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Zhou L, Fu Y, Zhang J, Wu Y, Gong X, Pan C, Wei A, Wang Y, Zhu T, Li H. Effects of Different Types of Medications on Olfactory Dysfunction in CRSwNP: A Systematic Review and Network Meta-Analysis. Laryngoscope 2025. [PMID: 40421816 DOI: 10.1002/lary.32289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 04/01/2025] [Accepted: 05/06/2025] [Indexed: 05/28/2025]
Abstract
OBJECTIVE To evaluate the efficacy of various pharmacological treatments for olfactory disorders in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). DATA SOURCES PubMed, Embase, Cochrane Library, and Web of Science. METHODS We searched the related literature in PubMed, Embase, Cochrane Library, and Web of Science up to Aug 2024 to appraise the effects of pharmacotherapy on olfactory sensation. After that, two reviewers independently screened the retrieved articles, extracted the pertinent data, and assessed the risk of bias in the included studies. Then we used Stata 14.2 to perform a network meta-analysis. RESULTS Ninteen randomized controlled trials (RCTs) and 2354 participants were included. Compared with placebo, biologics demonstrated the most significant improvement in subjective olfactory dysfunction (OD) [standardized mean difference (SMD) = -0.75, 95% confidence intervals (CI) (-1.08, -0.41)]. In terms of objective olfactory function improvement, biologics also exhibited the greatest effect (SMD = 0.93, 95% CI [0.56, 1.31]). Among various biologics, dupilumab was the most effective in alleviating both subjective OD (SMD = -1.30, 95% CI [-1.51, -1.09]) and objective OD (mean difference [MD] = 11.13, 95% CI [9.91, 12.35]). CONCLUSIONS Our research results indicated that biologics might show better performance in terms of improving the olfactory sensation of patients with CRSwNP, particularly dupilumab. However, given the limitations of this study, future research should employ more standardized olfactory assessment methods and conduct more large-scale RCTs, ultimately guiding clinicians and patients in making informed and optimal treatment choices. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Lei Zhou
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yijie Fu
- School of Preclinical Medicine, Chengdu University, Chengdu, Sichuan, China
| | - Jing Zhang
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yuqi Wu
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xinru Gong
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Chongsheng Pan
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Aiming Wei
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Yang Wang
- School of Sports Medicine and Health, Chengdu Sport University, Chengdu, Sichuan, China
| | - Tianmin Zhu
- School of Health Preservation and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Hui Li
- School of Preclinical Medicine, Chengdu University, Chengdu, Sichuan, China
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Doleman B, Jakobsen JC, Mathiesen O, Cooper N, Sutton A, Hardman J. Methodologies for network meta-analysis of randomised controlled trials in pain, anaesthesia, and perioperative medicine: a narrative review. Br J Anaesth 2025; 134:1029-1040. [PMID: 39979151 PMCID: PMC11947594 DOI: 10.1016/j.bja.2024.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Revised: 12/02/2024] [Accepted: 12/13/2024] [Indexed: 02/22/2025] Open
Abstract
Network meta-analysis has emerged as a method for analysing clinical trials, with a large increase in the number of publications over the past decade. Network meta-analysis offers advantages over traditional pairwise meta-analysis, including increased power, the ability to compare treatments not compared in the original trials, and the ability to rank treatments. However, network meta-analyses are inherently more complex than pairwise meta-analyses, requiring additional statistical expertise and assumptions. Many factors can affect the certainty of evidence from pairwise meta-analysis and can often lead to unreliable results. Network meta-analysis is prone to all these issues, although it has the additional assumption of transitivity. Here we review network meta-analyses, problems with their conduct and reporting, and methodological strategies that can be used by those conducting reviews to help improve the reliability of their findings. We provide evidence that violation of the assumption of transitivity is relatively common and inadequately considered in published network meta-analyses. We explain key concepts with clinically relevant examples for those unfamiliar with network meta-analysis to facilitate their appraisal and application of their results to clinical practice.
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Affiliation(s)
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark & Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital Køge, Køge, Denmark; Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Nicola Cooper
- Complex Reviews Synthesis Unit (CRSU), Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Alex Sutton
- Complex Reviews Synthesis Unit (CRSU), Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
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Qiu Y, Xue T, Bai Y, Han C, Xie M, Teng H, Yin Z, Chen Z, Zhang J, Wang Z. Comparison of different surgical strategies for cervical dystonia: Evidence from Bayesian network analysis. Eur J Neurol 2025; 32:e16527. [PMID: 39535380 PMCID: PMC11622514 DOI: 10.1111/ene.16527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 10/03/2024] [Accepted: 10/07/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND AND PURPOSE Several surgical techniques have been used to treat cervical dystonia (CD), however, to date, the optimal surgical technique for CD remains controversial. We therefore conducted the first network meta-analysis to compare different surgical strategies for CD to inform clinical practice. METHODS Electronic databases were searched for surgical strategies for treating CD. The primary outcome was improvement in total Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score. Subgroup analysis was performed to compare short-term (< 1 year) and long-term (≥ 1 year) outcomes. Safety outcomes included surgery-related adverse events (AEs). RESULTS A total of 55 trials with 2032 patients employing five surgical strategies were identified, including globus pallidus internus (GPi)/subthalamic nucleus (STN)-deep brain stimulation (DBS), selective peripheral denervation (SPD), microvascular decompression (MVD) and pallidotomy. All strategies led to significant improvement in total TWSTRS score (mean improvement range 18.65-28.22). GPi-DBS showed significantly greater enhancement than SPD for the whole dataset (mean difference [MD] 7.03, 95% credible interval [Crl] 1.53-12.56), while both GPi-DBS (MD 8.05, 95% Crl 2.35-13.80) and STN-DBS (MD 10.71, 95% Crl 2.22-19.20) exhibited more long-term improvement than SPD. Regarding safety outcomes, GPi/STN-DBS and MVD were associated with fewer surgery-related AEs than SPD (ln odds ratio range -1.68 to -1.41). CONCLUSION We conclude that DBS should be the preferred surgical option for CD, and the STN is a promising alternative target choice due to its comparable efficacy with the GPi. However, more direct evidence is still required.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
| | - Tao Xue
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Yutong Bai
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Chunlei Han
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Minjia Xie
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
| | - Haiyin Teng
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
| | - Ziqian Yin
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
| | - Zhouqing Chen
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research LaboratoryThe First Affiliated Hospital of Soochow UniversityJiangsuChina
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Carvalho PEP, Gewehr DM, Nascimento BR, Melo L, Burkhardt G, Rivera A, Braga MAP, Guimarães PO, Mehran R, Windecker S, Valgimigli M, Angiolillo DJ, Bhatt DL, Sandoval Y, Chen SL, Stone GW, Lopes RD. Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. JAMA Cardiol 2024; 9:1094-1105. [PMID: 39382876 PMCID: PMC11581547 DOI: 10.1001/jamacardio.2024.3216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/02/2024] [Indexed: 10/10/2024]
Abstract
Importance The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate. Objectives To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis. Data Sources MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024. Study Selection Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT. Data Extraction and Synthesis This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA). Main Outcomes and Measures The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding. Results A total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21). Conclusion and Relevance Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.
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Affiliation(s)
- Pedro E. P. Carvalho
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Douglas M. Gewehr
- Department of Internal Medicine, Federal University of Paraná, Curitiba, Brazil
| | - Bruno R. Nascimento
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Interventional Cardiology Department, Hospital Madre Teresa, Belo Horizonte, Brazil
| | - Lara Melo
- Department of Internal Medicine, Connecticut University, Farmington
| | | | - André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Marcelo A. P. Braga
- Department of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Roxana Mehran
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
- Associate Editor, JAMA Cardiology
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- The Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- The University of Bern, Bern, Switzerland
| | | | - Deepak L. Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yader Sandoval
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Shao-Liang Chen
- Nanjing Medical University and Nanjing First Hospital, Nanjing, China
| | - Gregg W. Stone
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Renato D. Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Florez ID, De La Cruz-Mena JE, Veroniki AA. Network meta-analysis: a powerful tool for clinicians, decision-makers, and methodologists. J Clin Epidemiol 2024; 176:111537. [PMID: 39307403 DOI: 10.1016/j.jclinepi.2024.111537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/18/2024] [Accepted: 09/16/2024] [Indexed: 10/27/2024]
Abstract
Network Meta-analysis (NMA) is an advanced statistical method that combines direct evidence (ie, from head-to-head comparisons) and indirect evidence (ie, estimated from the direct available evidence) to obtain network estimates. NMAs are helpful to determine the comparative effectiveness of interventions that have not been directly compared and may provide more precise estimates for those comparisons that have been directly compared. NMA provides hierarchies which can be helpful for decision-making, much more in scenarios when multiple interventions exist for the same indication. In this article we provide a summary of the key concepts that users, namely, clinicians and methodologists need to consider when using an NMA to inform decision making.
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Affiliation(s)
- Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia; Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellin, Colombia; School of Rehabilitation Science, McMaster University, Hamilton, Canada.
| | | | - Areti-Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Toronto, Ontario, Canada; Institute of Health Policy Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario, Canada
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Burkhardt BE, Hummel J, Rücker G, Stiller B. Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric patients undergoing surgery for congenital heart disease: a network meta-analysis. Cochrane Database Syst Rev 2024; 11:CD013707. [PMID: 39588800 PMCID: PMC11590178 DOI: 10.1002/14651858.cd013707.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2024]
Abstract
BACKGROUND Paediatric patients undergoing surgery for congenital heart disease (CHD) are at risk for postoperative low cardiac output syndrome (LCOS) and mortality. LCOS affects up to 25% of children after heart surgery. It consists of reduced myocardial function and increases postoperative morbidity, prolongs mechanical ventilation, and lengthens the duration of intensive care unit (ICU) stay. Pharmacological prophylaxis involves inotropes, including catecholamines, phosphodiesterase III inhibitors, or calcium sensitisers, to enhance myocardial contractility. It is unclear whether they are effective in preventing LCOS or death in this vulnerable population. OBJECTIVES 1. To evaluate the relative benefits and harms of inotropes for the prevention of LCOS and mortality in paediatric patients undergoing surgery for CHD. 2. To generate a clinically useful ranking of prophylactic inotropes for the prevention of LCOS and mortality in paediatric patients undergoing surgery for CHD according to benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Web of Science, and clinical trial registries, most recently in December 2023 and April 2024. We also checked reference lists from identified studies and review articles. We did not apply any language restrictions. SELECTION CRITERIA We included randomised controlled trials comparing inotropes from one drug class (catecholamines, phosphodiesterase type III inhibitors, calcium sensitisers) to another (either alone or in combination) or placebo, in paediatric patients (birth to 18 years of age) undergoing surgery for CHD. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data, assessed risk of bias, and rated the certainty of evidence using the CINeMA framework. We performed random-effects network and pairwise meta-analyses comparing the relative effects of each possible pair of medications with each other or placebo. Where meta-analysis was not possible, we provided a narrative description of the results. We ranked the prophylactic medications according to their effects relative to each other. The primary outcomes were all-cause mortality within 30 days, time to death, and LCOS incidence; secondary outcomes were length of ICU stay, length of hospital stay, duration of mechanical ventilation, inotrope score, mechanical circulatory support, and adverse events. MAIN RESULTS We included 13 studies with 937 participants. All except two multicentre studies were conducted at single tertiary care hospitals. Participants comprised children from birth to 14 years of age undergoing surgery for different types of CHD on cardiopulmonary bypass. Five studies compared levosimendan versus milrinone; two compared levosimendan versus placebo; two compared milrinone versus placebo (one comparing two different doses); one compared levosimendan versus dobutamine, another milrinone versus dobutamine. Two studies used combinations of inotropes. Study duration was between less than one year and 5.3 years, with follow-up mostly during ICU or hospital stay. Funding sources included governmental bodies and hospital departments, but also drug manufacturers. We downgraded the certainty of evidence for high risk of bias at study level, or imprecision at comparison level. Primary outcomes Compared to placebo, levosimendan likely results in a large reduction in mortality (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.15 to 2.13) and milrinone likely results in no difference (RR 0.97, 95% CI 0.11 to 8.49), whereas for dobutamine, no effect was estimable; all moderate-certainty evidence (9 studies, 557 participants, 14 events). LCOS was largely reduced with levosimendan (RR 0.45, 95% CI 0.24 to 0.83; high-certainty evidence), likely largely reduced with milrinone (RR 0.46, 95% CI 0.24 to 0.89; moderate-certainty evidence), and may be reduced with low-dose milrinone (RR 0.7, 95% CI 0.39 to 1.28; low-certainty evidence), compared with placebo (5 studies, 513 participants, 85 events). Secondary outcomes The length of ICU stay may be no different with levosimendan (ratio of means (ROM) 1.12, 95% CI 0.77 to 1.63; low-certainty evidence), and is likely no different with milrinone (ROM 1.13, 95% CI 0.75 to 1.69) or with dobutamine (ROM 1.11, 95% CI 0.66 to 1.86), compared with placebo (9 studies, 577 participants); both moderate-certainty evidence. The length of hospital stay, compared with placebo, is likely no different with levosimendan (ROM 1.03, 95% CI 0.84 to 1.27) or with milrinone (ROM 1, 95% CI 0.78 to 1.3), but is likely reduced with dobutamine (ROM 0.68, 95% CI 0.37 to 1.26); all moderate-certainty evidence (7 studies, 297 participants). The duration of mechanical ventilation, compared with placebo, is likely increased with levosimendan (ROM 1.17, 95% CI 0.65 to 2.12) or with milrinone (ROM 1.25, 5% CI 0.67 to 2.36) and is likely no different with dobutamine (ROM 1.04, 95% CI 0.45 to 2.38); all moderate-certainty evidence (9 studies, 577 participants). There is moderate-certainty evidence that adverse events are likely increased with levosimendan (incidence rate ratio (IRR) 1.23, 95% CI 0.78 to 1.96) or dobutamine (IRR 1.24, 95% CI 0.75 to 2.03) and low-certainty evidence that they may be increased with milrinone (IRR 1.31, 95% CI 0.96 to 1.79) and decreased with low-dose milrinone (IRR 0.84, 95% CI 0.47 to 1.5), compared with placebo (8 studies, 706 participants, 380 events). AUTHORS' CONCLUSIONS Levosimendan likely results in a large reduction in mortality compared to placebo in paediatric patients undergoing surgery for congenital heart disease, whereas milrinone likely results in no difference, and the effect of dobutamine is unknown. Low cardiac output syndrome (LCOS) is largely reduced with levosimendan, likely largely reduced with milrinone, and may be reduced with low-dose milrinone, compared to placebo. The length of ICU stay may be no different with levosimendan and is likely no different with milrinone or with dobutamine, compared to placebo. The length of hospital stay is likely no different with levosimendan or with milrinone, but is likely reduced with dobutamine, compared to placebo. The duration of mechanical ventilation is likely increased with levosimendan or with milrinone and is likely no different with dobutamine, compared to placebo. Adverse events are likely increased with levosimendan or dobutamine, and may be increased with milrinone and decreased with low-dose milrinone, compared to placebo. The evidence is based on few, heterogeneous studies, with small numbers of patients and short follow-up periods. Future research should include large numbers of patients, consistently report all co-interventions, and ensure the longest possible follow-up.
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Affiliation(s)
- Barbara Eu Burkhardt
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Johanna Hummel
- Department of Congenital Heart Disease/Pediatric Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Barrientos AF, Page GL, Lin L. Non-parametric Bayesian approach to multiple treatment comparisons in network meta-analysis with application to comparisons of anti-depressants. J R Stat Soc Ser C Appl Stat 2024; 73:1333-1354. [PMID: 39552751 PMCID: PMC11561732 DOI: 10.1093/jrsssc/qlae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 11/19/2024]
Abstract
Network meta-analysis is a powerful tool to synthesize evidence from independent studies and compare multiple treatments simultaneously. A critical task of performing a network meta-analysis is to offer ranks of all available treatment options for a specific disease outcome. Frequently, the estimated treatment rankings are accompanied by a large amount of uncertainty, suffer from multiplicity issues, and rarely permit possible ties of treatments with similar performance. These issues make interpreting rankings problematic as they are often treated as absolute metrics. To address these shortcomings, we formulate a ranking strategy that adapts to scenarios with high-order uncertainty by producing more conservative results. This improves the interpretability while simultaneously accounting for multiple comparisons. To admit ties between treatment effects in cases where differences between treatment effects are negligible, we also develop a Bayesian non-parametric approach for network meta-analysis. The approach capitalizes on the induced clustering mechanism of Bayesian non-parametric methods, producing a positive probability that two treatment effects are equal. We demonstrate the utility of the procedure through numerical experiments and a network meta-analysis designed to study antidepressant treatments.
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Affiliation(s)
- Andrés F Barrientos
- Department of Statistics, Florida State University, Tallahassee, FL 32306, USA
| | - Garritt L Page
- Department of Statistics, Brigham Young University, Provo, UT 84602, USA
| | - Lifeng Lin
- Department of Statistics, Florida State University, Tallahassee, FL 32306, USA
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ 85721, USA
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8
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Huang YB, Lin L, Li XY, Chen BZ, Yuan L, Zheng H. An indirect treatment comparison meta-analysis of digital versus face-to-face cognitive behavior therapy for headache. NPJ Digit Med 2024; 7:262. [PMID: 39343978 PMCID: PMC11439962 DOI: 10.1038/s41746-024-01264-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 09/17/2024] [Indexed: 10/01/2024] Open
Abstract
Cognitive behavioral therapy (CBT) is effective for headache disorders. However, it is unclear whether the emerging digital CBT is noninferior to face-to-face CBT. An indirect treatment comparison (ITC) meta-analysis was conducted to assess the relative effects between them using standard mean differences (SMDs). Effective sample size (ESS) and required sample size (RSS) were calculated to demonstrate the robustness of the results. Our study found that digital CBT had a similar effect on headache frequency reduction (SMD, 0.12; 95%CI, -2.45 to 2.63) compared with face-to-face CBT. The ESS had 84 participants, while the RSS had 466 participants to achieve the same power as a non-inferior head-to-head trial. Digital CBT is as effective as face-to-face CBT in preventing headache disorders. Due to the heterogeneity (I2 = 94.5%, τ2 = 1.83) and the fact that most of the included studies were on migraine prevention, further head-to-head trials are warranted.
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Affiliation(s)
- Yan-Bing Huang
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Lin
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xin-Yu Li
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bo-Zhu Chen
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lu Yuan
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hui Zheng
- The Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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9
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Florez ID, Parra-Rodas L. Persistent Pulmonary Hypertension of the Newborn: Should Sildenafil and Inhaled Nitric Oxide at Medium Concentration Be the Standard of Treatment? Crit Care Med 2024; 52:995-997. [PMID: 38752821 DOI: 10.1097/ccm.0000000000006278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Affiliation(s)
- Ivan D Florez
- Department of Pediatrics, Universidad de Antioquia, Medellin, Colombia
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellin, Colombia
| | - Luisa Parra-Rodas
- Pediatric Intensive Care Unit, Clínica Las Américas-AUNA, Medellin, Colombia
- School of Medicine, Universidad Pontificia Bolivariana, Medellin, Colombia
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10
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Fang CS, Tu YK, Chang SL, Kuo CC, Fang CJ, Chou FH. Effectiveness of sound and darkness interventions for critically ill patients' sleep quality: A systematic review and component network meta-analysis. Nurs Crit Care 2024; 29:134-143. [PMID: 37017370 DOI: 10.1111/nicc.12883] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Noise and lighting are prime factors of poor sleep quality in critically ill patients, which impair recovery and increase the risk of delirium or complications. AIM To identify and rank the effectiveness of sound and darkness interventions on the sleep quality of critically ill patients. STUDY DESIGN This systematic review and component network meta-analysis was based on the Preferred Reporting Items for Systematic Reviews incorporating the Network Meta-Analyses (PRISMA-NMA) Statement. The Embase, MEDLINE, Cochrane CENTRAL, CINAHL, Airiti Library, and Google Scholar databases were searched from inception to August 10, 2021, for randomized controlled trials (RCTs) on sound and darkness interventions targeting critically ill patients' sleep quality. We applied standard and component NMA to determine the effects of interventions. The certainty of evidence was evaluated using the Cochrane risk-of-bias tool (V.2.0) and the online Confidence in Network Meta-Analysis (CINeMA) application. RESULTS Twenty-four RCTs with 1507 participants who used combined interventions constituting seven competing interventions were included in the standard NMA. The combination of earplugs, eye masks, and music; eye masks alone; earplugs combined with eye masks; and music alone had beneficial intervention effects. The combination of earplugs, eye masks, and music was the best intervention, and these components had no interaction effect. An eye mask had the best relative effect, followed by music, quiet time, and earplugs. CONCLUSIONS This study provides clinical evidence of the effectiveness of using eye masks, music, and earplugs to improve sleep quality in critically ill patients. We also recommend future research using bedtime music, nocturnal eye masks, and quiet time, which had the best relative effects on sleep quality. RELEVANCE TO CLINICAL PRACTICE This study provides recommendations for interventions that nurses can use to improve critically ill patients' sleep quality.
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Affiliation(s)
- Chiu-Shu Fang
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Lun Chang
- Department of Otorhinolaryngology, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Pet Care and Groomimg, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - Chia-Chi Kuo
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Ching-Ju Fang
- Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Fan-Hao Chou
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Weng Y, Miao B, Hong D, Zhang M, Wang B, Zhao Q, Wang H. Effects of pharmacist-led interventions on glycaemic control, adherence, disease management and health-related quality of life in patients with type 2 diabetes: a protocol for a network meta-analysis. BMJ Open 2023; 13:e072960. [PMID: 37898486 PMCID: PMC10619031 DOI: 10.1136/bmjopen-2023-072960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION The increase in the number of patients with uncontrolled type 2 diabetes mellitus (T2DM) is in need of effective management interventions. However, research to date has been limited to the evaluation of the outcomes of community pharmacists alone. Therefore, the aim of the study protocol is to compare the effects of clinical pharmacist-led intervention strategies for the management of T2DM in the outpatient settings. METHOD AND ANALYSIS The study will collect and analyse data applying standard Cochrane methodological procedures. A search for eligible studies and ongoing trials will be conducted using PubMed, Embase, Medline (via Ovid), EBSCO (via Ovid), Lippincott Williams & Wilkins (LWW) Journals (via Ovid), ProQuest Health and Medical Complete, and ClinicalTrials.gov (clinicaltrials.gov) from database inception to December 2023. Clinical and health outcomes will be measured using both glycaemic control related indicators (eg, glycated haemoglobin, fasting blood glucose, postprandial glucose) and general indicators (eg, adherence, disease management and health-related quality of life). The meta-analysis will conduct pairwise meta-analysis using random effects models and network meta-analysis (NMA) employing the Bayesian hierarchical model. The visualisation and statistical analysis will be carried out using RevMan, R Studio and ADDIS. Additionally, we will evaluate the certainty of the evidence by using Grading of Recommendations Assessment, Development and Evaluation system. ETHICS AND DISSEMINATION There will be no primary data collection from NMA participants, and there is no requirement for formal ethical review. Our aim is to present the results of this NMA in a peer-reviewed scientific journal, at conferences, and in the mainstream media. PROSPERO REGISTRATION NUMBER CRD42022355368.
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Affiliation(s)
- Yiqing Weng
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Binghui Miao
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dongsheng Hong
- Department of Clinical Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
- Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Mengdie Zhang
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Beijia Wang
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qingwei Zhao
- Department of Clinical Pharmacy, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
- Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, Zhejiang University School of Medicine First Affiliated Hospital, Hangzhou, China
| | - Hongmei Wang
- Department of Social Medicine of School of Public Health and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Yunusa I, Rashid N, Seyedin R, Paratane D, Rajagopalan K. Comparative Efficacy, Safety, and Acceptability of Pimavanserin and Other Atypical Antipsychotics for Parkinson's Disease Psychosis: Systematic Review and Network Meta-Analysis. J Geriatr Psychiatry Neurol 2023; 36:417-432. [PMID: 36720473 DOI: 10.1177/08919887231154933] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The current comparative efficacy, safety, and acceptability of atypical antipsychotics (AAPs) in treating Parkinson's Disease Psychosis (PDP) are not entirely understood. OBJECTIVE To evaluate comparative efficacy, safety, and acceptability of AAPs in patients with PDP. METHODS We conducted a systematic review and a network meta-analysis to compare the efficacy, safety, and acceptability of pimavanserin, quetiapine, olanzapine, clozapine, ziprasidone, and risperidone. We estimated relative standardized mean differences (SMDs) for continuous outcomes and odds ratios (OR) for binary outcomes, with their respective 95% confidence intervals (CIs). RESULTS We included 19 unique studies evaluating AAPs in a total of 1,242 persons with PDP. Based on Clinical Global Impression Scale for Severity, pimavanserin (SMD, -4.81; 95% CI, -5.39, -4.24) and clozapine (SMD, -4.25; 95% CI, -5.24, -3.26) significantly improved symptoms compared with placebo. Also, compared to placebo, pimavanserin (OR, 1.16; 95% CI, 1.07, 1.24) significantly improved psychotic symptoms based on Scale for Assessment of Positive Symptoms for Parkinson's Disease Psychosis/Hallucinations and Delusions scores. In comparison to placebo, clozapine (SMD, -0.69; 95% CI, -1.35, -0.02), pimavanserin (SMD, -0.01; 95% CI, -0.56, 0.53), and quetiapine (SMD, 0.00; 95% CI, -0.68, 0.69) did not impair motor function per Unified Parkinson's Disease Rating scale. Based on Mini-Mental State Examination scale, quetiapine (SMD, 0.60; 95% CI, 0.07, 1.14) significantly impaired cognition compared to placebo. CONCLUSIONS In patients with PDP, pimavanserin and clozapine demonstrated significant improvement in psychosis without affecting motor function. With quetiapine being associated with a significant decline in cognition and despite not impairing motor function, our findings suggest that it should be avoided in patients with PDP and reduced cognitive abilities.
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Affiliation(s)
- Ismaeel Yunusa
- College of Pharmacy, University of South Carolina, Columbia, SC, USA
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Han J, Shi M, Bi LN, Wang LL, Cai YX. Efficacy of mind-body therapies for sleep disturbance in patients with early-stage cancer: A systematic review and network meta-analysis. Psychooncology 2023; 32:1315-1338. [PMID: 37395137 DOI: 10.1002/pon.6187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/30/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE To evaluate and compare the efficacy of different mind-body therapies (MBTs) for sleep disturbance in patients with early-stage cancer. METHODS Randomised controlled trials that included patients (aged ≥18 years) with early stage cancer who underwent MBTs (mindfulness, hypnosis, relaxation, yoga, and qigong) were searched in the CINAHL via the EBSCO Host, Cochrane Library, Embase, MEDLINE, PsycINFO, PubMed, and Scopus databases, from the date of database inception to October 2022. The outcomes were subjective sleep disturbance and objective sleep efficiency. Network meta-analysis (NMA) and comparative effects ranking were performed using STATA (v14.0; STATACorp, College Station, TX, USA). RESULTS Forty-seven studies investigating five MBTs were included in the NMA. For cancer patients receiving active treatment, mindfulness demonstrated the largest effect size in reducing subjective sleep disturbance (standardised mean difference [SMD]: 0.85; 95% confidence intervals [CI]: 0.20-1.50; Grading of Recommendations Assessment, Development, and Evaluation assessment: moderate), and had the highest cumulative probability compared to usual care or waitlist. For cancer patients who had completed active treatment, qigong demonstrated the largest effect size in reducing subjective sleep disturbance (SMD: 0.99; 95% CI: 0.35-1.63; GRADE: low), followed by hypnosis (SMD: 0.87; 95% CI: 0.32-1.42; GRADE: moderate), and mindfulness (SMD: 0.42; 95% CI: 0.24-0.59; GRADE: moderate). Qigong also demonstrated the largest effect size in improving objective sleep efficiency (weighted mean differences: 10.76; 95% CI: 2.01-19.50; GRADE: low); however, the effect of qigong was tested in only one study in this NMA. Among the eight different treatment conditions, cognitive behavioral therapy (CBT) showed the highest cumulative probability (surface under the cumulative ranking curve: 96.3%) in reducing subjective sleep disturbance and the second highest cumulative probability (SUCRA: 83.3%) in improving objective sleep efficiency. CONCLUSION There is no evidence supporting the use of MBTs to replace or be comparable to CBT. Mindfulness can be recommended as an optional treatment for reducing sleep disturbance in patients with early-stage cancer. Some support was observed for qigong and hypnosis in reducing sleep disturbances in patients with early-stage cancer who had completed active treatment. More rigorous trials are warranted to confirm whether different forms of MBTs have different effects on sleep in patients with cancer.
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Affiliation(s)
- Jing Han
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Ming Shi
- National and Local Joint Engineering Laboratory of Tumor Biotherapy, The First Clinical College of Xuzhou Medical University, Xuzhou, China
| | - Liu-Na Bi
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Lin-Lin Wang
- School of Nursing, Xuzhou Medical University, Xuzhou, China
| | - Yan-Xiu Cai
- School of Nursing, Xuzhou Medical University, Xuzhou, China
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Sbidian E, Chaimani A, Guelimi R, Garcia-Doval I, Hua C, Hughes C, Naldi L, Kinberger M, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2023; 7:CD011535. [PMID: 37436070 PMCID: PMC10337265 DOI: 10.1002/14651858.cd011535.pub6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the benefits and harms of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their benefits and harms. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2022: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment, and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 12 studies, taking the total number of included studies to 179, and randomised participants to 62,339, 67.1% men, mainly recruited from hospitals. Average age was 44.6 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (56%). We assessed a total of 20 treatments. Most (152) trials were multicentric (two to 231 centres). One-third of the studies (65/179) had high risk of bias, 24 unclear risk, and most (90) low risk. Most studies (138/179) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 49.16, 95% CI 20.49 to 117.95), bimekizumab (RR 27.86, 95% CI 23.56 to 32.94), ixekizumab (RR 27.35, 95% CI 23.15 to 32.29), risankizumab (RR 26.16, 95% CI 22.03 to 31.07). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab and ixekizumab were significantly more likely to reach PASI 90 than secukinumab. Bimekizumab, ixekizumab, and risankizumab were significantly more likely to reach PASI 90 than brodalumab and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab, and brodalumab), and anti-IL23 drugs except tildrakizumab were significantly more likely to reach PASI 90 than ustekinumab, three anti-TNF alpha agents, and deucravacitinib. Ustekinumab was superior to certolizumab. Adalimumab, tildrakizumab, and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with very low- to moderate-certainty evidence for all the comparisons. The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.6 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was very low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Robin Guelimi
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Valencia Carlo YE, Saracco-Alvarez RA, Valencia Carlo VA, Vázquez Vega D, Natera Rey G, Escamilla Orozco RI. Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis. Front Psychiatry 2023; 14:1189768. [PMID: 37441144 PMCID: PMC10333591 DOI: 10.3389/fpsyt.2023.1189768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/31/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment. Methods A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest. Results 87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation. Discussion Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.
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Affiliation(s)
| | | | | | - Daniela Vázquez Vega
- Health Sciences Program, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Guillermina Natera Rey
- Department of Epidemiological and Psychosocial Research, National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
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Nevill CR, Cooper NJ, Sutton AJ. A multifaceted graphical display, including treatment ranking, was developed to aid interpretation of network meta-analysis. J Clin Epidemiol 2023; 157:83-91. [PMID: 36870376 DOI: 10.1016/j.jclinepi.2023.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 12/21/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES Network meta-analysis (NMA) is becoming a popular statistical tool for analyzing a network of evidence comparing more than two interventions. A particular advantage of NMA over pairwise meta-analysis is its ability to simultaneously compare multiple interventions including comparisons not previously trialed together, permitting intervention hierarchies to be created. Our aim was to develop a novel graphical display to aid interpretation of NMA to clinicians and decision-makers that incorporates ranking of interventions. STUDY DESIGN AND SETTING Current literature was searched, scrutinized, and provided direction for developing the novel graphical display. Ranking results were often found to be misinterpreted when presented alone and, to aid interpretation and effective communication to inform optimal decision-making, need to be displayed alongside other important aspects of the analysis including the evidence networks and relative intervention effect estimates. RESULTS Two new ranking visualizations were developed-the 'Litmus Rank-O-Gram' and the 'Radial SUCRA' plot-and embedded within a novel multipanel graphical display programmed within the MetaInsight application, with user feedback gained. CONCLUSION This display was designed to improve the reporting, and facilitate a holistic understanding, of NMA results. We believe uptake of the display would lead to better understanding of complex results and improve future decision-making.
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Affiliation(s)
- Clareece R Nevill
- Department of Population Health Sciences, University of Leicester, UK; NIHR Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK.
| | - Nicola J Cooper
- Department of Population Health Sciences, University of Leicester, UK; NIHR Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
| | - Alex J Sutton
- Department of Population Health Sciences, University of Leicester, UK; NIHR Complex Reviews Support Unit, University of Leicester & University of Glasgow, Glasgow, UK
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Kebebe E, Ibrahim N, White R, Wittenberg K, Aukema H, McAllister T, Riediger N, Legesse G, McGeough E, Ominski K. Nutritional impact of excluding red meat from the Canadian diet. Meat Sci 2023; 201:109161. [PMID: 37031667 DOI: 10.1016/j.meatsci.2023.109161] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
The objective of the study was to examine differences in nutrient intake between consumers and non-consumers of red meat and to assess nutritional adequacy of consumers relative to Recommended Daily Allowance (RDA) in Canada. Matching estimators were used to identify differences in nutrient intake between the two groups. Statistically significant differences were observed in nutrient intake between red meat consumers and non-consumers, including lower daily intake of protein, riboflavin, niacin, vitamin D, and zinc and a higher daily intake of dietary fiber, folate, and magnesium among Canadians who did not consume red meat. Further, red meat consumers and non-consumers had nutrient intakes below RDA for dietary energy, fiber, and calcium. While individuals who did not consume red meat were at increased risk of calcium, vitamin D, energy, and potassium inadequacy, those who consumed red meat were at increased risk of dietary fiber, vitamin A, and magnesium inadequacy.
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Nast A, Dressler C, Schuster C, Saure D, Augustin M, Reich K. Methods used for indirect comparisons of systemic treatments for psoriasis. A systematic review. SKIN HEALTH AND DISEASE 2023; 3:e112. [PMID: 36751312 PMCID: PMC9892472 DOI: 10.1002/ski2.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 12/12/2022]
Abstract
Background Indirect comparisons (including network meta-analyses [NMAs]) allow us to compare benefits and risks of multiple interventions for the same clinical condition when head-to-head comparisons are not feasible. Objective To provide guidance to the clinical community on better understanding indirect comparison methods to help them to interpret their results by applying two quality standards to published indirect comparisons of systemic biologics for moderate to severe psoriasis. Methods A systematic literature review (SLR) of published indirect comparisons of biologics for the treatment of moderate to severe psoriasis in adults was conducted. Data extraction was performed using a predefined subset of NICE TSD7 (National Institute for Health and Care Excellence Technical Support Document 7) checklist questions and methods used to perform each analysis were descriptively compared. Methodological quality of the SLR underlying each indirect comparison was assessed using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews version 2). Results Twenty-two NMAs and four adjusted indirect comparisons (AICs) were identified. Although there were some similarities, for example, application of Bayesian random-effects models, several important methodological aspects varied considerably across NMAs identified, for example, classes of drugs, number of treatments and studies included, reporting and handling of different doses, and reporting of both checks for and investigations of inconsistency. Methodological comparisons across AICs were limited by the small number. The quality of most underlying SLRs described, assessed as overall level of confidence in the results, was 'critically low'. Conclusions Understanding that there are different methodologies employed to answer differing research questions is key to helping clinicians to interpret the indirect evidence currently available in psoriasis.
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Affiliation(s)
- Alexander Nast
- Division of Evidence‐Based MedicineDepartment of DermatologyVenereology and AllergyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Corinna Dressler
- Division of Evidence‐Based MedicineDepartment of DermatologyVenereology and AllergyCharité—Universitätsmedizin BerlinBerlinGermany
| | - Christopher Schuster
- Department of DermatologyMedical University of ViennaViennaAustria
- Eli Lilly and CompanyIndianapolisIndianaUSA
| | | | - Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing (IVDP)University Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
| | - Kristian Reich
- Institute for Health Services Research in Dermatology and Nursing (IVDP)University Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
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Augustin M, Schuster C, Mert C, Nast A. The Value of Indirect Comparisons of Systemic Biologics for Psoriasis: Interpretation of Efficacy Findings. Dermatol Ther (Heidelb) 2022; 12:1711-1727. [PMID: 35834062 PMCID: PMC9357597 DOI: 10.1007/s13555-022-00765-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/21/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION It can be challenging for dermatologists to keep abreast of the growing evidence from published indirect comparisons (ICs) of treatments for psoriasis. The objective of this analysis was to summarise comparative clinical efficacy and safety findings from ICs of systemic biologics for the treatment of moderate-to-severe psoriasis and to identify factors potentially affecting efficacy outcomes and their possible implications for clinical decision making. METHODS An umbrella review of short- and long-term efficacy and safety findings from 26 ICs visually compared 90% improvement in Psoriasis Area Severity Index (PASI90) treatment rankings and three safety outcome rankings side by side. Pearson's correlation coefficients measured the strength of the association between each pair of ICs on the basis of identified factors that could potentially affect efficacy findings. RESULTS Some consistency in short-term PASI90 efficacy rankings was observed for certain drugs, although rankings for most drugs varied by IC. Factors potentially affecting efficacy outcomes included the use of different methodologies for head-to-head comparison and statistical analyses, and variation in drugs and classes included treatment dosing and duration, outcome definitions and effect measures reported between ICs. Considerable variation in these factors was found across all 26 ICs. Comparative safety information of value to physicians was limited. CONCLUSIONS Substantial differences were identified between ICs in factors that could potentially affect efficacy outcomes. Treatment rankings must be interpreted alongside actual differences in IC outcomes to allow conclusions on clinical relevance. Drugs within a class cannot be considered of equal efficacy: therapies should be considered individually rather than by class.
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Affiliation(s)
- Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | | | - Can Mert
- HaaPACS GmbH, Schriesheim, Germany
| | - Alexander Nast
- Division of Evidence-Based Medicine, Department of Dermatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Davies AL, Papakonstantinou T, Nikolakopoulou A, Rücker G, Galla T. Network meta-analysis and random walks. Stat Med 2022; 41:2091-2114. [PMID: 35293631 PMCID: PMC9311228 DOI: 10.1002/sim.9346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/06/2021] [Accepted: 01/20/2022] [Indexed: 11/11/2022]
Abstract
Network meta-analysis (NMA) is a central tool for evidence synthesis in clinical research. The results of an NMA depend critically on the quality of evidence being pooled. In assessing the validity of an NMA, it is therefore important to know the proportion contributions of each direct treatment comparison to each network treatment effect. The construction of proportion contributions is based on the observation that each row of the hat matrix represents a so-called "evidence flow network" for each treatment comparison. However, the existing algorithm used to calculate these values is associated with ambiguity according to the selection of paths. In this article, we present a novel analogy between NMA and random walks. We use this analogy to derive closed-form expressions for the proportion contributions. A random walk on a graph is a stochastic process that describes a succession of random "hops" between vertices which are connected by an edge. The weight of an edge relates to the probability that the walker moves along that edge. We use the graph representation of NMA to construct the transition matrix for a random walk on the network of evidence. We show that the net number of times a walker crosses each edge of the network is related to the evidence flow network. By then defining a random walk on the directed evidence flow network, we derive analytically the matrix of proportion contributions. The random-walk approach has none of the associated ambiguity of the existing algorithm.
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Affiliation(s)
- Annabel L. Davies
- Theoretical Physics, Department of Physics and Astronomy, School of Natural SciencesThe University of ManchesterManchesterUK
| | - Theodoros Papakonstantinou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Adriani Nikolakopoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical CenterUniversity of FreiburgFreiburgGermany
| | - Tobias Galla
- Theoretical Physics, Department of Physics and Astronomy, School of Natural SciencesThe University of ManchesterManchesterUK
- Instituto de Física Interdisciplinar y Sistemas ComplejosIFISC (CSIC‐UIB), Campus Universitat Illes BalearsPalma de MallorcaSpain
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2022; 5:CD011535. [PMID: 35603936 PMCID: PMC9125768 DOI: 10.1002/14651858.cd011535.pub5] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2021: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 19 studies, taking the total number of included studies to 167, and randomised participants to 58,912, 67.2% men, mainly recruited from hospitals. Average age was 44.5 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (57%). We assessed a total of 20 treatments. Most (140) trials were multicentric (two to 231 centres). One-third of the studies (57/167) had high risk of bias; 23 unclear risk, and most (87) low risk. Most studies (127/167) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions, except anti-IL23. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23 and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 50.19, 95% CI 20.92 to 120.45), bimekizumab (RR 30.27, 95% CI 25.45 to 36.01), ixekizumab (RR 30.19, 95% CI 25.38 to 35.93), risankizumab (RR 28.75, 95% CI 24.03 to 34.39). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab, ixekizumab and risankizumab showed a higher proportion of patients reaching PASI 90 than other anti-IL17 drugs (secukinumab and brodalumab) and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab and brodalumab) and anti-IL23 drugs (risankizumab and guselkumab) except tildrakizumab showed a higher proportion of patients reaching PASI 90 than ustekinumab and three anti-TNF alpha agents (adalimumab, certolizumab and etanercept). Ustekinumab was superior to certolizumab; adalimumab and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with low- to moderate-certainty for all the comparisons (except methotrexate versus placebo, which was high-certainty). The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.5 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies and postmarketing reports from regulatory agencies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Chiocchia V, White IR, Salanti G. The complexity underlying treatment rankings: how to use them and what to look at. BMJ Evid Based Med 2022; 28:180-182. [PMID: 35501121 DOI: 10.1136/bmjebm-2021-111904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland
| | - Ian R White
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Comparative Outcomes of Commonly Used Off-Label Atypical Antipsychotics in the Treatment of Dementia-Related Psychosis: A Network Meta-analysis. Adv Ther 2022; 39:1993-2008. [PMID: 35247186 PMCID: PMC9056477 DOI: 10.1007/s12325-022-02075-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/03/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Dementia-related psychosis (DRP) is characterized by hallucinations and delusions, which may increase the debilitating effects of underlying dementia. This network meta-analysis (NMA) evaluated the comparative efficacy, safety, and acceptability of atypical antipsychotics (AAPs) commonly used off label to treat DRP. METHODS We included 22 eligible studies from a systematic literature review of AAPs (quetiapine, risperidone, olanzapine, aripiprazole, and brexpiprazole) used off label to treat DRP. Study outcomes were: (1) efficacy-neuropsychiatric inventory-nursing home (NPI-NH psychosis subscale), (2) safety-mortality, cerebrovascular events (CVAEs), and others (somnolence, falls, fractures, injuries, etc.), and (3) acceptability-discontinuations due to all causes, lack of efficacy, and adverse events (AEs). We used random-effects modeling to estimate pooled standardized mean differences (SMDs) for NPI-NH psychosis subscale scores and odds ratios (OR) for other dichotomous outcomes, with their respective 95% confidence intervals (CIs). RESULTS Compared with placebo, aripiprazole (SMD - 0.12; 95% CI - 0.31, 0.06), and olanzapine (SMD - 0.17; 95% CI - 0.04; 0.02) demonstrated small, non-significant numerical improvements in NPI-NH psychosis scores (5 studies; n = 1891), while quetiapine (SMD 0.04; 95% CI - 0.23, 0.32) did not improve symptoms. The odds of mortality (15 studies, n = 4989) were higher for aripiprazole (OR 1.58; 95% CI 0.62, 4.04), brexpiprazole (OR 2.22; 95% CI 0.30, 16.56), olanzapine (OR 2.21; 95% CI 0.84, 5.85), quetiapine (OR 1.68; 95% CI 0.70, 4.03), and risperidone (OR 1.63; 95% CI 0.93, 2.85) than for placebo. Risperidone (OR 3.68; 95% CI 1.68, 8.95) and olanzapine (OR 4.47; 95% CI 1.36, 14.69) demonstrated significantly greater odds of CVAEs compared to placebo. Compared with placebo, odds of all-cause discontinuation were significantly lower for aripiprazole (OR 0.71; 95% CI 0.51, 0.98; 20 studies; 5744 patients) and higher for other AAPs. Aripiprazole (OR 0.5; 95% CI 0.31, 0.82) and olanzapine (OR 0.48; 95% CI 0.31, 0.74) had significantly lower odds of discontinuation due to lack of efficacy (OR 12 studies; n = 4382) compared to placebo, while results for quetiapine and risperidone were not significant. Compared with placebo, the odds of discontinuation due to AEs (19 studies, n = 5445) were higher for olanzapine (OR 2.62; 95% CI 1.75, 3.92), brexpiprazole (OR 1.80; 95% CI 0.80, 4.07), quetiapine (OR 1.25; 95% CI 0.82, 1.91), aripiprazole (OR 1.38; 95% CI 0.90, 2.13), and risperidone (OR 1.41; 95% CI 1.02, 1.94). CONCLUSIONS Overall results demonstrate that, compared with placebo, quetiapine is not associated with improvement in psychosis in patients with dementia, while olanzapine and aripiprazole have non-significant small numerical improvements. These off-label AAPs (quetiapine, risperidone, olanzapine, aripiprazole, and brexpiprazole) are associated with greater odds of mortality, CVAEs, and discontinuations due to AEs than placebo. These results underscore the ongoing unmet need for newer pharmacological options with a more favorable benefit-risk profile for the treatment of DRP.
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Salanti G, Nikolakopoulou A, Efthimiou O, Mavridis D, Egger M, White IR. Introducing the Treatment Hierarchy Question in Network Meta-Analysis. Am J Epidemiol 2022; 191:930-938. [PMID: 35146500 PMCID: PMC9071581 DOI: 10.1093/aje/kwab278] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 08/30/2021] [Accepted: 11/15/2021] [Indexed: 12/14/2022] Open
Abstract
Comparative effectiveness research using network meta-analysis can present a hierarchy of competing treatments, from the most to the least preferable option. However, in published reviews, the research question associated with the hierarchy of multiple interventions is typically not clearly defined. Here we introduce the novel notion of a treatment hierarchy question that describes the criterion for choosing a specific treatment over one or more competing alternatives. For example, stakeholders might ask which treatment is most likely to improve mean survival by at least 2 years, or which treatment is associated with the longest mean survival. We discuss the most commonly used ranking metrics (quantities that compare the estimated treatment-specific effects), how the ranking metrics produce a treatment hierarchy, and the type of treatment hierarchy question that each ranking metric can answer. We show that the ranking metrics encompass the uncertainty in the estimation of the treatment effects in different ways, which results in different treatment hierarchies. When using network meta-analyses that aim to rank treatments, investigators should state the treatment hierarchy question they aim to address and employ the appropriate ranking metric to answer it. Following this new proposal will avoid some controversies that have arisen in comparative effectiveness research.
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Affiliation(s)
- Georgia Salanti
- Correspondence to Dr. Georgia Salanti, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, Bern 3012, Switzerland (e-mail: )
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Gudivada KK, Kumar A, Sriram K, Baby J, Shariff M, Sampath S, Sivakoti S, Krishna B. Antioxidant micronutrient supplements for adult critically ill patients: A bayesian multiple treatment comparisons meta-analysis. Clin Nutr ESPEN 2022; 47:78-88. [PMID: 35063246 DOI: 10.1016/j.clnesp.2021.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/26/2021] [Accepted: 12/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Antioxidant micronutrients (AxMs) have been administered to critically ill adults attempting to counteract the oxidative stress imposed during critical illness. However, results are conflicting and relative effectiveness of AxMs regimens is unknown. We conducted a Bayesian multi-treatment comparison (MTC) meta-analysis to identify the best AxM treatment regimen that will improve clinical outcomes. METHODS PubMed, EMBASE, Web of Science and Cochrane databases were searched from the inception of databases through August 2020. Randomized controlled trials (RCT) comparing AxMs supplementations with placebo among critically ill adults were included. Two authors assessed trial quality using Cochrane risk of bias tool and assessed certainty of evidence (CoE). A random effect model, non-informative priors Bayesian MTC meta-analysis using gemtc package in R version 3.6.2 was performed. AxMs treatment effect on clinical outcomes (mortality, infection rates, intensive care unit (ICU) and hospital stays and ventilator days) were represented by absolute risk differences (ARD) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Prior to final analysis, we repeated the search through January 2021. RESULTS 37 RCT (4905 patients) were included with 16 direct comparisons. With respect to mortality, the ARD for "vitamin E" compared with placebo was centred at -0.19 [95%CrI: -0.54,0.16; very low CoE] and was ranked the best treatment for mortality reduction as per surface under the cumulative ranking curve (SUCRA 0.71, 95%CrI: 0.07,1.00). A combination of "selenium, zinc and copper" was ranked the best for lowest ICU stay [-9.40, 95% CrI: -20.0,1.50; low CoE]. A combination of "selenium, zinc, copper and vitamin E" was ranked the best treatment for infection risk reduction [-0.22, 95% CrI: -0.61,0.17; very low CoE]. Ventilator days were least with a combination of "selenium, zinc and manganese" [2.80, 95% CrI: -6.30,0.89; low CoE]. Hospital stay was the lowest using a combination of "selenium, zinc and copper" [-13.00, 95% CrI: -38.00,13.00; very low CoE]. There is substantial uncertainty present in the rankings due to wide and overlapping 95% CrIs of SUCRA scores for the treatments. CONCLUSIONS Studies on critically ill adult patients have suggested a possible beneficial effects of certain AxM supplementations over and above the recommended dietary allowance. However, evidence does not support their use in clinical practice due to the low confidence in the estimates. Current studies evaluating specific AxMs or their combinations are limited with small sample sizes. REGISTRATION PROSPERO, CRD42020210199. TAKE-HOME MESSAGE Evidence suggesting a potential benefit of AxMs use more than recommended doses in critically ill adults is weak, indicating that there is no justification for this practice.
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Affiliation(s)
- Kiran Kumar Gudivada
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana, India.
| | - Ashish Kumar
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India; Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
| | - Krishnan Sriram
- US Veterans Affairs Tele Critical Care West, Minneapolis, MN, USA
| | - Jeswin Baby
- Division of Epidemiology and Biostatistics, St John's Research Institute, Bangalore, India
| | - Mariam Shariff
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India
| | - Sriram Sampath
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India
| | - Sumitra Sivakoti
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana 508126, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College, Bangalore, India
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Allen C, Walker AM, Premji ZA, Beauchemin-Turcotte ME, Wong J, Soh S, Hawboldt GS, Shinkaruk KS, Archer DP. Preventing Persistent Postsurgical Pain: A Systematic Review and Component Network Meta-analysis. Eur J Pain 2022; 26:771-785. [PMID: 35090077 DOI: 10.1002/ejp.1915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 01/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Evidence for perioperative methods to prevent persistent postsurgical pain (PPP) is uncertain, in part because few treatments have been directly compared. Here we have used component network meta-analysis (cNMA) to incorporate both direct and indirect evidence in the evaluation of the efficacy and tolerability of pharmacological and neural block treatments. DATABASES AND DATA TREATMENT We searched the Cochrane Central Registry of Controlled Trials, Embase, MEDLINE, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry up to January 2021, for randomized, double-masked, controlled trials that reported the prevalence of PPP. We assessed trial quality with the Cochrane risk of bias tool (RoB 2.0). We analyzed the results with frequentist cNMA models. The primary outcome was the relative risk (RR) of PPP. We assessed efficacy in relation to a clinically important effect size of RR = 0.9, which is a 10% improvement with treatment. RESULTS The analysis included 107 trials (13,553 participants) of 13 treatments. The effects of complex interventions were the multiplicative effects of their components. Compared with placebo, serotonin-norepinephrine reuptake inhibitors (SNRIs), neural block alone, or in combination with NMDA receptor blockers or gabapentanoids were effective. Treatments with benefit in the immediate post-operative period predicted a reduced risk of PPP. CONCLUSIONS Several treatments and treatment combinations effectively reduce PPP prevalence. Pain outcomes in the immediate postoperative period are an important mediator of PPP. Multimodal interventions can be analyzed using cNMA.
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Affiliation(s)
- Claire Allen
- Cumming School of Medicine, University of Calgary
| | | | - Zahra A Premji
- Health Research Librarian, University of Victoria Libraries, Victoria, BC, Canada
| | | | - Jenny Wong
- Cumming School of Medicine, University of Calgary
| | - Sonya Soh
- McGill University, Montreal, QC, Canada
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Watt JA, Del Giovane C, Jackson D, Turner RM, Tricco AC, Mavridis D, Straus SE, Veroniki AA. Incorporating dose effects in network meta-analysis. BMJ 2022; 376:e067003. [PMID: 35042687 DOI: 10.1136/bmj-2021-067003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Jennifer A Watt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Dan Jackson
- Statistical Innovation Group, AstraZeneca, Cambridge, UK
| | | | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Areti-Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
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Tricco AC, Thomas SM, Lillie E, Veroniki AA, Hamid JS, Pham B, Lee T, Agarwal A, Sharpe JP, Scott A, Warren R, Brahmbhatt R, Macdonald E, Janoudi G, Muni RH, Francisconi CLM, Richter T, Straus SE. Anti-vascular endothelial growth factor therapy for age-related macular degeneration: a systematic review and network meta-analysis. Syst Rev 2021; 10:315. [PMID: 34930439 PMCID: PMC8690960 DOI: 10.1186/s13643-021-01864-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 12/02/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The comparative safety and efficacy between anti-vascular endothelial growth factor agents (anti-VEGFs) and between combined therapies for patients with neovascular age-related macular degeneration (nAMD) is unclear. We conducted a systematic review to examine the comparative safety and efficacy anti-VEGFs for adults with nAMD. METHODS Studies were identified through MEDLINE, EMBASE, and Cochrane CENTRAL (inception to June 3, 2019), grey literature, and scanning reference lists. Two reviewers independently screened citations and full-text articles to identify randomized controlled trials (RCTs), extracted data, and appraised risk of bias. Pairwise random-effects meta-analysis and Bayesian network meta-analysis (NMA) were conducted. The primary outcomes were the proportion of patients experiencing moderate vision gain (≥ 15 letters on the Early Treatment Diabetic Retinopathy Study chart) and the proportion of patients experiencing moderate vision loss (≤ 15 letters). RESULTS After screening 3647 citations and 485 potentially relevant full-text articles, 92 RCTs with 24,717 patients were included. NMA (34 RCTs, 8809 patients, 12 treatments) showed small differences among anti-VEGFs in improving the proportion of patients with moderate vision gain, with the largest for conbercept versus broluczumab (OR 0.15, 95% CrI: 0.05-0.56), conbercept versus ranibizumab (OR 0.17, 95% CrI: 0.05-0.59), conbercept versus aflibercept (OR 0.19, 95% CrI: 0.06-0.65), and conbercept versus bevacizumab (OR 0.2, 95% CrI: 0.06-0.69). In NMA (36 RCTs, 9081 patients, 13 treatments) for the proportion of patients with moderate vision loss, small differences were observed among anti-VEGFs, with the largest being for conbercept versus aflibercept (OR 0.24, 95% CrI: 0-4.29), conbercept versus brolucizumab (OR 0.24, 95% CrI: 0-4.71), conbercept versus bevacizumab (OR 0.26, 95% CrI: 0-4.65), and conbercept versus ranibizumab (OR 0.27, 95% CrI: 0-4.67). CONCLUSION The only observed differences were that ranibizumab, bevacizumab, aflibercept, and brolucizumab were statistically superior to conbercept in terms of the proportion of patients with nAMD who experienced moderate vision gain. However, this finding is based on indirect evidence through one small trial comparing conbercept with placebo. This does not account for drug-specific differences when assessing anatomic and functional treatment efficacy in variable dosing regimens. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42015022041.
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Affiliation(s)
- Andrea C. Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Epidemiology Division and Institute for Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7 Canada
- Queen’s Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, School of Nursing, Queen’s University, 99 University Ave, Kingston, Ontario K7L 3N6 Canada
| | - Sonia M. Thomas
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Erin Lillie
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Areti Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Department of Primary Education, School of Education, University of Ioannina, 455 00 Ioannina, Mpizani Greece
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, Exhibition Rd, South Kensington, London, SW7 2BU UK
| | - Jemila S. Hamid
- Department of Mathematics and Statistics, University of Ottawa, 150 Louis-Pasteur Pvt, Ottawa, ON K1N 6N5 Canada
| | - Ba’ Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Taehoon Lee
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Arnav Agarwal
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Department of Medicine, University of Toronto, 1 King’s College Circle, Toronto, Ontario M5S 1A8 Canada
| | - Jane P. Sharpe
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Alistair Scott
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Rachel Warren
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Ronak Brahmbhatt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
| | - Erin Macdonald
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 6th floor, 155 College Street, Toronto, Ontario M5T 3M7 Canada
| | - Ghayath Janoudi
- Canadian Agency for Drugs and Technologies in Health (CADTH), 865 Carling Avenue, Ottawa, Ontario K1S 5S8 Canada
| | - Rajeev H. Muni
- St. Michael’s Hospital/Unity Health Toronto, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Carolina L. M. Francisconi
- St. Michael’s Hospital/Unity Health Toronto, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada
| | - Trevor Richter
- Canadian Agency for Drugs and Technologies in Health (CADTH), 865 Carling Avenue, Ottawa, Ontario K1S 5S8 Canada
| | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON M5B 1T8 Canada
- Department of Geriatric Medicine, University of Toronto, 27 King’s College Circle, Toronto, Ontario M5S 1A1 Canada
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Rosenberger KJ, Duan R, Chen Y, Lin L. Predictive P-score for treatment ranking in Bayesian network meta-analysis. BMC Med Res Methodol 2021; 21:213. [PMID: 34657593 PMCID: PMC8520624 DOI: 10.1186/s12874-021-01397-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/31/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Network meta-analysis (NMA) is a widely used tool to compare multiple treatments by synthesizing different sources of evidence. Measures such as the surface under the cumulative ranking curve (SUCRA) and the P-score are increasingly used to quantify treatment ranking. They provide summary scores of treatments among the existing studies in an NMA. Clinicians are frequently interested in applying such evidence from the NMA to decision-making in the future. This prediction process needs to account for the heterogeneity between the existing studies in the NMA and a future study. METHODS This article introduces the predictive P-score for informing treatment ranking in a future study via Bayesian models. Two NMAs were used to illustrate the proposed measure; the first assessed 4 treatment strategies for smoking cessation, and the second assessed treatments for all-grade treatment-related adverse events. For all treatments in both NMAs, we obtained their conventional frequentist P-scores, Bayesian P-scores, and predictive P-scores. RESULTS In the two examples, the Bayesian P-scores were nearly identical to the corresponding frequentist P-scores for most treatments, while noticeable differences existed for some treatments, likely owing to the different assumptions made by the frequentist and Bayesian NMA models. Compared with the P-scores, the predictive P-scores generally had a trend to converge toward a common value of 0.5 due to the heterogeneity. The predictive P-scores' numerical estimates and the associated plots of posterior distributions provided an intuitive way for clinicians to appraise treatments for new patients in a future study. CONCLUSIONS The proposed approach adapts the existing frequentist P-score to the Bayesian framework. The predictive P-score can help inform medical decision-making in future studies.
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Affiliation(s)
- Kristine J Rosenberger
- Department of Statistics, Florida State University, 411 OSB, 117 N Woodward Ave, Tallahassee, FL, 32306, USA
| | - Rui Duan
- Department of Biostatistics, Harvard University, Boston, MA, USA
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lifeng Lin
- Department of Statistics, Florida State University, 411 OSB, 117 N Woodward Ave, Tallahassee, FL, 32306, USA.
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Tian J, Gao Y, Zhang J, Yang Z, Dong S, Zhang T, Sun F, Wu S, Wu J, Wang J, Yao L, Ge L, Li L, Shi C, Wang Q, Li J, Zhao Y, Xiao Y, Yang F, Fan J, Bao S, Song F. Progress and challenges of network meta-analysis. J Evid Based Med 2021; 14:218-231. [PMID: 34463038 DOI: 10.1111/jebm.12443] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/28/2022]
Abstract
In the past years, network meta-analysis (NMA) has been widely used among clinicians, guideline makers, and health technology assessment agencies and has played an important role in clinical decision-making and guideline development. To inform further development of NMAs, we conducted a bibliometric analysis to assess the current status of published NMA methodological studies, summarized the methodological progress of seven types of NMAs, and discussed the current challenges of NMAs.
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Affiliation(s)
- Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhirong Yang
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, Shandong, China
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing'an District Central Hospital, Shanghai, China
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Shanshan Wu
- National Clinical Research Center of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jiarui Wu
- Department of Clinical Chinese Pharmacy, School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Junfeng Wang
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Long Ge
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Lun Li
- Department of Breast Cancer, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Quan Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, China
| | - Jiang Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Zhao
- First Clinical Medical College, Lanzhou University, Lanzhou, China
- Departments of Biochemistry and Molecular Biology, Melvin and Bren Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yue Xiao
- China National Health Development Research Center, Beijing, China
| | - Fengwen Yang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jinchun Fan
- Epidemiology and Evidence Based-Medicine, School of Public Health, Gansu University of Chinese Medicine, Lanzhou, China
| | - Shisan Bao
- Epidemiology and Evidence Based-Medicine, School of Public Health, Gansu University of Chinese Medicine, Lanzhou, China
- Sydney, NSW, Australia
| | - Fujian Song
- Public Health and Health Services Research, Norwich Medical School, University of East Anglia, Norwich, UK
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Bozzo A, Deng J, Abbas U, Bhasin R, Deodat M, Wariach S, Sanger S, Axelrod D, Masrouha K, Turcotte R, Wilson D, Ghert M. Which Bone-Modifying Agent is Associated with Better Outcomes in Patients with Skeletal Metastases from Lung Cancer? A Systematic Review and Network Meta-analysis. Clin Orthop Relat Res 2021; 479:2047-2057. [PMID: 33835092 PMCID: PMC8373570 DOI: 10.1097/corr.0000000000001749] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lung cancer is one of the most commonly diagnosed cancers and is the leading cause of cancer-related deaths. Metastatic bone disease occurs in 20% to 40% of patients with lung cancer, and these patients often present with pain or skeletal-related events (SREs) that are associated with decreased survival. Bone-modifying agents such as denosumab or bisphosphonates are routinely used; however, to our knowledge, there has been no quantitative synthesis of randomized controlled trial data to determine the most effective pharmacologic treatment of metastatic bone disease because of lung cancer. QUESTIONS/PURPOSES We aimed to perform a network meta-analysis of randomized trials to identify the bone-modifying agent that is associated with the (1) highest overall survival, (2) longest time to SRE, (3) lowest SRE incidence, and (4) greatest likelihood of pain resolution. METHODS We conducted our study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol and pre-registered the analysis on PROSPERO (ID: CRD42019124364). We performed a librarian-assisted search of MEDLINE, PubMed, EMBASE, Cochrane Library, and Chinese databases including China National Knowledge Infrastructure and Wanfang Data. We included randomized controlled trials reporting outcomes specifically for patients with lung cancer treated with a bisphosphonate or denosumab. SREs included pathologic fractures, spinal cord compression, hypercalcemia of malignancy, or pain resulting in surgical intervention or radiation therapy. We excluded trials exclusively reporting surrogate outcomes such as changes in bone turnover markers. Screening, data extraction, risk of bias evaluation, and Grading of Recommendations Assessment, Development, and Evaluation evaluations were performed in duplicate. We included 131 randomized controlled trials that evaluated 11,105 patients with skeletal metastases from lung cancer. The network meta-analysis was performed using a frequentist model and the R statistical software. Results are reported as relative risks or mean differences, and the I2 value is reported for heterogeneity. The P-score, a measure of ranking certainty that accounts for standard error, is reported for each outcome. Heterogeneity in the network was considered moderate for overall survival and time to SRE, mild for the incidence of SRE, and low for pain resolution. RESULTS For overall survival, denosumab was ranked above zoledronic acid and estimated to confer a mean of 3.3 months (95% CI 0.3-6.3) of increased overall survival compared with untreated patients (P-score = 89%). For the time to SRE, denosumab was ranked first with a mean of 9.1 additional SRE-free months (95% CI 6.7-11.5) compared with untreated patients (P-score = 99%), while zoledronic acid conferred an additional 4.8 SRE-free months (95% CI 3.6-6.1). Reduction in the incidence of SREs was not different between patients treated with denosumab (relative risk 0.54; 95% CI 0.33-0.87) and those treated with zoledronic acid (relative risk 0.56; 95% CI 0.46-0.67). Patients treated with the combination of ibandronate and systemic therapy were more likely to experience successful pain resolution than untreated patients (relative risk 2.4; 95% CI 1.8-3.2). CONCLUSION In this comprehensive synthesis of all available randomized controlled trial evidence guiding the pharmacologic treatment of bone metastases from lung cancer, denosumab was ranked above zoledronic acid for overall survival and time to SRE and was not different for reducing the incidence of SRE. Both were superior to no treatment for each of these outcomes. Given this, we encourage physicians to consider the use of denosumab or zoledronic acid in treating this patient population. The combination of ibandronate and systemic therapy was the most effective at reducing pain because of metastases. No cost-effectiveness analysis has yet been performed for denosumab and zoledronic acid on patients with metastatic lung cancer, and this represents an avenue for future research. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Anthony Bozzo
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Umaima Abbas
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Richa Bhasin
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Marisa Deodat
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sajid Wariach
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Sanger
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Axelrod
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karim Masrouha
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Juravinski Hospital and Cancer Center, Hamilton, Ontario, Canada
| | - Robert Turcotte
- Division of Orthopaedic Surgery, McGill University, Montreal, Quebec, Canada
| | - David Wilson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Juravinski Hospital and Cancer Center, Hamilton, Ontario, Canada
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Juravinski Hospital and Cancer Center, Hamilton, Ontario, Canada
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Wu YC, Shih MC, Tu YK. Using Normalized Entropy to Measure Uncertainty of Rankings for Network Meta-analyses. Med Decis Making 2021; 41:706-713. [PMID: 33754893 DOI: 10.1177/0272989x21999023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ranking of treatments offers a straightforward interpretation of results derived from network meta-analysis. However, some published network meta-analyses have overemphasized treatment ranking without paying attention to its uncertainty. According to a review of 91 network meta-analyses, 52 reported treatment ranking, but 43 of them did not report the uncertainty of ranking. Without reporting the uncertainty, small differences in the ranking of treatments may be overinterpreted. Rankograms, cumulative rankograms, the credible/confidence interval of mean rank, the surface under the cumulative ranking curve (SUCRA), and the interquartile range of median rank have been used to show the uncertainty of rankings. However, it is not always straightforward to compare the differences in the distribution of probabilities by inspecting rankograms or to compare the intervals or ranges of treatment ranks. We therefore proposed normalized entropy, which transforms the distribution of ranking probabilities into a single quantitative measure, to facilitate a refined interpretation of uncertainty of treatment ranking. We used 4 real examples to demonstrate the uncertainty of ranking quantified by ranking probabilities, 95% confidence interval of SUCRA, and normalized entropy. We showed that as normalized entropy ranges from 0 to 1 and is independent of the number of treatments, it can be used to compare the uncertainty of treatment ranking within a network meta-analysis (NMA) and between different NMAs. Normalized entropy is an alternative tool for measuring the uncertainty of treatment ranking by improving the translation of results from NMAs to clinical practice and avoiding naïve interpretation of treatment ranking. We therefore recommend normalized entropy to be included in the presentation and interpretation of results from NMAs.
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Affiliation(s)
- Yun-Chun Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei
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Fadda V, Bartoli L, Ferracane E, Trippoli S, Messori A. Simplified figure to present direct and indirect comparisons: Revisiting the graph 10 years later. World J Methodol 2021; 11:228-230. [PMID: 34322372 PMCID: PMC8299911 DOI: 10.5662/wjm.v11.i4.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/09/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
A “simplified” figure was proposed in 2011 to summarize the results of controlled trials that evaluate different treatments aimed at the same disease condition. The original criteria for classifying individual binary comparisons included superiority, inferiority and no significance difference; hence, they did not differentiate between no proof of difference vs proof of no difference. We updated the criteria employed in the original “simplified” figure in order to include this differentiation. A revised version of the simplified figure is proposed and described herein. An example of application is also presented. The example is focused on first-line treatments for paroxysmal atrial fibrillation. Three treatments (medical therapy, cryoballoon ablation, radiofrequency ablation) are compared with one another through direct and indirect comparisons.
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Franco JV, Jung JH, Imamura M, Borofsky M, Omar MI, Escobar Liquitay CM, Young S, Golzarian J, Veroniki AA, Garegnani L, Dahm P. Minimally invasive treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia: a network meta-analysis. Cochrane Database Syst Rev 2021; 7:CD013656. [PMID: 34693990 PMCID: PMC8543673 DOI: 10.1002/14651858.cd013656.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A variety of minimally invasive treatments are available as an alternative to transurethral resection of the prostate (TURP) for management of lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). However, it is unclear which treatments provide better results. OBJECTIVES Our primary objective was to assess the comparative effectiveness of minimally invasive treatments for lower urinary tract symptoms in men with BPH through a network meta-analysis. Our secondary objective was to obtain an estimate of relative ranking of these minimally invasive treatments, according to their effects. SEARCH METHODS We performed a comprehensive search of multiple databases (CENTRAL, MEDLINE, Embase, Scopus, Web of Science and LILACS), trials registries, other sources of grey literature, and conference proceedings, up to 24 February 2021. We had no restrictions on language of publication or publication status. SELECTION CRITERIA We included parallel-group randomized controlled trials assessing the effects of the following minimally invasive treatments, compared to TURP or sham treatment, on men with moderate to severe LUTS due to BPH: convective radiofrequency water vapor therapy (CRFWVT); prostatic arterial embolization (PAE); prostatic urethral lift (PUL); temporary implantable nitinol device (TIND); and transurethral microwave thermotherapy (TUMT). DATA COLLECTION AND ANALYSIS Two review authors independently screened the literature, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model for pair-wise comparisons and a frequentist network meta-analysis for combined estimates. We interpreted them according to Cochrane methods. We planned subgroup analyses by age, prostate volume, and severity of baseline symptoms. We used risk ratios (RRs) with 95% confidence intervals (CIs) to express dichotomous data and mean differences (MDs) with 95% CIs to express continuous data. We used the GRADE approach to rate the certainty of evidence. MAIN RESULTS We included 27 trials involving 3017 men, mostly over age 50, with severe LUTS due to BPH. The overall certainty of evidence was low to very low due to concerns regarding bias, imprecision, inconsistency (heterogeneity), and incoherence. Based on the network meta-analysis, results for our main outcomes were as follows. Urologic symptoms (19 studies, 1847 participants): PUL and PAE may result in little to no difference in urologic symptoms scores (MD of International Prostate Symptoms Score [IPSS]) compared to TURP (3 to 12 months; MD range 0 to 35; higher scores indicate worse symptoms; PUL: 1.47, 95% CI -4.00 to 6.93; PAE: 1.55, 95% CI -1.23 to 4.33; low-certainty evidence). CRFWVT, TUMT, and TIND may result in worse urologic symptoms scores compared to TURP at short-term follow-up, but the CIs include little to no difference (CRFWVT: 3.6, 95% CI -4.25 to 11.46; TUMT: 3.98, 95% CI 0.85 to 7.10; TIND: 7.5, 95% CI -0.68 to 15.69; low-certainty evidence). Quality of life (QoL) (13 studies, 1459 participants): All interventions may result in little to no difference in the QoL scores, compared to TURP (3 to 12 months; MD of IPSS-QoL score; MD range 0 to 6; higher scores indicate worse symptoms; PUL: 0.06, 95% CI -1.17 to 1.30; PAE: 0.09, 95% CI -0.57 to 0.75; CRFWVT: 0.37, 95% CI -1.45 to 2.20; TUMT: 0.65, 95% CI -0.48 to 1.78; TIND: 0.87, 95% CI -1.04 to 2.79; low-certainty evidence). Major adverse events (15 studies, 1573 participants): TUMT probably results in a large reduction of major adverse events compared to TURP (RR 0.20, 95% CI 0.09 to 0.43; moderate-certainty evidence). PUL, CRFWVT, TIND and PAE may also result in a large reduction in major adverse events, but CIs include substantial benefits and harms at three months to 36 months; PUL: RR 0.30, 95% CI 0.04 to 2.22; CRFWVT: RR 0.37, 95% CI 0.01 to 18.62; TIND: RR 0.52, 95% CI 0.01 to 24.46; PAE: RR 0.65, 95% CI 0.25 to 1.68; low-certainty evidence). Retreatment (10 studies, 799 participants): We are uncertain about the effects of PAE and PUL on retreatment compared to TURP (12 to 60 months; PUL: RR 2.39, 95% CI 0.51 to 11.1; PAE: RR 4.39, 95% CI 1.25 to 15.44; very low-certainty evidence). TUMT may result in higher retreatment rates (RR 9.71, 95% CI 2.35 to 40.13; low-certainty evidence). Erectile function (six studies, 640 participants): We are very uncertain of the effects of minimally invasive treatments on erectile function (MD of International Index of Erectile Function [IIEF-5]; range 5 to 25; higher scores indicates better function; CRFWVT: 6.49, 95% CI -8.13 to 21.12; TIND: 5.19, 95% CI -9.36 to 19.74; PUL: 3.00, 95% CI -5.45 to 11.44; PAE: -0.03, 95% CI -6.38, 6.32; very low-certainty evidence). Ejaculatory dysfunction (eight studies, 461 participants): We are uncertain of the effects of PUL, PAE and TUMT on ejaculatory dysfunction compared to TURP (3 to 12 months; PUL: RR 0.05, 95 % CI 0.00 to 1.06; PAE: RR 0.35, 95% CI 0.13 to 0.92; TUMT: RR 0.34, 95% CI 0.17 to 0.68; low-certainty evidence). TURP is the reference treatment with the highest likelihood of being the most efficacious for urinary symptoms, QoL and retreatment, but the least favorable in terms of major adverse events, erectile function and ejaculatory function. Among minimally invasive procedures, PUL and PAE have the highest likelihood of being the most efficacious for urinary symptoms and QoL, TUMT for major adverse events, PUL for retreatment, CRFWVT and TIND for erectile function and PUL for ejaculatory function. AUTHORS' CONCLUSIONS Minimally invasive treatments may result in similar or worse effects concerning urinary symptoms and QoL compared to TURP at short-term follow-up. They may result in fewer major adverse events, especially in the case of PUL and PAE; resulting in better rankings for symptoms scores. PUL may result in fewer retreatments compared to other interventions, especially TUMT, which had the highest retreatment rates at long-term follow-up. We are very uncertain about the effects of these interventions on erectile function. There was limited long-term data, especially for CRFWVT and TIND. Future high-quality studies with more extended follow-up, comparing different, active treatment modalities, and adequately reporting critical outcomes relevant to patients, including those related to sexual function, could provide more information on the relative effectiveness of these interventions.
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Affiliation(s)
- Juan Va Franco
- Associate Cochrane Centre, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Michael Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Muhammad Imran Omar
- Guidelines Office, European Association of Urology, Arnhem, Netherlands
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | | | - Shamar Young
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jafar Golzarian
- Department of Radiology, Division of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, Minnesota, USA
| | - Areti Angeliki Veroniki
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Luis Garegnani
- Associate Cochrane Centre, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Gupta AK, Shear NH, Piguet V, Bamimore MA. Efficacy of non-surgical monotherapies for hidradenitis suppurativa: a systematic review and network meta-analyses of randomized trials. J DERMATOL TREAT 2021; 33:2149-2160. [PMID: 33961535 DOI: 10.1080/09546634.2021.1927949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We determined the relative efficacy of non-surgical monotherapies for hidradenitis suppurativa (HS). METHODS Network meta-analyses were conducted to determine treatments' surface under the cumulative ranking curve (SUCRA) value (i.e., an estimate that ranks efficacy); pairwise comparisons were conducted. RESULTS AND CONCLUSIONS Ten trials were eligible for quantitative analyses; however, all did not have a common endpoint. Outcomes corresponded to pain severity, clinical response, quality of life and abscess count. For pain reduction, infliximab was ranked most efficacious (SUCRA =94%) compared to bermekimab, anakinra and placebo; infliximab reduced pain more significantly (p < 0.05) than anakinra and than placebo. For occurrence of clinical response, bimekizumab had the highest SUCRA (67%) relative to adalimumab, anakinra and placebo; bimekizumab was more efficacious than placebo (p < 0.05). For quality of life in mild HS, Botox had the highest SUCRA (94%) compared to adalimumab and placebo; Botox was more efficacious than placebo (p < 0.05). For reduction in abscess count, oral tetracycline had the highest SUCRA (48%) compared to topical clindamycin and vehicle. Our work-being the first NMA study on non-surgical HS monotherapies-contributes to the comparative effectiveness literature for this condition.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, Ontario, Canada.,Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada.,Division of Dermatology, Women's College Hospital, Toronto, Canada.,Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
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Thanigaimani S, Phie J, Sharma C, Wong S, Ibrahim M, Huynh P, Moxon J, Jones R, Golledge J. Network Meta-Analysis Comparing the Outcomes of Treatments for Intermittent Claudication Tested in Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019672. [PMID: 33890475 PMCID: PMC8200724 DOI: 10.1161/jaha.120.019672] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background No network meta-analysis has considered the relative efficacy of cilostazol, home exercise therapy, supervised exercise therapy (SET), endovascular revascularization (ER), and ER plus SET (ER+SET) in improving maximum walking distance (MWD) over short- (<1 year), moderate- (1 to <2 years), and long-term (≥2 years) follow-up in people with intermittent claudication. Methods and Results A systematic literature search was performed to identify randomized controlled trials testing 1 or more of these 5 treatments according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The primary outcome was improvement in MWD assessed by a standardized treadmill test. Secondary outcomes were adverse events and health-related quality of life. Network meta-analysis was performed using the gemtc R statistical package. The Cochrane collaborative tool was used to assess risk of bias. Forty-six trials involving 4256 patients were included. At short-term follow-up, home exercise therapy (mean difference [MD], 89.4 m; 95% credible interval [CrI], 20.9-157.7), SET (MD, 186.8 m; 95% CrI, 136.4-237.6), and ER+SET (MD, 326.3 m; 95% CrI, 222.6-430.6), but not ER (MD, 82.5 m; 95% CrI, -2.4 to 168.2) and cilostazol (MD, 71.1 m; 95% CrI, -24.6 to 167.9), significantly improved MWD (in meters) compared with controls. At moderate-term follow-up, SET (MD, 201.1; 95% CrI, 89.8-318.3) and ER+SET (MD, 368.5; 95% CrI, 195.3-546.9), but not home exercise therapy (MD, 99.4; 95% CrI, -174.0 to 374.9) or ER (MD, 84.2; 95% CrI, -35.3 to 206.4), significantly improved MWD (in meters) compared to controls. At long-term follow-up, none of the tested treatments significantly improved MWD compared to controls. Adverse events and quality of life were reported inconsistently and could not be meta-analyzed. Risk of bias was low, moderate, and high in 4, 24, and 18 trials respectively. Conclusions This network meta-analysis suggested that SET and ER+SET are effective at improving MWD over the moderate term (<2 year) but not beyond this. Durable treatments for intermittent claudication are needed.
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Affiliation(s)
- Shivshankar Thanigaimani
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - James Phie
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Chinmay Sharma
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Shannon Wong
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Muhammad Ibrahim
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Pacific Huynh
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Joseph Moxon
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Rhondda Jones
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia.,The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD011535. [PMID: 33871055 PMCID: PMC8408312 DOI: 10.1002/14651858.cd011535.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this living systematic review we updated our searches of the following databases monthly to September 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We searched two trials registers to the same date. We checked the reference lists of included studies and relevant systematic reviews for further references to eligible RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse events (SAEs) at induction phase. We did not evaluate differences in specific adverse events. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse events). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes and all comparisons, according to CINeMA, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer on treatment hierarchy: 0% (treatment is the worst for effectiveness or safety) to 100% (treatment is the best for effectiveness or safety). MAIN RESULTS We included 158 studies (18 new studies for the update) in our review (57,831 randomised participants, 67.2% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (58%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 20 treatments. In all, 133 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (53/158) as being at high risk of bias; 25 were at an unclear risk, and 80 at low risk. Most studies (123/158) declared funding by a pharmaceutical company, and 22 studies did not report their source of funding. Network meta-analysis at class level showed that all of the interventions (non-biological systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in reaching PASI 90. At class level, in reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the non-biological systemic agents. At drug level, infliximab, ixekizumab, secukinumab, brodalumab, risankizumab and guselkumab were significantly more effective in reaching PASI 90 than ustekinumab and three anti-TNF alpha agents: adalimumab, certolizumab, and etanercept. Ustekinumab and adalimumab were significantly more effective in reaching PASI 90 than etanercept; ustekinumab was more effective than certolizumab, and the clinical effectiveness of ustekinumab and adalimumab was similar. There was no significant difference between tofacitinib or apremilast and three non-biological drugs: fumaric acid esters (FAEs), ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab, and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness of these drugs was similar, except for ixekizumab which had a better chance of reaching PASI 90 compared with secukinumab, guselkumab and brodalumab. The clinical effectiveness of these seven drugs was: infliximab (versus placebo): risk ratio (RR) 50.29, 95% confidence interval (CI) 20.96 to 120.67, SUCRA = 93.6; high-certainty evidence; ixekizumab (versus placebo): RR 32.48, 95% CI 27.13 to 38.87; SUCRA = 90.5; high-certainty evidence; risankizumab (versus placebo): RR 28.76, 95% CI 23.96 to 34.54; SUCRA = 84.6; high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86; SUCRA = 81.4; high-certainty evidence; secukinumab (versus placebo): RR 25.79, 95% CI 21.61 to 30.78; SUCRA = 76.2; high-certainty evidence; guselkumab (versus placebo): RR 25.52, 95% CI 21.25 to 30.64; SUCRA = 75; high-certainty evidence; and brodalumab (versus placebo): RR 23.55, 95% CI 19.48 to 28.48; SUCRA = 68.4; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as mirikizumab, tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to moderate certainty for all the comparisons. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab and brodalumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the evidence for all the interventions was of low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials directly comparing active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between non-biological systemic agents and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Centre of Evidence Based Dermatology, Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Nikolakopoulou A, Mavridis D, Chiocchia V, Papakonstantinou T, Furukawa TA, Salanti G. Network meta-analysis results against a fictional treatment of average performance: Treatment effects and ranking metric. Res Synth Methods 2021; 12:161-175. [PMID: 33070439 DOI: 10.1002/jrsm.1463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Network meta-analysis (NMA) produces complex outputs as many comparisons between interventions are of interest. The estimated relative treatment effects are usually displayed in a forest plot or in a league table and several ranking metrics are calculated and presented. METHODS In this article, we estimate relative treatment effects of each competing treatment against a fictional treatment of average performance using the "deviation from the means" coding that has been used to parametrize categorical covariates in regression models. We then use this alternative parametrization of the NMA model to present a ranking metric (PreTA: Preferable Than Average) interpreted as the probability that a treatment is better than a fictional treatment of average performance. RESULTS We illustrate the alternative parametrization of the NMA model using two networks of interventions, a network of 18 antidepressants for acute depression and a network of four interventions for heavy menstrual bleeding. We also use these two networks to highlight differences among PreTA and existing ranking metrics. We further examine the agreement between PreTA and existing ranking metrics in 232 networks of interventions and conclude that their agreement depends on the precision with which relative effects are estimated. CONCLUSIONS A forest plot with NMA relative treatment effects using "deviation from means" coding could complement presentation of NMA results in large networks and in absence of an obvious reference treatment. PreTA is a viable alternative to existing probabilistic ranking metrics that naturally incorporates uncertainty.
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Affiliation(s)
- Adriani Nikolakopoulou
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center-University of Freiburg, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Virginia Chiocchia
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | | | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Chen L, Ferreira ML, Beckenkamp PR, Caputo EL, Feng S, Ferreira PH. Comparative Efficacy and Safety of Conservative Care for Pregnancy-Related Low Back Pain: A Systematic Review and Network Meta-analysis. Phys Ther 2021; 101:5991225. [PMID: 33210717 DOI: 10.1093/ptj/pzaa200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/23/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE More than one-half of pregnant women experience pregnancy-related low back pain (LBP). Pregnancy-related LBP greatly affects activities of daily life, and although many interventions have been proposed, the optimal treatment for pregnancy-related LBP remains unclear. The purpose of this study was to compare conservative care strategies on their efficacy and safety for women with pregnancy-related LBP through systematic review with pairwise meta-analysis and network meta-analysis. METHODS MEDLINE, Embase, the Cochrane Library, AMED, CINAHL, PEDro, PsycINFO, and ClinicalTrials.gov were searched from inception to November 2019. Randomized controlled trials and observational controlled studies were included without restriction to language, sample size, or duration of follow-up. Two independent investigators extracted the data and assessed the risk of bias. The quality of evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. RESULTS Twenty-three studies were included in the qualitative synthesis (18 randomized controlled trials were included in the network meta-analysis). For women with LBP during pregnancy, progressive muscle relaxation therapy (mean difference = -3.96; 95% CI = -7.19 to -0.74; moderate-quality evidence) and Kinesio Taping (mean difference = -3.71; 95% CI = -6.55 to -0.87; low-quality evidence) reduced pain intensity (Visual Analog Scale, range = 0 to 10) compared with placebo. Moderate-quality evidence suggested that transcutaneous electrical nerve stimulation improved physical function (mean difference = -6.33; 95% CI = -10.61 to -2.05; Roland Morris Disability Questionnaire, range = 0-24) compared with placebo. CONCLUSION For patients with LBP during pregnancy, progressive muscle relaxation therapy and Kinesio Taping may help to decrease pain, and transcutaneous electrical nerve stimulation may improve physical function. IMPACT This review helps fill the gap in evidence regarding optimal treatment for pregnancy-related LBP. LAY SUMMARY If you have LBP during pregnancy, your physical therapist has evidence to support the use of progressive muscle relaxation therapy and Kinesio Taping to help decrease pain and the use of transcutaneous electrical nerve stimulation to help improve physical function.
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Affiliation(s)
- Lingxiao Chen
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Manuela L Ferreira
- Institute of Bone and Joint Research, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Paula R Beckenkamp
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Eduardo L Caputo
- Postgraduate Program in Physical Education, Federal University of Pelotas, Pelotas, Brazil
| | - Shiqing Feng
- Department of Orthopaedics, Tianjin Medical University General Hospital, Tianjin, China
| | - Paulo H Ferreira
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
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Ciapponi A, Klein K, Colaci D, Althabe F, Belizán JM, Deegan A, Veroniki AA, Florez ID. Dexamethasone versus betamethasone for preterm birth: a systematic review and network meta-analysis. Am J Obstet Gynecol MFM 2021; 3:100312. [PMID: 33482400 DOI: 10.1016/j.ajogmf.2021.100312] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to evaluate the comparative clinical effectiveness and safety of dexamethasone vs betamethasone for preterm birth. DATA SOURCES The sources searched were MEDLINE, EMBASE, Cochrane Library, LILACS, ClinicalTrials.gov, and International Clinical Trials Registry Platform without language restrictions until October 2019 in addition to the reference lists of included studies. Field experts were also contacted. STUDY ELIGIBILITY CRITERIA Randomized or quasi-randomized controlled trials comparing any corticosteroids against each other or against placebo at any dose for preterm birth were included in the study. METHODS Three researchers independently selected and extracted data and assessed the risk of bias of the included studies by using Early Review Organizing Software and Covidence software. Random-effects pairwise meta-analysis and Bayesian network meta-analysis were performed. The primary outcomes were chorioamnionitis, endometritis or puerperal sepsis, neonatal death, respiratory distress syndrome, and neurodevelopmental disability. RESULTS A total of 45 trials (11,227 women and 11,878 infants) were included in the study. No clinical or statistical difference was found between dexamethasone and betamethasone in neonatal death (odds ratio, 1.05; 95% confidence interval, 0.62-1.84; moderate-certainty evidence), neurodevelopmental disability (odds ratio, 1.03; 95% confidence interval, 0.80-1.33; moderate-certainty evidence), intraventricular hemorrhage (odds ratio, 1.04; 95% confidence interval, 0.56-1.78); low-certainty evidence), or birthweight (+5.29 g; 95% confidence interval, -49.79 to 58.97; high-certainty evidence). There was no statistically significant difference, but a potentially clinically important effect was found between dexamethasone and betamethasone in chorioamnionitis (odds ratio, 0.70; 95% confidence interval, 0.45-1.06; moderate-certainty evidence), fetal death (odds ratio, 0.81; 95% confidence interval, 0.24-2.41; low-certainty evidence), puerperal sepsis (odds ratio, 2.04; 95% confidence interval, 0.72-6.06; low-certainty evidence), and respiratory distress syndrome (odds ratio, 1.34; 95% confidence interval, 0.96-2.11; moderate-certainty evidence). Meta-regression, subgroup, and sensitivity analyses did not reveal important changes regarding the main analysis. CONCLUSION Corticosteroids have proven effective for most neonatal and child-relevant outcomes compared with placebo or no treatment for women at risk of preterm birth. No important difference was found on neonatal death, neurodevelopmental disability, intraventricular hemorrhage, and birthweight between corticosteroids, and there was no statistically significant difference, but a potentially important difference was found in chorioamnionitis, fetal death, endometritis or puerperal sepsis, and respiratory distress syndrome. Further research is warranted to improve the certainty of evidence and inform health policies.
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Affiliation(s)
- Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina.
| | - Karen Klein
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Daniela Colaci
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Fernando Althabe
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - José M Belizán
- Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Allie Deegan
- School of Global Public Health, New York University, New York, NY
| | - Areti Angeliki Veroniki
- Department of Primary Education, School of Education Sciences, University of Ioannina, Ioannina, Greece; Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellín, Colombia; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Management of Frailty: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. J Am Med Dir Assoc 2020; 20:1190-1198. [PMID: 31564464 DOI: 10.1016/j.jamda.2019.08.009] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/05/2019] [Accepted: 08/19/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyze and determine the comparative effectiveness of interventions targeting frailty prevention or treatment on frailty as a primary outcome and quality of life, cognition, depression, and adverse events as secondary outcomes. DESIGN Systematic review and network meta-analysis (NMA). METHODS Data sources-Relevant randomized controlled trials (RCTs) were identified by a systematic search of several electronic databases including MEDLINE, EMBASE, CINAHL, and AMED. Duplicate title and abstract and full-text screening, data extraction, and risk of bias assessment were performed. Data extraction-All RCTs examining frailty interventions aimed to decrease frailty were included. Comparators were standard care, placebo, or another intervention. Data synthesis-We performed both standard pairwise meta-analysis and Bayesian NMA. Dichotomous outcome data were pooled using the odds ratio effect size, whereas continuous outcome data were pooled using the standardized mean difference (SMD) effect size. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) for each outcome. The quality of evidence was evaluated using the GRADE approach. RESULTS A total of 66 RCTs were included after screening of 7090 citations and 749 full-text articles. NMA of frailty outcome (including 21 RCTs, 5262 participants, and 8 interventions) suggested that the physical activity intervention, when compared to placebo and standard care, was associated with reductions in frailty (SMD -0.92, 95% confidence interval -1.55, -0.29). According to SUCRA, physical activity intervention and physical activity plus nutritional supplementation were probably the most effective intervention (100% and 71% likelihood, respectively) to reduce frailty. Physical activity was probably the most effective or the second most effective interventions for all included outcomes. CONCLUSION AND IMPLICATIONS Physical activity is one of the most effective frailty interventions. The quality of evidence of the current review is low and very low. More robust RCTs are needed to increase the confidence of our NMA results and the quality of evidence.
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Rivano M, Cancanelli L, Spazio LD, Chiumente M, Mengato D, Messori A. Restricted mean survival time as outcome measure in advanced urothelial bladder cancer: analysis of 4 clinical studies. Immunotherapy 2020; 13:95-101. [PMID: 33148090 DOI: 10.2217/imt-2020-0160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The purpose of this study was to assess the effectiveness of immune checkpoint inhibitors (ICIs) in advanced urothelial carcinoma. Materials & methods: We selected seven cohorts of patients published in four clinical trials. The restricted mean survival time (RMST) was used to analyze survival curves, perform the comparisons and rank the treatments based on their effectiveness. The performance of RMST was compared with that of a network meta-analysis. Results: Three ICIs, vinflunine and best standard care, given as second line, were examined. ICIs significantly improved overall survival compared with best standard care. However, the survival gain was quite limited (up to 2.27 months). Post hoc pairwise comparisons were calculated. Conclusion: Our results summarized the efficacy of these treatments and confirmed the good methodological performance of RMST.
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Affiliation(s)
- Melania Rivano
- Clinical Oncology Pharmacy Department, A. Businco Hospital, 09121 Cagliari, Italy
| | - Luca Cancanelli
- Hospital Pharmacy Department, Azienda ULSS 2 Marca Trevigiana, 31033 Castelfranco Veneto, Italy
| | - Lorenzo Di Spazio
- Hospital Pharmacy Department, S.Chiara Hospital, 38122 Trento, Italy
| | - Marco Chiumente
- Scientific Direction, Italian Society for Clinical Pharmacy & Therapeutics, Milan, Italy
| | - Daniele Mengato
- Hospital Pharmacy Department, Bolzano General Hospital, 39100 Bolzano, Italy
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Chaimani A, Porcher R, Sbidian É, Mavridis D. A Markov chain approach for ranking treatments in network meta-analysis. Stat Med 2020; 40:451-464. [PMID: 33105517 PMCID: PMC7821202 DOI: 10.1002/sim.8784] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 09/10/2020] [Accepted: 09/29/2020] [Indexed: 01/06/2023]
Abstract
When interpreting the relative effects from a network meta-analysis (NMA), researchers are usually aware of the potential limitations that may render the results for some comparisons less useful or meaningless. In the presence of sufficient and appropriate data, some of these limitations (eg, risk of bias, small-study effects, publication bias) can be taken into account in the statistical analysis. Very often, though, the necessary data for applying these methods are missing and data limitations cannot be formally integrated into ranking. In addition, there are other important characteristics of the treatment comparisons that cannot be addressed within a statistical model but only through qualitative judgments; for example, the relevance of data to the research question, the plausibility of the assumptions, and so on. Here, we propose a new measure for treatment ranking called the Probability of Selecting a Treatment to Recommend (POST-R). We suggest that the order of treatments should represent the process of considering treatments for selection in clinical practice and we assign to each treatment a probability of being selected. This process can be considered as a Markov chain model that allows the end-users of NMA to select the most appropriate treatments based not only on the NMA results but also to information external to the NMA. In this way, we obtain rankings that can inform decision-making more efficiently as they represent not only the relative effects but also their potential limitations. We illustrate our approach using a NMA comparing treatments for chronic plaque psoriasis and we provide the Stata commands.
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Affiliation(s)
- Anna Chaimani
- Université de Paris, Research Center of Epidemiology and Statistics (CRESS-U1153), INSERM, Paris, France.,Cochrane France, Paris, France
| | - Raphaël Porcher
- Université de Paris, Research Center of Epidemiology and Statistics (CRESS-U1153), INSERM, Paris, France
| | - Émilie Sbidian
- Université Paris-Est Créteil, UPEC, EpiDermE EA 7379, Créteil, France.,AP-HP, Hôpitaux Universitaires Henri Mondor, Département de Dermatologie, UPEC, Créteil, France
| | - Dimitris Mavridis
- Université de Paris, Research Center of Epidemiology and Statistics (CRESS-U1153), INSERM, Paris, France.,Department of Primary Education, University of Ioannina, Ioannina, Greece
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Davies AL, Galla T. Degree irregularity and rank probability bias in network meta-analysis. Res Synth Methods 2020; 12:316-332. [PMID: 32935913 DOI: 10.1002/jrsm.1454] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 11/09/2022]
Abstract
Network meta-analysis (NMA) is a statistical technique for the comparison of treatment options. Outcomes of Bayesian NMA include estimates of treatment effects, and the probabilities that each treatment is ranked best, second best and so on. How exactly network topology affects the accuracy and precision of these outcomes is not fully understood. Here we carry out a simulation study and find that disparity in the number of trials involving different treatments leads to a systematic bias in estimated rank probabilities. This bias is associated with an increased variation in the precision of treatment effect estimates. Using ideas from the theory of complex networks, we define a measure of "degree irregularity" to quantify asymmetry in the number of studies involving each treatment. Our simulations indicate that more regular networks have more precise treatment effect estimates and smaller bias of rank probabilities. Conversely, these topological effects are not observed for the accuracy of treatment effect estimates. This reinforces the importance of taking into account multiple measures, rather than making decisions based on a single metric. We also find that degree regularity is a better indicator for the accuracy and precision of parameter estimates in NMA than both the total number of studies in a network and the disparity in the number of trials per comparison. These results have implications for planning future trials. We demonstrate that choosing trials which reduce the network's irregularity can improve the precision and accuracy of parameter estimates from NMA.
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Affiliation(s)
- Annabel L Davies
- Theoretical Physics, Department of Physics and Astronomy, School of Natural Sciences, The University of Manchester, Manchester, UK
| | - Tobias Galla
- Theoretical Physics, Department of Physics and Astronomy, School of Natural Sciences, The University of Manchester, Manchester, UK.,Instituto de Física Interdisciplinar y Sistemas Complejos, IFISC (CSIC-UIB), Campus Universitat Illes Balears, Palma de Mallorca, Spain
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45
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Gazendam A, Ekhtiari S, Bozzo A, Phillips M, Bhandari M. Intra-articular saline injection is as effective as corticosteroids, platelet-rich plasma and hyaluronic acid for hip osteoarthritis pain: a systematic review and network meta-analysis of randomised controlled trials. Br J Sports Med 2020; 55:256-261. [DOI: 10.1136/bjsports-2020-102179] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 01/13/2023]
Abstract
ObjectiveIntra-articular (IA) injections represent a commonly used modality in the treatment of hip osteoarthritis (OA). Commonly used injections include corticosteroids (CCS), hyaluronic acid (HA) and platelet-rich plasma (PRP). A network meta-analysis allows for comparison among more than two treatment arms and uses both direct and indirect comparisons between interventions. The objective of this network meta-analysis is to compare the efficacy of the various IA injectable treatments in treating hip OA at up to 6 months of follow-up.DesignThis is a systematic review and network meta-analysis. Bayesian random-effects model was performed to assess the direct and indirect comparisons of all treatment options.Data sourcesPubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception to October 2019.Eligibility criteria for selected studiesRandomised controlled trials assessing the efficacy of CCS, HA, PRP and placebo in the form of IA saline injection for patients with hip OA.ResultsEleven randomised controlled trials comprising 1353 patients were included. For pain outcomes at both 2–4 and 6 months, no intervention significantly outperformed placebo IA injection. For functional outcomes at both 2–4 and 6 months, no intervention significantly outperformed placebo IA injection. Regarding change from baseline at 2–4 months and 6 months, pooled data demonstrated that all interventions (including placebo), with the exception of HA+PRP, led to a clinically important improvement in both pain, exceeding the minimal clinically important difference.ConclusionEvidence suggests that IA hip saline injections performed as well as all other injectable options in the management of hip pain and functional outcomes.
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Chiocchia V, Nikolakopoulou A, Papakonstantinou T, Egger M, Salanti G. Agreement between ranking metrics in network meta-analysis: an empirical study. BMJ Open 2020; 10:e037744. [PMID: 32819946 PMCID: PMC7440831 DOI: 10.1136/bmjopen-2020-037744] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To empirically explore the level of agreement of the treatment hierarchies from different ranking metrics in network meta-analysis (NMA) and to investigate how network characteristics influence the agreement. DESIGN Empirical evaluation from re-analysis of NMA. DATA 232 networks of four or more interventions from randomised controlled trials, published between 1999 and 2015. METHODS We calculated treatment hierarchies from several ranking metrics: relative treatment effects, probability of producing the best value [Formula: see text] and the surface under the cumulative ranking curve (SUCRA). We estimated the level of agreement between the treatment hierarchies using different measures: Kendall's τ and Spearman's ρ correlation; and the Yilmaz [Formula: see text] and Average Overlap, to give more weight to the top of the rankings. Finally, we assessed how the amount of the information present in a network affects the agreement between treatment hierarchies, using the average variance, the relative range of variance and the total sample size over the number of interventions of a network. RESULTS Overall, the pairwise agreement was high for all treatment hierarchies obtained by the different ranking metrics. The highest agreement was observed between SUCRA and the relative treatment effect for both correlation and top-weighted measures whose medians were all equal to 1. The agreement between rankings decreased for networks with less precise estimates and the hierarchies obtained from [Formula: see text] appeared to be the most sensitive to large differences in the variance estimates. However, such large differences were rare. CONCLUSIONS Different ranking metrics address different treatment hierarchy problems, however they produced similar rankings in the published networks. Researchers reporting NMA results can use the ranking metric they prefer, unless there are imprecise estimates or large imbalances in the variance estimates. In this case treatment hierarchies based on both probabilistic and non-probabilistic ranking metrics should be presented.
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Affiliation(s)
- Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, BE, Switzerland
| | | | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, BE, Switzerland
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, BE, Switzerland
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Janke K, Biester K, Krause D, Richter B, Schürmann C, Hirsch K, Hörn H, Kerekes MF, Kohlepp P, Wieseler B. Comparative effectiveness of biological medicines in rheumatoid arthritis: systematic review and network meta-analysis including aggregate results from reanalysed individual patient data. BMJ 2020; 370:m2288. [PMID: 32636183 PMCID: PMC7338922 DOI: 10.1136/bmj.m2288] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the comparative effectiveness of biological medicines in rheumatoid arthritis in sufficiently similar patient populations, based on the current definitions of key outcomes. DESIGN Systematic review and network meta-analysis including aggregate results from reanalysed individual patient data. DATA SOURCES Clinical study reports and aggregate results from reanalyses of individual patient data on key outcomes for rheumatoid arthritis provided by study sponsors for studies conducted up to 2017, and several databases and registries from inception up to February 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials investigating patient relevant outcomes in adults with rheumatoid arthritis treated with biological medicines in combination with methotrexate after methotrexate failure for at least 24 weeks. RESULTS 45 eligible trials were identified. Combining data from clinical study reports and aggregate results from reanalyses of individual patient data allowed extensive analyses yielding sufficiently similar populations and homogeneous study results for network meta-analyses, including up to 35 studies on eight biological medicines combined with methotrexate. These analyses showed few statistically significant differences between the combination treatments. For example, anakinra showed less benefit than almost all the other seven biological medicines regarding clinical remission or low disease activity (clinical disease activity index ≤2.8 or ≤10, respectively) and certolizumab pegol showed more harm than the other seven biological medicines regarding serious adverse events or infections. Some outcomes had very wide 95% confidence intervals, potentially implying unidentified differences between the eight biological medicines, but wide 95% confidence intervals were less prominent for low disease activity, serious adverse events, and infections. Owing to a lack of head-to-head trials, results were mainly based on indirect comparisons with a limited number of studies, and recently approved Janus kinase inhibitors could not be included. CONCLUSIONS For patients with rheumatoid arthritis after methotrexate failure, only minor differences in benefits and harms were seen between biological medicines in combination with methotrexate. However, the analysis was hampered by a lack of long term direct comparisons. The substantial information gain achieved by the reanalysis of individual patient data calls for the routine availability of individual patient data.
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Affiliation(s)
- Kirsten Janke
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Katharina Biester
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | | | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christoph Schürmann
- Medical Biometry Department, Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Katharina Hirsch
- Medical Biometry Department, Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Helmut Hörn
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Michaela Florina Kerekes
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Petra Kohlepp
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
| | - Beate Wieseler
- Drug Assessment Department, Institute for Quality and Efficiency in Health Care, Im Mediapark 8, Cologne 50670, Germany
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Plyukhova AA, Budzinskaya MV, Starostin KM, Rejdak R, Bucolo C, Reibaldi M, Toro MD. Comparative Safety of Bevacizumab, Ranibizumab, and Aflibercept for Treatment of Neovascular Age-Related Macular Degeneration (AMD): A Systematic Review and Network Meta-Analysis of Direct Comparative Studies. J Clin Med 2020; 9:1522. [PMID: 32443612 PMCID: PMC7291235 DOI: 10.3390/jcm9051522] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Since the efficacy of ranibizumab (RBZ), bevacizumab (BVZ) and aflibercept (AFB) is comparable in neovascular age-related macular degeneration (AMD), we conducted a systematic review and meta-analysis to evaluate the long-term safety profiles of these agents, including ocular safety. METHODS Systematic review identifying randomized controlled trials (RCTs) comparing RBZ, BVZ and AFB directly published before March 2019. Serious ocular adverse events (SOAE) of special interest were endophthalmitis, pseudo-endophthalmitis, retinal pigment epithelium tear and newly identified macular atrophy. RESULTS Thirteen RCTs selected for meta-analysis (4952 patients, 8723 people-years follow-up): 10 compared RBZ vs. BVZ and three RBZ vs. AFB. There were no significant differences in almost all adverse events (systemic and ocular) between BVZ, RBZ and AFB in up to two years' follow-up. Macular atrophy was reported heterogeneously and not reported as SOAE in most trials. CONCLUSIONS Direct comparison of RBZ, BVZ and AFB safety profiles in the RCT network meta-analytical setting have not revealed a consistent benefit of these three commonly used anti-vascular endothelial growth factor (anti-VEGF) agents in AMD. Network model ranking highlighted potential benefits of RBZ in terms of a systemic safety profile; however, this appears a hypothesis rather than a conclusion. Newly identified macular atrophy is underestimated in RCTs-future real-world data should be focused on SOAE.
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Affiliation(s)
- Anna A. Plyukhova
- Federal State Budget Scientific Research Institute “Scientific Research Institute of Eye Diseases”, 119021 Moscow, Russia;
| | - Maria V. Budzinskaya
- Federal State Budget Scientific Research Institute “Scientific Research Institute of Eye Diseases”, 119021 Moscow, Russia;
| | | | - Robert Rejdak
- Department of General Ophthalmology with Pediatric Service, Medical University of Lublin, 20079 Lublin, Poland; (R.R.); (M.D.T.)
| | - Claudio Bucolo
- Department of Biomedical and Biotechnological Sciences, School of Medicine, University of Catania, 95123 Catania, Italy;
| | - Michele Reibaldi
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy
| | - Mario D. Toro
- Department of General Ophthalmology with Pediatric Service, Medical University of Lublin, 20079 Lublin, Poland; (R.R.); (M.D.T.)
- Faculty of Medicine, Collegium Medicum Cardinal Stefan Wyszyński University, 01815 Warsaw, Poland
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49
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Seide SE, Jensen K, Kieser M. A comparison of Bayesian and frequentist methods in random-effects network meta-analysis of binary data. Res Synth Methods 2020; 11:363-378. [PMID: 31955519 DOI: 10.1002/jrsm.1397] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 01/15/2020] [Accepted: 01/15/2020] [Indexed: 01/11/2023]
Abstract
The performance of statistical methods is often evaluated by means of simulation studies. In case of network meta-analysis of binary data, however, simulations are not currently available for many practically relevant settings. We perform a simulation study for sparse networks of trials under between-trial heterogeneity and including multi-arm trials. Results of the evaluation of two popular frequentist methods and a Bayesian approach using two different prior specifications are presented. Methods are evaluated using coverage, width of intervals, bias, and root mean squared error (RMSE). In addition, deviations from the theoretical surface under the cumulative rankings (SUCRAs) or P-scores of the treatments are evaluated. Under low heterogeneity and when a large number of trials informs the contrasts, all methods perform well with respect to the evaluated performance measures. Coverage is observed to be generally higher for the Bayesian than the frequentist methods. The width of credible intervals is larger than those of confidence intervals and is increasing when using a flatter prior for between-trial heterogeneity. Bias was generally small, but increased with heterogeneity, especially in netmeta. In some scenarios, the direction of bias differed between frequentist and Bayesian methods. The RMSE was comparable between methods but larger in indirectly than in directly estimated treatment effects. The deviation of the SUCRAs or P-scores from their theoretical values was mostly comparable over the methods but differed depending on the heterogeneity and the geometry of the investigated network. Multivariate meta-regression or Bayesian estimation using a half-normal prior scaled to 0.5 seems to be promising with respect to the evaluated performance measures in network meta-analysis of sparse networks.
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Affiliation(s)
- Svenja E Seide
- Institute of Medical Biometry and Informatics, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Katrin Jensen
- Institute of Medical Biometry and Informatics, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
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50
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Niño-Serna LF, Acosta-Reyes J, Veroniki AA, Florez ID. Antiemetics in Children With Acute Gastroenteritis: A Meta-analysis. Pediatrics 2020; 145:peds.2019-3260. [PMID: 32132152 DOI: 10.1542/peds.2019-3260] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Several antiemetics have been used in children with acute gastroenteritis. However, there is still controversy over their use. OBJECTIVE To determine the effectiveness and safety of antiemetics for controlling vomiting in children with acute gastroenteritis. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Latin America and the Caribbean Literature on Health Sciences, and gray literature, until December 2018. STUDY SELECTION We selected randomized clinical trials comparing metoclopramide, ondansetron, domperidone, dexamethasone, dimenhydrinate, and granisetron. DATA EXTRACTION Two reviewers independently screened abstracts and full texts, extracted the data, and assessed the risk of bias. We performed pairwise and network meta-analysis using the random-effects model. RESULTS Twenty-four studies were included (3482 children). Ondansetron revealed the largest effect in comparison to placebo for cessation of vomiting (odds ratio = 0.28 [95% credible interval = 0.16 to 0.46]; quality of evidence: high) and for hospitalization (odds ratio = 2.93 [95% credible interval = 1.69 to 6.18]; quality of evidence: moderate). Ondansetron was the only intervention that reduced the need for intravenous rehydration and the number of vomiting episodes. When considering side effects, dimenhydrinate was the only intervention that was worse than placebo. LIMITATIONS Most treatment comparisons had low- or very low-quality evidence, because of risk of biases and imprecise estimates. CONCLUSIONS Ondansetron is the only intervention that revealed an effect on the cessation of vomiting, on preventing hospitalizations, and in reducing the need for intravenous rehydration. Ondansetron was also considered a safe intervention.
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Affiliation(s)
- Laura F Niño-Serna
- Department of Pediatrics, University of Antioquia, Medellín, Colombia.,Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Jorge Acosta-Reyes
- Department of Public Health, Universidad del Norte, Barranquilla, Colombia
| | - Areti-Angeliki Veroniki
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.,Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College, London, United Kingdom; and
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellín, Colombia; .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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