Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower.

METHODS

We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated.

RESULTS

We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening.

CONCLUSIONS

These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.

A population-based, province-wide, record-linkage interrupted time series analysis of impact of the universal seasonal influenza vaccination policy on seasonal influenza vaccine uptake among 5-64-year-olds in the province of Manitoba, Canada

INTRODUCTION

Universal seasonal influenza vaccination policy (USIVP) was introduced in Manitoba, Canada in 2010. Its impact on seasonal influenza vaccine (SIV) uptake remains underexplored.

METHODS

We used population-wide data from Manitoba to assess the impact of the USIVP on SIV uptake. The study covered twenty influenza seasons (2000/01-2019/20). We summarized SIV uptake for influenza seasons before and after the USIVP. Utilizing a single-group interrupted time series analysis and appropriately accounting for autocorrelation, we estimated absolute change and annual trend in SIV uptake percentages among 5-17-, 18-44-, and 45-64-year-olds across strata of certain population socioeconomic and health-related characteristics following the USIVP.

RESULTS

Average SIV uptake percentage in all age groups was significantly higher after compared with before the USIVP. Following the USIVP, there was no significant absolute change in SIV uptake percentage among 18-44- and 45-64-year-olds overall; however, a significant decrease was observed among 18-44-year-old males in the higher income quintiles, across healthcare utilization, and in some regions of residence. A significant increase was observed among 5-17-year-olds in the lowest income quintiles, in Northern Manitoba, and among those with less healthcare utilization, and no chronic disease. Overall, there was mostly no significant annual trend in SIV uptake percentage among 18-44-year-olds, and while a significant upward and downward trend was observed among 5-17-year-olds and 45-64-year-olds, respectively, a significant downward trend was observed across all strata of population characteristics within all age groups in Northern Manitoba.

CONCLUSIONS

The USIVP in Manitoba was followed by an absolute increase in SIV uptake percentage only in some socioeconomically disadvantaged subpopulations among 5-17-year-olds. While there was mostly an upward annual trend in SIV uptake percentage among 5-17-year-olds, a downward trend was observed among 45-64-year-olds and across all age groups and subpopulations in socioeconomically disadvantaged Northern Manitoba. These findings are novel for Manitoba and require investigation and public health attention.

Characteristics and determinants of seasonal influenza vaccination in Manitoba, Canada: A population-wide record-linkage study

Background

Seasonal influenza vaccine (SIV) uptake (receipt of vaccine) in Manitoba, Canada is consistently low notwithstanding vaccine availability and free-of-charge vaccination. Despite, there is a lack of published evidence on the determinants of uptake of the vaccine. We sought to assess the association between SIV uptake and certain population and primary care physician (PCP) characteristics in Manitoba.

Methods

We conducted a longitudinal study utilizing Manitoba administrative health databases. We summarized SIV uptake from 2000/01-2019/20 influenza seasons across subpopulations defined by socioeconomic, health-related and PCP characteristics. Utilizing multivariable generalized estimating equation logistic regression models, we assessed the association between SIV uptake and the socioeconomic, health-related and PCP characteristics, stratified by age group (<5-, 5-17-, 18-44-, 45-64-, ≥65-year-olds) and sex. Results are adjusted odds ratios with associated 95 % confidence intervals.

Results

SIV uptake percentage increased over time with 4.4 %, 13.1 %, 17.5 % and 21.7 % of < 5-year-olds, 2 %, 4.9 %, 9.7 % and 13.1 % of 5-17-year-olds, 5.4 %, 8.8 %, 10.7 % and 13.5 % of 18-44-year-olds, 16.8 %, 21.3 %, 23.6 % and 24.6 % of 45-64-year-olds receiving the SIV in 2000-2004, 2005-2009, 2010-2014 and 2015-2019, respectively. There was a decline among ≥ 65-year-olds from 58.5 % to 53.5 %. We observed a similar pattern across subpopulations. There were significantly increased odds of SIV uptake among females within the age groups ≥ 18 years, in higher income quintiles, mostly with increased contact with a PCP/hospitalization within age groups ≥ 18 years, among those who had older or female PCPs (the opposite observation among ≥ 65-year-olds) and whose PCP administered at least one SIV in prior influenza season. These observations were largely consistent irrespective of sex.

Conclusion

SIV uptake in Manitoba appears to increase with age, and many socioeconomic, health-related and PCP characteristics appear to be associated with it. These findings may inform targeted vaccination programs to optimize influenza vaccination in Manitoba and similar Canadian jurisdictions.

A global systematic evidence review with meta-analysis of the epidemiological characteristics of the 2022 Mpox outbreaks

BACKGROUND

In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarized published full-text epidemiological data from the outbreaks.

METHODS

A global evidence review (protocol: osf.io/j3kb7) with systematic literature search up to February 09, 2023. We focused on experimental/observational studies of laboratory confirmed Mpox, excluding case reports and case series of < 5 cases. Epidemiological data were pooled using an inverse variance, random-effects model, and pooled estimates presented with associated 95% confidence intervals.

RESULTS

We included 66 studies. Mean incubation period was 7.8 days (6.6-9.0 days, 8 studies: 560 cases), reproductive number 1.8 (1.7-1.9, 6 studies), mean duration from symptom onset to diagnosis 5.8 days (4.8-6.8 days, 4 studies: 982 cases), mean symptom duration 17.5 days (14.7-20.2 days, 3 studies: 292 cases), mean serial interval 8.5 days (7.3-9.9 days, 1 study), hospitalisation 6% (4-9%, 26 studies: 5339 cases), and vaccine effectiveness 78% (65-91%, 3 studies: 953 cases). Highly relevant clinical manifestations were pleomorphic skin lesions 82% (68-94%, 26 studies: 4093 cases), anogenital lesions 64% (51-77%, 9 studies: 10,398 cases), fever 54% (50-57%, 52 studies: 25,992 cases), and lymphadenopathy 51% (46-57%, 42 studies: 17,803 cases), with cases mostly men who have sex with men (MSM). Possibly relevant manifestations were perianal lesions, fatigue, asthenia, myalgia, and headache.

CONCLUSIONS

The 2022 Mpox outbreaks presented with sex-related clinical manifestations and were mostly reported among MSM.

Impact of the universal seasonal influenza vaccination policy in the province of Manitoba, Canada: A population-based, province-wide record-linkage study

INTRODUCTION

In 2010, the government of the province of Manitoba, Canada introduced universal seasonal influenza vaccination policy (USIVP), providing free-of-charge vaccination to all registered residents of the province at least six months of age. Impact of the policy on seasonal influenza vaccine (SIV) uptake (receipt of vaccine) in Manitoba remains unclear, as there is a lack of published evaluations.

METHODS

We conducted an ecological study, utilizing population-wide data from several linked de-identified Manitoba Health and Seniors Care administrative health databases. The study period was from 2000/01-2019/20 influenza seasons. The primary exposure was USIVP (five influenza seasons pre-policy [2005/06-2009/10] compared with post-policy [2010/11-2014/15]). The outcome was SIV uptake. We conducted pre/post logistic regression analysis stratified by age group (<5-, 5-17-, 18-44-, 45-64-, ≥65-year-olds) and certain population socioeconomic and health-related characteristics. Results are adjusted odds ratios with associated 95 % confidence intervals.

RESULTS

We observed significantly increased adjusted odds of SIV uptake post-policy relative to pre-policy in all age groups except ≥65-year-olds already covered from inception of the vaccination programme. The adjusted odds ratios ranged from 0.76 (0.75-0.76) among ≥65-year-olds to 2.15 (2.13-2.18) among 5-17-year-olds, and were largely homogeneous within age groups across sex, income quintiles, regions of residence, and categories of number of visits to primary care physician/hospitalization one year prior to an influenza season except among <5- and 5-17-year-olds. These findings were mostly consistent irrespective of sex and region of residence although there was variability across income quintiles in Northern Manitoba region.

CONCLUSIONS

Introduction of the USIVP in Manitoba was followed by a significant increase in SIV uptake in the five years post policy among <65-year-olds, with similar increased relative odds of vaccination observed within age groups across subpopulations. The observed variations in the relative odds of vaccination across income quintiles in Northern Manitoba region requires administrative attention.

Comparative evaluation of the clinical presentation and epidemiology of the 2022 and previous Mpox outbreaks: a rapid review and meta-analysis

BACKGROUND

In 2022, there were outbreaks of Mpox where the disease is not endemic. We summarised and compared the findings from published observational studies on the clinical presentation and epidemiology of the 2022 and previous outbreaks of Mpox.

METHODS

We registered a review protocol with the Open Science Framework (osf.io/j3kb7). We searched MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases, and relevant websites up to August 30, 2022. Retrieved literature citations were screened for eligibility, and summary clinical presentation and epidemiological data from the included studies were pooled, when possible, using an inverse variance, random-effects model.

RESULTS

Seventy-nine studies met the eligibility. Irrespective of outbreak, fever, headache, myalgia, lymphadenopathy, pleomorphic skin lesions, oral lesions, and sore throat were potentially highly relevant Mpox manifestations, while conjunctivitis, cough, and possibly reactivation of varicella zoster virus may be part of the clinical presentation. The mean incubation period for the 2022 outbreaks was 7.4 d (6.4-8.4 d, I² 64.2%; 4 studies: 270 cases) and for previous outbreaks, 12.9 d (10.4-15.5 d; one study: 31 cases), p < .001. None of the male cases from previous outbreaks was reported to have sex with men (MSM) whereas almost all reported male cases from the 2022 outbreak were MSM. Concomitant sexually transmitted infections and perianal lesions were reported only among male cases from the 2022 outbreak, with the cases mostly presenting with genital lesions.

CONCLUSIONS

The 2022 Mpox outbreaks appear to be mostly among MSM and have a lower incubation period compared with previous outbreaks.Key messages79 studies met the review's inclusion criteria.The 2022 Mpox outbreaks appear to have shorter incubation period compared with previous outbreaks.Established clinical presentation of Mpox includes fever, headache, myalgia, lymphadenopathy, pleomorphic skin lesions, oral lesions, and sore throat.Almost all reported cases from the 2022 Mpox outbreaks were men who had sex with men (MSM).Concomitant sexually transmitted infections and perianal lesions were only reported among cases from the 2022 Mpox outbreaks.A significantly higher proportion of Mpox cases from the 2022 outbreaks had genital lesions compared with cases from previous outbreaks.The 2022 Mpox outbreaks appear to be mostly among MSM.

An overview of the characteristics and methodological standards across systematic reviews with Meta-analysis of efficacy/effectiveness of influenza antiviral drugs

BACKGROUND

Influenza antiviral drugs remain controversial and it is not clear if conclusions on their efficacy/effectiveness are based on high quality systematic reviews (SRs). We systematically identified, critically appraised, and summarized the characteristics and adherence to methodological standards in SRs with meta-analysis of efficacy/effectiveness of influenza antiviral drugs for prevention and/or treatment of influenza.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL, Global Health, and CDSR for English-language SR publications up to July 2020. We summarized the characteristics, adherence to methodological standards and SR quality (AMSTAR 2).

RESULTS

From a total 3,898 citations after removal of duplicates from all identified citations, we included 24 SRs. Seventy-five percent (n = 18) were of a critically low quality, 8% (n = 2) of a low quality, 17% (n = 4) of a moderate quality, and none were of a high quality. Seventeen percent (n = 4) were industry-funded, 4% (n = 1) coauthored by industry employee(s), and 33% (n = 8) commissioned by an organization or authority. Only 33% percent (n = 8) reported protocol registration, 4% (n = 1) reported collaboration with a knowledge synthesis librarian/information specialist, and 17% (n = 4) utilized a systematic review reporting checklist.

CONCLUSIONS

The evidence suggests that SRs of efficacy/effectiveness of influenza antiviral drugs are mostly of critically low quality and do not follow current best SR practices. These findings are significant in view of the important role of SRs in decision-making and the controversies that surround the use of the influenza antiviral drugs. However, the findings should not be interpreted to mean curtailment/cessation of use of antiviral drugs for influenza.

Characteristics and methodological standards across systematic reviews with Meta-analysis of efficacy and/or effectiveness of influenza vaccines: an overview of reviews

BACKGROUND

While systematic reviews (SR) generally suggest that vaccination is an effective way to prevent influenza infection, it is not clear if these conclusions are based on high quality SR methods. As such, we systematically identified, critically appraised, and summarised the characteristics and adherence to methodological standards in SRs with meta-analysis of efficacy/effectiveness of influenza vaccines.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL, Global Health, and CDSR for English-language SR publications up to July 11, 2022. We summarised the characteristics, adherence to methodological standards and SR quality (AMSTAR 2).

RESULTS

From 11,193 retrieved citations, we included 48 publications (47 SRs). Seventy-five percent were of a critically low quality, 19% of a low quality, 2% of a moderate quality, and 4% of a high quality. Thirteen percent were industry-funded, about 13% co-authored by industry employee(s), and 4% commissioned by an organisation or authority. Only 45% percent reported protocol registration, 6% reported collaboration with a knowledge synthesis librarian/information specialist, and 60% utilised a reporting checklist (e.g. PRISMA).

CONCLUSIONS AND RELEVANCE

SRs with meta-analysis of efficacy/effectiveness of influenza vaccines are mostly of critically low quality and even the more recent reviews did not follow current best SR practices. These findings are significant in view of the controversies that surround influenza vaccines, and the use of SRs in informed decision-making. However, the findings do not justify curtailment or cessation of influenza vaccine use as vaccines continue to offer substantial net public health benefit.HighlightsWe systematically identified, critically appraised, and summarised the characteristics and adherence to methodological standards in 47 systematic reviews with meta-analysis of efficacy/effectiveness of influenza vaccines.13% of the reviews were industry-funded.About 13% of the reviews were co-authored by industry employee(s).4% of the reviews were commissioned by an organisation/authority.45% of the reviews reported protocol registration.6% of the reviews reported collaborating with a knowledge synthesis librarian/information specialist to prepare the search strategy.60% of the reviews reported using the PRISMA (or similar) checklist.75% of the reviews were judged to be of critically low quality; 19% of low quality; 2% of moderate quality; 4% of high quality.

Correlation between country-level numbers of COVID-19 cases and mortalities, and country-level characteristics: A global study

Background: Not much is known about correlations between country-level characteristics and country-level numbers of COVID-19 cases and mortalities. Methods: Using data from the World Health Organization and other international organisations, we summarised country-level COVID-19 case and mortality counts per 100,000 population, and COVID-19 case fatality rate from January 2020 to August 2021. We conducted adjusted linear regression analysis to assess relationships between these counts/rate and certain country-level characteristics. We reported adjusted regression coefficients, β and associated 95% confidence intervals. Results: There was a positive correlation between the number of cases and country-level male/female ratio, and positive correlations between the numbers of cases and mortalities and country-level proportion of 60+-year-olds, universal health coverage index of service coverage (UHC) and tourism. Country economic status correlated negatively with the numbers of cases and mortalities. COVID-19 case fatality rate was highest in Peru, South American region (9.2%), and lowest in Singapore, Western Pacific region (0.1%). A negative correlation was observed between case fatality rate and country-level male/female ratio, population density and economic status. These observations remained mostly among mid-/low-income countries, particularly a positive correlation between the number of cases and male/female ratio and proportion of 60+-year-olds. Conclusions: Various country-level characteristics such as male/female ratio, proportion of older adults, country economic status, UHC and tourism appear to be correlated with the country-level number of COVID-19 cases and/or mortalities. Consideration of these characteristics may be necessary when designing country-level COVID-19 epidemiological studies and in comparing COVID-19 data between countries.

Offloading devices for neuropathic foot ulcers in adult persons with type 1 or type 2 diabetes: a rapid review with meta-analysis and trial sequential analysis of randomized controlled trials

INTRODUCTION

Healing time for neuropathic planter foot ulcers (NPFUs) in persons with diabetes may be reduced through use of non-removable fiberglass total contact casting (F-TCC) compared with removable cast walkers (RCWs), although the evidence base is still growing.

RESEARCH DESIGN AND METHODS

We conducted a rapid review and systematically searched for, and critically assessed, randomized controlled trials (RCTs) that compared the efficacy of F-TCC versus RCW, focusing on the time to ulcer healing in adult persons (18+ years) with NPFUs and type 1 or type 2 diabetes. We meta-analysed the mean differences and associated 95% CIs using an inverse variance, random-effects model. We also conducted a trial sequential analysis (TSA) to assess if the available evidence is up to the required information size for a robust conclusion. We assessed and quantified statistical heterogeneity between the included studies using the I² statistic.

RESULTS

Out of 102 retrieved citations, five RCTs met the eligibility criteria. Participants' inclusion in relation to stage of ulcer was highly variable as was peripheral neuropathy complicating comparisons. F-TCC appeared to present a shorter ulcer healing time (-5.42 days, 95% CI -9.66 days to -1.17 days; I² 9.9%; 5 RCTs; 169 participants) compared with RCW. This finding was supported by the TSA.

CONCLUSIONS

There is limited evidence from RCTs to suggest that F-TCC has a shorter ulcer healing time compared with RCW among adults with diabetic NPFUs. Properly designed and conducted RCTs are still required for a stronger evidence base.

Implementing High-Quality Primary Care Through a Health Equity Lens

The COVID-19 pandemic highlighted the importance of centering health equity in future health system and primary care reforms. Strengthening primary care will be needed to correct the longstanding history of mistreatment of First Nations/Indigenous and racialized people, exclusion of health care workers of color, and health care access and outcome inequities further magnified by the COVID-19 pandemic. The National Academies of Sciences, Engineering, and Medicine (NASEM) released a report on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, that provided a framework for defining high-quality primary care and proposed 5 recommendations for implementing that definition. Using the report's framework, we identified health equity challenges and opportunities with examples from primary care systems in the United States and Canada. We are poised to reinvigorate primary care because the recent pandemic and the attention to continued racialized police violence sparked renewed conversations and collaborations around equity, diversity, inclusion, and health equity that have been long overdue. The time to transition those conversations to actionable items to improve the health of patients, families, and communities is now.Appeared as Annals "Online First" article.

Effectiveness of T cell-mediated rejection therapy: A systematic review and meta-analysis

The effectiveness of T cell-mediated rejection (TCMR) therapy for achieving histological remission remains undefined in patients on modern immunosuppression. We systematically identified, critically appraised, and summarized the incidence and histological outcomes after TCMR treatment in patients on tacrolimus (Tac) and mycophenolic acid (MPA). English-language publications were searched in MEDLINE (Ovid), Embase (Ovid), Cochrane Central (Ovid), CINAHL (EBSCO), and Clinicaltrials.gov (NLM) up to January 2021. Study quality was assessed with the National Institutes of Health Study Quality Tool. We pooled results using an inverse variance, random-effects model and report the binomial proportions with associated 95% confidence intervals (95% CI). Statistical heterogeneity was explored using the I²  statistic. From 2875 screened citations, we included 12 studies (1255 participants). Fifty-eight percent were good/high quality while the rest were moderate quality. Thirty-nine percent of patients (95% CI 0.26-0.53, I² 77%) had persistent ≥Banff Borderline TCMR 2-9 months after anti-rejection therapy. Pulse steroids and augmented maintenance immunosuppression were mainstays of therapy, but considerable practice heterogeneity was present. A high proportion of biopsy-proven rejection exists after treatment emphasizing the importance of histology to characterize remission. Anti-rejection therapy is foundational to transplant management but well-designed clinical trials in patients on Tac/MPA immunosuppression are lacking to define the optimal therapeutic approach.

The Number Needed to Vaccinate (NNV) against herpes zoster: a systematic review with meta-analysis

OBJECTIVES

The number needed to vaccinate (NNV) quantifies the effectiveness of vaccination programs. We summarised the published data on NNV against herpes zoster to inform vaccination policies.

METHODS

We systematically identified studies based on a priori established and registered methods. The main outcomes were the NNV against herpes zoster infection, hospitalisation and mortality. Where appropriate, we conducted meta-analyses using inverse variance, random-effects models, pooling estimated NNV with associated 95% confidence interval (CI). Statistical heterogeneity between pooled estimates was calculated using the I² statistic.

RESULTS

Out of 229 unique citations, we included eight nonrandomized studies. Among 50+ year-olds, the NNV against herpes zoster infection using the recombinant subunit vaccine was 11 (95%CI 8-14; I² = 0%; 3 studies) and variable (I² = 94.4%; 7 studies) using live attenuated vaccine, ranging from 10 (95%CI 1-19) to 58 (95%CI 49-67). Among 65+ year-olds, the NNV against herpes zoster infection using the recombinant subunit vaccine was 12 (95%CI: 9-15; I² = 0%; 2 studies) and variable (I² = 98.5%; 4 studies) using live attenuated vaccine, ranging from 14 (95%CI 5-23) to 75 (95%CI 66-84). The NNV against herpes zoster hospitalisation among 65+ year-olds using the live attenuated vaccine was 280 (95%CI 209-352; I² = 0%; 2 studies). There was a paucity of data to inform other meta-analyses.

CONCLUSION

Evidence on the NNV against herpes zoster is scarce. Vaccination with the recombinant subunit herpes zoster vaccine may be more effective than with the live attenuated vaccine in preventing infection among 50+ year-olds. More studies are needed for a stronger evidence base for decision-making.

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

OBJECTIVES

To summarise the current evidence regarding interventions for accurate and timely cancer diagnosis among symptomatic individuals.

DESIGN

A scoping review following the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SOURCES

MEDLINE (Ovid), CINAHL (EBSCOhost) and PsycINFO (Ovid) bibliographic databases, and websites of relevant organisations. Published and unpublished literature (grey literature) of any study type in the English language were searched for from January 2017 to January 2021.

ELIGIBILITY AND CRITERIA

Study participants were individuals of any age presenting at clinics with symptoms indicative of cancer. Interventions included practice guidelines, care pathways or other initiatives focused on achieving predefined benchmarks or targets for wait times, streamlined or rapid cancer diagnostic services, multidisciplinary teams and patient navigation strategies. Outcomes included accuracy and timeliness of cancer diagnosis.

DATA EXTRACTION AND SYNTHESIS

We summarised findings graphically and descriptively.

RESULTS

From 21 298 retrieved citations, 88 unique published articles and 16 unique unpublished documents (on 18 study reports), met the eligibility for inclusion. About half of the published literature and 83% of the unpublished literature were from the UK. Most of the studies were on interventions in patients with lung cancer. Rapid referral pathways and technology for supporting and streamlining the cancer diagnosis process were the most studied interventions. Interventions were mostly complex and organisation-specific. Common themes among the studies that concluded intervention was effective were multidisciplinary collaboration and the use of a nurse navigator.

CONCLUSIONS

Multidisciplinary cooperation and involvement of a nurse navigator may be unique features to consider when designing, delivering and evaluating interventions focused on improving accurate and timely cancer diagnosis among symptomatic individuals. Future research should examine the effectiveness of the interventions identified through this review.

Antiviral drugs for coronavirus disease 2019 (COVID-19): a systematic review with network meta-analysis

Background

To better inform clinical practice, we summarized the findings from randomized controlled trials (RCTs) of antivirals for COVID-19.

Methods

We systematically searched for literature up to September 2020, and included English-language publications of RCTs among hospitalized COVID-19 patients. We conducted network meta-analysis combining results of both the direct and indirect comparisons of interventions. The efficacy outcomes were clinical progression, all-cause mortality, and viral clearance, and safety outcomes were diarrhea, nausea, and vomiting. We generated treatment rankings (best to worst) and summarized rank probabilities using rankogram.

Results

We included 15 RCTs (14,418 patients) from 7,237 retrieved citations. There was no evidence for efficacy of the assessed antivirals compared with placebo/no treatment or with another antiviral for all efficacy outcomes. Lopinavir (400 mg)/ritonavir (100 mg) significantly increased diarrhea, nausea, and vomiting compared with placebo/no treatment and other antivirals, and was ranked worst for these outcomes, while triazavirin (250 mg), baloxavir marboxil (80 mg), and remdesivir (100 mg – 10 days) ranked best, respectively.

Conclusions and relevance

The available evidence does not support the use of any antiviral drugs for COVID-19. Cautious interpretations of the findings are, however, advised considering the paucity of the evidence. More RCTs are needed for a stronger evidence base.

Interventions on health care providers to improve seasonal influenza vaccination rates among patients: a systematic review and meta-analysis of the evidence since 2000

BACKGROUND

Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV.

OBJECTIVE

To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates.

METHODS

We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model.

RESULTS

We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions.

CONCLUSIONS

Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients.

Efficacy and safety of clinically managed weight loss programs: a systematic review and meta-analysis protocol

BACKGROUND

Obesity has become a major driver in the burden of chronic diseases. The Canadian Clinical Practice Guidelines recommend a lifestyle intervention for the management and prevention of obesity. This includes behavior modification, dietary counseling, and physical activity. With the market overwhelmed with weight loss programs, the majority are focused on low-calorie diets and general recommendations for exercise. Most are not personalized and are not administered by healthcare professionals. An interdisciplinary team of highly trained healthcare professionals has the ability to provide medically sound and safe advice in all aspects of an individuals' life, such as lifestyle, sleep, mental health, and behaviors. A clinically managed weight loss program is defined as a team including a dietitian, exercise professional, psychologist, and/or physician or nurse practitioner oversight. With limiting results in the literature regarding clinically managed weight loss programs, it is difficult to conclude whether it may be effective. Therefore, the objective of this systematic review is to assess clinically managed weight loss programs, with a physician or nurse practitioner oversight in comparison with non-clinically managed weight loss programs with no physician oversight or nurse practitioner oversight in adults who are living with overweight or obesity.

METHODS

A literature search will be executed by a knowledge synthesis librarian on MEDLINE, Cochrane Central, Embase, PsycINFO, and CINAHL. The data collected will be extracted, stored, and managed in MS Excel 2016. The extraction of the data will include study details, study population details, health team details, intervention details, and outcome details.

DISCUSSION

The prevalence of obesity has been increasing throughout the decades. The results from this systematic review may aid in recommending a more clinically safe weight loss program for those who struggle with overweight or obesity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020170014.

Remdesivir for coronavirus disease 2019 (COVID-19): a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials

Background

In view of many unanswered clinical questions regarding treatment of COVID-19 with remdesivir, we systematically identified, critically appraised and summarized the findings from randomized controlled trials (RCTs) of remdesivir for COVID-19.

Methods

We searched relevant databases/websites (up to September 2020) and selected English-language RCT publications of remdesivir for COVID-19. We conducted meta-analysis using an inverse variance, random-effects model in addition to trial sequential analysis (TSA) for the efficacy outcomes: all-cause mortality, viral burden and clinical progression. Safety outcomes were diarrhoea, nausea, and vomiting. We calculated the relative risk (RR) and 95% confidence interval (CI) for all outcomes. Statistical heterogeneity was calculated using the I² statistic.

Results

We included five RCTs (7540 participants) from 7237 citations. Most (80%) were of an unclear to high risk of bias. There was no evidence of a significant improvement with remdesivir (100 mg, 10 days) regarding all-cause mortality (RR 0.94, CI 0.82–1.07; I² = 0%; 4 RCTs; 7143 patients), clinical progression (RR 1.08, CI 0.99–1.18; I² = 70.4%; 3 RCTs; 1692 patients), or diarrhoea (RR 0.82, CI 0.40–1.66; I² = 0%; 2 RCTs; 630 patients). Nausea occurred more often with remdesivir (RR 2.77, CI 1.28–6.03; I² = 0%; 2 RCTs; 630 patients). TSA showed that the required information size was not reached for firm conclusions to be drawn.

Conclusions and relevance

There is insufficient evidence to support the use of remdesivir for treatment of COVID-19. More high-quality RCTs are needed for a stronger evidence. Until then, remdesivir should remain an experimental drug for COVID-19.

Interim seasonal influenza vaccine effectiveness estimates as proxy for final estimates: analysis of systematically identified matched pairs of interim/final estimates from test-negative design studies in outpatient settings from 2010/11 to 2018/19

OBJECTIVES

Limited time for seasonal influenza vaccine development means that the World Health Organization has to consider interim (early) rather than final vaccine effectiveness (VE) estimates in deciding influenza vaccine composition. We assessed agreement between interim and final VE estimates, and factors that may determine a substantial difference (≥10%) between point estimates.

METHODS

This was a mixed methods study. We systematically searched, identified, and matched interim/final VE studies of test-negative design (TND) type in outpatient settings after the 2009/10 influenza pandemic. The chi-square statistic (χ2) was used to assess the statistical significance of the difference between paired interim/final VE estimates. We calculated the difference between point estimates and used multivariable logistic regression to assess factors that may determine a substantial difference.

RESULTS

We identified 68 interim/final VE pairs. There was no statistically significant difference between almost all compared pairs. An inconsistent statistical model for interim/final VE estimation and interim VE estimation before the epidemic peak increased the odds of having a substantial difference between estimates.

CONCLUSION

: Interim influenza VE appears to be sufficient for vaccine composition decision-making. Consistency in interim/final VE estimation, and interim VE estimation during/after epidemic peak may increase agreement between the VE estimates.

Decline in Seasonal Influenza Vaccine Effectiveness With Vaccination Program Maturation: A Systematic Review and Meta-analysis

BACKGROUND

Evidence suggests that repeated influenza vaccination may reduce vaccine effectiveness (VE). Using influenza vaccination program maturation (PM; number of years since program inception) as a proxy for population-level repeated vaccination, we assessed the impact on pooled adjusted end-season VE estimates from outpatient test-negative design studies.

METHODS

We systematically searched and selected full-text publications from January 2011 to February 2020 (PROSPERO: CRD42017064595). We obtained influenza vaccination program inception year for each country and calculated PM as the difference between the year of deployment and year of program inception. We categorized PM into halves (cut at the median), tertiles, and quartiles and calculated pooled VE using an inverse-variance random-effects model. The primary outcome was pooled VE against all influenza.

RESULTS

We included 72 articles from 11 931 citations. Across the 3 categorizations of PM, a lower pooled VE against all influenza for all patients was observed with PM. Substantially higher reductions were observed in older adults (≥65 years). We observed similar results for A(H1N1)pdm09, A(H3N2), and influenza B.

CONCLUSIONS

The evidence suggests that influenza VE declines with vaccination PM. This study forms the basis for further discussions and examinations of the potential impact of vaccination PM on seasonal VE.

Sociodemographic and health-related determinants of seasonal influenza vaccination in pregnancy: A systematic review and meta-analysis of the evidence since 2000

INTRODUCTION

Vaccination is considered to be the most practical and effective preventative measure against influenza. It is highly recommended for population subgroups most at risk of developing complications, including pregnant women. However, seasonal influenza vaccine uptake remains suboptimal among pregnant women, even in jurisdictions with universal vaccination. We summarized the evidence on the determinants of seasonal influenza vaccine uptake during pregnancy to better understand factors that influence vaccine uptake among pregnant women.

MATERIAL AND METHODS

We systematically searched MEDLINE, Embase and CINAHL from January 2000 to February 2020 for publications in English reporting on sociodemographic and/or health-related determinants of seasonal influenza vaccine uptake during pregnancy. Two reviewers independently included studies. One reviewer extracted data and assessed study quality, and another reviewer checked extracted data and study quality assessments for errors. Disagreements were resolved through consensus, or a third reviewer. We meta-analyzed using the inverse variance, random-effects method, and reported the odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

From 1663 retrieved citations, we included 36 studies. The following factors were associated with increased seasonal influenza vaccine uptake: Older age (20 studies: OR 1.13, 95% CI 1.07-1.20), being nulliparous (13 studies: OR 1.26, 95% CI 1.15-1.38), married (8 studies: OR 1.11, 95% CI 1.07-1.15), employed (4 studies: OR 1.13, 95% CI 1.02-1.24), a non-smoker (8 studies: OR 1.25, 95% CI 1.04-1.51) and having prenatal care (3 studies: OR 3.36, 95% CI 2.25-5.02), a chronic condition (6 studies: OR 1.30, 95% CI 1.17-1.44), been previously vaccinated (9 studies: OR 4.88, 95% CI 3.14-7.57) and living in a rural area (9 studies: OR 1.09, 95% CI 1.05-1.14). Compared with being black, being white was also associated with increased seasonal influenza vaccine uptake (11 studies: OR 1.30, 95% CI 1.20-1.41).

CONCLUSIONS

The evidence suggests that several sociodemographic and health-related factors may determine seasonal influenza vaccination in pregnancy, and that parity, history of influenza vaccination, prenatal care and comorbidity status may be influential.

Variable seasonal influenza vaccine effectiveness across geographical regions, age groups and levels of vaccine antigenic similarity with circulating virus strains: A systematic review and meta-analysis of the evidence from test-negative design studies after the 2009/10 influenza pandemic

BACKGROUND

We examined the influence of some factors on seasonal influenza vaccine effectiveness (VE) from test-negative design (TND) studies.

METHODS

We systematically searched for full-text publications of VE against laboratory-confirmed influenza from TND studies in outpatient settings after the 2009/10 influenza pandemic. Two reviewers independently selected and extracted data from the included studies. We calculated pooled adjusted VE across geographical regions, age groups and levels of vaccine antigenic similarity with circulating virus strains, using an inverse variance, random-effects model.

RESULTS

We included 76 full-text articles from 11,931 citations. VE estimates against A(H1N1)pdm09, A(H3N2), influenza B, and all influenza were homogenous and point pooled VE higher in the Southern hemisphere compared with the Northern hemisphere. The difference in pooled VE between the Southern and Northern hemispheres was statistically significant for A(H3N2), influenza B, and all influenza. A consistent pattern was observed in pooled VE across both hemispheres and continents, with the highest point pooled VE being against A(H1N1)pdm09, followed by influenza B, and lowest against A(H3N2). A nearly consistent pattern was observed in pooled VE across age groups in the Northern hemisphere, with pooled VE mostly decreasing with age. Point pooled VE against A(H3N2), influenza B, and all influenza were statistically significantly higher when vaccine was antigenically similar to circulating virus strains compared with when antigenically dissimilar. Similar pattern was observed in the Northern hemisphere, but there was a lack of data from the Southern hemisphere.

CONCLUSION

Consistent patterns appear to exist in seasonal influenza VE across regions, age groups, and levels of vaccine antigenic similarity with circulating virus strains, with best vaccine performance against A(H1N1)pdm09 and worst against A(H3N2). The evidence highlights the need to consider geographical location, age, and vaccine antigenic similarity with circulating virus strains when designing and evaluating influenza VE studies.

Integration of geriatric assessment into clinical oncology practice: A scoping review

Sixty percent of newly diagnosed cancers occur in older adults and more complex planning is required to sustain quality care for older populations. Individualized care incorporating geriatric assessment can predict early mortality and treatment toxicity for older cancer patients. We mapped and summarized the available evidence on the integration of geriatric assessment into clinical oncology practice, and ascertained which domains have been implemented. We systematically searched bibliographic databases and trial registries for reports of clinical studies, clinical practice guidelines, systematic and non-systematic reviews, and grey literature published in English. We gathered data on study characteristics, geriatric domains and strategies evaluated, and relevant study objectives and findings. From a total of 10,124 identified citations, 38 articles met our eligibility criteria, 3 of which were clinical practice guidelines. Nearly half of these articles came from the United States. Domains of the geriatric assessment implemented in studies ranged from 1 to 12, with varied combinations. We identified 27 studies on strategies for implementing geriatric assessment and 24 studies on feasibility of implementing geriatric assessment, into clinical oncology practice. We also identified 3 main geriatric assessment models: 2 from the United States and 1 from Australia. Furthermore, we identified 2 reviews that reported varied components of geriatric assessment models. There is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with only 1 guideline (American Society of Clinical Oncology guideline) settling on a specific best practice. Protocol registration: Open Science Framework osf.io/mec93.

Seasonal influenza vaccination among cancer patients: A systematic review and meta-analysis of the determinants

Cancer patients are among high-risk individuals for whom seasonal influenza vaccine (SIV) is recommended, but rates of vaccination in this subpopulation remain suboptimal; even in jurisdictions with universal influenza vaccination programs. We sought to summarize the evidence to better understand the determinants of SIV uptake (vaccine receipt) among cancer patients. We searched MEDLINE, Embase, and CINAHL from 2000 to February 12, 2020, focusing on articles on the determinants of seasonal influenza vaccination among cancer patients, published in English. Study selection was conducted independently by 2 reviewers. One reviewer extracted data from the included studies and another reviewer checked the extracted data for errors. Outcomes were sociodemographic and health-related factors. We pooled adjusted results from studies using the inverse variance, random-effects method, and reported the odds ratios (OR) and their 95% confidence intervals (CI). Out of 2664 citations, 10 studies (mostly from USA and South Korea) met our eligibility criteria. Overall, being older (OR 2.23, 95% CI 1.46-3.38; I² 92.3%, [6 studies]), a nonsmoker (1.43, 1.32-1.51; I² 0%, [4 studies]), having a chronic illness (1.18, 1.07-1.29; I² 15.7%, [5 studies]), having had a medical check-up in the past year (1.75, 1.65-1.86; I² 0%, [2 studies]), and having health insurance (1.39, 1.13-1.72; I² 21.8%, [3 studies]) were associated with increased SIV uptake. Compared with being African-American, being Caucasian was also associated with increased SIV uptake (1.79, 1.47-2.13; I² 10.7%, [3 studies]). Limited evidence suggests seasonal influenza vaccination among cancer patients may be determined by some sociodemographic and health-related factors.

Variations in Seasonal Influenza Vaccine Effectiveness due to Study Characteristics: A Systematic Review and Meta-analysis of Test-Negative Design Studies

BACKGROUND

Study characteristics influence vaccine effectiveness (VE) estimation. We examined the influence of some of these on seasonal influenza VE estimates from test-negative design (TND) studies.

METHODS

We systematically searched bibliographic databases and websites for full-text publications of TND studies on VE against laboratory-confirmed seasonal influenza in outpatients after the 2009 pandemic influenza. We followed the Cochrane Handbook for Systematic Reviews of Interventions guidelines. We examined influence of source of vaccination information, respiratory specimen swab time, and covariate adjustment on VE. We calculated pooled adjusted VE against H1N1 and H3N2 influenza subtypes, influenza B, and all influenza using an inverse-variance random-effects model.

RESULTS

We included 70 full-text articles. Pooled VE against H1N1 and H3N2 influenza subtypes, influenza B, and all influenza was higher for studies that used self-reported vaccination than for those that used medical records. Pooled VE was higher with respiratory specimen collection within ≤7 days vs ≤4 days of symptom onset, but the opposite was observed for H1N1. Pooled VE was higher for studies that adjusted for age but not for medical conditions compared with those that adjusted for both. There was, however, a lack of statistical significance in almost all differences in pooled VE between compared groups.

CONCLUSIONS

The available evidence is not strong enough to conclude that influenza VE from TND studies varies by source of vaccination information, respiratory specimen swab time, or adjustment for age/medical conditions. The evidence is, however, indicative that these factors ought to be considered while designing or evaluating TND studies of influenza VE.

Directly Acting Oral Anticoagulants for the Prevention of Stroke in Atrial Fibrillation in England and Wales: Cost-Effectiveness Model and Value of Information Analysis

Objectives. Determine the optimal, licensed, first-line anticoagulant for prevention of ischemic stroke in patients with non-valvular atrial fibrillation (AF) in England and Wales from the UK National Health Service (NHS) perspective and estimate value to decision making of further research. Methods. We developed a cost-effectiveness model to compare warfarin (international normalized ratio target range 2-3) with directly acting (or non-vitamin K antagonist) oral anticoagulants (DOACs) apixaban 5 mg, dabigatran 150 mg, edoxaban 60 mg, and rivaroxaban 20 mg, over 30 years post treatment initiation. In addition to death, the 17-state Markov model included the events stroke, bleed, myocardial infarction, and intracranial hemorrhage. Input parameters were informed by systematic literature reviews and network meta-analysis. Expected value of perfect information (EVPI) and expected value of partial perfect information (EVPPI) were estimated to provide an upper bound on value of further research. Results. At willingness-to-pay threshold £20,000, all DOACs have positive expected incremental net benefit compared to warfarin, suggesting they are likely cost-effective. Apixaban has highest expected incremental net benefit (£7533), followed by dabigatran (£6365), rivaroxaban (£5279), and edoxaban (£5212). There was considerable uncertainty as to the optimal DOAC, with the probability apixaban has highest net benefit only 60%. Total estimated population EVPI was £17.94 million (17.85 million, 18.03 million), with relative effect between apixaban versus dabigatran making the largest contribution with EVPPI of £7.95 million (7.66 million, 8.24 million). Conclusions. At willingness-to-pay threshold £20,000, all DOACs have higher expected net benefit than warfarin but there is considerable uncertainty between the DOACs. Apixaban had the highest expected net benefit and greatest probability of having highest net benefit, but there is considerable uncertainty between DOACs. A head-to-head apixaban versus dabigatran trial may be of value.

Determinants of Seasonal Influenza Vaccine Uptake Among the Elderly in the United States: A Systematic Review and Meta-Analysis

Background: Despite the availability of a universal influenza vaccination program in the United States and Canada, seasonal influenza vaccine (SIV) uptake among the elderly remains suboptimal. Understanding the factors that determine SIV uptake in this important population subgroup is essential for designing effective interventions to improve seasonal influenza vaccination among the elderly. We evaluated the determinants of SIV uptake in the elderly in the United States and Canada. Methods: We systematically searched relevant bibliographic databases and websites from 2000 to 2017 for population-based clinical trials or observational studies conducted in community-based elderly individuals in the United States or Canada, irrespective of health status. Two reviewers independently screened the identified citations for eligibility using a two-stage sifting approach to review the title/abstract and full-text article. We gathered data on determinants of uptake (any vaccine receipt) and adherence (receipt of vaccine in more than one season) to seasonal influenza vaccination. Where possible, we pooled the data using inverse variance methods to minimize the variance of the weighted average. Results: Five cross-sectional studies on SIV uptake (none on adherence) from the United States met our eligibility criteria. Being older (pooled odds ratio [POR] = 1.44, 95% Confidence Interval [CI] = 1.11, 1.86); White (POR = 1.33, 95% CI = [1.10, 1.64]); and having higher income (POR = 1.06, 95% CI = [1.04, 1.09]); and health insurance (POR = 1.40, 95% CI = [1.25, 1.55]) were associated with increased SIV uptake. Conclusion: Older, ethnically White, higher income elderly individuals with access to health insurance coverage and a regular health care provider have higher SIV uptake in the United States. There was limited evidence for other socioeconomic and health-related determinants. Further studies are needed to provide an evidence base for planning more effective influenza vaccination programs in the United States.

Publication of Randomized Clinical Trials in Pediatric Research: A Follow-up Study

IMPORTANCE

Nonpublication of research results in considerable research waste and compromises medical evidence and the safety of interventions in child health.

OBJECTIVE

To replicate, compare, and contrast the findings of a study conducted 15 years ago to determine the impact of ethical, editorial, and legislative mandates to register and publish findings.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, abstracts accepted to the Pediatric Academic Societies (PAS) meetings from May 2008 to May 2011 were screened in duplicate to identify phase 3 randomized clinical trials enrolling pediatric populations. Subsequent publication was ascertained through a search of electronic databases in 2017. Study internal validity was measured using the Cochrane Risk of Bias Tool, the Jadad scale, and allocation concealment, and key variables (eg, trial design and study stage) were extracted. Associations between variables and publication status, time to publication, and publication bias were examined.

MAIN OUTCOMES AND MEASURES

Publication rate, trial registration rate, study quality, and risk of bias.

RESULTS

A total of 177 787 abstracts were indexed in the PAS database. Of these, 3132 were clinical trials, and 129 met eligibility criteria. Of these, 93 (72.1%; 95% CI, 53.8%-79.1%) were published. Compared with the previous analysis, the current analysis showed that fewer studies remained unpublished (183 of 447 [40.9%] vs 36 of 129 [27.9%], respectively; odds ratio [OR], 0.56; 95% CI, 0.36-0.86; P = .008). Fifty-one of 129 abstracts (39.5%) were never registered. Abstracts with larger sample sizes (OR, 1.92; 95% CI, 1.15-3.18; P = .01) and those registered in ClinicalTrials.gov (OR, 13.54; 95% CI, 4.78-38.46; P < .001) were more likely to be published. There were no differences in quality measures, risk of bias, or preference for positive results (OR, 1.60; 95% CI, 0.58-4.38; P = .34) between published and unpublished studies. Mean (SE) time to publication following study presentation was 26.48 (1.97) months and did not differ between studies with significant and nonsignificant findings (25.61 vs 26.86 months; P = .93). Asymmetric distribution in the funnel plot (Egger regression, -2.77; P = .04) suggests reduced but ongoing publication bias among published studies. Overall, we observed a reduction in publication bias and in preference for positive findings and an increase in study size and publication rates over time.

CONCLUSIONS AND RELEVANCE

These results suggest a promising trend toward a reduction in publication bias and nonpublication rates over time and positive impacts of trial registration. Further efforts are needed to ensure the entirety of evidence can be accessed when assessing treatment effectiveness.

Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Warfarin is effective for stroke prevention in atrial fibrillation (AF), but anticoagulation is underused in clinical care. The risk of venous thromboembolic disease during hospitalisation can be reduced by low-molecular-weight heparin (LMWH): warfarin is the most frequently prescribed anticoagulant for treatment and secondary prevention of venous thromboembolism (VTE). Warfarin-related bleeding is a major reason for hospitalisation for adverse drug effects. Warfarin is cheap but therapeutic monitoring increases treatment costs. Novel oral anticoagulants (NOACs) have more rapid onset and offset of action than warfarin, and more predictable dosing requirements.

OBJECTIVE

To determine the best oral anticoagulant/s for prevention of stroke in AF and for primary prevention, treatment and secondary prevention of VTE.

DESIGN

Four systematic reviews, network meta-analyses (NMAs) and cost-effectiveness analyses (CEAs) of randomised controlled trials.

SETTING

Hospital (VTE primary prevention and acute treatment) and primary care/anticoagulation clinics (AF and VTE secondary prevention).

PARTICIPANTS

Patients eligible for anticoagulation with warfarin (stroke prevention in AF, acute treatment or secondary prevention of VTE) or LMWH (primary prevention of VTE).

INTERVENTIONS

NOACs, warfarin and LMWH, together with other interventions (antiplatelet therapy, placebo) evaluated in the evidence network.

MAIN OUTCOME MEASURES

Efficacy Stroke, symptomatic VTE, symptomatic deep-vein thrombosis and symptomatic pulmonary embolism. Safety Major bleeding, clinically relevant bleeding and intracranial haemorrhage. We also considered myocardial infarction and all-cause mortality and evaluated cost-effectiveness.

DATA SOURCES

MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library, reference lists of published NMAs and trial registries. We searched MEDLINE and PREMEDLINE In-Process & Other Non-Indexed Citations, EMBASE and The Cochrane Library. The stroke prevention in AF review search was run on the 12 March 2014 and updated on 15 September 2014, and covered the period 2010 to September 2014. The search for the three reviews in VTE was run on the 19 March 2014, updated on 15 September 2014, and covered the period 2008 to September 2014.

REVIEW METHODS

Two reviewers screened search results, extracted and checked data, and assessed risk of bias. For each outcome we conducted standard meta-analysis and NMA. We evaluated cost-effectiveness using discrete-time Markov models.

RESULTS

Apixaban (Eliquis^®, Bristol-Myers Squibb, USA; Pfizer, USA) [5 mg bd (twice daily)] was ranked as among the best interventions for stroke prevention in AF, and had the highest expected net benefit. Edoxaban (Lixiana^®, Daiichi Sankyo, Japan) [60 mg od (once daily)] was ranked second for major bleeding and all-cause mortality. Neither the clinical effectiveness analysis nor the CEA provided strong evidence that NOACs should replace postoperative LMWH in primary prevention of VTE. For acute treatment and secondary prevention of VTE, we found little evidence that NOACs offer an efficacy advantage over warfarin, but the risk of bleeding complications was lower for some NOACs than for warfarin. For a willingness-to-pay threshold of > £5000, apixaban (5 mg bd) had the highest expected net benefit for acute treatment of VTE. Aspirin or no pharmacotherapy were likely to be the most cost-effective interventions for secondary prevention of VTE: our results suggest that it is not cost-effective to prescribe NOACs or warfarin for this indication.

CONCLUSIONS

NOACs have advantages over warfarin in patients with AF, but we found no strong evidence that they should replace warfarin or LMWH in primary prevention, treatment or secondary prevention of VTE.

LIMITATIONS

These relate mainly to shortfalls in the primary data: in particular, there were no head-to-head comparisons between different NOAC drugs.

FUTURE WORK

Calculating the expected value of sample information to clarify whether or not it would be justifiable to fund one or more head-to-head trials.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013005324, CRD42013005331 and CRD42013005330.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis

Objective To compare the efficacy, safety, and cost effectiveness of direct acting oral anticoagulants (DOACs) for patients with atrial fibrillation.Design Systematic review, network meta-analysis, and cost effectiveness analysis. Data sources Medline, PreMedline, Embase, and The Cochrane Library.Eligibility criteria for selecting studies Published randomised trials evaluating the use of a DOAC, vitamin K antagonist, or antiplatelet drug for prevention of stroke in patients with atrial fibrillation.Results 23 randomised trials involving 94 656 patients were analysed: 13 compared a DOAC with warfarin dosed to achieve a target INR of 2.0-3.0. Apixaban 5 mg twice daily (odds ratio 0.79, 95% confidence interval 0.66 to 0.94), dabigatran 150 mg twice daily (0.65, 0.52 to 0.81), edoxaban 60 mg once daily (0.86, 0.74 to 1.01), and rivaroxaban 20 mg once daily (0.88, 0.74 to 1.03) reduced the risk of stroke or systemic embolism compared with warfarin. The risk of stroke or systemic embolism was higher with edoxaban 60 mg once daily (1.33, 1.02 to 1.75) and rivaroxaban 20 mg once daily (1.35, 1.03 to 1.78) than with dabigatran 150 mg twice daily. The risk of all-cause mortality was lower with all DOACs than with warfarin. Apixaban 5 mg twice daily (0.71, 0.61 to 0.81), dabigatran 110 mg twice daily (0.80, 0.69 to 0.93), edoxaban 30 mg once daily (0.46, 0.40 to 0.54), and edoxaban 60 mg once daily (0.78, 0.69 to 0.90) reduced the risk of major bleeding compared with warfarin. The risk of major bleeding was higher with dabigatran 150 mg twice daily than apixaban 5 mg twice daily (1.33, 1.09 to 1.62), rivaroxaban 20 mg twice daily than apixaban 5 mg twice daily (1.45, 1.19 to 1.78), and rivaroxaban 20 mg twice daily than edoxaban 60 mg once daily (1.31, 1.07 to 1.59). The risk of intracranial bleeding was substantially lower for most DOACs compared with warfarin, whereas the risk of gastrointestinal bleeding was higher with some DOACs than warfarin. Apixaban 5 mg twice daily was ranked the highest for most outcomes, and was cost effective compared with warfarin.Conclusions The network meta-analysis informs the choice of DOACs for prevention of stroke in patients with atrial fibrillation. Several DOACs are of net benefit compared with warfarin. A trial directly comparing DOACs would overcome the need for indirect comparisons to be made through network meta-analysis.Systematic review registration PROSPERO CRD 42013005324.

Association Between Telomere Length and Risk of Cancer and Non-Neoplastic Diseases: A Mendelian Randomization Study

IMPORTANCE

The causal direction and magnitude of the association between telomere length and incidence of cancer and non-neoplastic diseases is uncertain owing to the susceptibility of observational studies to confounding and reverse causation.

OBJECTIVE

To conduct a Mendelian randomization study, using germline genetic variants as instrumental variables, to appraise the causal relevance of telomere length for risk of cancer and non-neoplastic diseases.

DATA SOURCES

Genomewide association studies (GWAS) published up to January 15, 2015.

STUDY SELECTION

GWAS of noncommunicable diseases that assayed germline genetic variation and did not select cohort or control participants on the basis of preexisting diseases. Of 163 GWAS of noncommunicable diseases identified, summary data from 103 were available.

DATA EXTRACTION AND SYNTHESIS

Summary association statistics for single nucleotide polymorphisms (SNPs) that are strongly associated with telomere length in the general population.

MAIN OUTCOMES AND MEASURES

Odds ratios (ORs) and 95% confidence intervals (CIs) for disease per standard deviation (SD) higher telomere length due to germline genetic variation.

RESULTS

Summary data were available for 35 cancers and 48 non-neoplastic diseases, corresponding to 420 081 cases (median cases, 2526 per disease) and 1 093 105 controls (median, 6789 per disease). Increased telomere length due to germline genetic variation was generally associated with increased risk for site-specific cancers. The strongest associations (ORs [95% CIs] per 1-SD change in genetically increased telomere length) were observed for glioma, 5.27 (3.15-8.81); serous low-malignant-potential ovarian cancer, 4.35 (2.39-7.94); lung adenocarcinoma, 3.19 (2.40-4.22); neuroblastoma, 2.98 (1.92-4.62); bladder cancer, 2.19 (1.32-3.66); melanoma, 1.87 (1.55-2.26); testicular cancer, 1.76 (1.02-3.04); kidney cancer, 1.55 (1.08-2.23); and endometrial cancer, 1.31 (1.07-1.61). Associations were stronger for rarer cancers and at tissue sites with lower rates of stem cell division. There was generally little evidence of association between genetically increased telomere length and risk of psychiatric, autoimmune, inflammatory, diabetic, and other non-neoplastic diseases, except for coronary heart disease (OR, 0.78 [95% CI, 0.67-0.90]), abdominal aortic aneurysm (OR, 0.63 [95% CI, 0.49-0.81]), celiac disease (OR, 0.42 [95% CI, 0.28-0.61]) and interstitial lung disease (OR, 0.09 [95% CI, 0.05-0.15]).

CONCLUSIONS AND RELEVANCE

It is likely that longer telomeres increase risk for several cancers but reduce risk for some non-neoplastic diseases, including cardiovascular diseases.

Use of neuraminidase inhibitors for rapid containment of influenza: a systematic review and meta-analysis of individual and household transmission studies

OBJECTIVES

To assess the effectiveness of neuraminidase inhibitors for use in rapid containment of influenza.

METHOD

We conducted a systematic review and meta-analysis in accordance with the PRISMA statement. Healthcare databases and sources of grey literature were searched up to 2012 and records screened against protocol eligibility criteria. Data extraction and risk of bias assessments were performed using a piloted form. Results were synthesised narratively and we undertook meta-analyses to calculate pooled estimates of effect, statistical heterogeneity and assessed publication bias.

FINDINGS

Nine randomised controlled trials (RCTs) and eight observational studies met the inclusion criteria. Neuraminidase inhibitors provided 67 to 89% protection for individuals following prophylaxis. Meta-analysis of individual protection showed a significantly lower pooled odds of laboratory confirmed seasonal or influenza A(H1N1)pdm09 infection following oseltamivir usage compared to placebo or no therapy (n = 8 studies; odds ratio (OR) = 0.11; 95% confidence interval (CI) = 0.06 to 0.20; p<0.001; I2 = 58.7%). This result was comparable to the pooled odds ratio for individual protection with zanamivir (OR = 0.23; 95% CI 0.16 to 0.35). Similar point estimates were obtained with widely overlapping 95% CIs for household protection with oseltamivir or zanamivir. We found no studies of neuraminidase inhibitors to prevent population-wide community transmission of influenza.

CONCLUSION

Oseltamivir and zanamivir are effective for prophylaxis of individuals and households irrespective of treatment of the index case. There are no data which directly support an effect on wider community transmission.

PROTOCOL REGISTRY

PROSPERO registration number: CRD42013003880.