Database Search Research Articles

Approaches, enablers and barriers to govern the private sector in health in low- and middle-income countries: a scoping review

IntroductionThe private sector plays a substantial role in delivering and financing healthcare in low- and middle-income countries (LMICs). Supporting governments to govern the private sector effectively, and so improve outcomes...

Abstract 4148089: Comparative Efficacy of Carvedilol versus Metoprolol in Patients with Implantable Cardioverter Defibrillators and Ventricular Arrhythmias: A Systematic Review and Meta-Analysis

Background: Ventricular arrhythmias are major causes of morbidity and mortality in patients with cardiovascular disease. Implantable cardioverter-defibrillators (ICDs) are commonly used to prevent sudden cardiac death in these patients. However, patients with ICDs frequently experience recurrent arrhythmias and inappropriate shocks, which can impact their quality of life. Beta-blockers, specifically carvedilol and metoprolol, are commonly prescribed to manage these arrhythmias. This meta-analysis aims to compare the impact of both medications in this patient population. Methods: A comprehensive literature search was conducted to identify relevant studies comparing carvedilol to metoprolol in patients with ventricular arrhythmias or ICDs. Study outcomes included all-cause mortality, recurrent ventricular arrhythmia, and inappropriate ICD shocks. Effect estimates are presented as hazard ratios (HR) with 95% confidence intervals (CI). Results: 1,453 studies were identified through database search. After full-text screening, a total of 5 studies involving 9,292 patients were included. We found no significant difference in the incidence of recurrent ventricular arrhythmias between carvedilol and metoprolol (HR = 0.99, 95% CI [0.75, 1.32], P = 0.97). Additionally, Carvedilol showed a trend toward reduction of all-cause mortality (HR = 0.83, 95% CI [0.68, 1.03], P = 0.09). On the other hand, Carvedilol was associated with a statistically significant reduction of inappropriate ICD shocks (HR = 0.61, 95% CI [0.48, 0.78], P < 0.001). Conclusion: Carvedilol may offer additional benefits over metoprolol in managing patients with ventricular arrhythmias or ICDs, particularly in minimizing the incidence of inappropriate ICD shocks. However, no significant difference was found in terms of all-cause mortality and recurrent ventricular arrhythmia incidence. Further research is needed to confirm these findings and guide clinical decision-making.

Abstract 4129733: Glucagon-like Peptide 1 Receptor Agonists Effect on Low-Density Lipoprotein Cholesterol and Total Cholesterol Levels Independent of Weight Reduction: A Meta-analysis and Meta-regression of Placebo-controlled Randomized Controlled Trials

Background: The impact of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on lipid components is unclear. The objective of this study was to measure the lipid-lowering effect of GLP-1RAs. Methods: A thorough database search was performed to identify placebo-controlled randomized controlled trials (RCTs) on GLP-1RA therapy through January 2023. From these trials, data was extracted and a robust statistical analysis was performed using a random effects model to determine outcomes with weighted mean difference (MD) in milligrams per deciliter (mg/dL) and 95% confidence intervals (CIs). The primary outcome was the mean difference in low-density lipoprotein cholesterol (LDL-C). Secondary outcomes were mean differences in total cholesterol (TC), triglycerides, high-density lipoprotein-C (HLD-C), and very low-density lipoprotein-C (VLDL-C). To account for covariates, subgroup analyses and meta-regression were performed. Results: A total of 33 studies were included in the final meta-analysis carried out between 2008 and 2023, which were conducted in 26 countries. Of the 5,918 participants, the study population comprised 2,603 (44%) males and 3,315 (56%) females, aged between 33.7 and 65.9 years. GLP-1RAs significantly reduced LDL-C compared to placebo (MD -2.93, 95% CI (-5.01, -0.85), P=0.01). Treatment effect was consistent regardless of duration of treatment;12 weeks or less MD: -5.39, 95% CI (-10.36, -0.42), P=0.03 vs >12 weeks MD: -2.39, 95% CI (-4.70, -0.007), P=0.04, P interaction 0.28). In our analysis, GLP-1RA reduced TC by ~7 mg/dl. There was no significant reduction in triglycerides (MD = -7.19, 95% CI (- 15.01, 0.62], P=0.07) and VLDL-C ~4 mg/dl (MD = -3.99, 95%, CI (-8.73, 0.75), P=0.10). Furthermore, GLP-1RA did not increase HDL-C (MD = -0.12, 95% CI (-0.73, 0.49], P=0.69. Regression analysis determined that weight loss did not affect the treatment effect on LDL-C (tau2=28.38, I2=99.83, R2=0.0, p=0.67), and total cholesterol (tau2=93.6, I2=99.86, R2=0.0, p=0.92). Conclusion: Patients on GLP-1RA experienced modest LDL-C and TC lowering compared to placebo. GLP-1RA did not decrease triglycerides and VLDL-C. GLP-1RA did not increase HDL-C.

Abstract 4137467: Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

Background: Intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) allows better visualization of atherosclerotic plaques than angiography alone. We conducted a systematic review and meta-analysis to comprehensively synthesize the available evidence regarding the efficacy of IVUS-guidance compared to angiography-guided PCI. Moreover, we conducted a sensitivity analysis to determine the applicability of IVUS guidance in complex PCI. Methods: We conducted a comprehensive literature search of major bibliographic databases from inception until May 2024 to identify randomized controlled trials (RCTs) comparing IVUS-guided versus angiography-guided PCI. Risk ratios (RR) with their corresponding 95% confidence intervals (CI) were pooled using the random-effects model, with a p-value <0.05 considered statistically significant. We conducted meta-regression to determine the moderating of baseline covariates on pooled outcomes. Results: Sixteen RCTs were included with 10,993 patients undergoing PCI (IVUS-guided PCI: 5684 patients; angiography-guided PCI: 5157 patients). IVUS-guided PCI demonstrated a significantly lower risk of cardiac death [RR: 0.49; 95% CI: 0.35, 0.68], major adverse cardiovascular events [RR: 0.64; 95% CI: 0.51, 0.80], myocardial infarction [RR: 0.73; 95% CI: 0.59, 0.89], stent thrombosis [RR: 0.45; 95% CI: 0.27, 0.75], target lesion revascularization [RR: 0.60; 95% CI: 0.49, 0.74], and target vessel revascularization [RR: 0.56; 95% CI: 0.45, 0.70] than angiography-guided PCI. IVUS-guided PCI demonstrated a nonsignificant trend toward a reduced risk of all-cause mortality [RR: 0.79; 95% CI: 0.61, 1.04]. Meta-regression showed a nonsignificant moderating effect of the duration of follow-up, age of patients, baseline dyslipidemia, and hypertension status on pooled outcomes. A sensitivity analysis was conducted for patients undergoing complex PCI. The sensitivity analysis showed the superiority of IVUS-guided PCI compared to angiography-guided PCI by resulting in a significant improvement in the clinical outcomes. Conclusion: This meta-analysis concluded that IVUS-guided PCI resulted in a reduction in cardiac death, major adverse cardiovascular events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization, compared to angiography-guided PCI. Moreover, we observed the superiority of IVUS guidance in complex PCI as well.

Abstract 4118611: Blood Pressure Lowering Effectiveness of Ultrasound Renal Denervation: A Systematic Review and Meta-analysis.

Background: Ultrasound Renal Denervation (uRDN) has emerged as an innovative therapeutic modality for resistant hypertension. However, there is uncertainty regarding the effectiveness of this procedure compared to other renal denervation techniques. We aimed to evaluate the effectiveness of uRDN especially on ambulatory and daytime blood pressure. Objectives: given the need for clarity in treatment approaches, our study aimed to evaluate the impact of ultrasound renal denervation particularly on ambulatory and daytime blood pressure in patients with hypertension. Methods: we conducted a systematic search of Embase, PubMed, and Cochrane Library databases up to March 2024 to identify randomized controlled trials (RCT) evaluating the effectiveness of uRDN. Statistical analyses were performed using RevMan 6.3 software, utilizing the mean and standard deviation method to calculate mean differences (MD) with a 95% confidence interval (CI). Results: four studies were included in the final analysis, involving 648 patients. Ultrasound renal denervation reduced daytime ambulatory SBP (5.12 mmHg; 95% CI -6.07 to -4.16, p = < 0.00001), 24 hours SBP (-4.87 mmHg; 95% CI 6.53 to -3.20, p = < 0.00001), office SBP (-5.03 mmHg; 95% CI -6.27 to -3.79, p = < 0.00001) at 2 months after the procedure and showed a decrease in patient medication at 6 months after the procedure. Conclusions: the use of uRND decreases the blood pressure among patients within 2-3 months following the procedure. However, after 6-months of procedure, there is no further significant reduction in blood pressure, although there is a notable decrease in medication. With this data, it is reassuring to conclude that endovascular uRDN using upgraded catheter technologies with the refinement of contemporary procedural techniques has improved the BP-lowering efficacy and safety of RDN during a 3 to 6-month follow-up, with decrease short-term need in medications. The impact of uRDN on the long term deserves further investigation.

Efficacy and safety of multi-day antiemetic treatment for patients undergoing multi-day chemotherapy: a systematic review of Clinical Practice Guidelines for Antiemesis 2023 from Japan Society of Clinical Oncology.

A standardized multi-day antiemetic regimen for multi-day chemotherapy remains elusive. This systematic review evaluated the efficacy and safety of multi-day antiemetic regimens in patients undergoing multi-day intravenous chemotherapy. We conducted a comprehensive search of PubMed, Cochrane Library, and Ichushi-Web databases for relevant studies published from January 1990 to December 2020. We included studies comparing multi-day and single-day antiemetic regimens for preventing chemotherapy-induced nausea and vomiting. No studies directly comparing multi-day versus single-day antiemetic regimens were found. Despite expanding control group criteria beyond "single-day antiemetic therapy" limited high-quality studies and variations in cancer types, chemotherapy regimens, and antiemetic treatments precluded meta-analysis. Among the included studies, some randomized controlled trials (RCTs) focused on complete response and vomiting rates. Two studies comparing two- and three-drug combinations reported higher complete response and no-vomiting rates with the three-drug regimen. Limited RCTs explored "nausea control" and "cost," and assessing "adverse events" proved challenging due to inconsistent reporting. The research on multi-day antiemetic therapy is limited, necessitating further investigation. Nonetheless, our findings suggest that three-drug combination therapy, including aprepitant, may offer superior antiemetic efficacy compared to two-drug regimens. Multi-day antiemetic therapy is strongly recommended during multi-day intravenous administration of cytotoxic anticancer drugs.

Abstract 4135465: Efficacy of SGLT-2 inhibitors combined with percutaneous coronary intervention on clinical and echocardiographic parameters in patients with acute myocardial infarction: A systematic review and meta-analysis

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have shown benefits in improving cardiovascular outcomes in heart failure (HF) patients and may mitigate symptom progression in myocardial infarction (MI). However, their efficacy in acute MI patients undergoing percutaneous coronary intervention (PCI) is unclear. This study aims to evaluate whether SGLT2i combined with PCI improves clinical and echocardiographic outcomes. Methods: A comprehensive search of electronic databases, PubMed, Cochrane Central and SCOPUS was conducted from inception till May 2024. The study was conducted adhering to the PRISMA guidelines. The clinical benefit of PCI plus SGLT2i was assessed through risk reduction of acute kidney injury (AKI), CV death (CVD), hospitalization due to HF (hHF), all-cause mortality (ACM), and revascularization. Echocardiographic outcomes assessed were change in left ventricular ejection fraction (LVEF) and LV end-diastolic volume (LVEDV). Results were presented as risk ratios (RR) along with their 95% CI for dichotomous data while weighted mean difference (WMD) were reported for continuous outcomes. The data was aggregated using a random effects model. Results: Our analysis included eleven records comprising 6,411 participants. The results indicated that PCI plus SGLT2i significantly reduced the risk of AKI (RR: 0.66, 95% CI: [0.52, 0.83], p<0.01) and ACM (RR: 0.54, 95% CI: [0.4, 0.7], p<0.01) compared to PCI alone. However, the reduction in risk for CVD was not statistically significant (RR: 0.56, 95% CI: [0.2, 1.1], p=0.09), as was the case for hHF (RR: 0.65, 95% CI: [0.3, 1], p=0.07). Additionally, there was no significant difference in the risk of revascularization between the two groups (RR: 2.9, 95% CI: [0.62, 14.39], p=0.17). PCI plus SGLT2i was also significantly associated with an increase in LVEF (WMD: 2.73, 95% CI: [1.09, 4.36], p<0.01) and decrease in LVEDV (WMD: -8.0, 95% CI: [-13.17, -2.90], p<0.02). Conclusion: Our study demonstrates that SGLT2i administration in MI patients undergoing PCI leads to improved renal and mortality outcomes, along with enhanced cardiac function. These benefits are hypothesized to result from kidney-mediated natriuretic effects, improved blood flow regulation, reduced endothelial dysfunction, and decreased arterial stiffness, which optimize cardiac function. We recommend future studies with larger sample sizes and longer follow-ups to assess the long-term benefits of SGLT2i combined with PCI.

Abstract 4144581: Diltiazem, Direct Oral Anticoagulants and Risk of Major Bleeding in Patients with Atrial Fibrillation

Background: Existing research suggests a potential increase in bleeding risk associated with the combined use of calcium channel blockers (CCBs) and direct oral anticoagulants (DOACs). However, the evidence remains inconclusive and conflicting. To clarify this relationship, we conducted a meta-analysis to investigate the risk of major bleeding in patients with atrial fibrillation (AF) using diltiazem. Methods: We conducted a comprehensive search of major electronic databases, including PubMed, Embase, and the Cochrane Library, from their inception through April 20, 2024 for relevant studies. The primary endpoint was major bleeding, defined as a composite of bleeding-related hospitalization, requiring blood transfusion, or fatal bleeding. We conducted a conventional meta-analysis using the Hartung-Knapp-Sidik-Jonkman random-effects model. Endpoints are expressed as hazard ratio (HR) and their corresponding confidence intervals (CI). Results: A total of 5 studies with 488,884 patients with AF were included in our study, of which 23.4% of patients were on diltiazem. All patients were also on DOACs. Results of the meta-analysis showed that there was no statistically significant difference between use of diltiazem and the risk of major bleeding (HR 1.16 ; 95% CI 0.94-1.42). Sensitivity analysis showed that this result remained unaltered in terms of magnitude and direction after excluding one study at a time. When stratified by type of control group, both active comparator (HR 1.09 ; 95% CI 0.92-1.30) and non-use subgroups (HR 1.24 ; 95% CI 0.87-1.77) showed that there was no significant difference in the risk of major bleeding with diltiazem use respectively. Conclusion: We observed that there was no significant difference in the risk of major bleeding in diltiazem use compared to controls in AF patients on DOACs. Further large-scale, longitudinal, and prospective studies are essential to validate these findings.

Abstract 4131100: Effect of metabolic surgery on cardiovascular outcomes in people with obesity and pre-existing cardiovascular disease: A systematic review and meta-analysis

Background: Previous literature shows that metabolic surgery effectively decreases the risk of cardiovascular disease (CVD) events in patients with obesity. The use of metabolic surgery has, however, been limited in people with obesity and pre-existing CVD due to concerns of poor post-operative cardiovascular outcomes. This study aims to determine the effectiveness and safety of metabolic surgery in patients with pre-existing CVD. Methods: A search of electronic databases, PubMed, Cochrane Central and SCOPUS was conducted from their inception till May 2024. The study was conducted adhering to the PRISMA guidelines. Outcomes of interest were risk of all-cause mortality, major adverse cardiovascular events (MACE), risk of myocardial infarction (MI), and cerebrovascular events in patients with and without prior CVD undergoing bariatric surgery. Data was pooled as generic inverse variance using a random effects model, and presented as hazard ratios (HR) with their 95% confidence intervals (CI). Results: We included four studies in our analysis (n = 5,244). Our pooled analysis shows that metabolic surgery leads to significant reduction in risk of all-cause mortality (HR = 0.51, 95% CI: [0.42, 0.61]; p<0.01). We also observed a significant risk reduction of 43% in MACE with metabolic surgery (HR = 0.57, 95% CI: [0.5, 0.64]; p<0.01). Metabolic surgery was not associated with a significant reduction in the risk of MI (HR = 0.53, 95% CI: [0.24, 1.18]; p = 0.12, I 2 = 83%). Similarly, a non-significant decrease in risk of cerebrovascular events was observed with metabolic surgery (HR = 0.89, 95% CI: [0.65, 1.22]; p = 0.48) Conclusion: Metabolic surgery is associated with decreased risk of all-cause mortality and MACE in patients with obesity and established CVD. These results are thought to be mediated through reduction in risk factors such as obesity, but also by reducing inflammatory mediators and having other beneficial effects on cardiac structure and left ventricular workload.

Abstract 4134873: Olezarsen for Hypertriglyceridemia in Patients at High Cardiovascular Risk - A Systematic Review and Meta Analysis

Background: Hypertriglyceridemia, a common lipid disorder linked to increased risks of cardiovascular diseases and metabolic syndrome, remains a global health challenge. Traditional treatments, though widely used, often have limited efficacy and adverse effects. Olezarsen, a novel antisense oligonucleotide, targets apolipoprotein C-III and shows promise in significantly reducing triglyceride levels. Aim: To conduct a meta-analysis comparing Olezarsen with placebo in patients with hypertriglyceridemia. Methods: We performed an extensive literature search of PubMed, EMBASE, and Cochrane Library databases up to May 2024 to identify studies comparing Olezarsen and placebo in patients with hypertriglyceridemia, irrespective of comorbid cardiovascular disease. Effect estimates were pooled using a random-effects model and reported as risk ratios (RR) for dichotomous outcomes and standard mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs) for each. Results: Three randomized controlled trials (RCTs) with a total of 334 participants were included. Olezarsen significantly reduced triglyceride levels at 6 months (SMD: -1.69; 95% CI -2.22 to -1.17; P < 0.00001; Figure ) and 12 months (SMD: -1.64; 95% CI -2.22 to -1.07; P < 0.00001; Figure ). VLDL levels also decreased at 6 months (SMD: -1.95; 95% CI -2.38 to -1.51; P < 0.00001) and 12 months (SMD: -0.83; 95% CI -1.13 to -0.53; P < 0.00001). Lipid profile improvements included reductions in total cholesterol, non-HDL cholesterol, and apoB levels, with increases in HDL cholesterol and apoA-1. Adverse events were comparable between Olezarsen and placebo, although serious adverse events were significantly higher in the Olezarsen group (RR: 2.55; 95% CI 1.17 to 5.58; p = 0.02). Conclusion: Olezarsen demonstrates significant efficacy in reducing triglyceride and VLDL levels while improving overall lipid profiles in hypertriglyceridemia patients. Despite higher rates of serious adverse events, its overall safety profile remains acceptable.

Abstract 4117690: Cardiac Rupture as a Life-Threatening Outcome of Takotsubo Syndrome: A Systematic Review.

Background: Takotsubo syndrome is a reversible cause of heart failure; however, a low percentage of patients can develop serious complications, including cardiac rupture. Aims: Analyze case reports or case series of cardiac rupture in patients with Takotsubo syndrome, detailing patient characteristics to uncover risk factors and prognosis for this severe complication. Methods: We conducted a systematic search of MEDLINE and Embase databases to identify case reports or case series of patients with Takotsubo syndrome complicated by cardiac rupture, from inception to October 2023. Results: We identified 39 reported cases, including 44 subjects (40 females; 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity. An emotional trigger was present in 15 (34%) subjects and common admission symptoms were chest pain (35 [80%]) and dyspnea (14 [32%]). ST-segment elevation was present in 39 (93%) of 42 cases, with the anterior myocardial segments (37 [88%]) being the most compromised, followed by lateral (26 [62%]) and inferior (14 [33%]) segments. The mean left ventricular ejection fraction was 40±13% and an apical ballooning pattern was observed in all (100%) ventriculographies. The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery treatment was attempted in 16 (36%) cases, and 28 (64%) patients did not survive (Figure). Conclusions: Cardiac rupture as a complication of Takotsubo syndrome is a rare clinical condition associated with high mortality. Elderly females, especially from White/Caucasian or East Asian/Japanese descent, presenting with ST-segment elevation in the anterior or lateral leads, and an apical ballooning pattern, are disproportionally affected. Additional studies with prospective collection of patient-level data are needed to better identify those at increased risk for cardiac rupture associated with Takotsubo syndrome and to address ways to improve mortality rates in this population.

UHPLC-QTOFMS Urine Drug Screening With Dilute-and-Shoot Sample Preparation and Vacuum-Insulated Probe-Heated Electrospray Ionization.

We developed a method for comprehensive urine drug screening by applying dilute-and-shoot extraction and vacuum-insulated probe-heated electrospray ionization with ultra-high performance liquid chromatography high-resolution quadrupole time-of-flight mass spectrometry (DS-UHPLC-VIP-HESI-QTOFMS). The method involved five-fold post-hydrolysis dilution of urine samples and chromatography on a C18 UHPLC column prior to QTOFMS analysis. The recently introduced VIP-HESI ion source was chosen due to its enhanced ionization efficiency and compatibility with UHPLC-QTOFMS. Extensive data was acquired in positive ion mode with a low collision energy (7 eV) and an elevated collision energy (30 eV), using the broadband collision-induced dissociation data acquisition scan mode that continuously generated high-resolution and accurate mass for parent and fragment qualifier ions, and parent ion isotopic patterns. Compound identification was performed against an in-house database with 1263 compound entries, using an automated post-run reverse target database search with preset identification criteria. Method validation with 56 different drugs showed acceptable results for the limit of identification (median 5 ng/mL), matrix effects (70-130%), repeatability of retention times (< 1%), mass accuracy (< 1 mDa), as well as for specificity and stability. As compared with an established UHPLC-QTOFMS method relying on solid-phase extraction and conventional electrospray ionization, DS-UHPLC-VIP-HESI-QTOFMS produced comparable results from authentic clinical urine samples for most drugs, but showed clearly improved detectability for pregabalin, gabapentin, and ritalinic acid. We anticipate that the new method will be a step forward for laboratories performing routine urine drug screening due to its fast turnaround time, reduced manual workload, cost efficiency, and broad substance coverage.

Association Between Gallstone Disease and Kidney Stone Disease: A Systematic Review and Meta-analysis

Background and aims: Gallstone disease (GSD) and kidney stone disease (KSD) have increased due to lifestyle in recent decades. This systematic review and meta-analysis aimed to investigate the association between these two diseases. Methods: A comprehensive electronic database search was conducted before August 25, 2024. This systematic review and meta-analysis included observational studies. The meta-analysis employed a random-effects model to compute the overall summary estimates of the association between GSD and KSD using risk ratios with 95% confidence intervals (CIs) as the primary measure of the effect size. Heterogeneity was evaluated using chi-square tests, the I² statistic, and forest plots. Publication bias was assessed through Begg’s and Egger’s tests. A P value of less than 0.05 was considered statistically significant, and all analyses were performed using Stata 17 software. Results: The meta-analysis included 9 studies encompassing 982847 participants. The pooled analysis revealed a statistically significant association between GSD and KSD, with a risk of 1.78 (95% CI: 1.572.03, P≤0.001). Begg’s and Egger’s tests demonstrated no significant bias (Begg’s test P=0.835, Egger’s test P=0.812). Variables such as study year, sample size, mean age of participants, mean follow-up, and study quality as determined by the Newcastle-Ottawa Scale (NOS) were examined, but none could significantly impact heterogeneity (P&gt;0.10). Conclusion: This systematic review and meta-analysis provide evidence of a significant association between GSD and KSD. Therefore, further investigation into the underlying mechanisms and potential risk factors is necessary.

Balancing between reality, ideality, and equity: critical reflections from recruiting key informants for qualitative health research.

Key informant interviews (KII) are a widely used method in qualitative health research to gain in-depth insights from individuals with specialized knowledge, experience, or access that is crucial to the research topic. However, there is growing criticism regarding how the selection of key informants is insufficiently described in research. This opacity is problematic as the authority and knowledge of key informants may be given undue weight in research findings, potentially overshadowing other non-expert samples. The resulting imbalance in representation can lead to favoring certain viewpoints while marginalizing others, and thereby reinforcing existing inequities. Using our KII study as an example, we demonstrate how we initially composed an ideal sample based on theoretical considerations and subsequently operationalized it in the field. We employed a selective recruitment strategy informed by intersectional theory, targeting physicians with migration backgrounds from Middle Eastern countries for a study on cancer prevention and screening. Our recruitment process combined direct methods, including database searches and email outreach, with indirect methods like snowball sampling and engagement with multipliers. The recruitment strategy was iterative, allowing for ongoing assessment and adaptation to ensure a diverse and representative sample. The KII study successfully recruited 21 physicians with diverse social categories, including different genders, migration backgrounds, language skills, and medical specialties. Direct recruitment was more effective than indirect methods and allowed for greater control in reaching out to specific subsamples. It highlights the importance of flexible and persistent recruitment strategies to achieve the desired sample. This KII study underscores the interplay between methodological ideals and the practical realities of recruiting a diverse, carefully composed sample of key informants in health research. Our intersectional approach aimed to ensure equitable representation by considering power dynamics and refining recruitment strategies, while balancing the challenges of real-world fieldwork-such as engaging busy physicians with specific recruitment criteria-with practical adaptability. Our KII study emphasizes the need for ongoing reflexivity to balance ideality and equity with practical feasibility.

Meta-Analysis: Prevalence of Frailty and Associated Adverse Events in Inflammatory Bowel Diseases.

The number of adults aged over 60 years with inflammatory bowel disease (IBD) is increasing. Frailty, rather than chronological age, may be a better predictor of adverse health outcomes. To summarise current knowledge about frailty in adults with IBD including the prevalence and associations of frailty and IBD-related adverse outcomes. We performed an electronic search of MEDLINE, EMBASE and EMBASE Classic databases using search terms for IBD and frailty from inception to 14 February 2024. All studies involving adults aged ≥ 16 with a confirmed diagnosis of IBD that included a frailty assessment were eligible for inclusion. We included 23 observational studies involving 1,893,448 adults. Risk of bias was low for 18 studies and moderate for five. Twelve methods of frailty assessment were used, the most common being the Hospital Frailty Risk Score. Pooled prevalence of frailty in IBD patients was 18% (95% confidence interval (CI) 12.4%-25.6%). Meta-analysis of unadjusted events data demonstrated that frailty increased the risk of infection-related admissions following treatment in two studies (relative risk (RR) 1.9; 95% CI 1.2-3.0), post-operative morbidity in three (RR 2.0; 95% CI 1.4-2.7) and mortality in seven (RR 4.3; 95% CI 2.6-7.4). Frailty is common in patients with IBD and is associated with IBD-related adverse outcomes including infection-related admissions following treatment, post-operative morbidity and death. Future work should focus on developing risk assessment tools to better support decision making for older people with frailty and IBD.

Outcomes of external versus internal fixation for traumatic lower limb fractures in low- and middle-income countries.

Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation. This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available. The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care.

The effect of virtual reality for anxiety and pain in dentistry: A systematic review and meta-analysis.

This study aimed to assess the impact of virtual reality (VR) on reducing anxiety and pain in dental patients across all age groups and dental procedures. Systematic review with comprehensive search of PubMed and Cochrane Library databases for randomized controlled trials (RCTs) comparing VR interventions with non-VR methods in dental settings up to April 2024. The selection followed the PRISMA-P guidelines. Inclusion criteria were based on the PICOS framework, focusing on studies involving dental patients of any age, utilizing VR during dental treatments, and reporting outcomes on anxiety and pain. Data extraction and quality appraisal were performed independently by two reviewers using the ROB-2 tool and GRADE methodology. Meta-analyses used a random-effects model. Twenty-seven studies met the inclusion criteria, encompassing several dental treatments. In meta-analysis VR reduced anxiety in children (SMD -1.44, 95% CI -2.24 to -0.63) but not adults (SMD -0.35, 95% CI -1.11 to 0.4). For pain reduction, VR was effective in both children (SMD -1.11, 95% CI -1.65 to -0.57) and adults (SMD -0.59, 95% CI -1.187 to -0.001). Heterogeneity was high across studies, and evidence quality ranged from low to moderate. VR is a promising intervention for reducing anxiety and pain in children during dental procedures. Its effectiveness in adults is limited to pain reduction. High heterogeneity and risk of bias suggest that findings should be interpreted with caution. Further research is needed to standardize VR content and explore its varying impacts across different age groups and dental procedures.

Over-the-Scope Clips vs Standard Endoscopic Interventions for First-line Treatment of NVUGI Bleeding: A Meta-analysis of Randomized Trials

Background and Aims: Recently, over-the-scope clips (OTSCs) have been extensively studied for hemostasis of nonvariceal upper gastrointestinal bleeding (NVUGIB). Our goal was to compare the efficacy of OTSCs with standard endoscopic interventions (SEIs) as first-line treatments. Methods: A comprehensive search of electronic databases was performed to identify Randomized Clinical Trials (RCTs) comparing OTSCs with SEIs as first-line therapy for NVUGIB. This search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results: Out of 819 reviewed studies, 5 RCTs comprising a total of 555 patients (277 OTSCs vs. 278 SEIs) were included. The OTSC group had a lower 30-day rebleeding rate (Risk Ratio [RR]: 0.43; 95% Confidence Interval [CI]: 0.24, 0.77; I²: 0%; p = 0.004) and a higher clinical success rate (RR: 1.19; 95% CI: 1.11, 1.28; I²: 0%; p &lt; 0.00001). There was no significant difference in technical success (RR: 1.06; 95% CI: 0.98, 1.14; I² = 73%; p = 0.13), 30-day all-cause mortality (RR: 0.50; 95% CI: 0.22, 1.14; I²: 0%; p = 0.10), need for further intervention (RR: 1.22; 95% CI: 0.43, 3.47; I²: 0%; p = 0.71), or length of hospital stay (Mean Difference: 0.31; 95% CI: -1.08, 1.70; I²: 0%; p = 0.66). The risk of bias, which was assessed using the Cochrane Risk of Bias 2.0 tool, indicated some concerns of bias. Conclusion: OTSCs are more efficient than SEIs as a first-line treatment in terms of rebleeding within 30 days and clinical success rates.

The influence of dental fluorosis on shear bond strength: a systematic review protocol

Dental fluorosis, a condition characterized by enamel hypoplasia caused by excessive fluoride intake, can potentially affect the adhesion of dental materials. This systematic review aimed to assess the influence of dental fluorosis on shear bond strength (SBS) and to provide clinical recommendations. A comprehensive search of electronic databases was conducted, followed by a rigorous selection process to include relevant in vitro studies. The quality of the included studies was assessed and data were extracted for analysis. Based on these findings, it is recommended to consider alternative bonding techniques or to use specific dental materials for fluorosis-affected teeth. Further research is needed to elucidate the mechanisms underlying the potential impact of dental fluorosis on shear bond strength and develop more targeted clinical strategies.

Comparison of adjuvant treatment regimens for high-risk hepatocellular carcinoma: a Bayesian network meta analysis and systematic review

BackgroundThe five-year recurrence rate for patients with hepatocellular carcinoma (HCC) is as high as 70%. Patients with high-risk recurrence factors experience significantly poorer prognosis. Local regional therapies, including transarterial chemoembolisation (TACE), hepatic arterial infusion chemotherapy (HAIC), radiotherapy, and emerging immunotherapy, are commonly used adjuvant treatment options. We conducted an indirect comparison of these adjuvant therapies for such patients.MethodsWe conducted a systematic search in public databases for relevant studies and assessed the efficacy and safety of the corresponding therapies by consolidating disease-free survival (DFS), overall survival (OS), and adverse events (AEs).ResultsA total of eight randomised controlled trials were ultimately included. The Gelman-Rubin plot and kernel density estimation indicate that the stability of the combined model is satisfactory.Conclusionimmunotherapy is not inferior to local regional therapies in delaying tumour recurrence, however, the higher incidence of AEs remains a significant concern. Adjuvant radiotherapy demonstrated superior efficacy in delaying tumour recurrence compared to adjuvant TACE, although further support from phase III clinical trial evidence is required.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42024576316.