Certainty Of Evidence Research Articles

A Meta-analysis Exploring the Efficacy of Neuropathic Pain Medication for Low Back Pain or Spine-Related Leg Pain: Is Efficacy Dependent on the Presence of Neuropathic Pain?

Highly variable pain mechanisms in people with low back pain or spine-related leg pain might contribute to inefficacy of neuropathic pain medication. This meta-analysis aimed todetermine how neuropathic pain is identified in clinical trials for people taking neuropathic pain medication for low back pain or spine-related leg pain and whether subgrouping based on the presence of neuropathic pain influences efficacy. EMBASE, MEDLINE,Cochrane Central,CINAHL[EBSCO], APA PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry weresearched from inception to 14 May, 2024.Randomized and crossover trials comparing first-line neuropathic pain medication for people with low back pain or spine-related leg pain to placebo or usual care were included. Two independent authors extracted data. Random-effects meta-analyses of all studies combined, and pre-planned subgroup meta-analyses based on the certainty of neuropathic pain (according to the neuropathic pain Special Interest Group [NeuPSIG] neuropathic pain grading criteria) were completed. Certainty of evidence was judged using the grading of recommendations assessment development and evaluation [GRADE] framework. Twenty-seven included studies reported on 3619 participants. Overall, 33% of studies were judged unlikely to include people with neuropathic pain, 26% remained unclear. Only 41% identified people with possible, probable, or definite neuropathic pain. For pain, general analyses revealed only small effects at short term (mean difference [MD] - 9.30 [95% confidence interval [CI] - 13.71, - 4.88], I2 = 87%) and medium term (MD - 5.49 [95% CI - 7.24, - 3.74], I2 = 0%). Subgrouping at short term revealed studies including people with definite or probable neuropathic pain showed larger effects on pain (definite; MD - 16.65 [95% CI - 35.95, 2.65], I2 = 84%; probable; MD - 10.45 [95% CI - 14.79, - 6.12], I2 = 20%) than studies including people with possible (MD - 5.50 [95% CI - 20.52, 9.52], I2 = 78%), unlikely (MD - 6.67 [95% CI - 10.58, 2.76], I2 = 0%), or unclear neuropathic pain (MD - 8.93 [95% CI - 20.57, 2.71], I2 = 96%). Similarly, general analyses revealed negligible effects on disability at short term (MD - 3.35 [95% CI - 9.00, 2.29], I2 = 93%) and medium term (MD - 4.06 [95% CI - 5.63, - 2.48], I2 = 0%). Sub-grouping at short term revealed larger effects in studies including people with definite/probable neuropathic pain (MD - 9.25 [95% CI - 12.59, - 5.90], I2 = 2%) compared with those with possible/unclear/unlikely neuropathic pain (MD -1.57 [95% CI - 8.96, 5.82] I2 = 95%). Medium-term outcomes showed a similar trend, but were limited by low numbers of studies. Certainty of evidence was low to very low for all outcomes. Most studies using neuropathic pain medication for low back pain or spine-related leg pain fail to adequately consider the presence of neuropathic pain. Meta-analyses suggest neuropathic pain medication may be most effective in people with low back pain or spine-related leg pain with a definite/probable neuropathic pain component. However, the low to very low certainty of evidence and poor identification of neuropathic pain in most studies prevent firm recommendations.

Early high-sensitivity troponin elevation in predicting short-term mortality in sepsis: A protocol for a systematic review with meta-analysis.

Sepsis is a common admission diagnosis in the intensive care unit (ICU). The Sepsis-3 consensus associates sepsis diagnosis with acute organ dysfunction. In these patients troponin elevation is a well-established phenomenon, but its clinical significance is not settled, as no systematic review has addressed the prognostic significance of the increasingly prevalent high-sensitivity troponin assays in acute organ dysfunction setting. This study aims to clarify the association between early serum troponin levels in high-sensitivity assays with short-term mortality risk in septic patients with acute organ dysfunction. We will systematically search PubMed, Scopus and Embase for original articles; additionally, a manual search will be carried out through relevant literature. Generally, studies will be deemed eligible for inclusion if they evaluate the association between high-sensitivity troponin in the first 24 hours of admission and ICU, 30-days, or In-hospital mortality; in patients with septic shock or sepsis related to acute organ dysfunction. Two reviewers will independently select studies and extract the data. A meta-analysis for mortality outcome will be performed for comparative data regarding two effect measures: Odd ratios and Standardized Mean differences. This study will provide further evidence about the role of high-sensitivity troponin assays in predicting mortality in septic patients; potentially helping to guide further research and yielding valuable information for patient assessment. Conclusion about the certainty of evidence will be presented in a ´Summary of findings´ table. PROSPERO registration: (CRD42024468883).

The effect of blended tube feeding compared to conventional formula on clinical outcomes in adults: A systematic review.

To explore the effect of blended tube feeding compared to conventional formulas on nutritional status, quality of life, anthropometry, diarrhoea and tube blockages in adults receiving tube feeding. The protocol was registered (PROSPERO CRD42022372443). Five databases (MEDLINE, EMBASE, CINAHL, Scopus, CENTRAL) were searched from commencement of database to 14th June 2023 to identify studies comparing blended tube feeding to conventional formulas in adults receiving tube feeding. Certainty assessment was conducted using the Cochrane Risk of Bias Tools and the Grading of Recommendations, Assessment, Development and Evaluations framework, and a narrative synthesis of results is provided. From 4227 studies screened, eight were included (total n = 763 patients, 9-215 patients). Three studies were hospital-based and five were home-based with duration from 8 days-8 months. Blended tube feeding and conventional formulas were nutritionally equivalent in only three studies; energy and protein concentration of formulas ranged from 1.7-7.1 kJ/mL and 21-68.5 g/L for the blended tube feeding groups, and 4.2-6.7 kJ/mL and 39-100 g/L for the conventional groups. No studies assessed nutrition status or quality of life using validated measures. Blended tube feeding was associated with a clinically relevant reduction in diarrhoea with a low level of certainty. For remaining outcomes, there were inconclusive findings and an overall very low certainty of evidence for each. The effect of blended tube feeding compared to conventional formulas on all outcomes remains uncertain. Blended tube feeding may reduce the incidence of diarrhoea. Future research using nutritionally equivalent comparisons and validated outcome measures is required.

Marginal Degradation of Universal Adhesive Restorations in NCCLs: A Systematic Review and Meta-analysis

Purpose This systematic review aimed to answer the PICO question: do adhesive protocols used for non-carious cervical lesions (NCCLs) using a universal adhesive system influence marginal degradation, marginal staining, and retention of these restorations? The self-etching adhesive strategy and selective enamel etching were compared with the etch-and-rinse strategy as a control. Materials and Methods The study searched various databases, including PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, Embase, and grey literature, to find randomized clinical trials (RCTs) comparing self-etching (SE) or selective enamel etching (SEE) to the etch and rinse (ER) strategy. The risk of methodological bias was assessed using the Cochrane RoB 2 tool. Data were dichotomized and analyzed using RevMan v 5.3, adopting the Mantel-Haenszel method. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results Twenty RCTs were included in the meta-analysis. Results showed that using universal adhesives with the SE strategy resulted in clinical signs of marginal degradation at 12 months, 24 months, and 36 months of follow-up, and marginal staining at 24 months. The adhesive strategy did not interfere with the retention of restorative material used for NCCLs over 36 months, as assessed based on both the United States Public Health Service (USPHS) and World Dental Federation (FDI) criteria. Conclusion With moderate certainty of evidence, after 24 months of follow-up, the SE strategy results in the detection of clinical signs of marginal degradation and staining. The adhesive strategy adopted did not influence the retention rate of the restorations over 36 months of follow-up.

The effect of prescription and over-the-counter medications on core temperature in adults during heat stress: a systematic review and meta-analysis

Heat stress impacts are an escalating global health concern. Public health bodies such as the World Health Organization (WHO) warn that certain medications impair thermoregulation, with limited supporting evidence. Our aim was to investigate whether medications listed by the WHO increase core temperature responses during heat stress. For this systematic review and meta-analysis, MEDLINE, PubMed, Scopus, CINAHL, Web of Science, and EMBASE were searched up to Jan.30, 2024. Randomised studies exposing humans to exertional and/or passive heat stress that investigated a drug identified by WHO compared to no drug/placebo were eligible. The primary outcome was core temperature (e.g., rectal, oesophageal, aural, tympanic). We assessed risk of bias (Cochrane's Risk of Bias 2) and certainty of evidence (GRADE). The study was pre-registered on PROSPERO (CRD42020170684). Thirty-five studies were included enrolling 353 individuals (16 women; 4.5%). Twenty-seven unique medications were tested. The average age of participants across studies was <30 years, and only one study included a clinical population. Under heat stress, there was moderate quality evidence that drugs with high anticholinergic properties increased core temperature at air temperatures ≥30°C (+0.42°C; 95% CI 0.04, 0.79°C; p=0.03) alongside reduced sweating, although evidence is limited to the drug atropine. Similarly, non-selective beta-blockers (+0.11°C; 95% CI 0.02, 0.19°C; p=0.02), adrenaline (+0.41°C; 95% CI 0.21, 0.61°C) and anti-Parkinson's agents (+0.13°C; 95% CI 0.07, 0.19°C; p=0.02) elevated core temperature. Antidepressants, diuretics, or drugs with weak anticholinergic effects did not alter core temperature responses. Current evidence supports strong anticholinergics, non-selective beta-blockers, adrenaline, and anti-Parkinson's agents impairing thermoregulation during heat stress. No evidence indicated thermoregulation is impacted by other WHO-listed medications. Evidence is predominantly limited to healthy young men, with short heat stress exposures. Studies over longer durations, in women, older adults and those with chronic diseases are required to better inform the pharmaceutical management of patients during hot weather. This study was supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (2021/GNT2009507; Holder: O. Jay).

Efficacy of endoscopic interventions versus surgery for pain management in patients with chronic calcific pancreatitis: a systematic review and meta-analysis.

Chronic calcific pancreatitis (CCP) is a debilitating inflammatory condition characterized by the accumulation of calcific deposits in the pancreatic tissue, leading to chronic abdominal pain and functional insufficiencies. This study aims to systematically review and meta-analyse comparative studies assessing the efficacy of endotherapy versus surgery in managing CCP-related pain. MEDLINE, EMBASE, and Cochrane library (CENTRAL and CDSR), from inception to October 2023, were searched. The inclusion criteria encompassed randomized controlled trials (RCTs) and non-randomized controlled trials (NRS), and cohort studies comparing endoscopic interventions to surgery for pain management in patients with CCP. Pain relief, procedural technical success, and procedural-related complications were the outcomes of interest. Two review authors (CN, KK) independently assessed study eligibility criteria and performed data extraction. Using a random-effects model, pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. The level of certainty of the evidence was assessed using the GRADE approach. Five studies were included. For the outcome of pain relief, a meta-analysis of five studies (3 RCTs and 2 cohort studies) demonstrated a significant therapeutic effect in favour of surgery with an OR of 2.36 (95% CI: 1.12 to 5.00, I2 = 41.70), with moderate level of certainty of evidence. In the analysis of five studies (3 RCTs, 1 NRS and 2 cohort studies), procedural technical success was comparable between the two groups (OR of 3.02, 95% CI: 0.47 to 19.59, I2 = 79.27%) as were adverse events (OR 1.31, 95% CI: 0.47 to 3.70, I2 = 50.93%). In conclusion, this systematic review and meta-analysis suggest that surgery may be more effective in relieving pain in patients with CCP compared to endoscopic interventions. Disease stage may be important to determine the appropriateness of each procedure. PROSPERO (CRD42023476153).

Sleep disturbances in anorexia nervosa.

Sleep is crucial for physical and psychological health, and disturbances are closely linked to psychiatric disorders, making their management essential for improving treatment outcomes and preventing relapse. Although sleep disturbances are implicated in psychopathology of eating disorders, its role in anorexia nervosa (AN) remains unclear. This review aimed to characterise sleep in AN. A systematic search was conducted in four scientific databases, including papers from inception to 25 May 2024. A machine learning algorithm (ASReview) was utilised to screen titles and abstracts for eligibility. Sleep quantity, architecture, and quality were investigated. Meta-analyses were conducted to investigate the difference between patients with AN and healthy controls (HC) in total sleep time (TST), wake after sleep onset (WASO), sleep onset latency (SOL), sleep efficiency, Sleep Stage 1, 2, slow wave sleep, rapid eye movement (REM) sleep and REM latency. Certainty of evidence was assessed using the GRADE approach. Out of 67 potentially eligible papers, 31 were included in this review, with 15 in the meta-analyses. Statistically significant average mean differences were found for TST (-32.1min [95% CI: -50.9, -13.4]), WASO (19.0min [95% CI: -2.4, 40.3]), and sleep efficiency (-4.4% [95% CI: -7.9, -0.9]). Additionally, Sleep stage 1 was significantly increased (2.4% [95%-CI: 0.05, 4.7]), while REM sleep was reduced (-2.1% [95%-CI: -4.2, -0.02]). Subgroup analysis showed that TST and WASO did not improve significantly after weight restoration. Sleep in patients with AN is impaired, with lower TST and sleep efficiency, higher WASO, more time in stage 1 sleep, and less in REM. Weight restoration alone may not improve sleep. While more research is needed, substantial accompanying sleep disturbances in AN justifies addressing these in current treatment practice, also because of the chronic character of AN and importance of sleep for long term (mental) health.

Exploring methodological approaches used in network meta-analysis of psychological interventions: A scoping review.

Psychological interventions are complex in nature and have been shown to benefit various clinical outcomes. Gaining insight into current practices would help identify specific aspects that need improvement to enhance the quality of network meta-analysis (NMA) in this field. This scoping review aimed to explore methodological approaches in the NMA of psychological interventions. We searched PubMed, EMBASE, and Cochrane CENTRAL in September 2023. We included NMAs of psychological interventions of randomized controlled trials that reported clinical outcomes. Three independent researchers assessed the eligibility and extracted relevant data. The findings were presented using descriptive statistics. Of the 1827 articles identified, 187 studies were included. Prior protocol registration was reported in 130 studies (69.5%). Forty-six studies (24.6%) attempted to search for gray literature. Ninety-four studies (50.3%) explicitly assessed transitivity. Nearly three-quarters (143 studies, 76.5%) classified treatment nodes by the type of psychological intervention, while 13 studies (7.0%) did so by lumping different intervention types into more broader intervention classes. Seven studies (3.7%) examined active components of the intervention using component NMA. Only three studies (1.6%) classified interventions based on factors affecting intervention practices, specifically intensity, provider, and delivery platform. Meanwhile, 29 studies (15.5%) explored the influential effects of these factors using meta-regression, subgroup analysis, or sensitivity analysis. The certainty of evidence was assessed in 80 studies (42.8%). The methodological approach in NMAs of psychological interventions should be improved, specifically in classifying psychological interventions into treatment nodes, exploring the effects of intervention-related factors, and assessing the certainty of evidence.

Robotic Versus Laparoscopic Versus Open Surgery for Non-Metastatic Pancreatic Neuroendocrine Tumors (pNETs): A Systematic Review and Network Meta-Analysis.

Background: This systematic review, using pairwise and network meta-analyses, aimed to compare the intraoperative, short-term, and long-term postoperative outcomes of minimally invasive surgery (MIS) and open surgery (OS) for the management of pancreatic neuroendocrine tumors (pNETs). Methods: Studies reporting on the effects of robotic, laparoscopic, and open surgery on pNETs published before November 2023 on PubMed, Scopus, and CENTRAL were analyzed. Results: Thirty-two studies with 5379 patients were included in this review, encompassing 2251 patients undergoing MIS (1334 laparoscopic, 508 robotic, and 409 unspecified MIS) and 3128 patients undergoing OS for pNETs management. Pairwise meta-analysis revealed that the MIS group had a significantly shorter length of hospital stay ((a low certainty of evidence), MD of -4.87 (-6.19 to -3.56)); less intraoperative blood loss ((a low certainty of evidence), MD of -108.47 (-177.47 to -39.47)); and decreased tumor recurrence ((a high certainty of evidence), RR of 0.46, 95% CI (0.33 to 0.63)). Subgroup analysis indicated a higher R0 resection rate and prolonged operative time for laparoscopic surgery than for OS. The network meta-analysis ranked the robotic approach as superior in terms of the length of hospital stay, followed by the laparoscopic and OS arms. Furthermore, it favored both MIS approaches over OS in terms of the R0 resection rate. No significant differences were found in severe postoperative complications, postoperative fistula formation, mortality, readmission, reoperation, or conversion rates. Conclusions: This review supports the safety of MIS for the treatment of pNETs. However, the varying certainty of evidence emphasizes the need for higher-quality studies.

Does sedentary behaviour cause spinal pain in children and adolescents? A systematic review with meta-analysis

ObjectiveTo evaluate whether sedentary behaviour is a risk or prognostic factor for spinal pain in children and adolescents. Specifically, to estimate the (1) direction and strength of the association; (2)...

Association between vitamin D deficiency and otitis media with effusion in children: a systematic review and meta-analysis

Background Vitamin D plays a crucial role in the regulation of inflammation. However, its effect on the development of otitis media effusion (OME), an inflammatory disease of the middle ear without signs of infection, remains largely unknown. Objective To assess the association between vitamin D deficiency and OME in children by systematic review and meta-analysis of the literature. Methods Eligible studies retrieved from PubMed, ProQuest, Embase, Cochrane databases and trial registries published up to 30 October 2022 were included in this review. The risk of bias of the included articles was assessed with the JBI Critical Appraisal Checklist for observational studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation framework. Results We included eight studies (six case-control and two cross-sectional studies) involving 1,114 children, of which four studies were eligible for meta-analysis due to the significant clinical heterogeneity. We found that vitamin D deficiency (defined as vitamin D concentration of 20 ng/mL or less, i.e., ?50 nmol/L) might increase the odds of developing OME by 66.0% (n=514; OR 1.66; 95%CI 1.09 to 2.54; I2=20%), albeit with a very low certainty of evidence. Conclusion There is a very low quality of evidence indicating that vitamin D deficiency is associated with the development of OME in children. Further large, high-quality cohorts and adjusting for confounding factors are warranted to confirm our findings, ideally by exploring the dose-response relationship between vitamin D concentration and the development of OME.

Pharmacological interventions for co-occurring psychopathology in people with borderline personality disorder: secondary analysis of the Cochrane systematic review with meta-analyses.

Medications are commonly used to treat co-occurring psychopathology in persons with borderline personality disorder (BPD). To systematically review and integrate the evidence of medications for treatment of co-occurring psychopathology in people with BPD, and explore the role of comorbidities. Building on the current Cochrane review of medications in BPD, an update literature search was done in March 2024. We followed the methods of this Cochrane review, but scrutinised all identified placebo-controlled trials post hoc for reporting of non BPD-specific ('co-occurring') psychopathology, and explored treatment effects in subgroups of samples with and without defined co-occurring disorders. GRADE ratings were done to assess the evidence certainty. Twenty-two trials were available for quantitative analyses. For antipsychotics, we found very-low-certainty evidence (VLCE) of an effect on depressive symptoms (standardised mean difference (SMD) -0.22, P = 0.04), and low-certainty evidence (LCE) of an effect on psychotic-dissociative symptoms (SMD -0.28, P = 0.007). There was evidence of effects of anticonvulsants on depressive (SMD -0.44, P = 0.02; LCE) and anxious symptoms (SMD -1.11, P < 0.00001; VLCE). For antidepressants, no significant findings were observed (VLCE). Exploratory subgroup analyses indicated a greater effect of antipsychotics in samples including participants with co-occurring substance use disorders on psychotic-dissociative symptoms (P = 0.001). Our findings, based on VLCE and LCE only, do not support the use of pharmacological interventions in people with BPD to target co-occurring psychopathology. Overall, the current evidence does not support differential treatment effects in persons with versus without defined comorbidities. Medications should be used cautiously to target co-occurring psychopathology.

Effect of Probiotics Supplementation on Cortisol Levels: A Systematic Review and Meta-Analysis.

Background: Several randomized controlled trials (RCTs) have shown conflicting results on cortisol levels following probiotic administration in healthy and diseased populations. Previous analyses were inconclusive due to limited studies, and evidence is lacking on how these effects vary by health status; region; therapy duration; medications, and use of single or multiple strains. Methods: In this systematic review and meta-analysis (PROSPERO [CRD42024538539]), we searched PubMed, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, ProQuest, and Web of Science Preprints until 13 August 2024, for RCTs on probiotic administration, either alone or combined, across all age groups and without specific medical condition requirements. We applied random-effects meta-analysis, assessed bias using the Cochrane RoB 2 tool, and evaluated evidence certainty with GRADE. Findings: We screened 1739 records and retrieved 46 RCTs (3516 participants). Probiotics supplementation decreased cortisol levels compared to the control arm [46 RCTs; SMD: -0.45; 95% CI: -0.83; -0.07; I2: 92.5%, low certainty]. Among various subgroups; probiotics supplementation decreased the cortisol levels in the subgroups without concomitant medications [37 RCTs; SMD: -0.30; 95% CI [-0.58; -0.03], I2: 88.7%] with a single probiotic strain [30 RCTs; SMD: -0.33; 95% CI: -0.63; -0.028; I2: 88.8%], in a healthy population [35 RCTs; SMD:-0.3; 95% CI: -0.58; -0.03; I2: 88.7] and in the Asia region [21 RCTs; SMD: -0.83; 95% CI: -1.58; -0.07; I2: 95%]. Interpretation: A low level of evidence suggests probiotics might reduce cortisol levels, but more targeted studies are needed to identify variables affecting the response in specific subgroups.

Envelope Protein in Differential Serodiagnosis of Dengue, Zika, and Chikungunya Viruses: A Systematic Review.

This systematic review was conducted to evaluate the applicability of the envelope (E) protein in the diagnosis of arboviruses. This review was performed in accordance with the PRISMA statement. Five databases were explored (PubMed, Web of Science, Scopus, EMBASE, and IEDB). The inclusion and exclusion criteria were applied to study eligibility. After data extraction, the risk of bias and evidence certainty were evaluated according to QUADAS and GRADE assessments, respectively. Eleven studies were included. A total of 11 studies were included in the review. ELISA was the most frequently utilized technique, with two studies employing it for antigen detection and nine for antibodies. The E protein was used as a whole protein, heterologous protein, and peptides. The diagnostic metrics were enhanced by optimizations on techniques, such as antibody capture, competitors, and nanosensors. Monoclonal antibodies showed improved specificity, including in coinfected samples. Seven studies demonstrated a minimal risk of bias, and the evidence certainty was considered moderate for dengue diagnosis. The E protein was successfully employed in different immunological assays with large-scale strategies, enhancing the applicability potential for differential arboviruses' diagnosis. Furthermore, both the antigen design and the implementation of innovative methodologies will have a substantial impact on the quality of the new tests. The PROSPERO protocol related to this work: CRD42021265243.

Relationship Between Iron Deficiency Anemia and Stunting in Pediatric Populations in Developing Countries: A Systematic Review and Meta-Analysis.

Iron deficiency anemia (IDA) and stunting are prevalent global health issues, particularly in developing countries, where previous studies have suggested a potential relationship between them. This systematic review aims to analyze the relationship between iron deficiency anemia and stunting in pediatric populations in developing countries. Literature searches were conducted on PubMed, EMBASE, Cochrane Library, and EBSCO Host. The primary outcome was the association between IDA and stunting. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) for cohort studies and the Effective Public Health Practice Project (EPHPP) for other observational studies. Meta-analysis was performed with a random-effects model and heterogeneity assessment. A Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment was performed to determine the certainty and importance of the study. Out of 19,095 articles, 15 studies were included in the systematic review, and 4 studies were included in the meta-analysis, encompassing 21,936 subjects aged 0 to 12 years. IDA prevalence ranged from 3.6 to 58.8%, while stunting prevalence varied from 6.6 to 44.5%. Nine articles supported a significant relationship between IDA and stunting, revealing that stunted children had a 1.31-6.785 times higher risk of developing IDA. The odds ratio of children with IDA to be stunted was 2.27 (95% CI = 1.30-3.95). All studies exhibited a moderate risk of bias. GRADE assessment suggested that the evidence's certainty is low but important. The high IDA prevalence in developing countries, including Indonesia, is associated with stunting in children, suggesting a synergistic relationship.

Efficacy and Safety of Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke: A Systematic Review and Meta-analysis

Introduction: Stroke remains a major cause of morbidity and mortality after cardiac surgery. One factor associated with stroke occurrence is postoperative AF (pAF), which predisposes to the formation of atrial thrombus. As most thrombi form in the left atrial appendage (LAA), there is significant interest in LAA as a potential therapeutic target. While guidelines recommend direct oral anticoagulants (DOACs) as the preferred therapy for stroke prevention in patients with AF and a CHA2DS2-VASc score of ≥2, they cannot be administered to all patients who are poor candidates for long-term oral anticoagulation because of the high risk of bleeding, drug compliance and drug tolerance. There are limited data on the efficacy and safety of LAA occlusion (LAAO) during cardiac surgery for stroke prevention. Methods: A comprehensive and relevant search of randomised controlled trials, cohort and case–control studies was conducted. Outcome measures for ischaemic stroke events, all-cause mortality and pAF were extracted and analysed using a random-effects model. Results: Twelve studies were included and 18,982 subjects were analysed. There were 231 ischaemic stroke events in 9,473 patients who received LAAO compared with 371 ischaemic stroke events in 9,509 patients who did not receive LAAO. Concomitant LAAO showed a significant difference in ischaemic event rate (risk ratio [RR] 0.65; [95% CI: 0.55–0.77]; p&lt;0.00001, I2=0%) and all-cause mortality (RR 0.74; 95% CI [0.57–0.97]; p=0.03; I2=68%). For pAF, there was no difference between the two groups (RR 1.08; 95% CI [0.95–1.22]; p=0.24; I2=72). Conclusion: Concomitant LAAO was more effective in preventing ischaemic stroke events and all-cause mortality, with an overall moderate certainty of evidence. However, pAF rates were similar between LAAO and non-LAAO groups.

Anterior quadratus lumborum blocks for postoperative pain treatment following intra-abdominal surgery: A systematic review with meta-analyses and trial sequential analyses.

The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery. We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach. Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias. The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.

Integrated care for children and young people with special health and care needs: a systematic review

ContextThere is a dearth of high-quality evidence on integrated, coordinated and cost-effective care for children with special health and care needs (CSHCN).ObjectiveTo assess the effectiveness of integrated/coordinated care models for...

Effect of serious games over conventional therapy in the rehabilitation of people with multiple sclerosis – a systematic review and meta-analysis

Purpose This meta-analysis aimed to quantify the effect of serious games over conventional therapy on upper-limb activity, balance, gait, fatigue, and cognitive functions in people with multiple sclerosis. Materials and methods Search strategies were developed for PubMed, Embase, Cochrane Library, and Scopus. Studies were selected if participants were adults with multiple sclerosis; the intervention consisted of a virtual reality serious game-based program; the control group received conventional therapy; outcomes included upper limb activity, balance, gait, fatigue, or cognitive functions; and used a randomized controlled trial design. Data were synthesized using a standardized mean difference with a random-effects model. Results From 2532 studies, seventeen trials were selected (n = 740). Overall, serious games programs effect on upper limb activity, gait, verbal memory, verbal fluency and attention seemed neutral. Balance functions appeared to be improved by semi-immersive virtual reality serious games (SMD = 0.48;95%CI = 0.12–0.84;p = 0.01;I2=0%), fatigue by treadmill serious games (SMD = 0.80;95%CI = 0.40–1.20;p < 0.001) and visuo-spatial memory by semi-immersive virtual reality general cognitive serious games (SMD = 0.35;95%CI = 0.04–0.65;p = 0.03;I2=0%). Conclusion This review suggests, with a very-low-to-low certainty of evidence, that while some specific serious games may improve balance, fatigue and visuo-spatial memory, their overall effect on upper limb activity, gait, and other cognitive functions appears neutral.

Effect of HIV on Lung Function and Structure: A Systematic Review and Meta-analysis.

Obstructive lung disease (OLD) pathogenesis includes inhalational (e.g., smoking) and non-inhalational mechanisms (e.g., infections). HIV has been suggested as a novel OLD risk factor. Substantial data have recently emerged about its effects on lung function and structure, especially in low-to-middle-income countries and regarding longitudinal lung function. To assess the association of HIV infection with OLD, impaired gas exchange, and emphysema. In this systematic review and meta-analysis, we searched PubMed, EMBASE, CENTRAL, CDSR, WoS, Scopus, CINAHL, and GIM through April 2023 for controlled and observational studies of people living with and without HIV reporting pulmonary function and/or emphysema. Primary outcomes were OLD by spirometry, gas exchange impairment by diffusing capacity for carbon monoxide, and visual emphysema by computed tomography. We performed random-effects meta-analyses using odds ratios (OR) with 95% confidence intervals (CIs). This study was registered in PROSPERO (CRD42021268498). We included 95 publications pertaining to 43 unique studies. HIV was associated with OLD (OR 1.29; 95% CI 1.02-1.63), impaired gas exchange (OR 2.63; 95% CI 0.96-7.24), emphysema (OR 1.46; 95% CI 1.02-2.09), and faster lung function decline. OLD risk was greatest in Africans with HIV. There were no gas exchange or emphysema data from Africa. Certainty of evidence was low to very low, primarily due to studies' observational design. People living with HIV have increased risk for OLD, gas exchange impairment, faster lung function decline, and emphysema. OLD risk in HIV varies regionally. We recommend both spirometry and DLCO be measured in people living with HIV and respiratory symptoms. Future studies should develop and validate HIV-specific screening and case-finding strategies for chronic lung disease.