Random-effects Model Meta-analysis Research Articles

Investigating the Use of Telemedicine by Health Care Providers to Diagnose and Manage Patients With Musculoskeletal Disorders: Systematic Review and Meta-Analysis.

Access to care is a major challenge for patients with musculoskeletal disorders (MSKDs). Telemedicine is one of the solutions to improve access to care. However, initial remote diagnosis of MSKDs involves some challenges, such as the impossibility of touching the patient during the physical examination, which makes it more complex to obtain a valid diagnosis. No meta-analysis has been performed to date to synthesize evidence regarding the initial assessment including a physical evaluation using telemedicine to diagnose patients with MSKDs. This study aims to appraise the evidence on diagnostic and treatment plan concordance between remote assessment using synchronous or asynchronous forms of telemedicine and usual in-person assessment for the initial evaluation of various MSKDs. An electronic search was conducted up to August 2023 using terms related to telemedicine and assessment of MSKDs. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Random-effect model meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to synthesize the quality and certainty of the evidence. A total of 23 concordance studies were eligible and included adult participants (N=1493) with various MSKDs. On the basis of high certainty, pooled κ and prevalence-adjusted and bias-adjusted κ for the diagnostic concordance between remote and in-person assessments of MSKDs were 0.80 (95% CI 0.72-0.89; 7 studies, 353 patients) and 0.83 (95% CI 0.76-0.89; 6 studies, 306 patients). On the basis of moderate certainty, pooled Gwet AC1 for treatment plan concordance between remote and in-person assessments of MSKDs was 0.90 (95% CI 0.80-0.99; 2 studies, 142 patients). The diagnostic concordance for MSKDs is good to very good. Treatment plan concordance is probably good to excellent. Studies evaluating the accuracy to detect red and yellow flags as well as the potential increase in associated health care resources use, such as imaging tests, are needed.

Erythropoiesis-stimulating agents for preventing acute kidney injury.

Acute kidney injury (AKI) is characterised by a rapid decline in kidney function and is caused by a variety of clinical conditions. The incidence of AKI in hospitalised adults is high. In animal studies, erythropoiesis-stimulating agents (ESA) have been shown to act as a novel nephroprotective agent against ischaemic, toxic, and septic AKI by inhibiting apoptosis, promoting cell proliferation, and inducing antioxidant and anti-inflammatory responses. As a result, ESAs may reduce the incidence of AKI in humans. Randomised controlled trials (RCTs) have been conducted on the efficacy and safety of ESAs, but no prior systematic reviews exist that comprehensively examine ESAs with respect to AKI prevention, although the effectiveness of these agents has been examined for a range of other diseases and clinical situations. This review aimed to look at the benefits and harms of ESAs for preventing AKI in the context of any health condition. We searched the Cochrane Kidney and Transplant Register of Studies up to 30 August 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. We included RCTs and quasi-RCTs (in which allocation to treatment was based on alternate assignment or order of medical records, admission dates, date of birth or other non-random methods) that compared ESAs with placebo or standard care in people at risk of AKI. Three authors independently extracted data and assessed the risk of bias for included studies. We used random-effects model meta-analyses to perform quantitative synthesis of the data. We used the I2 statistic to measure heterogeneity amongst the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (CI). We assessed the certainty of the evidence for each main outcome using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. A total of 20 studies (36 records, 5348 participants) were included. The number of participants ranged from 10 to 1302, and most studies were carried out in single centres (13/20). All the included studies compared ESAs to placebo or usual care. Many of the studies were judged to have unclear or high risk of reporting bias, but were at low risk for other types of bias. ESAs, when compared to control interventions, probably makes little or no difference to the risk of AKI (18 studies, 5314 participants: RR 0.97, 95% CI 0.85 to 1.10; I² = 19%; moderate-certainty evidence), or death (18 studies, 5263 participants: RR 0.92, 95% CI 0.80 to 1.06; I² = 0%; moderate-certainty evidence), and may make little or no difference to the initiation of dialysis (14 studies, 2059 participants: RR 1.16, 95% CI 0.90 to 1.51; I² = 0%; low-certainty evidence). Even with standardised measurement of AKI, the studies showed no difference in results between different routes of administration (subcutaneous or intravenous), background diseases (cardiac surgeries, children or neonates, other adults at risk of AKI), or duration or dose of ESA. ESAs may make little or no difference to the risk of thrombosis when compared to control interventions (8 studies, 3484 participants: RR 0.92, 95% CI 0.68 to 1.24; I² = 0%). Similarly, ESAs may have little or no effect on kidney function measures and adverse events such as myocardial infarction, stroke or hypertension. However, this may be due to the low incidence of these adverse events. In patients at risk of AKI, ESAs probably do not reduce the risk of AKI or death and may not reduce the need for starting dialysis. Similarly, there may be no differences in kidney function measures and adverse events such as thrombosis, myocardial infarction, stroke or hypertension. There are currently two ongoing studies that have either not been completed or published, and it is unclear whether they will change the results. Caution should be exercised when using ESAs to prevent AKI.

Effectiveness of combined targeted and hormonal therapies for post-menopausal women with hormone receptor-positive and HER2-negative advanced breast cancer: A systematic review and meta-analysis of RCTs.

we aim to synthesize available evidence on the effectiveness of hormonal plus targeted therapies for post-menopausal women with hormone receptor-positive and HER2-negative advanced breast cancer. We searched the following databases: Medline, PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, and African Journal. Only studies that investigated the effectiveness of hormonal therapy combined with targeted therapy for HR+/HER2- advanced breast cancer treatment were included. The outcomes were progression-free survival (PFS), overall survival (OS) and objective response rate (ORR). A random-effect meta-analysis model was employed. Statistical analysis was performed using Comprehensive Meta-analysis version 3. 24 studies were included in the meta-analysis with an overall sample size of 7635. Median PFS, OS and ORR were found to be significantly increased in the combination group compared to hormonal monotherapy [SMD = 6.072 (95% CI = 3.785-8.360), p < 0.001], [SMD = 1.614 (95% CI = 0.139-3.089), p = 0.032] and [OR = 1.584 (CI 1.134-2.213), p = 0.007] respectively. Subgroup analysis showed a significant difference in PFS and ORR between patients who received "hormonal therapy + CDK4/6 inhibitors" vs hormonal therapy only [SMD = 6.015 (CI 3.069-8.960), p < 0.001], (OR = 1.828 (CI 1.030-3.243), p = 0.039] respectively. Compared with hormonal monotherapy, targeted plus hormonal therapy significantly improves PFS, OS and ORR in postmenopausal women with HR+/HER2- advanced breast cancer.

Oral versus intravenous antibiotic therapy for Staphylococcus aureus bacteremia or endocarditis: a systematic review and meta-analysis of randomized controlled trials.

We conducted a systematic review of randomized controlled trials (RCTs) to generate more precise estimates of the efficacy and safety of oral versus intravenous antibiotic therapy for S. aureus bacteremia or endocarditis. MEDLINE, EMBASE, the Cochrane Library, and Web of Science database were searched through February 21st, 2024. RCTs were included if they compared oral versus intravenous antibiotic therapy for S. aureus bacteremia or endocarditis, and appropriately reported outcomes for each group. Risk of bias was assessed using the revised Cochrane tool for assessing risk of bias in randomized trials. Heterogeneity between studies was evaluated with the Cochran's Q-statistic and I2 test. Treatment effects were summarized with pooled risk ratios using a random effects model meta-analysis. (PROSPERO CRD42024481512). Only four RCTs met criteria for inclusion in meta-analysis. Among participants assessed for treatment failure, there was no difference between the oral and intravenous therapy groups (RR 0.99; 95% CI, 0.63-1.57; I2 = 0%). There was also no significant difference in adverse events between oral and intravenous therapy groups (RR 0.65; 95% CI, 0.07-5.94; I2 = 74%); however, the confidence interval is wide, and heterogeneity was high. In this systematic review of RCTs comparing oral to intravenous antibiotic therapy for S. aureus bacteremia or endocarditis, few studies met eligibility criteria for inclusion. Meta-analysis of these studies suggests that transitioning from intravenous to oral therapy is likely effective in a subgroup of carefully selected patients. Additional randomized trials are necessary before transition to oral therapy can be routinely recommended.

Magnetic resonance imaging-based machine learning classification of schizophrenia spectrum disorders: a meta-analysis.

Recent advances in multivariate pattern recognition have fostered the search for reliable neuroimaging-based biomarkers in psychiatric conditions, including schizophrenia. These approaches consider the complex pattern of alterations in brain function and structure, overcoming the limitations of traditional univariate methods. To assess the reliability of neuroimaging-based biomarkers and the contribution of study characteristics in distinguishing individuals with schizophrenia spectrum disorder (SSD) from healthy controls (HCs), we conducted a systematic review of the studies that used multivariate pattern recognition for this objective. We systematically searched PubMed, Scopus, and Web of Science for studies on SSD classification using multivariate pattern analysis on magnetic resonance imaging data. We employed a bivariate random-effects meta-analytic model to explore the classification of sensitivity (SE) and specificity (SP) across studies while also evaluating the moderator effects of clinical and non-clinical variables. A total of 119 studies (with 12,723 patients with SSD and 13,196 HCs) were identified. The meta-analysis estimated a SE of 79.1% (95% confidence interval [CI], 77.1%-81.0%) and a SP of 80.0% (95% CI, 77.8%-82.0%). In particular, the Positive and Negative Syndrome Scale and the Global Assessment of Functioning scores, age, age of onset, duration of untreated psychosis, deep learning, algorithm type, features selection, and validation methods had significant effects on classification performance. Multivariate pattern analysis reliably identifies neuroimaging-based biomarkers of SSD, achieving ∼80% SE and SP. Despite clinical heterogeneity, discernible brain modifications effectively differentiate SSD from HCs. Classification performance depends on patient-related and methodological factors crucial for the development, validation, and application of prospective models in clinical settings.

Individual participant data meta-analysis to examine linear or non-linear treatment-covariate interactions at multiple time-points for a continuous outcome.

Individual participant data (IPD) meta-analysis projects obtain, harmonise, and synthesise original data from multiple studies. Many IPD meta-analyses of randomised trials are initiated to identify treatment effect modifiers at the individual level, thus requiring statistical modelling of interactions between treatment effect and participant-level covariates. Using a two-stage approach, the interaction is estimated in each trial separately and combined in a meta-analysis. In practice, two complications often arise with continuous outcomes: examining non-linear relationships for continuous covariates and dealing with multiple time-points. We propose a two-stage multivariate IPD meta-analysis approach that summarises non-linear treatment-covariate interaction functions at multiple time-points for continuous outcomes. A set-up phase is required to identify a small set of time-points; relevant knot positions for a spline function, at identical locations in each trial; and a common reference group for each covariate. Crucially, the multivariate approach can include participants or trials with missing outcomes at some time-points. In the first stage, restricted cubic spline functions are fitted and their interaction with each discrete time-point is estimated in each trial separately. In the second stage, the parameter estimates defining these multiple interaction functions are jointly synthesised in a multivariate random-effects meta-analysis model accounting for within-trial and across-trial correlation. These meta-analysis estimates define the summary non-linear interactions at each time-point, which can be displayed graphically alongside confidence intervals. The approach is illustrated using an IPD meta-analysis examining effect modifiers for exercise interventions in osteoarthritis, which shows evidence of non-linear relationships and small gains in precision by analysing all time-points jointly.

Household food insecurity and symptoms of anxiety and depression during pregnancy: Systematic review and meta-analysis.

Household food insecurity (HFI) has been related to adverse maternal-child health outcomes and mental health worsening during pregnancy. Few studies evaluated the temporal association between HFI and anxiety and depressive symptoms in pregnant women, and this association remains not completely understood. This study aimed to systematically review the association between HFI and symptoms of depression and anxiety in pregnant individuals. The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (CRD42022373615). Systematic searches were conducted on 10 electronic databases and grey literature. Two researchers independently conducted the study selection, data extraction process, and the risk of bias assessment. Random-effects meta-analysis models were used, and I2 > 40% indicated high heterogeneity across studies. Eighteen articles were included for the systematic review, comprising n = 27,882, and a total of 18,987 pregnant individuals aged between 14 and 45 years were included in the meta-analysis. The prevalence of HFI reported in studies ranged from 12.6% to 62.1% (n = 17). The prevalence of depressive and anxiety symptoms ranged from 18% to 49% (n = 11) and 23% to 34% (n = 2), respectively. HFI during pregnancy was associated with increased odds of experiencing symptoms of depression [(OR: 2.52; 95% CI: 2.11-3.02), I2 = 73.23%]. The quality of evidence was very low due to high heterogeneity. Our findings highlighted the association between HFI and depression symptoms during pregnancy. Findings from this study suggest the importance of assessing HFI and mental health during pregnancy.

Professional Quality of Life Among Mental Health Nurses: A Systematic Review and Meta-Analysis.

The professional quality of life (ProQOL) is increasingly applied to nurses and is a measure of the positive and negative aspects of their work. This systematic review and meta-analysis evaluated the level of compassion satisfaction, burnout and secondary traumatic stress (STS) in empirical studies. Electronic databases Scopus, PubMed and Web of Science were searched on 7th February 2024, and the review followed PRISMA guidelines. The pooled estimate of compassion satisfaction, burnout and secondary traumatic stress mean scores using a random-effects model for meta-analyses was undertaken. R statistical software and the dmetar program were used to execute the analysis. Heterogeneity was evaluated with the I2 statistics, while publication bias was evaluated using Egger's regression test. Twenty-four studies (sample size = 4274) were systematically reviewed and 18 studies (n = 3163) were incorporated into the meta-analysis. Burnout, secondary traumatic stress and compassion satisfaction are found to be at moderate levels in this research. The qualitative analysis informs that variables such as healthy lifestyle, work environment and psychological resilience contribute towards optimum ProQOL scores. The pooled mean estimate was 32.79 (95% CI = 29.57-36) for compassion satisfaction, 24.99 (95% CI = 23.75-26.23) for burnout and 21.99 (95% CI = 18.93-25.06) for secondary traumatic stress, respectively. Mental health nurse managers need to address the factors in the work environment and promote interventions to enhance coping with burnout and STS. Subgroup analyses of country-based economies & regions and years revealed significant results.

Safety and Effectiveness of Direct Oral Anticoagulants Versus Warfarin in Patients with Venous Thromboembolism using Real-World Data: A Systematic Review and Meta-Analysis.

Direct oral anticoagulants (DOACs) have shown comparable efficacy and a superior safety profile in clinical trials for patients with venous thromboembolism (VTE). However, further study is needed to assess DOACs' effectiveness and safety compared to warfarin in a real-world context. Thus, this meta-analysis compares the effectiveness and safety of warfarin and DOACs in patients with VTE. A systematic review of the literature using PubMed and EMBASE was conducted from inception until June 2024. We examined observational studies that compared safety and effectiveness between DOACs and warfarin when used in treating VTE and reported adjusted hazard ratios (HRs) and/or odds ratios (ORs) for recurrent VTE, major bleeding, clinically relevant non-major bleeding, gastrointestinal bleeding, intracranial hemorrhage, and death from any cause. We then estimated the pooled effect using the random-effects model for meta-analysis. A total of 25 studies were included in the current meta-analysis. DOAC therapy was associated with significantly lower risks of recurrent VTE (HR 0.76, 95% confidence interval [CI] 0.69-0.85), major bleeding (HR 0.77, 95% CI 0.72-0.83), clinically relevant non-major bleeding (HR 0.82, 95% CI 0.77-0.88), and gastrointestinal bleeding (HR 0.75, 95% CI 0.68-0.83) compared to warfarin. However, no statistically significant difference was observed in all-cause mortality between the two groups (HR 0.96, 95% CI 0.83-1.10). This meta-analysis found that DOACs are associated with a significant reduction in VTE recurrence in addition to the known favorable safety profile when compared to warfarin.

SP7.1 - Risk Profile of Administration of 3- and 4-factor Prothrombin Complex Concentrate in Adult Anticoagulated Trauma Patients: A Systematic Review and Meta-Analysis

Abstract Aims To establish thromboembolic complication (TC, primary outcome) and mortality (secondary outcome) Odds Ratios (ORs) following 3-factor Prothrombin Complex Concentrate (PCC3, Comparator Group [CG] 1) and 4-factor Prothrombin Complex Concentrate (PCC4, CG2) administration, compared to Fresh Frozen Plasma (FFP) alone, in adult Vitamin K antagonist-anticoagulated trauma patients. Methods Systematic database and grey literature searches were performed. Random effects model meta-analyses were undertaken for each of this study’s outcomes, producing ORs and 95% Confidence Intervals (95%CIs). The I2 statistic was used to quantify interstudy heterogeneity. Inverse Variance, Mann-Whitney U and Kruskal-Wallis tests were used to examine interstudy demographic/treatment differences. Risk of bias was assessed with the Newcastle-Ottawa Scale, study quality with the GRADE tool. Results 8 papers met inclusion criteria (CG1 n=3, CG2 n=3), 2 were excluded due to insufficient reported information. TC incidence was not significantly increased following PCC3 administration (ORcombined effect1.57, 95% CI 0.24-10.51, p=0.64). Meta-analysis was not performed on TC incidence in CG2 owing to only 1 paper reporting this outcome. Mortality risk was not significantly increased following PCC3 (ORcombined effect1.61, 95%CI 0.27-9.51, p=0.60) or PCC4 (ORcombined effect2.19, 95%CI 0.96-4.98, p=0.06) administration. Admission Injury Severity Score (ISS) and age varied significantly between papers included in CG1 (mean­ISS=15.5, 95%CI=12.0-20.1, p&amp;lt;0.05, meanage=75.3years, 95%CI=65.5-86.7, p&amp;lt;0.05) and CG2 (meanISS=15.1, 95%CI=13.4-17.0, p&amp;lt;0.05, meanage=79.2years, 95%CI=74.7-84.1, p&amp;lt;0.05). Conclusion TC risk is not overtly increased following PCC3 administration, compared to FFP. The same is true for mortality risk following PCC3 and PCC4 administration. There is substantial room for bias in the results reported, further research is warranted.

Immunity to Varicella Zoster Virus in Healthcare Workers: A Systematic Review and Meta-Analysis (2024).

Healthcare workers (HCWs) are occupationally exposed to varicella zoster virus (VZV), and their inappropriate vaccination status could contribute to an outbreak involving both professionals and the patients they care for, with a potential impact on the general population. Therefore, since 2007, the Advisory Committee on Immunization Practices (ACIP) recommends that all HCWs have evidence of immunity against varicella. The present meta-analysis was therefore designed to collect the available evidence on the seronegative status of VZV among HCWs. PubMed, Scopus, and Embase databases were searched without backward limit for articles reporting on the seroprevalence of VZV among HCWs, and all articles meeting the inclusion criteria were included in a random-effect meta-analysis model. From 1744 initial entries, a total of 58 articles were included in the quantitative analysis (publication range: 1988 to 2024), for a pooled sample of 71,720 HCWs. Moreover, the included studies reported on seroprevalence data on measles (N = 36,043 HCWs) and rubella (N = 22,086 HCWs). Eventually, the pooled seronegative status for VZV was estimated to be 5.72% (95% confidence interval [95% CI] 4.59 to 7.10) compared to 6.91% (95% CI 4.79 to 9.87) for measles and 7.21% (5.36 to 9.64) for rubella, with a greater risk among subjects younger than 30 years at the time of the survey (risk ratio [RR] 1.434, 95% CI 1.172 to 1.756). Interestingly, medical history of either VZV infection/vaccination had low diagnostic performances (sensitivity 76.00%; specificity 60.12%; PPV of 96.12% but PNV of 18.64%). In summary, the available data suggest that newly hired HCWs are increasingly affected by low immunization rates for VZV but also for measles and rubella, stressing the importance of systematically testing test newly hired workers for all components of the measles-pertussis-rubella-varicella vaccine.

The Effect of Statins on Carotid Intima-Media Thickness and C-Reactive Protein in Type 2 Diabetes Mellitus: A Meta-Analysis.

The effect of statins on CIMT progression and C-reactive protein (CRP) in T2DM patients is widely reported. However, some studies demonstrated no effect of statins on CIMT and CRP in T2DM patients, while others reported otherwise. Thus, the current study comprehensively and quantitatively analyzes data from previous studies to evaluate the overall effect of statins on CIMT and CRP in T2DM to rule out any inconsistencies observed in previous clinical evidence. Therefore, the aim of this meta-oanalysis was to evaluate the effect of statins on CIMT progression and CRP in T2DM. A comprehensive search for studies was performed using PubMed, Scopus, Web of Sciences, and the Cochrane Library, for publications from their inception to 16 July 2024. The meta-analysis was conducted using Jamovi (version 4.2.8) and Review Manager (version 5.4), with the overall effect sizes reported as standardized mean differences (SMD) and 95% confidence intervals (CI). Evidence from eleven studies (fifteen statin dosages) that met the inclusion criteria with a sample size of 983 T2DM patients on statin treatment was analyzed. The overall effect size from the random effect model meta-analysis showed a reduction in the CIMT status amongst T2DM patients post-statin treatment compared to at baseline [SMD = -0.47, 95%CI (-0.76, -0.18), p = 0.001]. Furthermore, there was a reduction in the level of CRP in T2DM patients post-treatment [SMD = -1.80, 95% CI (-2.76, -0.84), p < 0.001]. Evidence gathered in this study suggests that statin therapy effectively reduces CIMT and CRP levels among patients living with T2DM. Interestingly, this evidence suggests that 20 mg of atorvastatin is more effective in reducing CIMT and CRP. Therefore, we recommend conducting further trials with larger sample sizes and proper methodology for T2DM.

Time to pars plana vitrectomy in adults with retained lens fragments: a systematic review and meta-analysis

ObjectiveTo compare visual outcomes and complication risk based on the timing of pars plana vitrectomy (PPV) following cataract surgery with retained lens fragments. MethodsMEDLINE (Ovid), EMBASE, and Cochrane Library were searched between 2000 to February 2022 for studies comparing visual outcomes and complications based on time to PPV. Discrete outcomes were analyzed using a random-effects meta-analysis model on Review Manager (RevMan 5.4). The certainty of evidence of outcomes was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach. ResultsTen studies and 1,693 eyes were included. The incidence of patients achieving a final best-corrected visual acuity (BCVA) of >6/12 Snellen may be similar among patients receiving PPV within 1 week or after 1 week of cataract surgery (RR = 1.06, 95% CI = [0.96, 1.17], p = 0.25), and patients receiving PPV within 1 month or after 1 month of cataract surgery (RR = 1.12, 95% CI = [0.95, 1.32]; p = 0.18). Incidence of glaucoma or elevated intraocular pressure for patients may be similar among patients receiving PPV within 1 week or after 1 week of cataract surgery (RR = 1.08, 95% CI = [0.62, 1.87]; p = 0.79), and patients receiving PPV within 1 month or after 1 month of cataract surgery (RR = 0.33, 95% CI = [0.09, 1.23]; p = 0.10). ConclusionIncidence of patients achieving a final BCVA of >6/12 Snellen or postoperative adverse effects was similar between patients who underwent early and late PPV following cataract surgery. However, all studies had an overall serious risk of bias, primarily because of confounding and reporting bias.

Understanding Global Access to Topical Onychomycosis Therapy: A Systematic Review and Meta-Analysis.

Equal access to medicines is crucial to ensuring public health, but access is difficult to measure, especially for infections where changes in infective species make treatment choices highly dynamic. This study investigated if the combination of infection prevalence with medicine efficacy and regulatory availability could access medicines access of topical onychomycosis medicines. Two databases, PubMed and Web of Science, were used to identify relevant information published between 1990 and 2019. For the meta-analysis, human onychomycosis investigations using PCR analysis were included. Reviewers independently selected eligible articles, extracted data and assessed the study quality. A random-effects meta-analysis model with a Freeman-Tukey transformation was employed to the PCR data. For the meta-analysis, the global infection trends and regional differences in the infective organisms were determined. Of the 26 studies analysed, the PCR analysis in 18 studies confirmed onychomycosis in about half of the visually suspected cases (55%, CI 43%-67%). Across all 26 studies dermatophytes were the most prevalent infective organism (57%, CI 37%-76%), but a sub-group analysis showed yeasts predominated in females (31%, CI 0%-84%) (p < 0.0001), in fingernail infections (42%, CI 21%-65%) (p < 0.0001) and in arid countries (p < 0.0001). Combining these results with medicine efficacy data showed that residents from 83 of the 92 countries assessed (90%) could not access the most efficacious topical product, and 22% could not access any broad-spectrum agents. Countries in Africa had the poorest access to topical onychomycosis medicines. This study identified that access to effective topical products for onychomycosis is a global problem. This issue appeared to be due to under-representation of candida infections in pivotal clinical studies of topical onychomycosis products. A head-to-head multicentre study for topical efinaconazole or a novel broad spectrum topical agent is needed to help resolve these access problems. PROSPERO-CRD42023464744.

P182 AORTIC VASCULAR BIOMARKERS FOR THE EARLY DETECTION OF PLACENTAL SYNDROMES DURING PREGNANCY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Placental syndromes (PS) cause over 14 million complications and the death of more than 350,000 women each year. Women with preeclampsia (PE) or gestational hypertension (GH) typically exhibit late gestational acute brachial hypertension, making early intervention difficult. Non-invasive aortic waveform assessments provide nuanced insight to global cardiovascular function. Our objective is to delineate cardiovascular differences between complicated and normotensive pregnancies (NP), to identify early vascular markers of at-risk women. Methods: A systematic search (March 2024) for studies reporting both NP and PS pregnancies was performed across five databases: PubMed; Medline; CINAHL Complete; Web of Science; and Scopus. Inclusion criteria required reporting before, during (trimester: T1; T2; T3), or after pregnancy (&lt; 1 year post-delivery) of at least one of the following vascular biomarkers from aortic pulse pressure waveform: aortic systolic blood pressure (aSBP); aortic pulse pressure (aPP); augmentation index normalised to a heart rate of 75 bpm (AIx@75); or arterial stiffness measured by carotid femoral pulse wave velocity (cfPWV). A meta-analysis of continuous random-effects model calculated Hedges’ g with 95% confidence intervals. Results: The systematic search yielded 19 studies. Analysis depicted PS having significantly higher aggregated measures than NP throughout pregnancy (p &lt;0.001) and a stronger effect size of AIx@75, aSBP, cfPWV in each trimester [T1, Hedges g 1.4(CI .64 - 2.0); T2, 1.1(CI .64 - 1.5); T3, 3.4(CI 2.1 – 4.6) p&lt;0.001]. Overall, cfPWV had the highest effect size particularly during T1 and T3 [T1, 2.8(CI 2.5 – 3.1); T2, 1.7(CI 1.2 – 2.1); T3, 5.3(CI 4.6 – 5.9)]. Low aPP reporting allowed only analysis of T3 which showed similar effect sizes to other markers [3.14(CI 1.23 – 5.05)]. Conclusions: Early indication of PS was quantifiable from vascular biomarkers, along with each trimester of pregnancy being elevated compared to NP. Pulse wave analysis and arterial stiffness assessment could enhance risk assessment from as early as the first trimester, improving and informing prenatal care.

Radiotherapy vs Surgery for Survival and Locoregional Control of Head and Neck Extramedullary Plasmacytoma

There are significant gaps in the literature pertaining to the locoregional control and survival rates of extramedullary plasmacytoma (EMP) with respect to various treatment approaches. To systematically evaluate the differences in radiotherapy and surgical outcomes in EMP. Databases including PubMed, Scopus, Web of Science, Embase, and ScienceDirect were systematically searched from their inception up to November 2023. Articles reporting radiotherapy and surgical outcomes of head and neck EMP were included. A random-effects model for meta-analysis was used to obtain pooled estimates and calculate hazard ratios for survival and odds ratios for recurrence and progression of EMP. Survival, tumor control, and progression rates to multiple myeloma (MM) between radiation therapy and surgery for EMP of the head and neck. Of 742 included patients from 12 studies, 527 (71.0%) were male, and the median (IQR) age was 59.1 (53-62) years. A total of 505 patients (68.1%) received radiotherapy only, while 237 (31.9%) underwent surgery-only treatment for EMP. All included patients had an initial diagnosis of EMP without MM. Comparable trends were observed in overall survival and disease-free survival (DFS) rates at 2, 3, 5, and 10 years between patients with EMP treated with radiotherapy only and surgery only. Notably, there were no significant differences in recurrence rate (odds ratio, 0.65; 95% CI, 0.20-2.06) between radiotherapy-only and surgery-only treatment. However, radiotherapy-only treatment of EMP was associated with decreased odds of progression to MM compared with surgery (odds ratio, 0.4; 95% CI, 0.1-0.9). Sensitivity analysis revealed that the radiotherapy-only population had significantly better 5-year DFS (hazard ratio, 0.55; 95% CI, 0.31-0.96) compared with surgery-only treatment. This systematic review and meta-analysis provides evidence that patients with EMP receiving radiotherapy had significantly lower chances of progression to MM compared with surgery-only therapy. Additionally, radiotherapy had better 5-year DFS outcomes compared with surgery. Comparable outcomes in terms of overall survival rates, recurrence, and mortality rates were noted between radiotherapy-only and surgery-only EMP treatment groups.

Workplace violence against female healthcare workers: a systematic review and meta-analysis

BackgroundWorkplace violence (WPV) is highly prevalent in the health sector and remains a major occupational issue causing significant harm, ranging from bodily and psychological harm to death. Female healthcare workers...

Electronic Alert Systems for Patients With Acute Kidney Injury

The acute kidney injury (AKI) electronic alert (e-alert) system was hypothesized to improve the outcomes of AKI. However, its association with different patient outcomes and clinical practice patterns remains systematically unexplored. To assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns. A search of Embase and PubMed on March 18, 2024, and a search of the Cochrane Library on March 20, 2024, to identify all relevant studies. There were no limitations on language or article types. Studies evaluating the specified outcomes in adult patients with AKI comparing AKI e-alerts with standard care or no e-alerts were included. Studies were excluded if they were duplicate cohorts, had insufficient outcome data, or had no control group. Two investigators independently extracted data and assessed bias. The systematic review and meta-analysis followed the PRISMA guidelines. Random-effects model meta-analysis, with predefined subgroup analysis and trial sequential analyses, were conducted. Primary outcomes included mortality, AKI progression, dialysis, and kidney recovery. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAID), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, hospital length of stay, costs, and AKI documentation. Thirteen unique studies with 41 837 unique patients were included (mean age range, 60.5-79.0 years]; 29.3%-48.5% female). The risk ratios (RRs) for the AKI e-alerts group compared with standard care were 0.96 for mortality (95% CI, 0.89-1.03), 0.91 for AKI stage progression (95% CI, 0.84-0.99), 1.16 for dialysis (95% CI, 1.05-1.28), and 1.13 for kidney recovery (95% CI, 0.86-1.49). The AKI e-alerts group had RRs of 1.45 (95% CI, 1.04-2.02) for nephrologist consultation, 0.75 (95% CI, 0.59-0.95) for post-AKI NSAID exposure. The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06) and 1.28 (95% CI, 1.04-1.58) for AKI documentation. Use of AKI e-alerts was not associated with lower hospital length of stay (mean difference, -0.09 [95% CI, -0.47 to 0.30] days) or lower cost (mean difference, US $655.26 [95% CI, -$656.98 to $1967.5]) but was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]). Trial sequential analysis confirmed true-positive results of AKI e-alerts on increased nephrologist consultations and reduced post-AKI NSAID exposure and its lack of association with mortality. In this systematic review and meta-analysis, AKI e-alerts were not associated with a lower risk for mortality but were associated with changes in clinical practices. They were associated with lower risk for AKI progression. Further research is needed to confirm these results and integrate early AKI markers or prediction models to improve outcomes.

The burden of iatrogenic obstetric fistulas in Sub-Saharan Africa: Systematic review and meta-analysis protocol.

Obstetric fistulas are abnormal open connection(s) between the vagina and the urinary tract or the rectum resulting from tragic injuries sustained by mothers during childbirth that lead to urine and/or faecal incontinence. Due to the rapidly growing middle class in sub-Saharan Africa (SSA) and the corresponding quest for hospital delivery and caesarean section, surgery-related (iatrogenic) obstetric fistulas are on the rise. Worryingly, there is scanty data on surgery-related fistulas. This review aims to collate empirical evidence on the magnitude of iatrogenic obstetric fistulas in SSA, generate country-specific data and explore factors that influence obstetric surgery-related fistulas. All relevant databases, PubMed, LILACS, CINAHL, SCOPUS and Google Scholar will be searched from 1st January 2000 to 31st March 2024 using search terms developed from the major concepts in the title without restrictions by language. The Cochrane Library, African Journals Online, Data Base of African Thesis and Dissertations Including Research (DATAD-R D Space) and preprint repositories will also be searched. Reference lists of relevant studies will be searched and experts in the field will be contacted for additional (unpublished) studies. The search output will be exported to Endnote where duplicate studies will be removed. The deduplicated studies will be exported to Rayyan where study screening and selection will be conducted. At least two authors will independently select studies, extract data and assess quality in the included studies using pretested tools. Disagreements between reviewers will be resolved through discussion. Data analysis will be performed with RevMan 5.4. Comparative binary outcomes will be reported as odds ratio (OR) or risk ratio (RR) and for continuous outcomes, mean difference and standard deviations (SDs) will be used. Non-comparative studies will be analysed as weighted proportions. Heterogeneity between studies will be assessed graphically and statistically, and where a significant level is detected, the random-effects model meta-analysis will be performed. All estimates will be reported with their 95% confidence intervals (CIs). Where data permit, we will conduct subgroup and sensitivity analyses to test the robustness of the estimates on key quality domains. The overall quality of the evidence will be assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). This systematic review and meta-analysis uses rigorous methods and best practices to attempt to collate all empirical evidence and estimate country-specific proportions of iatrogenic (surgery-related) fistulas among obstetric fistula patients across countries in SSA. This review will explore context-specific variables, provide insights into their impact and relate them to the type and experience of personnel performing the obstetric procedures that lead to obstetric fistulas. The findings of the full review are expected to inform the development of national and regional Training Programs for Medical Officers, support the development of a consensus "minimum acceptable standard of care" and inform quality assurance standards for clinicians involved in the provision of surgical obstetric care.

Cardiac magnetic resonance for ventricular arrhythmias: a systematic review and meta-analysis

BackgroundCardiac magnetic resonance (CMR) allows comprehensive myocardial tissue characterisation, revealing areas of myocardial inflammation or fibrosis that may predispose to ventricular arrhythmias (VAs). With this study, we aimed to estimate...