedema and muscle strength; and (2) evaluate the extent of improvement in lymphedema with different exercise dosages in breast cancer patients.

METHODS

Eight English and Chinese electronic databases were searched from their inception up to April 7, 2024. A dose-response meta-analysis was performed with R software. Egger's regression analysis and funnel plots were utilized to assess the potential for publication bias.

RESULTS

Thirty studies were synthesized in the systematic review. Resistance training was found to reduce lymphedema (SMD = - 0.28; 95% CI = - 0.44 to - 0.15) and significantly enhance upper and lower limb muscle strength. High-intensity training [5 ~ 8 repetition maximum (RM)] with a frequency of four times per week and a duration of 120~180 min per week showed a larger effect on lymphedema compared to moderate- to low-intensity training (8 ~ 20 RM) with three or fewer sessions per week and a duration of up to 120 min. Additionally, exercise programs lasting 12 weeks were more effective than those lasting less than 12 weeks.

CONCLUSIONS

High-intensity resistance training is more effective than low-intensity training in reducing lymphedema and enhancing muscle strength. Breast cancer patients with lower tolerance to exercise intensity can achieve maximal benefits in improving lymphedema by appropriately increasing the frequency and duration of exercise. Additionally, patients are encouraged to exercise for at least 12 weeks to ensure the effects.

Animal studies reveal downregulation of the Beclin-1 autophagy pathway as shared mechanism in Autism Spectrum Disorder: a systematic review and meta-analysis

BACKGROUND

Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental condition with complex etiology, involving genetic and environmental influences on brain development and behavior. Dysregulation of mammalian target of rapamycin (mTOR) signaling alters neuronal growth and synaptic plasticity, and has emerged as a potential underlying pathway in ASD.

GOAL AND METHODS

To investigate mTOR dysregulation as a common mechanism in ASD, we performed a systematic review, and a meta-analysis of 192 studies examining mTOR signaling in diverse genetic and environmental animal models.

RESULTS

Our random-effects model identified significant alterations in mTOR pathway-related proteins. For several proteins (p-AKT, PTEN, p-mTOR, p-EIF4e, LC3-II, p-S6K and p-S6), subgroup analyses revealed clear species-, sex-, age-, or brain region-specific effects. Interestingly, Beclin-1 was consistently downregulated across all subgroups.

CONCLUSION

Our findings support mTOR-pathway dysregulation in ASD. The observed consistent downregulation of Beclin-1 highlights autophagy as a common mechanism, and provides new leads for novel ASD biomarker and treatment development.

A virtual approach: Systematic review and meta-analysis of virtual reality-based therapies for convergence insufficiency

Convergence insufficiency (CI) is a common binocular vision disorder that significantly impacts visual comfort and quality of life. It has been hypothesized that CI therapy can also be provided effectively with Virtual reality (VR). Recently, a few studies were conducted on virtual reality-based CI therapy. However, to the best of the authors' knowledge, no systematic review and meta-analysis has been performed on the effectiveness of VR-based CI therapy. Therefore, this study aims to fill this critical gap and investigate the effectiveness of VR-based CI therapy. Consequently, it may be helpful to the clinicians, patients, and researchers to choose therapy, and develop future research studies. A systematic search was conducted on Google scholar, Scopus, PubMed and Science Direct until October 1, 2024. A total of 649 studies were screened, of which 3 studies were eligible to be included. We evaluated the quality and risk of bias for the included studies. Using the random-effects model, we found an overall mean difference of 3.38 (95% CI: 1.61, 5.16) before and after VR-based therapy. I² was 54.82% in our study, which indicates moderate heterogeneity. Then, we performed a Q test and found Q (df = 2) = 4.3593 and p-value = 0.1131, which indicates that albeit some heterogeneity observed in our analysis, it was not statistically significant. We also performed Leave-One-Out sensitivity analysis, which indicates that the overall findings of our analysis were relatively stable and not excessively dependent on any single selected study. No significant evidence of publication bias was found by using a funnel plot, Begg's test (Kendall's Tau = 1, p-value = 0.33), and Egger's test (intercept = 2.45, p-value = 0.40). Although we found VR based CI therapy has a positive effect, small sample size and variability in study methodologies make the current evidence insufficient to draw definitive conclusions regarding its effectiveness. Further studies are required to have more robust and reliable data.

Preclinical extracellular matrix-based treatment strategies for myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Administrating extracellular matrix (ECM) to restore cardiac function post-myocardial infarction (MI) shows promise, however study variability obscures its true impact. We therefore conducted a systematic review and meta-analysis of preclinical studies to assess the effects of ECM treatments on cardiac function and tissue homeostasis post-MI.

METHODS

We searched PubMed and SCOPUS from inception to June 28, 2024, for animal studies describing ECM treatment post-MI (pre-registered on PROSPERO, CRD42022368400). Random effects meta-analyses compared ECM treatment to controls regarding left ventricular ejection fraction (LVEF), fractional shortening, infarct size, stroke volume, and left ventricular wall thickness. Subgroup analyses examined the influence of sex, species, ECM source, and administration method. Funnel plots and Egger's regression assessed publication bias.

RESULTS

We identify 88 articles which meet our inclusion criteria. These studies describe the use of rats (51%), mice (38%), and pigs (11%). 44% of studies use males, 34% females, 5% both sexes, and 17% did not report sex. Most studies employ permanent MI models (85%) over ischemia reperfusion models (15%), and deliver ECM via intramyocardial injection (59%), cardiac patch (39%), cardiac sleeve (1%), or osmotic pump (1%). Our meta-analysis demonstrates that ECM treatment significantly improves LVEF (MD: 10.9%, 95% CI: [8.7%;13.0%]; p = 8.057e-24), fractional shortening (MD: 8.2%, 95% CI: [5.6%; 10.9%]; p = 1.751e-09), stroke volume (SMD 0.6, 95% CI: [0.2;1.0], p = 0.004), left ventricular wall thickening (SMD 1.2, 95% CI: [0.9; 1.5], p = 1.321e-17), while reducing infarct size (-11.7%, 95% CI: [-14.7%;-8.6%], p = 3.699e-14). We find no significant differences between the various subgroups and no indication of publication bias.

CONCLUSIONS

ECM-based treatments significantly enhance cardiac function and tissue homeostasis in preclinical post-MI models, supporting further research toward clinical translation.

Does short-term intraoperative electrical stimulation enhance nerve regeneration following peripheral nerve repair? A systematic review and meta-analysis

BACKGROUND

Although intraoperative electrical nerve stimulation appears to be a promising neuroenhancing adjunct to peripheral nerve repair, insight into its effects on nerve regeneration is essential to advocate its application in clinical settings.

OBJECTIVE

This study examined whether electrical stimulation during microsurgical repair of peripheral nerve injury results in enhanced nerve regeneration compared to suture repair alone in experimental animals.

METHODS

A systematic search in Embase, MEDLINE, Web of Science, and Google Scholar databases was performed from inception to March 22, 2024. The search included animal studies assessing outcomes following peripheral nerve repair with and without intraoperative electrical stimulation. Outcomes were subdivided into 4 categories: motor function, sensory function, electrophysiology, and histology. We calculated standardized mean differences and combined these using random effects models to estimate the overall effect. The risk of bias was assessed using the SYRCLE tool.

RESULTS

From 3615 references, 21 articles were included. Thirteen studies evaluated motor functional outcomes and showed that electrical stimulation improved functional index, muscle mass, muscle force, footstep accuracy, footprint, and joint angle measures. Six studies examined sensory function and found that electrical stimulation improved mechanical algesimetry. Nine studies assessed electrophysiology outcomes. Although conduction velocity did not differ between the groups, electrical stimulation resulted in a higher amplitude and lower latency. Twenty studies evaluated the histological outcomes and demonstrated increased axon count and myelin thickness, whereas axon diameter and G-ratio did not differ.

DISCUSSION

The results suggest that intraoperative electrical stimulation following peripheral nerve repair accelerates and improves nerve regeneration compared with nerve repair alone.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023455066.

Impact of intravenous antihypertensive therapy on cerebral blood flow and neurocognition: a systematic review and meta-analysis

BACKGROUND

Intravenous antihypertensivedrugs are commonly used in acute care settings, yet their impact on cerebral blood flow (CBF) remains uncertain.

METHODS

A systematic review and meta-analysis of 50 studies evaluated the effects of commonly used i.v. antihypertensive agents on CBF in normotensive, hypertensive, and intracranial pathology populations. Meta-analyses used standardised mean differences (SMD), stratified by population type, consciousness state, antihypertensive agent, and CBF measurement method.

RESULTS

Intravenous antihypertensivedrug therapy significantly reduced CBF in normotensive individuals without intracranial pathology (SMD -0.31, 95% confidence interval -0.51 to -0.11), primarily driven by nitroprusside and nitroglycerin in awake subjects (SMD -0.80, 95% confidence interval -1.15 to -0.46), with a median CBF decrease of 14% (interquartile range 13-16%) and a median mean arterial pressure reduction of 17% (interquartile range 9-22%). Other antihypertensives showed no significant effects on CBF in normotensive individuals, nor were changes observed in hypertensive patients or those with intracranial pathology when the median mean arterial pressure reduction was ∼20%. No correlation was found between mean arterial pressure reduction and CBF change, supporting intact cerebral autoregulation. Historical data revealed neurocognitive changes when CBF fell to ∼30 ml 100 g-1 min-1, associated with a 58% mean arterial pressure reduction and a 38% CBF reduction.

CONCLUSIONS

Most i.v. antihypertensive agents do not significantly affect CBF in clinical dose ranges; however, nitroprusside and nitroglycerin can reduce CBF under specific clinical conditions. The certainty of evidence remains low. Neurocognitive changes appear to depend on the magnitude of blood pressure and CBF reductions.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42024511954).

Systematic Review and Meta-Analysis: Imputing Response Rates for First-Line Psychological Treatments for Posttraumatic Stress Disorder in Youth

OBJECTIVE

Meta-analyses assessing psychological therapies for posttraumatic stress disorder (PTSD) in youth have demonstrated their effectiveness using standardized mean differences. Imputation of response rates (ie, 50% or greater reduction in symptoms) may facilitate easier interpretation for clinicians.

METHOD

We searched 4 databases (MEDLINE, PsycINFO, PTSDPubs, and Web of Science) and screened 1,654 records to include 60 randomized controlled trials (52 trauma-focused cognitive-behavioral therapy [TF-CBT], 8 eye movement desensitization [EMDR]) with a total of 5,113 participants, comparing psychological therapies for PTSD against control conditions in youth. Data from randomized controlled trials of EMDR and TF-CBT for PTSD were used to impute response rates, establishing how many patients display 50% reduction, 20% reduction, and reliable improvement and deterioration (using reliable change indices) in PTSD and depression.

RESULTS

The proportion of youth exhibiting a 50% reduction in PTSD symptoms was 0.48 (95% CI = 0.41-0.55) for TF-CBT, 0.30 (0.24-0.37) for EMDR, and 0.46 (0.39-0.52) for all psychological therapies, compared to 0.20 (0.16-0.24) for youth in control conditions. Reliable improvement was displayed by 0.53 (0.45-0.61; TF-CBT 0.55 [0.46-0.64], EMDR 0.42[0.30-0.55]) of youth receiving psychological therapies, compared to 0.25 (0.20-0.30) of youth in control conditions. Reliable deterioration was seen in 0.01 (0.01-0.02) of youth receiving psychological therapies, compared to 0.13 (0.08-0.20) of youth in control conditions. There was a high degree of heterogeneity in the included studies.

CONCLUSION

Psychological therapies, in particular TF-CBT, for young people with PTSD are effective and unlikely to cause deterioration, with around half of youth receiving TF-CBT exhibiting 50% symptom reduction.

Global Prevalence of Myocardial Fibrosis among Individuals with Cardiometabolic Conditions: A Systematic Review and Meta-Analysis

BACKGROUND

Cardiometabolic conditions including hypertension, diabetes, hyperlipidaemia and obesity are significant risk factors for cardiovascular diseases. Myocardial fibrosis (MF) is a complication and final common pathway of these conditions, potentially leading to heart failure, arrhythmias and sudden death. Existing reviews explored pathophysiological changes and treatment of MF, but the global prevalence of MF among individuals with cardiometabolic conditions remain limited.

OBJECTIVES

To evaluate the global prevalence of MF in individuals with cardiometabolic conditions and explore factors influencing its rate.

METHODS

CINAHL, Cochrane Library, Embase, PubMed, ProQuest Theses and Dissertations, Scopus, and Web of Science were systematically reviewed until January 2024. Studies included individuals with hypertension, type 2 diabetes mellitus, hyperlipidaemia, and obesity, with MF prevalence assessed via biopsy or Late Gadolinium Enhancement-Cardiac Magnetic Resonance (LGE-CMR). Meta-analysis was conducted using jamovi and factors associated with MF were synthesised narratively. This review is registered on PROSPERO, CRD42024544632.

RESULTS

The meta-analysis included 52 articles involving 5,921 individuals. 32.7% of individuals with cardiometabolic conditions developed MF, with hypertension demonstrating the highest prevalence [35.2%(95%CI:25.5-45.0)]. Biopsy-based studies reported a higher prevalence [75.6%(95%CI:53.6-97.6)] compared to LGE-CMR studies [26.8%(95%CI:20.6-33.0)]. Key factors associated with MF included increased LV mass/LV hypertrophy, reduced LV function, and myocardial stiffness.

CONCLUSIONS

This first global review estimates that one-third of individuals with cardiometabolic conditions develop MF, with the rate expected to rise. Standardized CMR measures cut-offs are needed to address prevalence inconsistencies. Future research should explore MF prevalence using diverse samples, combined CMR measures, considering socio-demographic and clinical factors for more accurate estimates.

Characterization of preclinical models to investigate spinal cord stimulation for neuropathic pain: a systematic review and meta-analysis

Despite advancements in preclinical and clinical spinal cord stimulation (SCS) research, the mechanisms of SCS action remain unclear. This may result from challenges in translatability of findings between species. Our systematic review (PROSPERO: CRD42023457443) aimed to comprehensively characterize the important translational components of preclinical SCS models, including stimulating elements and stimulation specifications. Databases (Embase, PubMed, Web of Science, and WikiStim) were searched on October 5, 2023, identifying 78 studies meeting the search criteria. We conducted a post hoc meta-analysis, including subgroup analyses and meta-regression, to assess SCS efficacy on mechanical hypersensitivity in rats subjected to neuropathic pain. Although monopolar electrodes were predominantly used as stimulating elements until 2013, quadripolar paddle and cylindrical leads gained recent popularity. Most research was conducted using 50 Hz and 200 µs stimulation. Motor threshold (MT) estimation was the predominant strategy to determine SCS intensity, which was set to 71.9% of MT on average. Our analysis revealed a large effect size for SCS (Hedge g = 1.13, 95% CI: [0.93, 1.32]) with similar magnitudes of effect between conventional (≤100 Hz) and nonconventional SCS paradigms while sham SCS had nonsignificant effect size. In addition, different stimulation intensity, frequency, and electrode design did not affect effect size. The risk of bias was assessed using Systematic Review Centre for Laboratory animal Experimentation criteria and was unclear, and only the frequency subgroup analysis showed publication bias. In summary, our review characterizes the critical components of preclinical SCS models and provides recommendations to improve reproducibility and translatability, thereby advancing the scientific foundation for SCS research.

Reformulating the meta-analytical random effects model of the standardized mean difference as a mixture model

The classical meta-analytical random effects model (REM) has some weaknesses when applied to the standardized mean difference, g. Essentially, the variance of the studies involved is taken as the conditional variance, given a δ value, instead of the unconditional variance. As a consequence, the estimators of the variances involve a dependency between the g values and their variances that distorts the estimates. The classical REM is expressed as a linear model and the variance of g is obtained through a framework of components of variance. Although the weaknesses of the REM are negligible in practical terms in a wide range of realistic scenarios, all together, they make up an approximate, simplified version of the meta-analytical random effects model. We present an alternative formulation, as a mixture model, and provide formulas for the expected value, variance and skewness of the marginal distribution of g. A Monte Carlo simulation supports the accuracy of the formulas. Then, unbiased estimators of both the mean and the variance of the true effects are proposed, and assessed through Monte Carlo simulations. The advantages of the mixture model formulation over the "classical" formulation are discussed.

Expertise advantage of automatic prediction in visual motion representation is domain-general: A meta-analysis

The expertise advantage denotes the superior perceptual-cognitive skills exhibited by experts. Nevertheless, the extent to which the expertise advantage influences automatic prediction in visual motion representation remains unclear. This meta-analysis aims to consolidate findings from various studies on the expertise advantage of automatic prediction in visual motion representation. We identified empirical research literature that measured expertise advantage of automatic prediction from the Web of Science (Core Collection), APA PsycInfo, PubMed, and Cochrane Library databases. We identified 16 studies contributing 23 effect sizes from a pool of 1110 records. The standardized mean difference (Hedges' g) was computed for the expertise advantage. The meta-analysis results reveal that, in comparison to novices, experts demonstrate superior automatic prediction in visual motion representation (Hedges' g = 0.73, 95% CI [0.54, 0.92]). Moderator analyses suggest that, when measuring the expertise advantage of automatic prediction, the effect size of the recall task is significantly larger than that of the recognition task. Other moderating variables did not exhibit significant moderating effects. These results suggest that the expertise advantage extends to automatic prediction in visual motion representation, and that this advantage is general, stable, and widespread.

Virtual reality-enhanced interventions on preoperative anxiety symptoms in adults undergoing elective surgery: A meta-analysis and meta-regression

BACKGROUND

Virtual reality exposure and distraction are recent novel technologies for reducing preoperative anxiety symptoms. However, the effectiveness of virtual reality-enhanced interventions in adults is still controversial and has yet to be evaluated in a systematic review.

OBJECTIVES

The study aimed to (1) evaluate the effectiveness of virtual reality-enhanced interventions on preoperative anxiety symptoms in adults compared to comparators; and (2) identify the factors affecting the effectiveness of interventions.

DESIGN

Systematic review, meta-analysis, and meta-regression analysis of randomised controlled trials.

METHODS

We conducted a three-step systematic search from inception until May 1, 2024, using (1) eleven databases, (2) two clinical registries, and (3) citation and grey literature searches in either English or Chinese. The package meta of R software version 4.3.1 was used to perform the meta-analysis, subgroup analysis, and meta-regression analyses. We adopted the restricted maximum likelihood estimator for random-effects meta-analysis and univariate random-effects meta-regression analyses. The Cochrane risk-of-bias tool version 2 and the Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to examine quality assessment and the certainty of evidence.

RESULTS

We selected 26 randomised controlled trials with 2357 participants from 12 different countries. Random-effects meta-analyses showed that virtual reality-enhanced interventions had a statistically significant reduction in preoperative anxiety symptoms (t = -5.58, p < 0.001) with a moderate to large effect size (Hedges' g = -0.76, 95 % confidence interval: -1.03 to -0.48) compared to usual care. Statistically significant subgroup differences were found for the nature of the intervention, geographical region, country, and type of surgery. The improvement in preoperative anxiety symptom outcomes was greater when the virtual reality-enhanced interventions were chosen by patients (g = -2.55, 95 % CI: -3.08 to -2.02) when compared to virtual reality exposure interventions with educational content (g = -0.72, 95%CI: -1.07 to -0.38) or virtual reality distraction interventions (g = -0.64, 95 % CI: -1.04 to -0.23). Trials conducted in Asia had a greater effect on preoperative anxiety symptom outcomes (g = -0.98, 95 % CI: -1.33 to -0. 62) in comparison with those conducted in non-Asia (g = -0.23, 95 % CI: -0.54 to 0.07). The random-effects meta-regression identified sample size (β = -0.008, p = 0.031) as a statistically significant covariate of preoperative anxiety symptoms. The overall certainty of the evidence was very low.

CONCLUSIONS

Virtual reality-enhanced interventions can be considered supplementary interventions for adults undergoing elective surgery. Future trials on a large scale with follow-up assessments are needed.

REGISTRATION

PROSPERO registration ID: CRD42024486343.

A meta-analysis of animal studies evaluating the effect of hydrogen sulfide on ischemic stroke: is the preclinical evidence sufficient to move forward?

Hydrogen sulfide (H2S) is a gasotransmitter that has been studied for its potential therapeutic effects, including its role in the pathophysiology and treatment of stroke. This systematic review and meta-analysis aimed to determine the sufficiency of overall preclinical evidence to guide the initiation of clinical stroke trials with H2S and provide tailored recommendations for their design. PubMed, Web of Science, Scopus, EMBASE, and MEDLINE were searched for studies evaluating the effect of any H2S donor on in vivo animal models of regional ischemic stroke, and 34 publications were identified. Pooling of the effect sizes using the random-effect model revealed that H2S decreased the infarct area by 34.5% (95% confidence interval (CI) 28.2-40.8%, p < 0.0001), with substantial variability among the studies (I2 = 89.8%). H2S also caused a 37.9% reduction in the neurological deficit score (95% CI 29.0-46.8%, p < 0.0001, I2 = 63.8%) and in the brain water content (3.2%, 95% CI 1.4-4.9%, p = 0.0014, I2 = 94.6%). Overall, the studies had a high risk of bias and low quality of evidence (median quality score 5/15, interquartile range 4-9). The majority of the included studies had a "high" or "unclear" risk of bias, and none of the studies overall had a "low" risk. In conclusion, H2S significantly improves structural and functional outcomes in in vivo animal models of ischemic stroke. However, the level of evidence from preclinical studies is not sufficient to proceed to clinical trials due to the low external validity, high risk of bias, and variable design of existing animal studies.

Which experimental factors govern successful animal-to-human translation in multiple sclerosis drug development? A systematic review and meta-analysis

BACKGROUND

Despite successes in multiple sclerosis (MS) drug development, the effectiveness of animal studies in predicting successful bench-to-bedside translation is uncertain. Our goal was to identify predictors of successful animal-to-human translation for MS by systematically comparing animal studies of approved disease-modifying therapies (DMTs) with those that failed in clinical trials due to efficacy or safety concerns.

METHODS

Systematic review of animal studies testing MS DMTs, identified from searches in PubMed and EMBASE. A random effect meta-analysis was fitted to the data to compare outcome effect sizes for approved versus failed DMTs. Effect sizes and testing under diverse experimental conditions were assessed as potential predictors for successful translation.

FINDINGS

We included 497 animal studies, covering 15 approved and 11 failed DMTs, tested in approximately 30'000 animals. DMTs were tested in a small repertoire of experimental parameters: about 86% of studies used experimental autoimmune encephalomyelitis (EAE), 80% used mice, and 76% used female animals. There was no association between animal study outcomes or testing DMTs under varied conditions (e.g., different laboratories or models) and successful approval. Surprisingly, 91% of animal studies were published after first-in-MS trial and 91% after official regulatory approval.

INTERPRETATION

Our findings emphasize the complexity in carrying drugs from animals to clinical practice. Specific challenges include limited experimental methods in animal research and a disconnect between preclinical and clinical research. We advocate for efforts to streamline drug development for MS to improve animal research's relevance for patients.

FUNDING

NIH, Swiss National Science Foundation, Universities Federation for Animal Welfare.

Nephroprotective effects of hyperbaric oxygen therapy in murine models of acute kidney injury: A systematic review and meta-analysis

AIMS

Acute kidney injury (AKI) is a life-threatening condition marked by sudden kidney function loss and azotemia. While its management is limited to supportive care, the effects of hyperbaric oxygen therapy (HBO) on AKI remain a subject of conflicting animal research. This study aimed to systematically review and meta-analyze HBO's effects on renal function biomarkers serum creatinine (SCr) and blood urea nitrogen (BUN) in murine AKI models, also exploring tissue-level nephroprotection.

MAIN METHODS

The PUBMED, SciELO, and LILACS databases were searched until September 5, 2024. Effect sizes of HBO on SCr and BUN levels were expressed as standardized mean difference (SMD) alongside 95 % confidence interval (CI), calculated by random-effects model. Extracted data also included murine specie/strain, HBO parameters, AKI induction method (toxic, ischemic, others), and histological findings. Study quality and publication bias were respectively assessed using the CAMARADES checklist and Egger's test. This review adhered to PRISMA guidelines and was registered in PROSPERO (CRD42022369804).

KEY FINDINGS

Data synthesis from 21 studies demonstrates that HBO effectively reduces azotemia in AKI-affected animals (SCr's SMD = -1.69, 95 % CI = -2.38 to -0.99, P < 0.001; BUN's SMD = -1.51, 95 % CI = -2.32 to -0.71, P < 0.001) while mitigating histological damage. Subgroup analyses indicate that HBO particularly benefits ischemic and other AKI types (P < 0.05). In contrast, data from toxic AKI models were inconclusive due to insufficient statistical power (P > 0.05, 1-β < 30 %).

SIGNIFICANCE

This meta-analysis provides compelling evidence supporting the adjunctive use of HBO in AKI management.

Bridging the pain gap after cancer surgery - Evaluating the feasibility of transitional pain service to prevent persistent postsurgical pain - A systematic review and meta-analysis

Background and Aims

The lack of a dedicated pain service catering to the postsurgical period has resulted in the origination of the pain-period gap. This has led to a resurgence of transitional pain service (TPS). Our objective was to evaluate the feasibility of TPS in pain practice among postsurgical cancer patients and its prevention of persistent postsurgical pain (PPSP), culminating in chronic pain catastrophising.

Methods

The protocol for this meta-analysis was registered in the International Prospective Register of Systematic Reviews (ID: CRD42023407190). This systematic review included articles involving all adult cancer patients undergoing cancer-related surgery experiencing pain, involving pharmacological, non-pharmacological and interventional pain modalities after an initial systematic pain assessment by pain care providers across diverse clinical specialities, targeting multimodal integrative pain management. Meta-analysis with meta-regression was conducted to analyse the feasibility of TPS with individual subgroup analysis and its relation to pain-related patient outcomes.

Results

Three hundred seventy-four articles were evaluated, of which 14 manuscripts were included in the meta-analysis. The lack of randomised controlled trials evaluating the efficacy of TPS in preventing PPSP and pain catastrophising led to the analysis of its feasibility by meta-regression. The estimate among study variances τ2 was determined and carried out along with multivariate subgroup analysis. A regression coefficient was attained to establish the correlation between the feasibility of TPS and its patient outcome measures and opioid-sparing.

Conclusion

TPS interventions carried out by multidisciplinary teams incorporating bio-physical-psychological pain interventions have resulted in its successful implementation with improved pain-related patient outcomes mitigating the occurrence of PPSP.

Methods for assessing inverse publication bias of adverse events

In medical research, publication bias (PB) poses great challenges to the conclusions from systematic reviews and meta-analyses. The majority of efforts in methodological research related to classic PB have focused on examining the potential suppression of studies reporting effects close to the null or statistically non-significant results. Such suppression is common, particularly when the study outcome concerns the effectiveness of a new intervention. On the other hand, attention has recently been drawn to the so-called inverse publication bias (IPB) within the evidence synthesis community. It can occur when assessing adverse events because researchers may favor evidence showing a similar safety profile regarding an adverse event between a new intervention and a control group. In comparison to the classic PB, IPB is much less recognized in the current literature; methods designed for classic PB may be inaccurately applied to address IPB, potentially leading to entirely incorrect conclusions. This article aims to provide a collection of accessible methods to assess IPB for adverse events. Specifically, we discuss the relevance and differences between classic PB and IPB. We also demonstrate visual assessment through contour-enhanced funnel plots tailored to adverse events and popular quantitative methods, including Egger's regression test, Peters' regression test, and the trim-and-fill method for such cases. Three real-world examples are presented to illustrate the bias in various scenarios, and the implementations are illustrated with statistical code. We hope this article offers valuable insights for evaluating IPB in future systematic reviews of adverse events.

Gut Microbiota Regulation by Acupuncture and Moxibustion: A Systematic Review and Meta-Analysis

There have been numerous studies investigating the impact of acupuncture and/or moxibustion on the gut microbiota, but the results have been inconclusive. Therefore, we conducted a systematic review and meta-analysis that included both preclinical and clinical studies to assess the current evidence regarding the effects of acupuncture on gut microbiota changes. We collected relevant studies from EMBASE and PubMed, collected outcomes including diversity and relative abundance measures of the gut microbiome, and the summarized effect estimates were calculated using the ratio of means (ROM) with 95% confidence intervals. Our analysis identified three clinical studies and 20 preclinical studies, encompassing various diseases and models, including colitis and obesity. The pooled results indicated no significant difference in alpha diversity changes between treatment groups and controls, except for the Simpson index measure, which was significantly higher in the treatment groups. Additionally, the pooled results showed an increase in the Firmicutes and a decrease in the Bacteroidetes in the treatment groups, along with increases in the Lactobacillus and Ruminococcus genera. These findings suggest acupuncture treatment can target the modification of specific phyla and genera of gut microbiota. However, it is important to note that the effects of acupuncture on the gut microbiome are heterogeneous across studies, particularly in different disease models.

Utilisation of endocrine therapy for cancer in Indigenous peoples: a systematic review and meta-analysis

BACKGROUND

Indigenous peoples worldwide experience inequitable cancer outcomes, and it is unclear if this is underpinned by differences in or inadequate use of endocrine treatment (ET), often used in conjunction with other cancer treatments. Previous studies examining ET use in Indigenous peoples have predominately focused on the sub-national level, often resulting in small sample sizes with limited statistical power. This systematic review aimed to collate the findings ofarticles on ET utilisation for Indigenous cancer patients and describe relevant factors that may influence ET use.

METHODS

We conducted a systematic review and meta-analysis of studies reporting ET use for cancer among Indigenous populations worldwide. PubMed, Scopus, CINAHL, Web of Science, and Embase were searched for relevant articles. A random-effect meta-analysis was used to pool proportions of ET use. We also performed a subgroup analysis (such as with sample sizes) and a meta-regression to explore the potential sources of heterogeneity. A socio-ecological model was used to present relevant factors that could impact ET use.

RESULTS

Thirteen articles reported ET utilisation among Indigenous populations, yielding a pooled estimate of 67% (95% CI:54 - 80), which is comparable to that of Indigenous populations 67% (95% CI: 53 - 81). However, among studies with sufficiently sized study sample/cohorts (≥ 500), Indigenous populations had a 14% (62%; 95% CI:43 - 82) lower ET utilisation than non-Indigenous populations (76%; 95% CI: 60 - 92). The ET rate in Indigenous peoples of the USA (e.g., American Indian) and New Zealand (e.g., Māori) was 72% (95% CI:56-88) and 60% (95% CI:49-71), respectively. Compared to non-Indigenous populations, a higher proportion of Indigenous populations were diagnosed with advanced cancer, at younger age, had limited access to health services, lower socio-economic status, and a higher prevalence of comorbidities.

CONCLUSIONS

Indigenous cancer patients have lower ET utilisation than non-Indigenous cancer patients, despite the higher rate of advanced cancer at diagnosis. While reasons for these disparities are unclear, they are likely reflecting, at least to some degree, inequitable access to cancer treatment services. Strengthening the provision of and access to culturally appropriate cancer care and treatment services may enhance ET utilisation in Indigenous population. This study protocol was registered on Prospero (CRD42023403562).

Digital Health Interventions for Chronic Wound Management: A Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions (DHIs) have shown promising results for the management of chronic wounds. However, its effectiveness compared to usual care and whether variability in the type of intervention affects wound outcomes are unclear.

OBJECTIVE

The main objective was to determine the effectiveness of DHIs on wound healing outcomes in adult patients with chronic wounds. The secondary objectives were to assess if there was any variation in wound healing outcomes across the various types of DHIs.

METHODS

In total, 9 databases were searched for the literature up to August 1, 2023. Randomized controlled trials (RCTs), cohort studies, and quasi-experimental studies comparing the efficacy of DHIs with controls in improving wound outcomes in adult patients with chronic wounds were included. Study selection, data extraction, and risk of bias assessment were conducted independently by 2 reviewers. We assessed the quality of each RCT, cohort study, and quasi-experimental study separately using the Cochrane risk of bias tool, ROBINS-I, and the Joanna Briggs Institute Critical Appraisal tools checklists. Relative risks (RRs) and 95% CIs were pooled using the random effects model, and heterogeneity was assessed by the I2 statistic. Subgroup analysis and sensitivity analysis were also performed.

RESULTS

A total of 25 studies with 8125 patients were included in this systematic review, while only 20 studies with 6535 patients were included in the meta-analysis. Efficacy outcomes in RCTs showed no significant differences between the DHIs and control groups in terms of wound healing (RR 1.02, 95% CI 0.93-1.12; P=.67) and all-cause mortality around 1 year (RR 1.08, 95% CI 0.55-2.12; P=.83). Compared with the control group, the use of DHIs was associated with significant changes in adverse events (RR 0.44, 95% CI 0.22-0.89; P=.02). Subgroup analysis suggested a positive effect of the digital platforms in improving wound healing (RR 2.19, 95% CI 1.35-3.56; P=.002). Although meta-analysis was not possible in terms of wound size, cost analysis, patient satisfaction, and wound reporting rates, most studies still demonstrated that DHIs were not inferior to usual care in managing chronic wounds.

CONCLUSIONS

The findings of our study demonstrate the viability of adopting DHIs to manage chronic wounds. However, more prominent, high-quality RCTs are needed to strengthen the evidence, and more detailed clinical efficacy research is required.

TRIAL REGISTRATION

PROSPERO CRD42023392415; https://tinyurl.com/4ybz6bs9.

Umbilical cord blood-derived therapy for preterm lung injury: a systematic review and meta-analysis

INTRODUCTION

Lung injuries, such as bronchopulmonary dysplasia (BPD), remain a major complication of preterm birth, with limited therapeutic options. One potential emerging therapy is umbilical cord blood (UCB)-derived therapy.

OBJECTIVES

To systematically assess the safety and efficacy of UCB-derived therapy for preterm lung injury in preclinical and clinical studies.

METHODS

A systematic search of MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO International Trials Registry Platform was performed. A meta-analysis was conducted with Review Manager (5.4.1) using a random effects model. Data was expressed as standardized mean difference (SMD) for preclinical data and pooled relative risk (RR) for clinical data, with 95% confidence intervals (CI). Potential effect modifiers were investigated via subgroup analysis. Certainty of evidence was assessed using the GRADE system.

RESULTS

Twenty-three preclinical studies and six clinical studies met eligibility criteria. Statistically significant improvements were seen across several preclinical outcomes, including alveolarization (SMD, 1.32, 95%CI [0.99, 1.65]), angiogenesis (SMD, 1.53, 95%CI [0.87, 2.18]), and anti-inflammatory cytokines (SMD, 1.68, 95%CI [1.03, 2.34]). In clinical studies, 103 preterm infants have received UCB-derived therapy for preterm lung injury and no significant difference was observed in the development of BPD (RR, 0.93, 95%CI [0.73, 1.18]). Across both preclinical and clinical studies, administration of UCB-derived therapy appeared safe. Certainty of evidence was assessed as "low."

CONCLUSIONS

Administration of UCB-derived therapy was associated with statistically significant improvements across several lung injury markers in preclinical studies. Early clinical studies demonstrated the administration of UCB-derived therapy as safe and feasible but lacked data regarding efficacy.

Interventions with a clear focus on achieving behaviour change are important for maintaining training-related gains in people with chronic obstructive pulmonary disease: a systematic review

QUESTIONS

In people with chronic obstructive pulmonary disease (COPD) who complete an exercise training program (ETP) offered at a sufficient dose to result in training-related gains, to what extent are these gains maintained 12 months after program completion? Do variables such as the application of behaviour change techniques moderate the maintenance of these training-related gains?

DESIGN

Systematic review, meta-analysis and meta-regression of randomised controlled trials.

PARTICIPANTS

People with stable COPD.

INTERVENTION

Trials were included if they applied ≥ 4 weeks of a whole-body ETP and reported outcome data immediately following program completion and 12 months after initial program completion. The control group received usual care that did not include a formal exercise training component.

OUTCOME MEASURES

Exercise tolerance, health-related quality of life and dyspnoea during activities of daily living.

DATA SOURCES

EMBASE, PEDro, PubMed and the Cochrane Library.

RESULTS

Nineteen randomised trials with 2,103 participants were found, of which 12 had a sufficiently similar design to be meta-analysed. At 12 months after ETP completion, compared with the control group, the experimental group demonstrated better exercise tolerance (SMD 0.48, 95% CI 0.19 to 0.77) and quality of life (SMD 0.22, 95% CI 0.03 to 0.41) with no clear effect on dyspnoea. Meta-regression using data from all 19 trials demonstrated that the magnitude of between-group differences at the 12-month follow-up was moderated by: behaviour change being a core aim of the strategies implemented following completion of the ETP; the experimental group receiving more behaviour change techniques during the program; and the magnitude of between-group change achieved from the program.

CONCLUSION

At 12 months after completion of an ETP of ≥ 4 weeks, small gains were maintained in exercise tolerance and health-related quality of life. Applying behaviour change techniques with a clear focus on participants integrating exercise into daily life beyond initial program completion is important to maintain training-related gains.

REGISTRATION

CRD42020193833.

The Ceiling Effects of EQ-5D-3L and 5L in General Population Health Surveys: A Systematic Review and Meta-Analysis

OBJECTIVES

This review aims to examine the ceiling effects of EQ-5D-3L (3L) and EQ-5D-5L (5L) in general adult populations and identify the factors influencing these effects.

METHODS

We searched 8 databases for observational studies published in English from inception to 24 July 2023. Ceiling effects were calculated by dividing the number of participants reporting full health at dimension or profile level by the total sample size. Subgroup analysis and meta-regression using the metafor package in R software were performed.

RESULTS

We identified 94 studies from 70 articles, including 4 543 647 adults across 37 countries. The global pooled proportion of individuals reporting full health ("11111") was 56% (95% CI 51%-62%) for 3L and 49% (95% CI 44%-54%) for 5L. The self-care dimension showed the highest ceiling effects (3L: 97%; 5L: 94%), whereas pain/discomfort had the lowest (3L: 69%; 5L: 60%). The ceiling effects in East/South-East Asia were higher than in Europe by 25% (95% CI 18%-32%) in 3L and 9% (95% CI -2%-20%) in 5L. Adjusting for mean age and proportion of males, significant regional differences persisted in the overall profile level of 3L, in all 3L dimensions (except for self-care), and 5L dimensions (except for pain/discomfort and anxiety/depression).

CONCLUSIONS

This review highlights significant ceiling effects in the EQ-5D, especially in Asian populations. The 5L version exhibited fewer ceiling effects than the 3L, indicating its superiority for general population surveys. Further research is crucial to understand the disparities in self-reported health outcomes between Asians and other populations.

PROTOCOL: Key characteristics of effective preschool-based interventions to promote self-regulation: A systematic review and meta-analysis

This is the protocol for a Cochrane Review. The objectives are as follows: The aim of this systematic review is to advance our understanding of the key characteristics of effective preschool-based interventions designed to foster self-regulation. To accomplish this, the review addresses the following questions: 1. What types of preschool-based interventions have been developed to promote self-regulation? 2. What is the average effect of these preschool-based interventions on self-regulation, focusing on four key constructs: integrative effortful control, integrative executive function, self-regulation, and self-regulated learning? 3. What characteristics-such as Resource Allocation, Activity Type, and Instruction Method-could potentially contribute to the effects of preschool-based interventions in promoting self-regulation?

Assessing Inhibitory Control Deficits in Adult ADHD: A Systematic Review and Meta-analysis of the Stop-signal Task

In recent years, there has been an increasing quest in improving our understanding of the neurocognitive deficits underlying adult attention-deficit/hyperactivity disorder (ADHD). Current statistical manuals of psychiatric disorders emphasize inattention and hyperactivity-impulsivity symptoms, but empirical studies have also shown consistent alterations in inhibitory control. To date, there is no established neuropsychological test to assess inhibitory control deficits in adult ADHD. A common paradigm for assessing response inhibition is the stop-signal task (SST). Following PRISMA-selection criteria, our systematic review and meta-analysis integrated the findings of 26 publications with 27 studies examining the SST in adult ADHD. The meta-analysis, which included 883 patients with adult ADHD and 916 control participants, revealed reliable inhibitory control deficits, as expressed in prolonged SST response times, with a moderate effect size g = 0.51 (95% CI: 0.376-0.644, p < 0.0001). The deficits were not moderated by study quality, sample characteristics or clinical parameters, suggesting that they may be a phenotype in this disorder. The analyses of secondary outcome measures revealed greater SST omission errors and reduced go accuracy in patients, indicative of altered sustained attention. However, only few (N < 10) studies were available for these measures. Our meta-analysis suggests that the SST, in conjunction with other tests and questionnaires, could become a valuable tool for assessing inhibitory control deficits in adult ADHD.

A systematic review and meta-analysis of the effectiveness of co-designed, in-person, mental health interventions for reducing anxiety and depression symptoms

BACKGROUND

Co-design is recommended in mental health fields and has been associated with improved intervention efficacy. Despite its growing popularity, syntheses of evidence on the effectiveness of co-designed interventions are scarce, and little is known about their impact on anxiety and depression.

METHODS

The purpose of this systematic review and meta-analysis was to consolidate evidence on the effectiveness of in-person, co-designed mental health interventions for reducing anxiety and depression symptoms. An exhaustive search was conducted across six electronic databases (PubMed, PsycINFO, Embase, CINAHL, CENTRAL, and ProQuest) and grey literature. Criteria for inclusion comprised studies utilizing randomized or quasi-randomized methods, implementing non-digital/in-person, co-designed interventions for mental health enhancement, and assessing anxiety and/or depression. Intervention impacts were evaluated using random-effects meta-analyses.

RESULTS

The review identified 20 studies, with only three using the term 'co-design'. Other terminologies included 'co-developed' (n = 2), 'co-produced' (n = 2), and 'CBPR' (n = 11). Seventeen studies exhibited moderate risk of bias, while three demonstrated high risk. Meta-analyses demonstrated a moderate non-significant effect size of 0.5 (95 % CI: -0.8, 1.08; p = 0.08) on depression outcomes, and a small non-significant effect size of 0.12 (95 % CI: -0.1, 0.33; p = 0.23) on anxiety outcomes.

LIMITATIONS

The majority of studies lacked sufficient statistical power to detect between-group differences. Following GRADE criteria, confidence in estimates was low.

CONCLUSIONS

Notwithstanding widespread enthusiasm for co-design, the current evidence base is inadequate to confirm the impact of in-person, co-designed mental health interventions on anxiety and depression. More full-scale evaluation trials of higher quality are urgently needed, along with uniform terminology and measurement.

Effects of radiofrequency electromagnetic field (RF-EMF) exposure on male fertility: A systematic review of experimental studies on non-human mammals and human sperm in vitro

BACKGROUND

The World Health Organization is coordinating an international project aimed at systematically reviewing the evidence regarding the association between radiofrequency electromagnetic field (RF-EMF) exposure and adverse health effects. Reproductive health outcomes have been identified among the priority topics to be addressed.

OBJECTIVES

To evaluate the effect of RF-EMF exposure on male fertility of experimental mammals and on human sperm exposed in vitro.

METHODS

Three electronic databases (PubMed, Scopus and EMF Portal) were last searched on September 17, 2022. Two independent reviewers screened the studies, which were considered eligible if met the following criteria: 1) Peer-reviewed publications of sham controlled experimental studies, 2) Non-human male mammals exposed at any stage of development or human sperm exposed in vitro, 3) RF-EMF exposure within the frequency range of 100 kHz-300 GHz, including electromagnetic pulses (EMP), 4) one of the following indicators of reproductive system impairment:Two reviewers extracted study characteristics and outcome data. We assessed risk of bias (RoB) using the Office of Health Assessment and Translation (OHAT) guidelines. We categorized studies into 3 levels of overall RoB: low, some or high concern. We pooled study results in a random effects meta-analysis comparing average exposure to no-exposure and in a dose-response meta-analysis using all exposure doses. For experimental animal studies, we conducted subgroup analyses for species, Specific Absorption Rate (SAR) and temperature increase. We grouped studies on human sperm exposed in vitro by the fertility status of sample donors and SAR. We assessed the certainty of the evidence using the GRADE approach after excluding studies that were rated as "high concern" for RoB.

RESULTS

One-hundred and seventeen papers on animal studies and 10 papers on human sperm exposed in vitro were included in this review. Only few studies were rated as "low concern" because most studies were at RoB for exposure and/or outcome assessment. Subgrouping the experimental animal studies by species, SAR, and temperature increase partly accounted for the heterogeneity of individual studies in about one third of the meta-analyses. In no case was it possible to conduct a subgroup analysis of the few human sperm in vitro studies because there were always 1 or more groups including less than 3 studies. Among all the considered endpoints, the meta-analyses of animal studies provided evidence of adverse effects of RF-EMF exposure in all cases but the rate of infertile males and the size of the sired litters. The assessment of certainty according to the GRADE methodology assigned a moderate certainty to the reduction of pregnancy rate and to the evidence of no-effect on litter size, a low certainty to the reduction of sperm count, and a very low certainty to all the other meta-analysis results. Studies on human sperm exposed in vitro indicated a small detrimental effect of RF-EMF exposure on vitality and no-effect on DNA/chromatin alterations. According to GRADE, a very low certainty was attributed to these results. The few studies that used EMP exposure did not show effects on the outcomes. A low to very low certainty was attributed to these results.

DISCUSSION

Many of the studies examined suffered of severe limitations that led to the attribution of uncertainty to the results of the meta-analyses and did not allow to draw firm conclusions on most of the endpoints. Nevertheless, the associations between RF-EMF exposure and decrease of pregnancy rate and sperm count, to which moderate and low certainty were attributed, are not negligible, also in view of the indications that in Western countries human male fertility potential seems to be progressively declining. It was beyond the scope of our systematic review to determine the shape of the dose-response relationship or to identify a minimum effective exposure level. The subgroup and the dose-response fitting analyses did not show a consistent relationship between the exposure levels and the observed effects. Notably, most studies evaluated RF-EMF exposure levels that were higher than the levels to which human populations are typically exposed, and the limits set in international guidelines. For these reasons we cannot provide suggestions to confirm or reconsider current human exposure limits. Considering the outcomes of this systematic review and taking into account the limitations found in several of the studies, we suggest that further investigations with better characterization of exposure and dosimetry including several exposure levels and blinded outcome assessment were conducted.

PROTOCOL REGISTRATION

Protocols for the systematic reviews of animal studies and of human sperm in vitro studies were published in Pacchierotti et al., 2021. The former was also registered in PROSPERO (CRD42021227729 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID = 227729) and the latter in Open Science Framework (OSF Registration DOI https://doi.org/10.17605/OSF.IO/7MUS3).

Fetal and post-natal outcomes in offspring after intrauterine metformin exposure: A systematic review and meta-analysis of animal experiments

AIMS

The impact of maternal metformin use during pregnancy on fetal, infant, childhood and adolescent growth, development, and health remains unclear. Our objective was to systematically review the available evidence from animal experiments on the effects of intrauterine metformin exposure on offspring's anthropometric, cardiovascular and metabolic outcomes.

METHODS

A systematic search was conducted in PUBMED and EMBASE from inception (searched on 12th April 2023). We extracted original, controlled animal studies that investigated the effects of maternal metformin use during pregnancy on offspring anthropometric, cardiovascular and metabolic measurements. Subsequently, risk of bias was assessed and meta-analyses using the standardized mean difference and a random effects model were conducted for all outcomes containing data from 3 or more studies. Subgroup analyses were planned for species, strain, sex and type of model in the case of 10 comparisons or more per subgroup.

RESULTS

We included 37 articles (n = 3133 offspring from n = 716 litters, containing n = 51 comparisons) in this review, mostly (95%) on rodent models and 5% pig models. Follow-up of offspring ranged from birth to 2 years of age. Thirty four of the included articles could be included in the meta-analysis. No significant effects in the overall meta-analysis of metformin on any of the anthropometric, cardiovascular and metabolic offspring outcome measures were identified. Between-studies heterogeneity was high, and risk of bias was unclear in most studies as a consequence of poor reporting of essential methodological details.

CONCLUSION

This systematic review was unable to establish effects of metformin treatment during pregnancy on anthropometric, cardiovascular and metabolic outcomes in non-human offspring. Heterogeneity between studies was high and reporting of methodological details often limited. This highlights a need for additional high-quality research both in humans and model systems to allow firm conclusions to be established. Future research should include focus on the effects of metformin in older offspring age groups, and on outcomes which have gone uninvestigated to date.

The Perils of Misinterpreting and Misusing "Publication Bias" in Meta-analyses: An Education Review on Funnel Plot-Based Methods

Publication bias refers to a systematic deviation from the truth in the results of a meta-analysis due to the higher likelihood for published studies to be included in meta-analyses than unpublished studies. Publication bias can lead to misleading recommendations for decision and policy making. In this education review, we introduce, explain, and provide solutions to the pervasive misuses and misinterpretations of publication bias that afflict evidence syntheses in sport and exercise medicine, with a focus on the commonly used funnel-plot based methods. Publication bias is more routinely assessed by visually inspecting funnel plot asymmetry, although it has been consistently deemed unreliable, leading to the development of statistical tests to assess publication bias. However, most statistical tests of publication bias (i) cannot rule out alternative explanations for funnel plot asymmetry (e.g., between-study heterogeneity, choice of metric, chance) and (ii) are grossly underpowered, even when using an arbitrary minimum threshold of ten or more studies. We performed a cross-sectional meta-research investigation of how publication bias was assessed in systematic reviews with meta-analyses published in the top two sport and exercise medicine journals throughout 2021. This analysis highlights that publication bias is frequently misused and misinterpreted, even in top tier journals. Because of conceptual and methodological problems when assessing and interpreting publication bias, preventive strategies (e.g., pre-registration, registered reports, disclosing protocol deviations, and reporting all study findings regardless of direction or magnitude) offer the best and most efficient solution to mitigate the misuse and misinterpretation of publication bias. Because true publication bias is very difficult to determine, we recommend that future publications use the term "risk of publication bias".

Practical approaches to improving translatability and reproducibility in preclinical pain research

Pain research continues to face the challenge of poor translatability of pre-clinical studies. In this short primer, we are summarizing the possible causes, with an emphasis on practical and constructive solutions. In particular, we stress the importance of increased heterogeneity in animal studies; formal or informal pre-registration to combat publication bias; and increased statistical training in order to help pre-clinical scientists appreciate the usefulness of available experimental design and reporting guidelines.

Robust variance estimation in small meta-analysis with the standardized mean difference

Conventional random-effects models in meta-analysis rely on large sample approximations instead of exact small sample results. While random-effects methods produce efficient estimates and confidence intervals for the summary effect have correct coverage when the number of studies is sufficiently large, we demonstrate that conventional methods result in confidence intervals that are not wide enough when the number of studies is small, depending on the configuration of sample sizes across studies, the degree of true heterogeneity and number of studies. We introduce two alternative variance estimators with better small sample properties, investigate degrees of freedom adjustments for computing confidence intervals, and study their effectiveness via simulation studies.

A Meta-Analysis on Presynaptic Changes in Alzheimer's Disease

BACKGROUND

A key aspect of synaptic dysfunction in Alzheimer's disease (AD) is loss of synaptic proteins. Previous publications showed that the presynaptic machinery is more strongly affected than postsynaptic proteins. However, it has also been reported that presynaptic protein loss is highly variable and shows region- and protein-specificity.

OBJECTIVE

The objective of this meta-analysis was to provide an update on the available literature and to further characterize patterns of presynaptic protein loss in AD.

METHODS

Systematic literature search was conducted for studies published between 2015-2022 which quantified presynaptic proteins in postmortem tissue from AD patients and healthy controls. Three-level random effects meta-analyses of twenty-two identified studies was performed to characterize overall presynaptic protein loss and changes in specific regions, proteins, protein families, and functional categories.

RESULTS

Meta-analysis confirmed overall loss of presynaptic proteins in AD patients. Subgroup analysis revealed region specificity of protein loss, with largest effects in temporal and frontal cortex. Results concerning different groups of proteins were also highly variable. Strongest and most consistently affected was the family of synaptosome associated proteins, especially SNAP25. Among the most severely affected were proteins regulating dense core vesicle exocytosis and the synaptic vesicle cycle.

CONCLUSIONS

Results confirm previous literature related to presynaptic protein loss in AD patients and provide further in-depth characterization of most affected proteins and presynaptic functions.

The effect of smoking on response to methotrexate in rheumatoid arthritis patients: A systematic review and meta-analysis

OBJECTIVES

In the current study, we aimed to investigate the effect of smoking on inadequate response to methotrexate (MTX-IR) in rheumatoid arthritis (RA) patients.

METHODS

We searched PubMed, Embase, and Web of Science until 6 June 2022. Observational or interventional studies investigating MTX-IR in RA patients based on smoking status were included. Two independent reviewers assessed the risk of bias and the certainty of the evidence using the Risk of Bias in Nonrandomized Studies-of Interventions and Grades of Recommendation, Assessment, Development, and Evaluation tools, respectively.

RESULTS

We included 23 studies in the systematic review and 13 in the meta-analysis. Of the 13 included studies, 6 had a moderate risk, 3 had a serious risk, and 4 had a critical risk of bias. The overall random-effect meta-analysis suggested that smokers were 58% more likely to be MTX-IR when compared with nonsmokers [odds ratio (OR) 1.58, 95% confidence interval 1.21-2.06; P = .001; I2 = 69.3%]. The common-effect meta-analysis of the adjusted ORs demonstrated an overall OR of 2.69 (1.88-3.83; P < .001; I2 = 27.1%).

CONCLUSIONS

The current study showed that smoking is a significant predictor of MTX-IR, especially in disease-modifying antirheumatic drug-naïve early RA patients, as most of the included studies in the meta-analysis consisted of this population.

Effectiveness of resilience interventions among cancer patients - A systematic review, meta-analysis, and meta-regression of randomised controlled trials

PURPOSE

This systematic review, meta-analysis and meta-regression aimed to (1) evaluate the effects of resilience interventions on cancer patients' resilience and posttraumatic growth and (2) identify essential contents and features of resilience interventions.

METHODS

A systematic review, meta-analysis, and meta-regression analyses were conducted. Published and unpublished randomised controlled trials evaluating the effects of resilience interventions among cancer patients were retrieved from nine databases, trial registries, and grey literature. The mean and standard deviation scores were used to compute the effect sizes.

RESULTS

23 randomised controlled trials comprising 3287 cancer patients were included. The random effects model found that resilience interventions had beneficial impacts on patients' resilience, posttraumatic growth, quality of life, anxiety, and depressive symptoms with moderate to large effects. The subgroup analyses concluded that theoretically guided interventions that adopted synchronous communication delivered physically had greater effect sizes. Interventions comprising skills that promote patients' cognitive flexibility, self-efficacy, self-esteem, self-regulation, and coping had greater effect in comparison with interventions lacking these components. The meta-regression analyses revealed that sample size has a significant effect on posttraumatic growth scores. More well-designed trials are needed to confirm the effects of resilience interventions.

CONCLUSIONS

There is merit in utilizing resilience interventions to improve cancer patients' resilience and psychological well-being. Resilience interventions should be incorporated into the routine care for cancer patients and survivors.

Oral language interventions can improve language outcomes in children with neurodevelopmental disorders: A systematic review and meta-analysis

Background

Young people who fail to develop language as expected face significant challenges in all aspects of life. Unfortunately, language disorders are common, either as a distinct condition (e.g., Developmental Language Disorder) or as a part of another neurodevelopmental condition (e.g., autism). Finding ways to attenuate language problems through intervention has the potential to yield great benefits not only for the individual but also for society as a whole.

Objectives

This meta-analytic review examined the effect of oral language interventions for children with neurodevelopmental disorders.

Search Methods

The last electronic search was conducted in April 2022.

Selection Criteria

Intervention studies had to target language skills for children from 2 to 18 years of age with Developmental Language Disorder, autism, intellectual disability, Down syndrome, Fragile X syndrome, and Williams syndrome in randomised controlled trials or quasi-experimental designs. Control groups had to include business-as-usual, waiting list, passive or active conditions. However, we excluded studies in which the active control group received a different type, delivery, or dosage of another language intervention. Eligible interventions implemented explicit and structured activities (i.e., explicit instruction of vocabulary, narrative structure or grammatical rules) and/or implicit and broad activities (i.e., shared book reading, general language stimulation). The intervention studies had to assess language skills in receptive and/or expressive modalities.

Data Collection and Analysis

The search provided 8195 records after deduplication. Records were screened by title and abstract, leading to full-text examinations of 448 records. We performed Correlated and Hierarchical Effects models and ran a retrospective power analysis via simulation. Publication bias was assessed via p-curve and precision-effect estimate.

Main Results

We examined 38 studies, with 46 group comparisons and 108 effects comparing pre-/post-tests and eight studies, with 12 group comparisons and 21 effects at follow-up. The results showed a mean effect size of d = 0.27 at the post-test and d = 0.18 at follow-up. However, there was evidence of publication bias and overestimation of the mean effects. Effects from the meta-analysis were significantly related to these elements: (1) receptive vocabulary and omnibus receptive measures showed smaller effect sizes relative to expressive vocabulary, grammar, expressive and receptive discourse, and omnibus expressive tests; and (2) the length of the intervention, where longer sessions conducted over a longer period of time were more beneficial than brief sessions and short-term interventions. Neither moderators concerning participants' characteristics (children's diagnosis, diagnostic status, age, sex, and non-verbal cognitive ability and severity of language impairment), nor those regarding of the treatment components and implementation of the language interventions (intervention content, setting, delivery agent, session structure of the intervention or total number of sessions) reached significance. The same occurred to indicators of study quality. The risk of bias assessment showed that reporting quality for the studies examined in the review was poor.

Authors’ Conclusions

In sum, the current evidence base is promising but inconclusive. Pre-registration and replication of more robust and adequately powered trials, which include a wider range of diagnostic conditions, together with more long-term follow-up comparisons, are needed to drive evidence-based practice and policy.

Adult Organophosphate and Carbamate Insecticide Exposure and Sperm Concentration: A Systematic Review and Meta-Analysis of the Epidemiological Evidence

BACKGROUND

Evidence of the negative impacts of contemporary use insecticides on sperm concentration has increased over the last few decades; however, meta-analyses on this topic are rare.

OBJECTIVES

This investigation assessed the qualitative and quantitative strength of epidemiological evidence regarding adult exposure to two classes of contemporary use insecticides-organophosphates (OPs) and N -methyl carbamates (NMCs)-and sperm concentration using robust and reproducible systematic review and meta-analysis methods.

METHODS

Three scientific databases (PubMed, Scopus, and Web of Science), two U.S. government databases (NIOSHTIC-2 and Science.gov), and five nongovernmental organization websites were searched for relevant primary epidemiological studies published in any language through 11 August 2022. Risk of bias and strength of evidence were evaluated according to Navigation Guide systematic review methodology. Bias-adjusted standardized mean difference effect sizes were calculated and pooled using a three-level, multivariate random-effect meta-analysis model with cluster-robust variance estimation.

RESULTS

Across 20 studies, 21 study populations, 42 effect sizes, and 1,774 adult men, the pooled bias-adjusted standardized mean difference in sperm concentration between adult men more- and less-exposed to OP and NMC insecticides was - 0.30 (95% CI: - 0.49 , - 0.10 ; P Satt < 0.01 ). Sensitivity and subgroup analyses explored statistical heterogeneity and validated the model robustness. Although the pooled effect estimate was modified by risk of bias, insecticide class, exposure setting, and recruitment setting, it remained negative in direction across all meta-analyses. The body of evidence was rated to be of moderate quality, with sufficient evidence of an association between higher adult OP and NMC insecticide exposure and lower sperm concentration.

DISCUSSION

This comprehensive investigation found sufficient evidence of an association between higher OP and NMC insecticide exposure and lower sperm concentration in adults. Although additional cohort studies can be beneficial to fill data gaps, the strength of evidence warrants reducing exposure to OP and NMC insecticides now to prevent continued male reproductive harm. https://doi.org/10.1289/EHP12678.

The effect of SSRIs on fear learning: a systematic review and meta-analysis

RATIONALE

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medication for anxiety-like disorders such as panic disorder, generalized anxiety disorder, and post-traumatic stress disorder. Fear learning plays an important role in the development and treatment of these disorders. Yet, the effect of SSRIs on fear learning are not well known.

OBJECTIVE

We aimed to systematically review the effect of six clinically effective SSRIs on acquisition, expression, and extinction of cued and contextual conditioned fear.

METHODS

We searched the Medline and Embase databases, which yielded 128 articles that met the inclusion criteria and reported on 9 human and 275 animal experiments.

RESULTS

Meta-analysis showed that SSRIs significantly reduced contextual fear expression and facilitated extinction learning to cue. Bayesian-regularized meta-regression further suggested that chronic treatment exerts a stronger anxiolytic effect on cued fear expression than acute treatment. Type of SSRI, species, disease-induction model, and type of anxiety test used did not seem to moderate the effect of SSRIs. The number of studies was relatively small, the level of heterogeneity was high, and publication bias has likely occurred which may have resulted in an overestimation of the overall effect sizes.

CONCLUSIONS

This review suggests that the efficacy of SSRIs may be related to their effects on contextual fear expression and extinction to cue, rather than fear acquisition. However, these effects of SSRIs may be due to a more general inhibition of fear-related emotions. Therefore, additional meta-analyses on the effects of SSRIs on unconditioned fear responses may provide further insight into the actions of SSRIs.

Neurobehavioral effects of fungicides in zebrafish: a systematic review and meta-analysis

Pesticides are widely used in global agriculture to achieve high productivity levels. Among them, fungicides are specifically designed to inhibit fungal growth in crops and seeds. However, their application often results in environmental contamination, as these chemicals can persistently be detected in surface waters. This poses a potential threat to non-target organisms, including humans, that inhabit the affected ecosystems. In toxicologic research, the zebrafish (Danio rerio) is the most commonly used fish species to assess the potential effects of fungicide exposure, and numerous and sometimes conflicting findings have been reported. To address this, we conducted a systematic review and meta-analysis focusing on the neurobehavioral effects of fungicides in zebrafish. Our search encompassed three databases (PubMed, Scopus, and Web of Science), and the screening process followed predefined inclusion/exclusion criteria. We extracted qualitative and quantitative data, as well as assessed reporting quality, from 60 included studies. Meta-analyses were performed for the outcomes of distance traveled in larvae and adults and spontaneous movements in embryos. The results revealed a significant overall effect of fungicide exposure on distance, with a lower distance traveled in the exposed versus control group. No significant effect was observed for spontaneous movements. The overall heterogeneity was high for distance and moderate for spontaneous movements. The poor reporting practices in the field hindered a critical evaluation of the studies. Nevertheless, a sensitivity analysis did not identify any studies skewing the meta-analyses. This review underscores the necessity for better-designed and reported experiments in this field.

Effects of Radiofrequency Electromagnetic Field (RF-EMF) exposure on pregnancy and birth outcomes: A systematic review of experimental studies on non-human mammals

BACKGROUND

The World Health Organization is coordinating an international project aimed at systematically reviewing the evidence regarding the association between radiofrequency electromagnetic field (RF-EMF) exposure and adverse health effects. Within the project, 6 topics have been prioritized by an expert group, which include reproductive health outcomes.

OBJECTIVES

According to the protocol published in 2021, a systematic review and meta-analyses on the adverse effects of RF-EMF exposure during pregnancy in offspring of experimental animals were conducted.

METHODS

Three electronic databases (PubMed, Scopus and EMF Portal) were last searched on September 8 or 17, 2022. Based on predefined selection criteria, the obtained references were screened by two independent reviewers. Studies were included if they met the following criteria: 1) original, sham controlled experimental study on non-human mammals exposed in utero, published in peer-reviewed journals, 2) the experimental RF-EMF exposure was within the frequency range 100 kHz-300 GHz, 3) the effects of RF-EMF exposure on fecundity (litter size, embryonic/fetal losses), on the offspring health at birth (decrease of weight or length, congenital malformations, changes of sex ratio) or on delayed effects (neurocognitive alterations, female infertility or early-onset cancer) were studied. Study characteristics and outcome data were extracted by two reviewers. Risk of bias (RoB) was assessed using the Office of Health Assessment and Translation (OHAT) guidelines. Study results were pooled in a random effects meta-analysis comparing average exposure to no-exposure and in a dose-response meta-analysis using all exposure doses, after exclusion of studies that were rated at "high concern" for RoB. Subgroup analyses were conducted for species, Specific Absorption Rate (SAR) and temperature increase. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Eighty-eight papers could be included in this review. Effects on fecundity. The meta-analysis of studies on litter size, conducted at a whole-body average SAR of 4.92 W/kg, did not show an effect of RF-EMF exposure (MD 0.05; 95% CI -0.21 to 0.30). The meta-analysis of studies on resorbed and dead fetuses, conducted at a whole-body average SAR of 20.26 W/kg, showed a significant increase of the incidence in RF-EMF exposed animals (OR 1.84; 95% CI 1.27 to 2.66). The results were similar in the dose-response analysis. Effects on the offspring health at birth. The meta-analysis of studies on fetal weight, conducted at a whole-body average SAR of 9.83 W/kg, showed a small decrease in RF-EMF exposed animals (SMD 0.31; 95% CI 0.15 to 0.48). The meta-analysis of studies on fetal length, conducted at a whole-body average SAR of 4.55 W/kg, showed a moderate decrease in length at birth (SMD 0.45; 95% CI 0.07 to 0.83). The meta-analysis of studies on the percentage of fetuses with malformations, conducted at a whole-body average SAR of 6.75 W/kg, showed a moderate increase in RF-EMF exposed animals (SMD -0.45; 95% CI -0.68 to -0.23). The meta-analysis of studies on the incidence of litters with malformed fetuses, conducted at a whole-body average SAR of 16.63 W/kg, showed a statistically significant detrimental RF-EMF effect (OR 3.22; 95% CI 1.9 to 5.46). The results were similar in the dose-response analyses. Delayed effects on the offspring health. RF-EMF exposure was not associated with detrimental effects on brain weight (SMD 0.10; 95% CI -0.09 to 0.29) and on learning and memory functions (SMD -0.54; 95% CI -1.24 to 0.17). RF-EMF exposure was associated with a large detrimental effect on motor activity functions (SMD 0.79; 95% CI 0.21 to 1.38) and a moderate detrimental effect on motor and sensory functions (SMD -0.66; 95% CI -1.18 to -0.14). RF-EMF exposure was not associated with a decrease of the size of litters conceived by F2 female offspring (SMD 0.08; 95% CI -0.39 to 0.55). Notably, meta-analyses of neurobehavioural effects were based on few studies, which suffered of lack of independent replication deriving from only few laboratories.

DISCUSSION

There was high certainty in the evidence for a lack of association of RF-EMF exposure with litter size. We attributed a moderate certainty to the evidence of a small detrimental effect on fetal weight. We also attributed a moderate certainty to the evidence of a lack of delayed effects on the offspring brain weight. For most of the other endpoints assessed by the meta-analyses, detrimental RF-EMF effects were shown, however the evidence was attributed a low or very low certainty. The body of evidence had limitations that did not allow an assessment of whether RF-EMF may affect pregnancy outcomes at exposure levels below those eliciting a well-known adverse heating impact. In conclusion, in utero RF-EMF exposure does not have a detrimental effect on fecundity and likely affects offspring health at birth, based on the meta-analysis of studies in experimental mammals on litter size and fetal weight, respectively. Regarding possible delayed effects of in utero exposure, RF-EMF probably does not affect offspring brain weight and may not decrease female offspring fertility; on the other hand, RF-EMF may have a detrimental impact on neurobehavioural functions, varying in magnitude for different endpoints, but these last findings are very uncertain. Further research is needed on the effects at birth and delayed effects with sample sizes adequate for detecting a small effect. Future studies should use standardized endpoints for testing prenatal developmental toxicity and developmental neurotoxicity (OECD TG 414 and 426), improve the description of the exposure system design and exposure conditions, conduct appropriate dosimetry characterization, blind endpoint analysis and include several exposure levels to better enable the assessment of a dose-response relationship.

PROTOCOL REGISTRATION AND PUBLICATION

The protocol was published in Pacchierotti et al., 2021 and registered in PROSPERO CRD42021227746 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227746).

Global Prevalence and Factors Related to Intimate Partner Violence Amongst People Living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome: A Systematic Review, Meta-Analysis, and Meta-Regression

Reviews of intimate partner violence (IPV) have primarily focused on women and same-sex relationships, but little is known about the global epidemiology of IPV among people living with HIV/AIDS (PLWHA). This review employed meta-analytic approaches to determine the worldwide prevalence and factors related to different forms of IPV among PLWHA. Databases including PubMed, Cochrane review, EMBASE, Scopus, PsycINFO, CINAHL, ProQuest, and registers, were systematically reviewed until November 5, 2021. The meta-analysis was conducted using the metafor package in R software. The Newcastle Ottawa Scale and Cochrane Risk of Bias Tool version 1 were used to assess the study quality and risk of bias, respectively. A total of 49 published articles and 42,280 participants, were included in the meta-analysis. Over their lifetime, four in ten PLWHA have experienced some type of IPV. Over a quarter have experienced physical, emotional, or psychological IPV. One in five PLWHA experienced at least one form of IPV during the recall period of last year, with emotional IPV being the most prevalent. Rates of physical and any types of IPV differed substantially between IPV measurements. IPV rates also varied significantly by the study design, with physical (29%) and sexual (18%) IPV rates being more prevalent in cross-sectional studies. Public health measures are critical for preventing and combating IPV among PLWHA. Additional cross-national research using robust sampling methods is required to obtain more representative samples and thus a more reliable prevalence estimate of IPV prevalence.

A systematic review and meta-analysis of thigmotactic behaviour in the open field test in rodent models associated with persistent pain

Thigmotaxis is an innate predator avoidance behaviour of rodents. To gain insight into how injury and disease models, and analgesic drug treatments affect thigmotaxis, we performed a systematic review and meta-analysis of studies that assessed thigmotaxis in the open field test. Systematic searches were conducted of 3 databases in October 2020, March and August 2022. Study design characteristics and experimental data were extracted and analysed using a random-effects meta-analysis. We also assessed the correlation between thigmotaxis and stimulus-evoked limb withdrawal. This review included the meta-analysis of 165 studies We report thigmotaxis was increased in injury and disease models associated with persistent pain and this increase was attenuated by analgesic drug treatments in both rat and mouse experiments. Its usefulness, however, may be limited in certain injury and disease models because our analysis suggested that thigmotaxis may be associated with the locomotor function. We also conducted subgroup analyses and meta-regression, but our findings on sources of heterogeneity are inconclusive because analyses were limited by insufficient available data. It was difficult to assess internal validity because reporting of methodological quality measures was poor, therefore, the studies have an unclear risk of bias. The correlation between time in the centre (type of a thigmotactic metric) and types of stimulus-evoked limb withdrawal was inconsistent. Therefore, stimulus-evoked and ethologically relevant behavioural paradigms should be viewed as two separate entities as they are conceptually and methodologically different from each other.

Effect of Type and Dose of Exercise on Neuropathic Pain After Experimental Sciatic Nerve Injury: A Preclinical Systematic Review and Meta-Analysis

This preclinical systematic review aimed to determine the effectiveness of different types and doses of exercise on pain behavior and biomarkers in preclinical models of focal neuropathic pain. We searched MEDLINE, EMBASE, Web of Science, PubMed, SCOPUS, CINAHL, and Cochrane library from inception to November 2022 for preclinical studies evaluating the effect of exercise compared to control interventions on neuropathic pain behavior after experimental sciatic nerve injury. If possible, data were meta-analyzed using random effect models with inverse-variance weighting. Thirty-seven studies were included and 26 meta-analyzed. Risk of bias (SYRCLE tool) remained unclear in most studies and reporting quality (CAMARADES) was variable. Exercise reduced mechanical (standardized mean differences [SMD] .53 (95% CI .31, .74), P = .0001, I2 = 0%, n = 364), heat (.32 (.07, .57), P = .01, I2 = 0%, n = 266) and cold hypersensitivity (.51 (.03, 1.0), P = .04, I2 = 0%, n = 90) compared to control interventions. No relationship was apparent between exercise duration or intensity and antinociception. Exercise modulated biomarkers related to different systems (eg, immune system, neurotrophins). Whereas firm conclusions are prevented by the use of male animals only, variable reporting quality and unclear risk of bias in many studies, our results suggest that aerobic exercise is a promising tool in the management of focal neuropathic pain. PERSPECTIVE: This systematic review and meta-analysis demonstrates that aerobic exercise reduces neuropathic pain-related behavior in preclinical models of sciatic nerve injury. This effect is accompanied by changes in biomarkers associated with inflammation and neurotrophins among others. These results could help to develop exercise interventions for patients with neuropathic pain.

Exposure to halogenated ethers causes neurodegeneration and behavioural changes in young healthy experimental animals: a systematic review and meta analyses

The FDA issued a warning that repeated and prolonged use of inhalational anaesthetics in children younger than 3 years may increase the risk of neurological damage. Robust clinical evidence supporting this warning is however lacking. A systematic review of all preclinical evidence concerning isoflurane, sevoflurane, desflurane and enflurane exposure in young experimental animals on neurodegeneration and behaviour may elucidate how severe this risk actually is PubMed and Embase were comprehensively searched on November 23, 2022. Based on predefined selection criteria the obtained references were screened by two independent reviewers. Data regarding study design and outcome data (Caspase-3 and TUNEL for neurodegeneration, Morris water maze (MWM), Elevated plus maze (EPM), Open field (OF) and Fear conditioning (FC)) were extracted, and individual effect sizes were calculated and subsequently pooled using the random effects model. Subgroup analyses were predefined and conducted for species, sex, age at anesthesia, repeated or single exposure and on time of outcome measurement. Out of the 19.796 references screened 324 could be included in the review. For enflurane there were too few studies to conduct meta-analysis (n = 1). Exposure to sevoflurane, isoflurane and desflurane significantly increases Caspase-3 levels and TUNEL levels. Further, sevoflurane and isoflurane also cause learning and memory impairment, and increase anxiety. Desflurane showed little effect on learning and memory, and no effect on anxiety. Long term effects of sevoflurane and isoflurane on neurodegeneration could not be analysed due to too few studies. For behavioural outcomes, however, this was possible and revealed that sevoflurane caused impaired learning and memory in all three related outcomes and increased anxiety in the elevated plus maze. For isoflurane, impaired learning and memory was observed as well, but only sufficient data was available for two of the learning and memory related outcomes. Further, single exposure to either sevoflurane or isoflurane increased neurodegeneration and impaired learning and memory. In summary, we show evidence that exposure to halogenated ethers causes neurodegeneration and behavioural changes. These effects are most pronounced for sevoflurane and isoflurane and already present after single exposure. To date there are not sufficient studies to estimate the presence of long term neurodegenerative effects. Nevertheless, we provide evidence in this review of behavioral changes later in life, suggesting some permanent neurodegenerative changes. Altogether, In contrast to the warning issued by the FDA we show that already single exposure to isoflurane and sevoflurane negatively affects brain development. Based on the results of this review use of sevoflurane and isoflurane should be restrained as much as possible in this young vulnerable group, until more research on the long term permanent effects have been conducted.

Individual-level interventions for reducing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from work-related stress as a result of an imbalance of demands, skills and social support at work. This may lead to stress, burnout and psychosomatic problems, and deterioration of service provision. This is an update of a Cochrane Review that was last updated in 2015, which has been split into this review and a review on organisational-level interventions.  OBJECTIVES: To evaluate the effectiveness of stress-reduction interventions targeting individual healthcare workers compared to no intervention, wait list, placebo, no stress-reduction intervention or another type of stress-reduction intervention in reducing stress symptoms.  SEARCH METHODS: We used the previous version of the review as one source of studies (search date: November 2013). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Web of Science and a trials register from 2013 up to February 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCT) evaluating the effectiveness of stress interventions directed at healthcare workers. We included only interventions targeted at individual healthcare workers aimed at reducing stress symptoms.  DATA COLLECTION AND ANALYSIS: Review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We categorised interventions into ones that: 1. focus one's attention on the (modification of the) experience of stress (thoughts, feelings, behaviour);  2. focus one's attention away from the experience of stress by various means of psychological disengagement (e.g. relaxing, exercise);  3. alter work-related risk factors on an individual level; and ones that 4. combine two or more of the above.  The crucial outcome measure was stress symptoms measured with various self-reported questionnaires such as the Maslach Burnout Inventory (MBI), measured at short term (up to and including three months after the intervention ended), medium term (> 3 to 12 months after the intervention ended), and long term follow-up (> 12 months after the intervention ended).  MAIN RESULTS: This is the second update of the original Cochrane Review published in 2006, Issue 4. This review update includes 89 new studies, bringing the total number of studies in the current review to 117 with a total of 11,119 participants randomised.  The number of participants per study arm was ≥ 50 in 32 studies. The most important risk of bias was the lack of blinding of participants.  Focus on the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention Fifty-two studies studied an intervention in which one's focus is on the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (standardised mean difference (SMD) -0.37, 95% confidence interval (CI) -0.52 to -0.23; 41 RCTs; 3645 participants; low-certainty evidence) and medium term (SMD -0.43, 95% CI -0.71 to -0.14; 19 RCTs; 1851 participants; low-certainty evidence). The SMD of the short-term result translates back to 4.6 points fewer on the MBI-emotional exhaustion scale (MBI-EE, a scale from 0 to 54). The evidence is very uncertain (one RCT; 68 participants, very low-certainty evidence) about the long-term effect on stress symptoms of focusing one's attention on the experience of stress. Focus away from the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention  Forty-two studies studied an intervention in which one's focus is away from the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (SMD -0.55, 95 CI -0.70 to -0.40; 35 RCTs; 2366 participants; low-certainty evidence) and medium term (SMD -0.41 95% CI -0.79 to -0.03; 6 RCTs; 427 participants; low-certainty evidence). The SMD on the short term translates back to 6.8 fewer points on the MBI-EE. No studies reported the long-term effect. Focus on work-related, individual-level factors versus no intervention/no stress-reduction intervention Seven studies studied an intervention in which the focus is on altering work-related factors. The evidence is very uncertain about the short-term effects (no pooled effect estimate; three RCTs; 87 participants; very low-certainty evidence) and medium-term effects and long-term effects (no pooled effect estimate; two RCTs; 152 participants, and one RCT; 161 participants, very low-certainty evidence) of this type of stress management intervention.  A combination of individual-level interventions versus no intervention/wait list/no stress-reduction intervention Seventeen studies studied a combination of interventions. In the short-term, this type of intervention may result in a reduction in stress symptoms (SMD -0.67 95%, CI -0.95 to -0.39; 15 RCTs; 1003 participants; low-certainty evidence). The SMD translates back to 8.2 fewer points on the MBI-EE. On the medium term, a combination of individual-level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect (SMD -0.48, 95% CI -0.95 to 0.00; 6 RCTs; 574 participants; low-certainty evidence). The evidence is very uncertain about the long term effects of a combination of interventions on stress symptoms (one RCT, 88 participants; very low-certainty evidence). Focus on stress versus other intervention type  Three studies compared focusing on stress versus focusing away from stress and one study a combination of interventions versus focusing on stress. The evidence is very uncertain about which type of intervention is better or if their effect is similar.

AUTHORS' CONCLUSIONS

Our review shows that there may be an effect on stress reduction in healthcare workers from individual-level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. Long-term effects of individual-level stress management interventions remain unknown. The same applies for interventions on (individual-level) work-related risk factors. The bias assessment of the studies in this review showed the need for methodologically better-designed and executed studies, as nearly all studies suffered from poor reporting of the randomisation procedures, lack of blinding of participants and lack of trial registration. Better-designed trials with larger sample sizes are required to increase the certainty of the evidence. Last, there is a need for more studies on interventions which focus on work-related risk factors.

Patient decision support interventions for candidates considering elective surgeries: a systematic review and meta-analysis

BACKGROUND

The increase in elective surgeries and varied postoperative patient outcomes has boosted the use of patient decision support interventions (PDSIs). However, evidence on the effectiveness of PDSIs are not updated. This systematic review aims to summarize the effects of PDSIs for surgical candidates considering elective surgeries and to identify their moderators with an emphasis on the type of targeted surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched eight electronic databases for randomized controlled trials evaluating PDSIs among elective surgical candidates. We documented the effects on invasive treatment choice, decision-making-related outcomes, patient-reported outcomes, and healthcare resource use. The Cochrane Risk of Bias Tool version 2 and Grading of Recommendations, Assessment, Development, and Evaluations were adopted to rate the risk of bias of individual trials and certainty of evidence, respectively. STATA 16 software was used to conduct the meta-analysis.

RESULTS

Fifty-eight trials comprising 14 981 adults from 11 countries were included. Overall, PDSIs had no effect on invasive treatment choice (risk ratio=0.97; 95% CI: 0.90, 1.04), consultation time (mean difference=0.04 min; 95% CI: -0.17, 0.24), or patient-reported outcomes, but had a beneficial effect on decisional conflict (Hedges' g =-0.29; 95% CI: -0.41, -0.16), disease and treatment knowledge (Hedges' g =0.32; 95% CI: 0.15, 0.49), decision-making preparedness (Hedges' g =0.22; 95% CI: 0.09, 0.34), and decision quality (risk ratio=1.98; 95% CI: 1.15, 3.39). Treatment choice varied with surgery type and self-guided PDSIs had a greater effect on disease and treatment knowledge enhancement than clinician-delivered PDSIs.

CONCLUSIONS

This review has demonstrated that PDSIs targeting individuals considering elective surgeries had benefited their decision-making by reducing decisional conflict and increasing disease and treatment knowledge, decision-making preparedness, and decision quality. These findings may be used to guide the development and evaluation of new PDSIs for elective surgical care.

The effectiveness of low-dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A systematic review with meta-analysis

OBJECTIVE

To evaluate the effectiveness of low-dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain.

INTRODUCTION

Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low-dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low-dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP).

INCLUSION CRITERIA

Randomized controlled trials that evaluate low-dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary-based rehabilitation (MBR) were excluded.

METHODS

Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of "chronic back pain", "exercise intervention", "cognitive-behavioral therapy", "primary care" and "randomized controlled trials" were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13-item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2022 CRD42022302771.

RESULTS

Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta-analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post-treatment (standardized mean difference (SMD) = -1.09, 95% confidence interval (CI) = -1.84 to -0.34, I2  = 97%, p = 0.004) as well as at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004), long term (SMD = -0.79, 95% CI = -1.42 to -0.17, I2  = 96%, p = 0.01) and very long-term (SMD = -1.13, 95% CI = -1.93 to -0.33, I2  = 94%, p = 0.005) follow-up. Significant effects in favor of PCBI for physical function were found post-treatment (SMD = -1.33, 95% CI = -2.17 to -0.49, I2  = 97%, p = 0.002) at short-term (SMD = -0.20, 95% CI = -0.36 to -0.04, I2  = 0%, p = 0.01) and at long-term follow-up (SMD = -1.17, 95% CI = -2.06 to -0.28, I2  = 98%, p = 0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain-neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3-12 weeks) and contact times (2-15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short-term (SMD = -0.23, 95% CI = -0.39 to -0.08, I2  = 0%, p = 0.004) and long-term follow-up (SMD = -0.22, 95% CI = -0.41 to -0.03, I2  = 39%, p = 0.02).

CONCLUSIONS

This meta-analysis suggests that low-dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta-analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low-dosed) CLBP interventions.

Effects of thermal fluctuations on biological processes: a meta-analysis of experiments manipulating thermal variability

Thermal variability is a key driver of ecological processes, affecting organisms and populations across multiple temporal scales. Despite the ubiquity of variation, biologists lack a quantitative synthesis of the observed ecological consequences of thermal variability across a wide range of taxa, phenotypic traits and experimental designs. Here, we conduct a meta-analysis to investigate how properties of organisms, their experienced thermal regime and whether thermal variability is experienced in either the past (prior to an assay) or present (during the assay) affect performance relative to the performance of organisms experiencing constant thermal environments. Our results-which draw upon 1712 effect sizes from 75 studies-indicate that the effects of thermal variability are not unidirectional and become more negative as mean temperature and fluctuation range increase. Exposure to variation in the past decreases performance to a greater extent than variation experienced in the present and increases the costs to performance more than diminishing benefits across a broad set of empirical studies. Further, we identify life-history attributes that predictably modify the ecological response to variation. Our findings demonstrate that effects of thermal variability on performance are context-dependent, yet negative outcomes may be heightened in warmer, more variable climates.

Shellfish as a bioremediation tool: A review and meta-analysis

Over the last century, human activities have increased the amount of nutrients inputs to terrestrial and aquatic ecosystems. These activities have altered nitrogen (N) and phosphorus (P) cycling, causing substantial changes in ecosystem function such as provision of clean air and water. Strategies that reduce and remove excess nutrients are urgently needed to remediate impacted systems. Reef-forming shellfish (oysters and mussels) can play a crucial role in nutrient cycling, particularly in N removal from aquatic systems by providing substrate for microbial colonisation and enhancing microbial denitrification in the surrounding sediments. However, the potential for shellfish to enhance nutrient cycling (and denitrification) will likely vary spatially and in response to several environmental factors. Here, we used 1) a qualitative analysis to review nutrient processes occurring on shellfish; and 2) a meta-analysis to evaluate the influence of shellfish on benthic metabolism and nutrient cycling in surrounding sediments, and how that is influenced by environmental factors such as grain size, seasonality, water body type, and tidal position. Overall, we found that shellfish increased oxygen consumption, with consequent release of ammonia (NH_4⁺) and phosphate (PO₄^3-) from shellfish and their surrounding sediments. These parameters did not depend on grain size, water body type and tidal height, but the release of PO₄^3- was variable between seasons, being highest during summer and autumn. Shellfish presence also enhanced denitrification measured as dinitrogen gas (N₂) efflux on both reefs and sediments. Denitrification was highest in lagoons; in sandy sediments; and during the warmest season (summer). Thus, our findings highlight that environmental context can mediate the effects of shellfish reefs on sediment function. This information is important for managers seeking to use these animals as an effective bioremediation tool.

Digital training for building resilience: Systematic review, meta-analysis, and meta-regression

Resilience is learnable and broadly described as an individual's adaptive coping ability, its potential value for stress reduction must be explored. With a global coronavirus pandemic, innovative ways to deliver resilience training amidst heightened mental health concerns must be urgently examined. This systematic review aimed to (1) evaluate the effectiveness of digital training for building resilience and reducing anxiety, depressive and stress symptoms and (2) to identify essential features for designing future digital training. A three-step search was conducted in eight electronic databases, trial registries and grey literature to locate eligible studies. Randomised controlled trials examining the effects of digital training aimed at enhancing resilience were included. Data analysis was conducted using the Stata version 17. Twenty-two randomised controlled trials involving 2876 participants were included. Meta-analysis revealed that digital training significantly enhanced the participants' resilience with moderate to large effect (g = 0.54-1.09) at post-intervention and follow-up. Subgroup analyses suggested that training delivered via the Internet with a flexible programme schedule was more effective than its counterparts. This review supports the use of digital training in improving resilience. Further high-quality randomised controlled trials with large sample size are needed.