Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Accurate assessments of current and future fertility-including overall trends and changing population age structures across countries and regions-are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.

METHODS

To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.

FINDINGS

During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.

INTERPRETATION

Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Emerging pharmacotherapy for the treatment of cannabis use disorder

INTRODUCTION

About one-fifth of cannabis users, the most commonly used illicit substance, have cannabis use disorder (CUD). Psychiatric disorders and suicide are more common in these patients, and the disability-adjusted life years were reported to be 0.69 million. Pharmacotherapy for CUD is an unmet public health need, as current evidence-based therapies have limited efficacy.

AREAS COVERED

After explaining the pathophysiology of CUD, the effects of emerging pharmacological interventions in its treatment obtained from randomized controlled trials were reviewed in light of mechanisms of action. Superiority over control of cannabidiol, gabapentin, galantamine, nabilone plus zolpidem, nabiximols, naltrexone, PF-04457845, quetiapine, varenicline, and topiramate were observed through the cannabinoid, glutamatergic, γ-aminobutyric acidergic, serotonergic, noradrenergic, dopaminergic, opioidergic, and cholinergic systems. All medications were reported to be safe and tolerable.

EXPERT OPINION

Adding pharmacotherapy to psychotherapy is the optimal treatment for CUD on a case-by-case basis. Drug development to add to psychotherapy is the main path, but time and cost suggest repurposing and repositioning existing drugs. Considering sample size, follow-up, and effect size, further studies using objective tools are necessary. The future of CUD treatment is promising.

The effect of psychedelics on the level of brain-derived neurotrophic factor: A systematic review and meta-analysis

BACKGROUND

Recent interest in the potential therapeutic effects of psychedelics has led to investigations into their influence on molecular signaling pathways within the brain.

AIMS

Integrated review and analysis of different studies in this field.

METHODS

A systematic search was conducted across international databases including Embase, Scopus, Web of Science, and PubMed from inception to 9 July 2023. Eligibility criteria encompassed published and peer-reviewed studies evaluating changes in brain-derived neurotrophic factor (BDNF) levels after psychedelic consumption.

OUTCOMES

A total of nine studies were included in our study. The meta-analysis demonstrated significantly higher BDNF levels in psychedelic consumers compared to healthy controls, with a pooled standardized mean difference of 0.26 (95% CI: 0.10-0.42, I2 = 38.51%, p < 0.001). Leave-one-out analysis indicated robustness in results upon removal of individual psychedelics. No significant publication bias was observed. The results highlight the potential influence of psychedelics on neuroplasticity by altering BDNF levels.

CONCLUSIONS

More precisely, the documented rise in BDNF levels indicates a neurobiological mechanism by which psychedelics could enhance synaptic plasticity and foster the growth of neurons. Given the limited data available on this topic, the conclusions remain uncertain. Consequently, we highly recommend additional research with more extensive sample sizes to yield more reliable evidence in this field.

Sex-controlled differences in sertraline and citalopram efficacies in major depressive disorder: a randomized, double-blind trial

To investigate the response to antidepressants while controlling for sex, which has been controversial, 92 outpatient males and females with major depressive disorder were assigned to sertraline (100 mg/day) or citalopram (40 mg/day) in two strata and were assessed using Hamilton depression rating scale (HDRS) scores and brain-derived neurotrophic factor (BDNF), interleukin (IL)-6 and cortisol serum levels in this 8-week, randomized, parallel-group, double-blind clinical trial. Data of 40 sertraline and 40 citalopram recipients with equal representation of males and females assigned to each medication were analyzed, while their baseline characteristics were not statistically different (P > 0.05). There were no significant differences between sertraline and citalopram recipients in outcome changes (P > 0.05), all of which indicated improvement, but a significant time-treatment-sex interaction effect in BDNF levels was observed (P = 0.035). Regarding this, subgroup analyses illustrated a significantly greater increase in male BDNF levels following sertraline treatment (P = 0.020) with a moderate to large effect size (Cohen's d = 0.76 and ). Significant associations were observed between percentage changes in IL-6 levels and BDNF levels in sertraline recipients (P = 0.033) and HDRS scores in citalopram recipients (P < 0.001). Sex was an effect modifier in BDNF alterations following sertraline and citalopram administration. Further large-scale, high-quality, long-term studies are recommended.

Segmental artery angioembolization as an efficient treatment modality for delayed hematuria with normal angiography: two case reports

BACKGROUND

Percutaneous nephrolithotomy is the most commonly used modality for the removal of kidney stones larger than 2 cm in size. Like other stone removal methods, percutaneous nephrolithotomy also has some complications, including bleeding and delayed hematuria. These complications are improved with conservative management and bed rest most of the time. However, it may require more invasive treatments. Angioembolization following an abnormal renal angiography is an efficient treatment modality for delayed hematuria. Furthermore, nephrectomy is suggested in uncontrolled cases of delayed hematuria when renal angiography is normal.

CASE PRESENTATION

We described two cases of uncontrolled delayed hematuria after percutaneous nephrolithotomy and angioembolization were carried out rather than potential nephrectomies. The first case was a 61-year-old Iranian man with left kidney stones, for whom percutaneous nephrolithotomy was planned. The patient was referred to the hospital after discharge with massive hematuria and had normal angiographic findings. An angioembolization was suggested for the patient and was carried out. His hematuria was dramatically improved within 30 minutes, and his hemoglobin level started to increase 2 days later. The second case was a 53-year-old Iranian man with kidney stones who was a candidate for right kidney percutaneous nephrolithotomy. The patient was referred to the hospital 4 days after discharge with a decreased hemoglobin level and massive hematuria. The patient had normal angiographic findings and was planned for angioembolization to control his hemorrhage, which dramatically decreased after the angioembolization within 60 minutes.

CONCLUSION

Embolization of the segmental arteries of the targeted calyx can eliminate hematuria of the patient and prevent further nephrectomy.

Current evidence regarding alternative techniques for enterocystoplasty using regenerative medicine methods: a systematic review

Enterocystoplasty is the most commonly used treatment for bladder reconstruction. However, it has some major complications. In this study, we systematically reviewed the alternative techniques for enterocystoplasty using different scaffolds. A comprehensive search was conducted in PubMed, Embase, and Cochrane Library, and a total of 10 studies were included in this study. Five different scaffolds were evaluated, including small intestinal submucosa (SIS), biodegradable scaffolds seeded with autologous bladder muscle and urothelial cells, dura mater, human cadaveric bladder acellular matrix graft, and bovine pericardium. The overall results revealed that bladder reconstruction using regenerative medicine is an excellent alternative method to enterocystoplasty regarding the improvement of bladder capacity, bladder compliance, and maximum detrusor pressure; however, more large-scale studies are required.

Emerging drugs for the treatment of irritability associated with autism spectrum disorder

INTRODUCTION

Autism spectrum disorder (ASD) is an early-onset disorder with a prevalence of 1% among children and reported disability-adjusted life years of 4.31 million. Irritability is a challenging behavior associated with ASD, for which medication development has lagged. More specifically, pharmacotherapy effectiveness may be limited against high adverse effects (considering side effect profiles and patient medication sensitivity); thus, the possible benefits of pharmacological interventions must be balanced against potential adverse events in each patient.

AREAS COVERED

After reviewing the neuropathophysiology of ASD-associated irritability, the benefits and tolerability of emerging medications in its treatment based on randomized controlled trials were detailed in light of mechanisms and targets of action.

EXPERT OPINION

Succeeding risperidone and aripiprazole, monotherapy with memantine may be beneficial. In addition, N-acetylcysteine, galantamine, sulforaphane, celecoxib, palmitoylethanolamide, pentoxifylline, simvastatin, minocycline, amantadine, pregnenolone, prednisolone, riluzole, propentofylline, pioglitazone, and topiramate, all adjunct to risperidone, and clonidine and methylphenidate outperformed placebo. These effects were through glutamatergic, γ-aminobutyric acidergic, inflammatory, oxidative, cholinergic, dopaminergic, and serotonergic systems. All medications were reported to be safe and tolerable. Considering sample size, follow-up, and effect size, further studies are necessary. Along with drug development, repositioning and combining existing drugs supported by the mechanism of action is recommended.

Role of long non-coding RNAs in cholangiocarcinoma: A systematic review and meta-analysis

BACKGROUND

Cholangiocarcinoma (CCA), as a rare malignancy of the biliary tree, has a poor prognosis most of the time. CCA is highly epigenetically regulated and several long non-coding RNAs (lncRNA) have been investigated to have a diagnostic and prognostic role in CCA. The current study aimed to assess the studies finding relevant lncRNAs in CCA systematically.

METHODS

International databases, including PubMed, Cochrane Library, and Embase, were comprehensively searched in order to identify studies investigating any lncRNA in CCA. After screening by title/abstract and full-text, necessary data were extracted. Random-effect meta-analysis was performed for pooling the areas under the curve (AUCs), specificity, and sensitivity of lncRNAs for the diagnosis of CCA.

RESULTS

A total of 33 studies were chosen to be included in the final analysis, comprised of 2677 patients. Meta-analysis of AUCs for evaluation of CCA resulted in pooled AUC of 0.79 (95% CI: 0.75-0.82; I2 = 69.11, p < .01). Additionally, overall sensitivity of 0.80 (95% CI 0.75-0.84) and specificity of 0.77 (95% CI: 0.68-0.84) were observed. Measurement of lncRANs in the assessment of CCA also improved overall survival significantly (effect size 1.61, 95% CI: 1.39-1.82). A similar result was found for progression-free survival (effect size 1.57, 95% CI: 1.20-1.93).

CONCLUSION

Based on our findings, lncRNAs showed promising results as biomarkers in the diagnosis of CCA since they had acceptable sensitivity and specificity, in addition to the fact that improved survival in this poor prognosis cancer. Further studies might be needed to address this issue and find the best clinically useful lncRNA.

Anosmia or Ageusia Following COVID-19 Vaccination: A Systematic Review

Aim: To systematically review the cases of anosmia or ageusia after receiving the coronavirus disease 2019 (COVID-19) vaccine. Methods: A systematic search was conducted in electronic databases, including Web of Science, Scopus, Embase, and PubMed, to identify any published study that evaluated the anosmia or ageusia after receiving the COVID-19 vaccine, including case reports, case series, letter to editor articles with reported cases regarding our topic, or observational studies with at least 1 eligible patient consisted with our criteria. We excluded the studies that reported anosmia or ageusia due to COVID-19 infection and non-COVID-19 vaccines. Results: Five studies consisting of 11 patients were included in this systematic review. Of the 11 patients, 5 patients had received the Pfizer COVID-19 vaccine and 6 patients received the Oxford-AstraZeneca COVID-19 vaccine, of which 6 patients developed symptoms after the first dose of vaccination and 5 patients were symptomatic after the second vaccine dose. Most of the patients developed symptoms within 1 week after the vaccination. The disorders of the patients included partial or total anosmia, parosmia, phantosmia, hyposmia, ageusia, and dysgeusia. Also, the patients had symptoms other than smell or taste disorders, including arthralgia, fever, chills, rhinorrhea, myalgia, abdominal pain, fatigue, muscle weakness, altered bowel pattern, aural fullness, tinnitus, and headache. Most of the evaluated patients did not receive any treatment as for their disorders. However, in some cases, treatment with oral corticosteroids or dietary supplementation was required. Conclusion: Anosmia and ageusia are important symptoms of COVID-19 vaccination. These symptoms will resolve without any treatment in most cases, although some interventions may be needed in some patients.

Brain-derived neurotrophic factor (BDNF) as a potential marker of endometriosis: a systematic review and meta-analysis

BACKGROUND

The existing literature on the association between BDNF protein levels and endometriosis presents inconsistent findings. This systematic review and meta-analysis aim to synthesize the available evidence and evaluate the possible relationship between BDNF protein levels and endometriosis.

METHODS

Electronic databases (PubMed, Embase, Scopus, PsycINFO, and Web of Science) were used to conduct a comprehensive literature search from inception to June 2023. The search strategy included relevant keywords and medical subject headings (MeSH) terms related to BDNF, endometriosis, and protein levels. A random-effects model was used for the meta-analysis, and to explore heterogeneity subgroup analyses were performed. funnel plots and statistical tests were used for assessing the publication bias.

RESULTS

A total of 12 studies were included. The pooled standardized mean difference (SMD) of BDNF levels between women with endometriosis and controls was 0.87 (95% confidence interval [CI] 0.34 to 1.39, p = 0.001; I2 = 93%). The results showed that blood levels of BDNF are significantly higher in endometriosis patients (SMD: 1.13 95% CI 0.54 to 1.73, p = 0.0002; I2 = 93%). No significant publication bias was observed based on the results of Egger's regression test ((p = 0.15).

CONCLUSION

This study revealed a significant difference between patients diagnosed with endometriosis and healthy control in the level of BDNF. The results indicate that women with endometriosis have higher levels of BDNF. Further studies are needed to be undertaken to investigate the role of BDNF in endometriosis pathophysiology and the diagnostic value of BDNF in endometriosis.

Brain-derived neurotrophic factor levels in perinatal depression: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aim to synthesize the available evidence and determine the overall brain-derived neurotrophic factor (BDNF) levels in individuals diagnosed with perinatal depression (PND).

METHODS

We performed a thorough search of electronic databases, including PubMed, Embase, PsycINFO, and Web of Science, from their start until April 30, 2023. Our search strategy involved using specific keywords and medical subject headings (MeSH) terms related to BDNF, perinatal, post-partum, and antepartum depression. In the meta-analysis, we employed a random-effects model, and subgroup analyses were conducted to investigate any variations in the results.

RESULTS

A total of 15 studies met the inclusion criteria, of which 10 were used in the quantitative analysis. The meta-analysis demonstrated a significant decrease in BDNF levels in both individuals with antepartum depression (SMD: -0.31; 95% CI: -0.48 to -0.13; p-value = 0.0008; I2  = 71%), and post-partum depression (SMD: -0.61; 95% CI: -0.99 to -0.22; p-value = 0.0002 I2  = 77%). Furthermore, a significantly higher rate of PND among individuals in the lowest BDNF quartile (OR: 2.64; 95% CI: 1.01 to 6.89; p-value = 0.05; I2  = 90%) was seen. The results of subgroup analyses showed a statistically significant effect of the depression assessment tool on overall heterogeneity between studies.

CONCLUSION

This systematic review and meta-analysis provide evidence of lower BDNF protein levels in individuals diagnosed with PND. The results indicate that BDNF dysregulation may play a part in the development of PND. More research is needed to understand the mechanisms behind this and explore potential therapeutic applications.

Hamstring Injury Treatments and Management in Athletes: A Systematic Review of the Current Literature

BACKGROUND

The field of sports medicine presents a varied landscape of research on hamstring injuries in athletes, characterized by inconclusive and sometimes conflicting findings on effective treatment and rehabilitation strategies. This discordance prompted the current systematic investigation.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for conducting the systematic review. Multiple international bibliometric databases (Scopus, PubMed, Web of Science, and Embase) were searched to identify studies evaluating any treatment option for the management of hamstring injuries in athletes. Eligible studies were appraised for quality using Joanna Briggs Institute and Risk of Bias 2 tools.

RESULTS

A total of 30 studies with 1,195 participants were included. Of the reviewed studies, treatments varied from aggressive rehabilitation, platelet-rich plasma (PRP) injections, manual techniques, various exercise protocols to modalities like high-power laser and nonsteroidal anti-inflammatory drugs. Evidence suggested benefits from treatments like extensive muscle lengthening during eccentric actions, progressive agility, and trunk stabilization. PRP injections produced mixed results regarding return to sport and reinjury rates. Stretching exercises, sometimes combined with cryotherapy, showed benefits.

CONCLUSION

Treatments for hamstring injuries exhibit varied efficacy. Although rest, ice, compression, and elevation remains essential for acute management, rehabilitation focusing on muscle strengthening and flexibility is crucial. The potential benefits of PRP injections, especially for chronic cases, require more conclusive research. A comprehensive approach, combining evidence-based practices and patient-centric factors, is vital for effective management and recovery.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Frailty as a predictor of adverse outcomes in burn patients: a systematic review

BACKGROUND

The identification of new prognostic tools for the prediction of burn patients' morbidity outcomes is necessary. Considering the feasibility of frailty assessment in the clinical setting, we aim to systematically review the literature on the associations between frailty and adverse outcomes in burn patients.

METHODS

Studies were retrieved from MEDLINE (through PubMed), Web of Science, Scopus, and Embase from their inception up to 8 September 2022. Included studies were those that used frailty indices to predict adverse outcomes in burn patients. The quality assessment was done using the National, Heart, Lung, and Blood Institute (NHLBI) checklist. The results were synthesized narratively.

RESULTS

We included 18 studies. The sample size among the included studies varied between 42-1615 patients. There were 12 research articles and 6 conference abstracts. Most of the studies were recently published in 2021 and 2022. Seven different frailty measures were evaluated. The following frailty measures were used: Canadian Study for Health and Ageing (CSHA) Clinical Frailty score (CFS), Modified frailty index-11 (mFI-11), Hospital frailty index, FRAIL scale, Emergency General Surgery Frailty Index (EGSFI), and Burn frailty index (BFI). There was only one report regarding a specific frailty index designed for the burn population (BFI). Except for one study (which used mFI-11), all included studies have shown a significant effect between assessing frailty and predicting worse outcomes. The CFS was an independent predictor of mortality among the burn population with high certainty of evidence. We found a significant association for other frailty indices as a predictor of mortality, however, the certainty of evidence regarding those was not high. Eight studies found a positive association between assessing frailty and unfavorable discharge location. There was no association between frailty and increased length of stay.

CONCLUSION

In conclusion, the postadmission assessment of frailty can be a reliable tool for predicting unfavorable outcomes and mortalities among patients with burn injuries. In addition, future studies with various populations from other countries are required to evaluate the efficacy of frailty indices measurement in order to strengthen the available evidence.

Effect of alcohol on Brain-Derived Neurotrophic Factor (BDNF) blood levels: a systematic review and meta-analysis

Brain-Derived Neurotrophic Factor (BDNF) is a vital protein involved in neuronal development, survival, and plasticity. Alcohol consumption has been implicated in various neurocognitive deficits and neurodegenerative disorders. However, the impact of alcohol on BDNF blood levels remains unclear. This systematic review and meta-analysis aimed to investigate the effect of alcohol consumption on BDNF blood levels. A comprehensive search of electronic databases was conducted to identify relevant studies. Eligible studies were selected based on predefined inclusion criteria. Data extraction was performed, and methodological quality was assessed using appropriate tools. A meta-analysis was conducted to estimate the overall effect size of alcohol consumption on BDNF levels. A total of 25 studies met the inclusion criteria and were included in the final analysis. Alcohol use and BDNF blood levels were significantly correlated, according to the meta-analysis (p = 0.008). Overall, it was discovered that drinking alcohol significantly decreased BDNF levels (SMD: - 0.39; 95% CI: - 0.68 to - 0.10; I2: 93%). There was a non-significant trend suggesting that alcohol withdrawal might increase BDNF levels, with an SMD of 0.26 (95% CI: - 0.09 to 0.62; I2: 86%; p = 0.14). Subgroup analysis based on the source of BDNF demonstrated significant differences between the subgroups (p = 0.0008). No significant publication bias was observed. This study showed that alcohol consumption is associated with a significant decrease in BDNF blood levels. The findings suggest a negative impact of alcohol on BDNF levels regardless of alcohol dosage. Further studies are needed to strengthen the evidence and elucidate the underlying mechanisms.

Is skin autofluorescence a novel non-invasive marker in diabetes? A systematic review and meta-analysis of case-control studies

Background

The advanced glycation end product (AGE) is produced from the nonenzymatic reaction between glucose and macromolecules by aging. Accumulation of AGE causes functional and structural changes in body proteins that lead to impairment of tissue protein functions. We aimed to validate AGE measurement by skin autofluorescence (SAF) in diabetes mellitus (DM) compared to the nondiabetes population.

Materials and Methods

We searched the PubMed, Cochrane, and Scopus databases from their inception till September 18, 2022, for casecontrol studies measuring AGE by SAF. Nonhuman studies, as well as review articles, study proposals, editorials, case reports, or congress posters, were excluded. We used a random effects model to assess the standard mean difference (MD) of age, body mass index (BMI), HbA1c, and SAF between diabetes and nondiabetes individuals.

Results

Higher SAF in DM patients indicated more accumulation of AGE compared with the nondiabetic population. Furthermore, HbA1c was considerably higher in DM patients. The MD of age, male gender, and BMI were significantly different between the DM individuals, compared with nondiabetic subjects, which can lead to altered SAF level and AGE production. There was a remarkable heterogeneity between diabetes and nondiabetes when measuring age, gender, and BMI, as well as HbA1c and SAF level.

Conclusion

This study could not confirm the validity of SAF as a surrogate marker in diabetes patients. Interestingly, metabolic load and high BMI can increase SAF, considerably. Altogether, SAF could be helpful in the future as a marker for metabolic syndrome or diabetes.

Pain management following septorhinoplasty surgery: evidence from a systematic review

PURPOSE

We investigated recent evidence on the analgesics available for postoperative pain management among patients undergoing septoplasty or rhinoplasty surgery.

METHODS

Studies were retrieved from MEDLINE (through PubMed), Web of Science, and Embase up to 3 August 2022.

RESULTS

Forty-seven studies including 3717 patients were included. There were 45 randomized clinical trials and 2 observational cohort studies. Most of the studies were recently published and conducted in Turkey (n = 27). The majority of the studies performed the intervention preoperatively (n = 26), 11 studies postoperatively, 6 studies intraoperative, 2 studies preoperative plus intraoperative, and 2 studies performed the intervention with preoperative plus postoperative timing. The most evaluated medication was lidocaine (n = 10), followed by levobupivacaine (n = 4), and gabapentin (n = 4). Regarding post-operative pain assessment, the most used scale was the visual analog scale (VAS) (n = 36). Compared to controls, almost all interventions showed a significant benefit in managing post-operative pain. Although it should be mentioned regarding the comparison between opioids and NSAIDs consumption after surgery for pain management, most studies did not show a significant difference between the groups. No major side effects except nausea and vomiting were observed among the reviewed studies.

CONCLUSION

This study summarized the most recent options that are available to manage pain following septorhinoplasty surgery. Recent investigations showed local interventions vs pre/post-operative analgesic medications are highly suggested to be replaced with opioids and NSAIDs as they have shown prominent efficacy with no significant adverse events. Future research is advised to determine the best dosage and administration techniques.

Frailty among patients undergoing breast reconstruction surgery: A systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the predictive value of frailty for predicting postsurgical complications in patients undergoing breast reconstruction surgery.

METHODS

MEDLINE (PubMed), Scopus, Web of Science, and Embase were searched for relevant studies up to September 13, 2022. A systematic review and meta-analysis of studies were performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement criteria.

RESULTS

Nine studies were included in this research. The rates of overall complications (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.17-1.97, I2 = 76%; p = 0.002), wound complications (OR 1.87, 95% CI 1.56-2.26, I2 = 16%; p < 0.0001), readmissions (OR 1.94, 95% CI 1.61-2.34, I2 = 15%; p < 0.0001), and reoperations (OR 1.41, 95% CI 1.12-1.77, I2 = 39%; p = 0.003) were significantly greater in frail patients than in nonfrail undergoing breast reconstruction surgery. Furthermore, compared with nonfrail patients, this difference remained significantly higher among prefrail individuals (overall complications: OR 1.27, 95% CI 1.13-1.41, I2 = 67%; p < 0.001, wound complications: OR 1.48, 95% CI 1.33-1.66, I2 = 24%; p < 0.0001, readmission: OR 1.47, 95% CI 1.34-1.61, I2 = 0%; p < 0.0001, reoperation: OR 1.32, 95% CI 1.23-1.42, I2 = 0%; p < 0.0001). We found that frail patients undergoing immediate autologous reconstruction surgery are the most vulnerable to experiencing overall postoperative complications.

CONCLUSION

Frailty is a strong predictor of postsurgical complications after breast reconstruction surgery in frail and prefrail patients. The most frailty index utilized was the modified five-item frailty index (mFI-5). More research is needed on this topic to assess the utility of frailty in practice, especially in countries other than the United States.

Herpesviruses reactivation following COVID-19 vaccination: a systematic review and meta-analysis

BACKGROUND

The reactivation of herpesviruses (HHV) in COVID-19 patients is evident in the literature. Several reports have been published regarding the reactivation of these viruses (HSV, VZV, EBV, and CMV) among those who got COVID-19 vaccines. In this study, we aimed to review the current evidence to assess whether HHVs reactivation has any association with the prior administration of COVID-19 vaccines.

METHODS

A systematic search was conducted on 25 September 2022 in PubMed/MEDLINE, Web of Science, and EMBASE. We included all observational studies, case reports, and case series which reported the reactivation of human herpesviruses following administration of COVID-19 vaccines.

RESULTS

Our systematic search showed 80 articles that meet the eligibility criteria. Among the evaluated COVID-19 vaccines, most of the vaccines were mRNA based. Evidence from observational studies showed the possible relation between COVID-19 vaccine administration and VZV and HSV reactivation. The results of our proportion meta-analysis showed that the rate of VZV reactivation among those who received the COVID-19 vaccine was 14 persons per 1000 vaccinations (95% CI 2.97-32.80). Moreover, our meta-analysis for HSV reactivation showed the rate of 16 persons per 1000 vaccinations (95% CI 1.06-46.4). Furthermore, the evidence from case reports/series showed 149 cases of HHV reactivation. There were several vaccines that caused reactivation including BNT162b2 mRNA or Pfizer-BioNTech (n = 76), Oxford-AstraZeneca (n = 22), mRNA-1273 or Moderna (n = 17), Sinovac (n = 4), BBIBP-CorV or Sinopharm (n = 3), Covaxin (n = 3), Covishield (n = 3), and Johnson and Johnson (n = 1). Reactivated HHVs included varicella-zoster virus (VZV) (n = 114), cytomegalovirus (CMV) (n = 15), herpes simplex virus (HSV) (n = 14), Epstein-Barr virus (EBV) (n = 6), and HHV-6 (n = 2). Most cases reported their disease after the first dose of the vaccine. Many patients reported having comorbidities, of which hypertension, diabetes mellitus, dyslipidemia, chicken pox, and atrial fibrillation were common.

CONCLUSION

In conclusion, our study showed the possible association between COVID-19 vaccination and herpesvirus reactivation. The evidence for VZV and HSV was supported by observational studies. However, regarding other herpesviruses (EBV and CMV), further research especially from observational studies and clinical trials is required to elucidate the interaction between COVID-19 vaccination and their reactivation.

Phosphodiesterase 5 (PDE-5) inhibitors (sildenafil, tadalafil, and vardenafil) effects on esophageal motility: a systematic review

BACKGROUND

Esophageal motility disorders are a group of disorders associated with dysfunctional swallowing resulting from impaired neuromuscular coordination. Phosphodiesterase 5 (PDE-5) inhibitors induce smooth relaxation and are proposed as a treatment option for esophageal motility disorders such as achalasia.

METHODS

This study is conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically searched MEDLINE/ PubMed, Scopus, EMBASE, and Web of Science databases for esophageal outcomes of individuals treated with PDE5 inhibitors. A random effect meta-analysis was conducted.

RESULTS

A total of 14 studies were included. They were conducted in different countries, with Korea and Italy having the highest number of articles. The main drug assessed was sildenafil. PDE-5 inhibitors resulted in a significant reduction in lower esophageal sphincter pressure (SMD - 1.69, 95% CI: -2.39 to -0.99) and the amplitude of contractions (SMD - 2.04, 95% CI: -2.97 to -1.11). Residual pressure was not significantly different between the placebo and sildenafil groups (SMD - 0.24, 95% CI: -1.20 to 0.72). Furthermore, a recent study reported contractile integral, stating that ingestion of sildenafil leads to a significant reduction in distal contractile integral and a significant increase in proximal contractile integral.

CONCLUSION

PDE-5 inhibitors significantly reduce LES resting pressure and esophageal peristaltic vigor, decreasing esophageal body contractility and contraction reserve. Therefore, using these drugs in patients affected by esophageal motility disorders may potentially improve their condition regarding symptom relief and prevention of further associated complications. Future reports investigating larger sample size is necessary in order to establish definite evidence regarding the efficacy of these drugs.

Comparison of insulin resistance indices in predicting albuminuria among patients with type 2 diabetes

PURPOSE

Diabetes is the leading cause of kidney disease. Up to 40% of the population with diabetes experience diabetic kidney disease (DKD). The correlation of DKD with insulin resistance (IR) indices has been shown in previous studies. In this study, the objective was to evaluate surrogate IR indices, including the Triglyceride-Glucose (TyG) index, Visceral Adiposity Index (VAI), Lipid Accumulation Product (LAP), and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) to find the most valuable index for the correlation between albuminuria and IR in the type 2 diabetes (T2D) population. Albuminuria is defined as urine albumin excretion of > 30 mg/day.

METHODS

In this cross-sectional study, 2934 participants were enrolled and evaluated for urinary albumin excretion, and albuminuria was detected in 526 of the entries. The logistic regression models and Receiver Operating Characteristic (ROC) curve analysis were performed to assess the relationship of TyG index, VAI, LAP, and HOMA-IR's with albuminuria in patients with T2D.

RESULTS

The TyG index had the highest association (OR 1.67) with the presence of albuminuria in patients with T2D, followed by HOMA-IR (OR 1.127), VAI (OR 1.028), and LAP (OR 1.004). These four indices remained independent after adjustment for multiple confounders. Based on the ROC curve, TyG revealed the best area under the curve (AUC) for revealing albuminuria with sufficient accuracy (AUC: 0.62) in comparison with other measured indices. The calculated TyG index cut-off point for the presence of albuminuria was 9.39.

CONCLUSION

Among the indices, TyG index had the most significant correlation with albuminuria in patients with T2D.

Ultrasound versus fluoroscopy as imaging guidance for percutaneous nephrolithotomy: A systematic review and meta-analysis

OBJECTIVES

To determine whether the outcomes of ultrasound-guided percutaneous nephrolithotomy (UG-PCNL), an alternative to traditional fluoroscopy-guided percutaneous nephrolithotomy (FG-PCNL), are comparable.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library was carried out to discover investigations comparing UG-PCNL to FG-PCNL, and accordingly, a meta-analysis of those studies was performed. The primary outcomes included the stone-free rate (SFR), overall complications based on Clavien-Dindo classification, duration of surgery, duration of patients' hospitalization, and hemoglobin (Hb) drop during the surgery. All statistical analyses and visualizations were implemented utilizing R software.

RESULTS

Nineteen studies, including eight randomized clinical trials (RCTs) and eleven observational cohorts, comprising 3016 patients (1521 UG-PCNL patients) and comparing UG-PCNL with FG-PCNL met the inclusion criteria of the current study. Considering SFR, overall complications, duration of surgery, duration of hospitalization, and Hb drop, our meta-analysis revealed no statistically significant difference between UG-PCNL and FG-PCNL patients, with p-values of 0.29, 0.47, 0.98, 0.28, and 0.42, respectively. Significant differences were discovered between UG-PCNL and FG-PCNL patients in terms of the length of time they were exposed to radiation (p-value< 0.0001). Moreover, FG-PCNL had shorter access time than UG-PCNL (p-value = 0.04).

CONCLUSION

UG-PCNL provides the advantage of requiring less radiation exposure while being just as efficient as FG-PCNL; thus, this study suggests prioritizing the use of UG-PCNL.

Accuracy of airway ultrasound parameters to predict difficult airway using the LEMON criteria as a reference: A cross-sectional diagnostic accuracy study

OBJECTIVES

Ultrasound (US) airway indexes were frequently compared with other scoring systems such as Mallampati score and Cormack - Lehane classification system, but to the best of our knowledge never with LEMON. Here, in this study, we evaluated the accuracy of some recommended airway US parameters in terms of screening difficult airway using the LEMON criteria as a reference.

METHODS

This was a cross-sectional diagnostic accuracy study in which people with at least 18 years old coming to the emergency departments for any reason who had consent for participation, were enrolled with the simple random sampling method. Hyo-mental distance (HMD), skin to epiglottis distance (EP), and peri-epiglottic space to epiglottis to vocal cord ratio (PEP/E. VC) were the US indexes that were calculated in all participants. Using a preprepared checklist, measured US parameters were recorded. For each participant, the LEMON score variables were also assessed and recorded, and the cutoff point for considering as a difficult airway case, based on LEMON score, was 2. Demographic characteristics of the participants were also registered.

RESULTS

A total of 299 cases with a mean age of 41.1 years (95% confidence interval [CI]: 39.3-42.9), were participated. Based on LEMON score ≥2, 20 participants (6.7%) were categorized in difficult airway group. Comparison of the PEP/E. VC (P = 0.007) and EP distance (P = 0.049) of the participants based on LEMON score showed a statistically significant difference; but comparison of the means of HMD in the two groups was not statistically significant (P = 0.144). The median of EP of the participants was 7.70 mm (interquartile range [IQR]: 6.70-9.40). The best cutoff point of EP distance for evaluating a difficult airway was 12.27 mm and more with the sensitivity of 35% and the specificity of 86.96% (accuracy = 0.614; 95% CI: 0.492-0.736). The median of PEP/E. VC was 1.01(IQR: 0.79-1.23). The best cutoff point of PEP/E. VC for evaluating a difficult airway was 0.88 and less with the sensitivity of 70% and the specificity of 67.38% (accuracy = 0.701; 95% CI: 0.583-0.818).

CONCLUSION

As per our results, PEP/E. VC and EP distance measured with sonography can be used in distinguishing the difficult airway, using the LEMON criteria as the reference. However, further studies are needed to use PEP/E. VC and EP distance as a part of reliable indexes.

Diagnostic Performance of Magnetic Resonance Imaging for Detection of Acute Appendicitis in Pregnant Women; a Systematic Review and Meta-Analysis

INTRODUCTION

The diagnosis of acute appendicitis (AA) in pregnant women is commonly challenging owing to the normal results of laboratory tests, organ displacement, and normal physiological inflammatory alterations. This meta-analysis aimed to investigate the accuracy of magnetic resonance imaging (MRI) in diagnosis of AA in pregnant women.

METHODS

Two investigators independently performed a comprehensive systematic literature search of electronic databases including MEDLINE, Cochrane Central, EMBASE, Web of Science, Scopus, and Google Scholar to identify studies that reported accuracy of MRI for diagnosis of AA in pregnant women from inception to April 1, 2022.

RESULTS

Our systematic search identified a total of 525 published papers. Finally, a total of 26 papers were included in the meta-analysis. The pooled sensitivity and specificity of MRI in diagnosis of AA in pregnant women were 0.92 (95% CI: 0.88-0.95) and 0.98 (95% CI 0.97-0.98), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 29.52 (95% CI: 21.90-39.81) and 0.10 (95% CI: 0.04-0.25), respectively. The area under hierarchical summary receiver operating characteristic (HSROC) curve indicated that the accuracy of MRI for diagnosis of AA in pregnant women is 99%.

CONCLUSION

This meta-analysis showed that MRI has high sensitivity, specificity, and accuracy for diagnosis of AA in pregnant women and can be used as a first-line imaging modality for suspected cases of AA during pregnancy. Furthermore, it should be noted that when the result of ultrasonography is inconclusive, the use of MRI can reduce unnecessary appendectomy in pregnant patients.