Pooled Risk Research Articles

Association between serum TSH concentration and bone mineral density: an umbrella review.

The aim of this study was to summarize the results of previous studies, standardize the data, and present new statistical results in orderto provide physicians with clinically significant outcomes regarding the association between serum TSH concentration and bone mineral density (BMD). To perform this umbrella review, a systematic search was conducted in which major online medical databases, such as PubMed, Web of Science, Embase, Scopus, Cochrane Library, and Google Scholar, were searched for meta-analyses and systematic reviews regarding the effect of TSH on BMD. Furthermore, all primary studies were screened for statistical analysis. The statistical outcomes of the present study were based on the data of 75,898 patients. The pooled risk ratio of any kind of fracture in patients with subclinical hyperthyroidism was estimated to be 1.36 (95% CI: 1.18-1.56; p < 0.001). The SMD for BMD in the distal radius in male patients receiving L-thyroxine suppression therapy was estimated to be -0.61 (95% CI: -1.10-(-0.11); p = 0.02). Furthermore, the pooled risk ratio of any fracture in patients receiving L-thyroxine suppression therapy was estimated to be 1.98 (95% CI: 0.98 - 3.98; p = 0.06). In these patients, the BMD may significantly differ from that in non-treated patients. However, the difference depends on the type of bone. Our data confirmed that subclinical hyperthyroidism has a detrimental effect on bones, causing decreased BMD. Based on the obtained results, the authors suggest that a reduced TSH serum level itself may be an individual factor associated with decreased BMD and, thus, with a greater risk of bone fracture. Nevertheless, it should be noted that the effects of TSH suppression therapy differ between areas of interest for assessing BMD. Furthermore, the results have shown that this issue may, in specific areas, concern not only postmenopausal women but also male patients. These conclusions should contribute to a careful consideration of the application of TSH suppressive therapy in all patients. Particular attention should be given to patients after DTC, while all the advantages and disadvantages of implementing L-thyroxine therapy should be individually considered.

Differential attrition in randomized controlled trials of digital mental health interventions in the workplace: A systematic review and meta-analysis (EMPOWER H2020 project)

IntroductionDigital interventions have been found to be successful in preventing occupational mental health concerns, however, they seem to be affected by attrition bias through high attrition rates and differential attrition. Differential attrition arises when the rates of participant dropouts differ across different treatment conditions and is considered a significant challenge to internal validity.ObjectivesWe aimed at systematically review and meta-analyse differential attrition of digital mental health interventions in the workplace setting.MethodsOn January 2, 2022, we performed a search in the following electronic databases: PubMed, Scopus, and Web of Science Core. We utilized a combination of terms from five distinct areas, namely mental health, intervention, workplace, implementation, and study design. The study encompassed adult employees who took part in a randomized control trial aimed at preventing mental health issues in the workplace through an online intervention. A team of six reviewers collaborated on the study selection process, while two independent researchers conducted the data extraction for the selected studies. We performed a meta-analysis of the log-transformed relative attrition rates of the included studies using a random-effects model with limited maximum-likelihood (REML) estimation to account for the degree of heterogeneity.ResultsA total of 19 studies were included in the meta-analysis. For baseline to post-intervention, the average total attrition was 26.27% (SD = 21.16%, range = 0 – 66.3%) and the random effects model revealed a higher attrition rate in the intervention group compared to the control group, with a pooled risk ratio of 1.05 (95% CI: 1.01 - 1.10, p = .014). For baseline to follow-up measurement the average total attrition was 27.71% (SD = 20.80%, range = 0 – 67.78%), however, in this case the random effects model did not indicate a higher attrition in the intervention group when compared to the control group (pooled risk ratio = 1.05, 95% CI: 0.98 – 1.12, p = .183).ConclusionsThere is an indication of higher attrition in the intervention group as compared to the control group in occupational e-mental health interventions from baseline to post-intervention, however this does not seem to be the case for baseline to follow-up attrition. These results should be taken into account in the design process of studies and statistical analyses should be adapted to counteract the bias that could result from differential attrition.Disclosure of InterestNone Declared

Follicle-Stimulating Hormone and Diabetes in Postmenopausal Women: A Systematic Review and Meta-Analysis.

The co-occurrence of hormonal changes during menopause and the risk of cardio-metabolic disorders has been well studied. We explored the association of circulating levels of follicle-stimulating hormone (FSH) with diabetes (DM) among postmenopausal women. In this systematic review and meta-analysis, the search was performed in PubMed, Scopus, Web of Sciences, Epistemonikos, and Cochrane Library up to September 2023. Risk of bias was assessed by Newcastle-Ottawa Quality Assessment Scale. Pooled estimates of mean differences in FSH levels were compared between postmenopausal women with and without DM. Correlations between FSH and fasting blood glucose (FBG)/insulin/homeostatic model assessment for insulin resistance (HOMA-IR) as well as pooled effect sizes with their 95% CIs for risk of DM were calculated. In this study, 14 articles, including 7878 postmenopausal women, met eligibility criteria. Most of the included studies had a low/moderate risk of bias. Women with DM had significantly lower FSH levels than those without DM (standardized mean difference [SMD] -0.751 [95% CI, -1.129 to -.372], I2 = 82.46%, n = 1416). The pooled effect size for diabetes was 0.861 (95% CI, 0.740-1.001; I2 = 80.11%). The pooled risk estimate for DM based on the categorical FSH levels (high vs low) was (HR = 0.550; 95% CI, 0.356-0.850, I2 = 0). The significant inverse correlation was found between FSH levels and glycemic parameters: FBG (r= -0.285 [95% CI -0.441 to -0.113]; n = 1229), HOMA-IR (r = -0.241[-0.378 to -0.0924]; n = 1229) and insulin (r = -0.337 [-0.434 to -0.232]; n = 959)]. There were no statistically significant differences between estradiol levels among diabetic and nondiabetic groups; however, the SMD for luteinizing hormone was similar to that reported for FSH. The available data indicated an indirect association between FSH levels and glucose disturbances among postmenopausal women, notwithstanding heterogeneity among included studies, and the complexity of various influential factors needs to be considered. Further efforts should be made to clarify the underlying mechanisms.

Comparative Risks of Post-ERCP Adverse Events in Patients with Asymptomatic and Symptomatic Choledocholithiasis: A Systematic Review and Meta-Analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care for the management of choledocholithiasis but carries risk of complications which may result in significant morbidity and mortality. While currently available guidelines endorse the use of ERCP for the management of symptomatic common bile duct stones, the need for ERCP in incidentally found asymptomatic choledocholithiasis is more controversial, and practice varies on a geographic and institutional level. This systematic review and meta-analysis is conducted to compare post-ERCP adverse events between asymptomatic and symptomatic choledocholithiasis patients. We searched PubMed/Embase/Web of Science databases to include all studies comparing post-ERCP outcomes between asymptomatic and symptomatic choledocholithiasis patients. The primary outcome was post-ERCP pancreatitis (PEP), while secondary outcomes included post-ERCP cholangitis, bleeding, and perforation. We calculated pooled risk ratios (RR) and 95% confidence intervals (CIs) using the Mantel-Haenszel method within a random-effect model. Our analysis included six observational studies, totaling 2,178 choledocholithiasis patients (392 asymptomatic and 1786 symptomatic); 53% were female. Asymptomatic patients exhibited a higher risk of PEP compared with symptomatic patients (11.7% versus 4.8%; RR 2.59, 95% CI 1.56-4.31, p ≤ 0.001). No significant difference was observed in post-ERCP cholangitis, bleeding, or perforation rates between the two groups. Asymptomatic patients with choledocholithiasis appear to have a higher risk of PEP than symptomatic patients, while the risk of other post-ERCP adverse events is similar between the two groups. Interventional endoscopists should thoroughly discuss potential adverse events (particularly PEP) with asymptomatic patients before performing ERCP and utilize PEP-prevention measures more liberally in this subgroup of patients.

The economics of deep and machine learning-based algorithms for COVID-19 prediction, detection, and diagnosis shaping the organizational management of hospitals

Research background: Deep and machine learning-based algorithms can assist in COVID-19 image-based medical diagnosis and symptom tracing, optimize intensive care unit admission, and use clinical data to determine patient prioritization and mortality risk, being pivotal in qualitative care provision, reducing medical errors, and increasing patient survival rates, thus diminishing the massive healthcare system burden in relation to severe COVID-19 inpatient stay duration, while increasing operational costs throughout the organizational management of hospitals. Data-driven financial and scenario-based contingency planning, predictive modelling tools, and risk pooling mechanisms should be deployed for additional medical equipment and unforeseen healthcare demand expenses. Purpose of the article: We show that deep and machine learning-based and clinical decision making systems can optimize patient survival likelihood and treatment outcomes with regard to susceptible, infected, and recovered individuals, performing accurate analyses by data modeling based on vital and clinical signs, surveillance data, and infection-related biomarkers, and furthering hospital facility optimization in terms of intensive care unit bed allocation. Methods: The review software systems employed for article screening and quality evaluation were: AMSTAR, AXIS, DistillerSR, Eppi-Reviewer, MMAT, PICO Portal, Rayyan, ROBIS, and SRDR. Findings &amp; value added: Deep and machine learning-based clinical decision support tools can forecast COVID-19 spread, confirmed cases, and infection and mortality rates for data-driven appropriate treatment and resource allocations in effective therapeutic and diagnosis protocol development, by determining suitable measures and regulations and by using symptoms and comorbidities, vital signs, clinical and laboratory data and medical records across intensive care units, impacting the healthcare financing infrastructure. As a result of heightened use of personal protective equipment, hospital pharmacy and medication, outpatient treatment, and medical supplies, revenue loss and financial vulnerability occur, also due to expenses related to hiring additional staff and to critical resource expenditures. Hospital costs for COVID-19 medical care, screening, treatment capacity expansion, and personal protective equipment can lead to further financial losses while affecting COVID-19 frontline hospital workers and patients.

The effects of government subsidy on manufacturers' technology sharing behavior with risk consideration

AbstractThis study focuses on how consumer subsidy (COS) and manufacturer subsidy (MAS) influence a focal risk‐averse manufacturer's technology sharing, who balances between risk pooling effect and competition effect along with new entry for decision. When consumers' uncertain valuations are highly positively (or negatively) correlated for the manufacturers' products, the higher COS and the higher MAS can (or cannot) enhance the manufacturer's technology sharing because the risk pooling effect is strong (or weak), but the competition effect is weak (or strong). Only when the risk pooling effect dominates the competition effect, COS is more conducive than MAS to promoting technology sharing.

Isolated fetal umbilical vein varix and the association with intrauterine fetal death and fetal growth restriction: A systematic review, meta-analysis, and nested retrospective cohort study.

To assess the risk of intrauterine fetal death (IUFD) and fetal growth restriction (FGR) in fetuses with an isolated fetal intra-abdominal umbilical vein varix (i-FIUVV). A retrospective cohort study combined with a systematic review and meta-analysis of the literature was performed. In the retrospective cohort study, all singleton fetuses with an i-FIUVV in the fetal medicine units of the Amsterdam UMC (between 2007 and 2023) were analyzed. The primary outcome measures were IUFD and FGR. The sample proportions of IUFD and FGR were depicted as risk percentages. The IUFD proportion was compared to the regional reference population and the FGR proportion was compared to the reported proportions in Europe. The secondary outcome measures were gestational age at diagnosis, initial and maximal FIUVV diameter, fetal monitoring in pregnancy, turbulent flow in the varix, thrombus formation in the varix, induction of labor, gestational age at birth, and birthweight centile. The proportion of fetuses with a birthweight below the 10th centile was compared with that of the regional reference population. The systematic review included all cases from eligible literature published between 2007 and 2023 supplemented by the data of our retrospective cohort study. In the systematic review and meta-analysis, the pooled proportions of IUFD and FGR were assessed in fetuses with i-FIUVV. The retrospective cohort included 43 singletons with an i-FIUVV. The IUFD risk was 0% [Confidence Interval, CI: 0%-8.2%], which did not differ significantly from 0.3% in the reference population, p=1.0. The risk of FGR was 16.3% [CI: 6.8%-30.7%] in the studied population, which is higher than the reported incidence of FGR in Europe ranging from 5%-10%. The proportion of fetuses with birthweights below the 10th centile was higher in our cohort compared with the reference population (23.3 vs. 9.9%, p<0.01). The systematic review included 12 articles, three abstracts, and our current cohort. In total, 513 cases with an i-FIUVV were included. The pooled risk was 0.4% [CI: 0.1%-1.7%] for IUFD and 5.2% [CI: 1.1%-21.3%] for FGR. The mean gestational age at birth did not exceed 39weeks in neither the cohort (38.7weeks) nor the pooled literature (37.6weeks). An i-FIUVV in singletons is not associated with an increased IUFD risk up to 39weeks of gestation but is possibly associated with FGR. The incidence of FGR in our cohort was higher than in the pooled literature (16.3% vs. 5%) but FGR definitions in the included studies varied. The proportion of birthweights below the 10th percentile in our cohort was significantly higher than in the reference group. Thus, based on these findings, we suggest conducting sonographic growth assessments while simultaneously assessing the i-FIUVV. No further monitoring and follow-up are indicated up to 39weeks of gestation. After 39weeks of gestation, data on fetuses with i-FIUVV and their outcomes are lacking.

Cold endoscopic mucosal resection versus cold snare polypectomy for colorectal lesions: a systematic review and meta-analysis of randomized controlled trials.

Cold resection of colorectal lesions is widely performed because of its safety and effectiveness; however, it remains uncertain whether adding submucosal injection could improve the efficacy and safety. We aimed to compare cold endoscopic mucosal resection (C-EMR) versus cold snare polypectomy (CSP) for colorectal lesions. We performed a systematic review of randomized controlled trials (RCTs) identified from PubMed, Cochrane Library, and Embase. The primary outcome was complete resection. Secondary outcomes were procedure time, en bloc resection, and adverse events (AEs). Prespecified subgroup analyses based on the size and morphology of the polyps were performed. The random-effects model was used to calculate the pooled risk ratio (RR) and mean difference, with corresponding 95%CIs, for dichotomous and continuous variables, respectively. Heterogeneity was assessed using the Cochran Q test and I 2 statistics. 7 RCTs were included, comprising 1556 patients, with 2287 polyps analyzed. C-EMR and CSP had similar risk ratios for complete resection (RR 1.02, 95%CI 0.98-1.07), en bloc resection (RR 1.08, 95%CI 0.82-1.41), and AEs (RR 0.74, 95%CI 0.41-1.32). C-EMR had a longer procedure time (mean difference 42.1 seconds, 95%CI 14.5-69.7 seconds). In stratified subgroup analyses, the risk was not statistically different between C-EMR and CSP for complete resection in polyps<10 mm or ≥10 mm, or for complete resection, en bloc resection, and AEs in the two groups among nonpedunculated polyps. The findings of this meta-analysis suggest that C-EMR has similar efficacy and safety to CSP, but significantly increases the procedure time. CRD42023439605.

The Impact of Taxation on the Effective Tax Rate, Operating Risk, and Portfolio Risk Diversification Effectiveness under Risk Pooling

The Impact of Taxation on the Effective Tax Rate, Operating Risk, and Portfolio Risk Diversification Effectiveness under Risk Pooling

Comparative Effectiveness of mRNA-1273 and BNT162b2 COVID-19 Vaccines Among Older Adults: Systematic Literature Review and Meta-Analysis Using the GRADE Framework.

The mRNA vaccines mRNA-1273 and BNT162b2 demonstrated high efficacy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in phase 3 clinical trials, including among older adults. To inform coronavirus disease 2019 (COVID-19) vaccine selection, this systematic literature review (SLR) and meta-analysis assessed the comparative effectiveness of mRNA-1273 versus BNT162b2 in older adults. We systematically searched for relevant studies reporting COVID-19 outcomes with mRNA vaccines in older adults aged ≥ 50years by first cross-checking relevant published SLRs. Based on the cutoff date from a previous similar SLR, we then searched the WHO COVID-19 Research Database for relevant articles published between April 9, 2022, and June 2, 2023. Outcomes of interest were SARS-CoV-2 infection, symptomatic SARS-CoV-2 infection, severe SARS-CoV-2 infection, COVID-19-related hospitalization, and COVID-19-related death following ≥ 2 vaccine doses. Random effects meta-analysis models were used to pool risk ratios (RRs) across studies. Heterogeneity was evaluated using chi-square testing. Evidence certainty was assessed per GRADE framework. Twenty-four non-randomized real-world studies reporting clinical outcomes with mRNA vaccines in individuals aged ≥ 50years were included in the meta-analysis. Vaccination with mRNA-1273 was associated with significantly lower risk of SARS-CoV-2 infection (RR 0.72 [95% confidence interval (CI) 0.64‒0.80]), symptomatic SARS-CoV-2 infection (RR 0.72 [95% CI 0.62‒0.83]), severe SARS-CoV-2 infection (RR 0.67 [95% CI 0.57‒0.78]), and COVID-19-related hospitalization (RR 0.65 [95% CI 0.53‒0.79]) but not COVID-19-related death (RR 0.80 [95% CI 0.64‒1.00]) compared with BNT162b2. There was considerable heterogeneity between studies for all outcomes (I2 > 75%) except death (I2 = 0%). Multiple subgroup and sensitivity analyses excluding specific studies generally demonstrated consistent results. Certainty of evidence across outcomes was rated as low (type 3) or very low (type 4), reflecting the lack of randomized controlled trial data. Meta-analysis of 24 observational studies demonstrated significantly lower risk of asymptomatic, symptomatic, and severe infections and hospitalizations with the mRNA-1273 versus BNT162b2 vaccine in older adults aged ≥ 50years.

Exercise-based cardiac rehabilitation for adults with heart failure.

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting. To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure. We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers. We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF. We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence. We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes. This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Effectiveness of telemedicine for the prevention of mother-to-child transmission of HIV in low-income and middle-income countries: a systematic review and meta-analysis

ObjectivesWe aimed to estimate the effectiveness of telemedicine for the prevention of mother-to-child transmission (PMTCT) program of HIV in low- and middle-income countries (LMICs). MethodsWe did a systematic literature search of 15 databases for articles published from database inception to October 26, 2022, and performed meta-analyses to estimate the pooled risk ratio of intervention effect (RR) and its 95% confidence interval (CI). We used subgroup analyses and meta-regressions to explore variation in the RRs. Funnel plots and Egger regression tests were also performed to assess publication bias. ResultsSeventeen studies were included in the systematic review, with a total sample size of 9118 participants. We found that telemedicine was beneficial for early infant diagnosis (EID) in the sixth week (RR 1.04 [95% CI 1.00-1.09]), exclusive breastfeeding (RR 1.12 [95% CI 1.01-1.24]) and PMTCT retention (RR 1.34 [95% CI 1.16-1.55]). However, we did not find a significant effect of telemedicine on infant prophylaxis, HIV transmission, and ART adherence. Besides, the heterogeneity of ART adherence was associated with enrollment time, while retention was related to ART initiation. ConclusionsOur meta-analysis demonstrated the benefits of telemedicine in improving PMTCT, especially for EID, exclusive breastfeeding, and PMTCT retention.

High-risk pooling for mitigating risk selection incentives in health insurance markets with sophisticated risk equalization: an application based on health survey information

BackgroundDespite sophisticated risk equalization, insurers in regulated health insurance markets still face incentives to attract healthy people and avoid the chronically ill because of predictable differences in profitability between these groups. The traditional approach to mitigate such incentives for risk selection is to improve the risk-equalization model by adding or refining risk adjusters. However, not all potential risk adjusters are appropriate. One example are risk adjusters based on health survey information. Despite its predictiveness of future healthcare spending, such information is generally considered inappropriate for risk equalization, due to feasibility challenges and a potential lack of representativeness.MethodsWe study the effects of high-risk pooling (HRP) as a strategy for mitigating risk selection incentives in the presence of sophisticated– though imperfect– risk equalization. We simulate a HRP modality in which insurers can ex-ante assign predictably unprofitable individuals to a ‘high risk pool’ using information from a health survey. We evaluate the effect of five alternative pool sizes based on predicted residual spending post risk equalization on insurers’ incentives for risk selection and cost control, and compare this to the situation without HRP.ResultsThe results show that HRP based on health survey information can substantially reduce risk selection incentives. For example, eliminating the undercompensation for the top-1% with the highest predicted residual spending reduces selection incentives against the total group with a chronic disease (60% of the population) by approximately 25%. Overall, the selection incentives gradually decrease with a larger pool size. The largest marginal reduction is found moving from no high-risk pool to HRP for the top 1% individuals with the highest predicted residual spending.ConclusionOur main conclusion is that HRP has the potential to considerably reduce remaining risk selection incentives at the expense of a relatively small reduction of incentives for cost control. The extent to which this can be achieved, however, depends on the design of the high-risk pool.

Outcomes of ablative therapy and radical treatment for prostate cancer: a systematic review and meta-analysis.

To compare biochemical recurrence, sexual potency and urinary continence outcomes of ablative therapy and radical treatment (radical prostatectomy or radiotherapy with androgen deprivation therapy). A systematic review and meta-analysis followed the PRISMA guidelines were performed. We searched MEDLINE/PubMed. Biochemical recurrence at three and five years; incontinence rate (patients who used one pad or more) and erectile dysfunction rate at 12 and 36 months (patients who did not have sufficient erection to achieve sexual intercourse) were evaluated. The Mantel-Haenszel method was applied to estimate the pooled risk difference (RD) in the individual studies for categorical variables. All results were presented as 95% confidence intervals (95%CI). Random effects models were used regardless of the level of heterogeneity (I²). (PROSPERO CRD42022296998). Eight studies comprising 2,677 men with prostate cancer were included. There was no difference in biochemical recurrence between ablative and radical treatments. We observed the same biochemical recurrence between ablative therapy and radical treatment within five years (19.3% vs. 16.8%, respectively; RD 0.07; 95%CI=-0.05, 0.19; I2=68.2%; P=0.08) and continence rate at 12 months (9.2% vs. 31.8%, respectively; RD -0.13; 95%CI, -0.27, 0.01; I2=89%; P=0.32). When focal treatment was analyzed alone, two studies with 582 patients found higher erectile function at 12 months in the ablative therapy group than in the radical treatment (88.9% vs. 30.8%, respectively; RD -0.45; 95%CI -0.84, -0.05; I2=93%; P=0.03). Biochemical recurrence and urinary continence outcomes of ablative therapy and radical treatment were similar. Ablative therapy appears to have a high rate of sexual potency.

Obesity and mortality in patients with COVID-19: A meta-analysis of prospective studies.

Previous prospective studies have reported inconsistent findings on the associ-ation between obesity and mortality in patients with COVID-19. This study aimed to investigate the associa-tion between them by using a meta-analysis of prospective studies. We searched PubMed and EMBASE to retrieve studies using keywords related to this topic on January 3, 2022. Data were extracted for a random-effects meta-analysis to calculate a pooled odds ratio (OR), relative risk (RR), or hazard ratio (HR) with a 95% confidence interval (CI). In the meta-analysis of 15 prospective cohort studies, obesity significantly increased the risk of mortality in patients with COVID-19 (OR/RR/HR, 1.52; 95% CI, 1.26 to 1.84; I2 = 90.4%). Most of the included studies were conducted in European (n = 10) and North American (n = 4) countries. In the subgroup meta-analysis by continent, there was a significant association between them in European countries (OR/RR/HR, 1.78; 95% CI, 1.30 to 2.43; I2 = 81.4%). Also, in the subgroup meta-analysis by data source, obesity was significantly associated with the increased mortality in patients with COVID-19 in both population- and hospital-based data. We found that obesity is associated with the increased risk of mortality in patients of COVID-19.

Risk factors for pulmonary tuberculosis recurrence, relapse and reinfection: a systematic review and meta-analysis

BackgroundThe rate of pulmonary tuberculosis (TB) recurrence is substantial. Identifying risk factors can support the development of prevention strategies.MethodsWe retrieved studies published between 1 January 1980 and 31 December 2022...

Effectiveness of Janus kinase inhibitors in rheumatoid arthritis: systematic review and meta-analysis

Aim. To assess the efficacy profiles of different dosing regimens of tofacitinib, baricitinib, and upadacitinib — novel selective oral Janus activated kinase inhibitors, in rheumatoid arthritis (RA). Materials and methods. Randomized controlled trials of tofacitinib, baricitinib and upadacitinib in RA were identified from MEDLINE, and Cochrane databases. Random- effects models were used to estimate pooled mean differences (MD) and relative risks (RRs). American College of Rheumatology 20 % (ACR20), Health Assessment Questionnaire–Disability Index (HAQ-DI) were calculated. Results. Twenty trials with an overall low risk of bias were identified. Tofacitinib, baricitinib, and upadacitinib improved RA control as deter -mined by ACR20 (RR, 2.03; 95 % CI, 1.87 to 2.20) and HAQ-DI (MD, −0.31; 95% CI, −0.34 to −0.28) compared with placebo. Conclusion. Tofacitinib, baricitinib, and upadacitinib significantly improve RA control. To make further decisions, comparative clinical trials of the Janus kinase inhibitors in the real-world clinical practice are necessary.

재조합 인플루엔자 백신과 불활성화 인플루엔자 백신의 면역원성 비교

To compare surrogate markers of immunogenicity between recombinant and inactivated influenza vaccines, this study conducted a systematic review and meta-analysis for each strain. Three databases of Medline (Pubmed), Embase and Cochrane Central were searched to identify all published literature up to July 2023. Out of a total of 1,658 initially identified articles, 14 randomized controlled trials were selected based on inclusion and exclusion criteria. The program R version 4.3.1 was used to estimate the mean difference of geometric mean titer (GMT) and the pooled risk ratio (RR) of seroconversion and seroprotection with 95% confidence intervals. The meta-analysis results found higher GMT effect sizes for recombinant influenza vaccines compared to inactivated vaccines for A/H3N2 (MD=124.87, 95% CI 52.63-197.11) and B/Yamagata (MD=19.89, 95% CI 7.61-32.17) strains. In terms of seroconversion rates, recombinant influenza vaccines exhibited higher seroconversion for A/H3N2 (RR=1.33, 95% CI 1.26-1.40) and B/Yamagata (RR=1.75, 95% CI 1.06-2.89) strains. Slightly higher seroprotection rates were observed for A/H3N2 (RR=1.04, 95% CI 1.02-1.07) and B/Yamagata (RR=1.07, 95% CI 1.01-1.13) strains with recombinant vaccines. The findings from this study contribute valuable evidence for regulatory decisions when introducing recombinant vaccines in South Korea.

Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review.

Recurrent respiratory papillomatosis (RRP) is a non-malignant disease, characterized by the production of wart-like growths in the respiratory tract, affecting both young people and adults (juvenile-onset recurrent respiratory papillomatosis, JORRP, and adult-onset recurrent respiratory papillomatosis, AORRP, respectively). Infection caused by human papillomavirus (HPV) is known as the main factor involved in RRP development. Complications of RRP may rarely occur, including lung involvement and malignant transformation. The present systematic review aimed to evaluate the prevalence of severe complications, such as lung involvement and lung tumor in JORRP and AORRP patients, and assess the role of HPV genotypes in the progression of disease severity following the guideline for reporting systematic reviews and meta-analysis (PRISMA Statement). A total of 378 studies were found on PubMed and Scopus using the following MESH terms: "recurrent respiratory papillomatosis and lung tumor" and "pulmonary tumor and recurrent respiratory papillomatosis". Basing on inclusion and exclusion criteria, a total of 11 studies were included in the systematic review. We found a pooled prevalence of 8% (95% CI: 4-14%; I2: 87.5%) for lung involvement in RRP patients. In addition, we found a pooled risk difference of 5% in lung involvement between JORRP and AORRP (95% CI: -7-18%; I2: 85.6%, p-value: 0.41). Among patients with lung involvement, we observed a pooled prevalence of lung tumor of 4% (95% CI:1-7%; I2: 67.1%) and a pooled prevalence mortality for this group of 4% (95% CI:2-6%; I2: 0%). Overall, the positivity rate for HPV-6 and -11 in patients with RRP was 91%. Considering only cases with pulmonary involvement, the pooled prevalence for HPV-11 was 21% (95% CI: 5-45%; I2: 77.2%). Our results evidenced a low/middle risk of pulmonary involvement and lung tumor in JORRP and AORRP patients, with an increased risk for HPV-11-positive patients. Further studies should be performed to improve knowledge and adopt preventive measures to contrast the progression to severe diseases in RRP patients.

Influence of a private-public risk pool and an opt-out framing on earthquake protection demand for Canadian homeowners in Quebec and British Columbia.

This article describes the design and analysis of web-based choice experiments that examine how the demand for earthquake protection in Quebec and British Columbia (BC), Canada, is influenced by the default option and the structure of the insurance plan. Homeowners in both provinces were given the opportunity to purchase protection against earthquake losses when presented with one of the following options: the current private insurance plan and proposed public-private Risk Pools with different levels of the public layer. The default frame was changed so the homeowner could either opt-in by purchasing this coverage or opt-out of being given this protection and receiving a premium discount. Assigning participants to the public-private Risk Pools rather than the current private insurance plan increases the likelihood of purchasing earthquake insurance protection by an odds ratio of 2.7 or greater in BC and Quebec. Furthermore, opt-out enrollment design substantially increases take-up of earthquake protection relative to opt-in enrollment. The policy implications of these findings are discussed.