Systematic Reviews

BackgroundThe predominant airway inflammation in chronic obstructive pulmonary disease (COPD) is neutrophilic, although numerous studies have shown that eosinophilic inflammation contributes significantly to COPD. Eosinophilic COPD patients are characterized by a greater number of total exacerbations and higher hospitalization rates. Biological therapy targets multiple steps in eosinophilic inflammation, providing a promising approach to reduce exacerbation frequency and mortality. ObjectiveTo provide a timely, rigorous, and continuously updated summary of the evidence available on the role of biological therapy for the treatment of patients with COPD. DesignThis is a Living Evidence synthesis, that starts with a baseline synthesis report of the effects of the intervention on the main predefined outcomes. Based on its conclusions, we will set up the living evidence approach, and the evidence monitoring will begin. MethodsO_ST_ABSEvidence identification, screening, and selectionC_ST_ABSAutomated living searches were performed in relevant databases following the Epistemonikos procedures. Results were incorporated into the Epistemonikos "Living OVerview of Evidence (L.OVE)" platform which was used for evidence screening, and selection. Two reviewers screened all titles and abstracts supported by the platform automated classifiers that excluded references with a low probability of being relevant. For this baseline report we included randomized trials that evaluated the use of biological therapy compared to the use of standard-of-therapy alone in adult patients with COPD. Main outcomes defined as critical or important for decision making include exacerbation rate, exacerbation-free time, lung function and quality of life. Two reviewers independently screened each study for eligibility, extract data, and assess its methodological quality using appropriate tools. We performed meta-analyses of the studys results when pertinent. We applied the GRADE approach to assess the certainty of the evidence found for each outcome. We will continuously monitor the evidence by performing daily searches and monthly screening of the retrieved references. Additionally, each three months we will manually search for ongoing studies in the International Clinical Trials Registry Platform trial registries. The evidence monitoring, including decisions to incorporate evidence and withdraw the question from the living mode will follow the process proposed by the Living Evidence to Inform Health Decisions framework (ref) as stated in our protocol. A living, web-based version of this review will be openly available during the next year at https://livingevidenceihd.com/lesrepo/. We will resubmit it every time the conclusions change or whenever there are substantial updates. ResultsInitial searches retrieved 24 systematic reviews, 2 evaluating the use of biologics on COPD, which included 6 randomized control trials. Additional searches retrieved 125 randomized controlled trials (RCTs). Of these, 31 RCTs were deemed potentially eligible and were reviewed in full text. Ultimately, 9 RCTs evaluating the use of biological therapies (MEDI8968, benralizumab, mepolizumab, dupilumab, astegolimab, and itepekimab) compared to placebo in COPD patients were included. The GRADE quality of evidence for the main outcomes was assessed as intermediate. ConclusionsThe evidence suggests that biological therapies may reduce the risk of exacerbations in patients with chronic obstructive pulmonary disease (COPD). However, the overall impact on lung function and quality of life remains inconclusive. The variability in study outcomes, particularly concerning SGRQ scores and FEV1, emphasizes the need for continuing monitoring evidence. PROSPERO /OSF Protocol Registration DOI: 10.17605/OSF.IO/SUYD2 STRUCTURED ABSTRACTO_ST_ABSObjectiveC_ST_ABSTo synthesize and update evidence on the efficacy and safety of biological therapy for chronic obstructive pulmonary disease (COPD). MethodsThis living evidence synthesis included systematic reviews (SRs) and randomized controlled trials (RCTs) comparing biological therapies (e.g., benralizumab, mepolizumab, dupilumab) with placebo or standard care in adults with moderate to severe COPD. Automated searches were conducted using the Epistemonikos "Living Overview of Evidence" (L.OVE) platform, supplemented by manual searches. Two reviewers independently screened studies, extracted data, and assessed risk of bias using Cochrane RoB2 for RCTs and AMSTAR II for SRs. Meta-analyses were performed, and the certainty of evidence was evaluated using the GRADE approach. ResultsNine RCTs were included. Biological therapy probably reduces annual exacerbation rates (moderate certainty; MD -0.12, 95% CI -0.23 to 0.00). The evidence is very uncertain about its effect on quality of life (SGRQ score: MD 0.05, 95% CI -0.04 to 0.14; very low certainty) due to serious inconsistency (I{superscript 2} = 95.5%) and imprecision. Biological therapy may result in little to no difference in lung function (FEV1: MD 0.02, 95% CI -0.02 to 0.06; low certainty), with serious inconsistency (I{superscript 2} = 76.8%) and imprecision. Biological therapy probably results in no difference in total adverse events (moderate certainty; RR 1.02, 95% CI 0.99 to 1.05) but likely reduces severe adverse events (high certainty; RR 0.84, 95% CI 0.77 to 0.93). ConclusionsCurrent evidence suggests that biological therapies for COPD provide little to no clinical benefit over standard care in terms of exacerbation rates, lung function, or safety, with uncertain effects on quality of life. Biological therapy probably has little to no effect on annual exacerbations compared with standard care. There is likely no meaningful difference in lung function (FEV1) compared with standard care. Biologicals probably result in no difference in the number of total adverse events. Regarding the effect on quality of life, measured by the SGRQ compared with standard care, the evidence is very uncertain; therefore, no conclusions can be drawn. Overall, the certainty of the evidence supporting these statements is generally moderate, but is particularly limited by imprecision in estimates when considering thresholds for the minimal important difference (MID).

IntroductionRecently, a Cochrane review by Jefferson et al. on physical interventions to slow the spread of respiratory viruses concluded that, "Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks", though this finding had a wide confidence interval. Cochrane issued a rare clarifying statement, fueling controversy. We sought to contextualize the findings of the review by Jefferson et al. MethodsWe searched for consecutive reviews by Cochrane published on or before March 9th, 2023. We included studies where a central finding showed an intervention offered no statistically significant benefit, and ascertained the language used by reviewers to describe that result. We compare this to the report by Jefferson et al., and deemed it consistent or inconsistent with the language of their report. ResultsWe found between November 21st, 2022, and March 9th, 2023, there were 20 Cochrane reviews that met the inclusion criteria. We found that 95% (n = 19) of the reviews used language that was consistent with Jeffersons findings, while 5% (n = 1) used language inconsistent with Jeffersons conclusion, describing the effect of the intervention on the outcome as "unclear". DiscussionMost reviews performed by Cochrane conclude that interventions which fail to show statistically significant benefits make "no difference" have "no effect" or do not "increase or decrease" the outcome, and this occurs despite wide confidence intervals. The conclusions by Jefferson et al. are consistent with Cochrane reporting guidelines and clarification from the organization was unjustified.

ObjectivesTo examine whether high flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) strategies impact mortality, the need for invasive mechanical ventilation (IMV), or hospital and intensive care unit (ICU) length of stay compared to standard oxygen therapy (SOT) or each other in patients with severe or critical COVID-19 with acute hypoxemic respiratory failure. MethodsA rapid review of randomized controlled trials (RCTs) identified through published systematic and rapid reviews supplemented with a search of bibliographic databases. RCTs were eligible if they compared HFNO, CPAP, or NIV to SOT or another ventilation strategy. Studies were screened, selected, and extracted by a single reviewer and checked by a second reviewer. We assessed risk of bias of included studies using the Cochrane Risk of bias tool and used the grading of recommendations, assessment, development, and evaluation (GRADE) approach to judge the certainty of the evidence for mortality, need for IMV, and hospital and ICU length of stay. We sought RCT evidence for non-COVID-19 patients with acute hypoxemic respiratory failure and acute respiratory distress to inform additional comparisons and to supplement the available data for COVID-19. ResultsA total of 5 RCTs comparing ventilation strategies in patients with severe or critical COVID-19 were included. Patient and study characteristics were extracted and evidence and certainty of evidence assessments were completed for comparisons of HFNO and CPAP to standard oxygen therapy and NIV and CPAP to HFNO. An additional 22 RCTs of non-COVID-19 patients were also included and considered. Results from meta-analysis suggest reductions in mortality and IMV with HFNO (RR mortality 0.87 (0.66-1.13), IMV 0.89 (0.77-1.03); low quality evidence) or CPAP (RR mortality 0.87 (0.64-1.18) low quality evidence, IMV 0.81 (0.67-0.98) moderate quality evidence) compared to SOT. Helmet NIV may reduce IMV (RR 0.69 (0.43-1.09)) and CPAP may reduce IMV (RR 0.69 (0.43-1.09)) and hospital (1.67 days fewer (5.43 fewer-2.09 more) or ICU length of stay (1.02 days fewer (3.97 fewer-1.93 more)) compared to HFNO (low quality evidence). ConclusionsThis rapid systematic review highlights the available evidence to support the use of noninvasive ventilation strategies including high flow nasal oxygen, noninvasive ventiltaion (e.g., BiPAP), or CPAP in hospitalized patients with severe or critical COVID-19 and acute hypoxemic respiratory failure who do not need emergent intubation. Findings based on moderate to very low certainty evidence suggest that noninvasive ventilation may be considered as an alternative to standard oxygen therapy to reduce hypoxemia and dyspnea. Additional high quality RCTs are warranted to reduce uncertainty and to fill in important knowledge gaps.

ObjectiveTo examine the scientific literature on mask-use as source control to protect others from respiratory infections before and after the onset of the COVID-19 pandemic. DesignSystematic review. MethodsWe examined primary research on mask usage as a means of source control to protect others by reducing the spread of respiratory diseases and contrasted the literature published before the onset of the COVID-19 pandemic with that published afterward. Articles were obtained through a search of PubMed and a review of article references. March 1, 2020 was selected as the cutoff date to distinguish between the pre-COVID-19 and post-COVID-19 periods. Results195 articles met our inclusion criteria. The sample included 55 articles on source control published before the start of the COVID-19 pandemic, and 140 articles published after the pandemic began, representing a 154.5% increase. The percentage of randomized control trials (RCT) and cluster RCTs declined by 94.9% (p<0.001), representing only 1.4% of the post-pandemic literature. The percentage of studies conducted on human subjects declined by 48.8% (p<0.001), and the percentage of studies in healthcare facilities declined by 64.5% (p=0.019). One in 5 post-pandemic studies (21.4%) were conducted in "real world" settings; 1 in 10 post-pandemic studies (10.0%) were done with computer modeling. Study authors were significantly more supportive of masks as source control in the post-pandemic literature. ConclusionsThe quality of evidence in the published literature on masks as source control is lower after the start of the COVID-19 pandemic, with notable shifts in methodologies, research subjects, setting, and author tone.

ObjectivesTo develop an organising framework for healthcare decarbonisation research which goes beyond classification schemes based on Scope 1, 2 and 3 emissions or lists of loosely connected themes, and which is intended to support the coordination, funding and application of research into policy and practice. The organising framework should be focused on the NHS in England but enable application to healthcare systems more broadly. DesignAn exploratory manual (non-machine-led) classification study of over 160 research questions derived from a scoping review of 10 systematic reviews (118 screened), 13 stakeholder documents (35 key stakeholder websites searched), two research priority exercises, and four research funder sources (over 430 funding areas screened). The above and a further 21 sources were also used to identify areas without explicit research questions but of clear thematic relevance. SettingPrimarily high-income healthcare systems, with a focus on the NHS in England. ParticipantsNot applicable. Primary outcomeA multi-level thematic framework representing current and missing areas of research in healthcare decarbonisation. ResultsThe framework comprises six top-level themes, grouping 39 sub-themes at level two, and 86 sub-themes at level three. The top-level themes are: Natural resource use and sources of carbon; Healthcare contexts; Solutions; Stakeholders; Organisational levers for change; and Scientific measurement and theory (the "NHS-SOS framework"). ConclusionsThis framework offers a structured, empirically derived representation of the emerging field of healthcare decarbonisation research. It is intended as a living tool to support shared understanding, prioritisation and action, and to foster coherence in a currently fragmented research landscape. Article summaryO_ST_ABSStrengths and limitations of this studyC_ST_ABSO_LIThe study used a transparent and structured process to derive themes from over 160 research questions, sourced from a diverse set of systematic reviews, stakeholder documents, research priority exercises, and funding calls. C_LIO_LIThe inductive approach respected the complexity, breadth and multiple perspectives inherent to healthcare decarbonisation research. C_LIO_LIThe study drew on a wide range of sources selected for conceptual and perspectival breadth but was nonetheless small relative to the volume of publications in the field. C_LIO_LIMany of the research questions were not explicitly stated in the source documents and had to be derived through interpretive analysis. This introduced a potential for bias, which was mitigated through a clearly documented and transparent process outlining how interpretations were made. C_LI

BackgroundEvaluating risk of bias (RoB) is a crucial step in systematic reviews and meta-analyses to ensure trustworthy evidence. Cochranes RoB 2 tool is the most widely used approach for assessing risk of bias in randomized controlled trials. However, its application can be challenging, particularly in fields like psychotherapy, where standard trial procedures such as double blinding are often unfeasible. ObjectiveThis article presents a context-specific operationalization and implementation guideline for applying RoB 2 to psychotherapy trials, addressing common challenges and ambiguities in this field. MethodThis guideline was developed based on empirical evidence, an expert consensus process, and iterative piloting. It provides a structured interpretation of all RoB 2 domains and signalling questions, adapted to the common methodological features of psychotherapy trials. ResultsThe operationalization resulted in 24 standardized RoB items with a harmonized scoring logic, accompanied by a practical handbook offering domainspecific advice and examples relevant to psychotherapy research. To support its use, two open-access digital assistant tools (web-based and spreadsheet formats) were developed to guide users through the rating process and facilitate integration with systematic review workflows (metapsy.org/rob). ConclusionThis guidance offers a practical approach for applying RoB 2 in psychotherapy outcome research. It is intended to be used alongside the Cochrane manual and may help improve the transparency and reproducibility of RoB 2 assessments for psychotherapy trials.

BackgroundHealthcare workplaces experience significant interpersonal conflicts affecting staff wellbeing, patient safety, and organizational performance. Traditional punitive approaches to conflict management often fail to address underlying issues, potentially perpetuating cycles of dysfunction. Restorative justice, emphasizing healing, accountability, and relationship repair over punishment, offers promising alternatives for healthcare conflict resolution. Despite growing implementation, systematic evidence synthesis regarding effectiveness, implementation factors, and outcomes remains absent. ObjectivesThis systematic review protocol aims to synthesize evidence on restorative justice approaches for managing workplace conflicts in healthcare settings, examining implementation processes, effectiveness, barriers, facilitators, and impacts on staff wellbeing, patient care, and organizational culture. MethodsFollowing PRISMA-P guidelines, we will search ten databases (PubMed, MEDLINE, CINAHL, PsycINFO, Embase, Scopus, Web of Science, Business Source Premier, Cochrane Library, and ProQuest) from inception to December 2025. The SPIDER framework guides eligibility criteria focusing on healthcare workers involved in restorative justice interventions, their experiences and outcomes across diverse healthcare contexts. Covidence will facilitate study screening and selection. Quality assessment will employ the Mixed Methods Appraisal Tool (MMAT), with risk of bias evaluated using appropriate domain-specific tools. Narrative synthesis and thematic analysis will integrate quantitative and qualitative findings. GRADE-CERQual will assess confidence in qualitative evidence synthesis. DiscussionThis protocol anticipates generating comprehensive evidence regarding restorative justice implementation models, effectiveness indicators, contextual factors influencing success, stakeholder experiences, and comparative advantages over traditional approaches. Evidence generated will inform policy development, implementation guidelines, and training programs for healthcare organizations seeking transformative conflict resolution approaches that prioritize healing, learning, and relationship restoration over punitive measures.

AbstractsO_ST_ABSBackgroundC_ST_ABSSelf-management is essential for stroke survivors to maintain a healthy lifestyle and reduce recurrence risk. Although theory-based self-management interventions are widely recommended, the theoretical frameworks underpinning them and their comparative effectiveness remain unclear. AimsTo systematically identify the theories, models, and frameworks (TMFs) used in self-management interventions for stroke survivors, to explore how they guide interventions, and evaluate their effectiveness on self-management behaviors and self-efficacy. MethodsPubMed, Embase, Web of Science, ProQuest Health & Medical Collection and the Cochrane Library were searched from inception to July 15, 2025. Randomized controlled trials or quasi-experimental studies evaluating theory-based self-management interventions for stroke survivors were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias (Cochrane RoB 2.0). Meta-analyses were performed using random-effects models. ResultsFrom 11,495 records, 32 studies with 3,212 participants were included. Sixteen distinct TMFs were identified; self-efficacy theory was most frequent (13/32), followed by social cognitive theory (6/32). All TMFs were middle-range theories. Meta-analysis showed TMFs-based interventions significantly improved self-management behaviors (SMD = 4.26, 95%CI: 0.20-8.31, I{superscript 2} = 98.2%) and self-efficacy (SMD = 0.60, 95%CI: 0.32-0.88, I{superscript 2} = 72.8%). However, the effect for behaviors is likely inflated due to extreme heterogeneity and theoretical diversity. Theory-specific analysis of self-efficacy theory (k = 8) confirmed significant effects on self-efficacy (SMD = 0.64, 95%CI: 0.21-1.08). ConclusionsThis review identified 16 distinct theoretical models; self-efficacy theory was most frequently applied, followed by social cognitive theory. Theory-based interventions significantly improved self-management behaviours and self-efficacy.

IntroductionLong COVID affects individuals labour market participation in many ways. While some cannot work at all, others may return to work (RTW) in a limited capacity. Determining what rehabilitation or related strategies are safe and effective for facilitating RTW is necessary. ObjectivesTo synthesize evidence on RTW interventions for people living with Long COVID and to identify promising interventions for enhancing work ability and RTW. MethodsWe followed Arksey & OMalleys methodology and the PRISMA extension for scoping reviews. Five electronic bibliographic databases and grey literature were searched. The included various study designs, such as randomized controlled trials (RCT), quasi-experimental designs, and observational studies. Two reviewers conducted screening and data extraction, with disagreements resolved through consensus. Intervention studies were categorized as promising (statistically significant RTW outcomes or [&ge;] 50% RTW), somewhat promising (20% to < 50% RTW), or not promising (non-statistically significant RTW outcomes or < 20% RTW). ResultsEleven recommendations and eleven intervention studies were identified. Of the intervention studies, 6 were cohort studies, 3 quasi-experimental studies, 1 RCT and 1 case report. Promising interventions included multimodal and interdisciplinary work-focused rehabilitation (1 article), psychoeducation, pacing, and breathing strategies (2 articles), shifting focus from symptom monitoring to optimizing functional outcomes (1 article), and enhanced external CounterPulsation (EECP) inflatable pressure to improve blood flow (1 article). ConclusionMany uncertainties remain regarding which RTW interventions are effective or the optimal characteristics of these interventions.

There is paucity of evidence related to mechanical ventilation in the general ward setting. We aimed to study the clinico-etiological profile, outcomes and prognostic factors of patients receiving invasive mechanical ventilation in non-ICU (ward) setting, and compare these parameters with that of patients in the ICU, wherever it was reported. A systematic review and meta-analysis was done on articles published till June 2020. Two authors independently extracted the data. The study population included patients who received mechanical ventilation in ward setting. Fourteen studies reporting on 20833 patients were included (20252 exclusively ventilated in ward), with most of the studies being from Israel, USA, Japan and Taiwan. Risk of bias was estimated using the Newcastle-Ottawa Scale for observational studies, and was found to be low. Most common reason for intubation was respiratory illness. Most common variables predicting mortality were prognostic scores like APACHE-II and Acute Physiology Score (APS). Pooled mortality rate in ward across 6 studies was 0.72 (95% CI 0.69-0.74) with no heterogeneity among these 6 studies (I2=0.0). Mortality rate varied significantly with study population characteristics, and was lower among patients being weaned in ward. A major limitation of our study was the paucity of studies and significant heterogeneity among existing studies, with respect to outcomes like duration of ventilation, hospital stay, rates of complications, and prognostic factors. This systematic review and meta-analysis found that mortality among patients receiving invasive mechanical ventilation in ward settings remains high. Data regarding other outcomes and prognostic factors predicting mortality was very heterogeneous highlighting the need for future studies concentrating specifically on these aspects. Systematic review registration: PROSPERO 2020 (CRD42020166775)

OBJECTIVETo assess the effectiveness of hand hygiene, surface disinfecting, and other hygiene interventions in preventing or reducing the spread of illnesses from respiratory viruses. DESIGNUpdate of a systematic review and meta-analysis focussing on randomised controlled trials (RCTs) and cluster-RCTs (c-RCTs) evidence only. DATA SOURCESEligible trials from the previous Cochrane review, search of the Cochrane Central Register of Controlled Trials, PubMed, Embase and CINAHL from 01 October 2010 to 01 April 2020, and forward and backward citation analysis of included studies. DATA SELECTIONRCTs and c-RCTs involving people of any age, testing the use of hand hygiene methods, surface disinfection or cleaning, and other miscellaneous barrier interventions. Face masks, eye protection, and person distancing are covered in Part 1 of our systematic review. Outcomes included acute respiratory illness (ARI), influenza-like illness (ILI) or laboratory-confirmed influenza (influenza) and/or related consequences (e.g. death, absenteeism from school or work). DATA EXTRACTION AND ANALYSISSix authors working in pairs independently assessed risk of bias using the Cochrane tool and extracted data. The generalised inverse variance method was used for pooling by using the random-effects model, and results reported with risk ratios (RR) and 95% confidence intervals (CIs). RESULTSWe identified 51 eligible trials. We included 25 randomised trials comparing hand hygiene interventions with a control; 15 of these could be included in meta-analyses. We pooled 8 trials for the outcome of ARI. Hand hygiene showed a 16% relative reduction in the number of participants with ARI (RR 0.84, 95% CI 0.82 to 0.86) in the intervention group. When we considered the more strictly defined outcomes of ILI and influenza, the RR for ILI was 0.98 (95% CI 0.85 to 1.14), and for influenza the RR was 0.91 (95% CI 0.61 to 1.34). Three trials measured absenteeism. We found a 36% relative reduction in absentee numbers in the hand hygiene group (RR 0.64, 95% CI 0.58 to 0.71). Comparison of different hand hygiene interventions did not favour one intervention type over another. We found no incremental effects of combining hand hygiene with using face masks or disinfecting surfaces or objects. CONCLUSIONSDespite the lack of evidence for the impact of hand hygiene in reducing ILI and influenza, the modest evidence for reducing the burden of ARIs, and related absenteeism, justifies reinforcing the standard recommendation for hand hygiene measures to reduce the spread of respiratory viruses. Funding for relevant trials with an emphasis on adherence and compliance with such a measure is crucial to inform policy and global pandemic preparedness with confidence and precision.

ObjectiveSystematic reviews (SRs) are essential to ensure that decisions are informed by an up-to-date and complete understanding of the relevant research evidence. Conducting SRs within a doctoral thesis can reduce redundant, harmful and unethical research, identify knowledge gaps, and help the doctoral student obtain important skills to conduct and use research. The output and learning process of SRs overlaps with the aims of doctoral programs. We aim to explore to what extent SRs are included in doctoral theses from all medical faculties in Sweden, and to describe the type, topic and assess the credibility of the reviews. Study design and settingDuplicate assessors independently searched local and national repositories for doctoral theses published in 2021 within all seven medical faculties in Sweden, and categorized identified reviews based on review type, topic, and credibility using AMSTAR-2. Results5.4% (45/852) of all doctoral theses included a review, and 1.3% (45/3461) of all included studies were reviews. Of these, two thirds (31) were SRs and the rest (14) were broader big picture reviews. The most common topics were interventions (42%) and exposure/etiology (32%), with no reviews of diagnostic tests. The majority of the SRs had very low (71%) or low (19%) credibility, and few reached a high (7%) or moderate (3%) credibility. The most common issues were limitations with protocols, limited search strategies, and failure to account for risk of bias in drawn conclusions. ConclusionsFew doctoral students included SRs in their theses, and the few SRs included in doctoral theses generally had a low credibility. Increasing the rate and quality of SRs in doctoral theses can help improve quality and relevance of subsequent primary research, and help students develop important skills. Actions are needed to support doctoral students to conduct high quality SRs. What is new?O_LIFew doctoral students included systematic reviews (SRs) in their theses C_LIO_LIThe few SRs included in doctoral theses generally had a low credibility C_LIO_LIIncreasing the rate of SRs can help improve the relevance of subsequent research C_LIO_LIMoreover, to support development of important skills and reach educational goals C_LIO_LIActions are needed to support doctoral students to conduct high quality SRs C_LI

BackgroundDifferent comprehensive care programmes (CCPs) have been developed for patients with chronic obstructive pulmonary disorder (COPD), but data regarding their effectiveness have been controversial. PubMed and Embase were searched to 1st June 2017 for articles that investigated the effects of the different types of CCPs on hospitalization or mortality rates in COPD. ResultsA total of 67 studies including 3472633 patients (mean age: 76.1{+/-}12.7 years old; 41% male) were analyzed. CCPs reduced all-cause hospitalizations (hazard ratio [HR]: 0.70, 95% confidence interval [CI]: 0.63-0.79; P<0.001; I2:96%) and mortality (HR: 0.69, 95% CI: 0.573-0.83; P<0.001; I2:75%). Subgroup analyses for different CCP types were performed. Hospitalizations were reduced by pharmacist-led medication reviews (HR: 0.54; 95% CI: 0.37-0.78; P=0.001; I2:49%), structured care programmes (HR: 0.76; 95% CI: 0.66-0.87; P<0.0001; I2:88%) and self-management programmes (HR: 0.79; 95% CI: 0.64-0.99; P<0.05; I2:78%), but not continuity of care programmes (HR: 0.70; 95% CI: 0.36-1.36; P=0.29; I2:100%), early support discharge or home care packages (HR: 0.97; 95% CI: 0.91-1.04; P=0.37; I2:0%) or telemonitoring (HR: 0.61; 95% CI: 0.32-1.18; P=0.14; I2:94%). Mortality was reduced by early support discharge or home care packages (HR: 0.49; 95% CI: 0.30-0.80; P<0.01; I2:72%), structured care programmes (HR: 0.69; 95% CI: 0.53-0.90; P<0.01; I2:61%) and telemonitoring (HR: 0.52; 95% CI: 0.31-0.89; P<0.05; I2:0%), but not self-management programmes (HR: 0.79; 95% CI: 0.64-0.99; P<0.05; I2:78%). ConclusionsComprehensive care programmes reduce hospitalization and mortality in COPD patients.

BackgroundStroke survivors are primarily physically inactive. Physiotherapy practice might represent professional support to improve this alarming lifestyle. However, evidence is scarce regarding the effectiveness of active physiotherapy on physical activity level in stroke survivors. MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, i.e., involving exercises that require voluntary effort by the patient. Outcome measure: Physical activity level. ResultsOut of 5590 identified references, 25 RCTs were eligible, and 21 had available data. Pooling resulted in a small significant effect size in favor of active physiotherapy (standardized mean difference (SMD) 0.22, 95% confidence interval (CI) 0.04 to 0.40, heterogeneity I2=65%), and medium significant effect when physical activity level was measured using an objective tool (SMD 0.48, 95% CI 0.03 to 0.92, I2=73%). In addition, meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. Finally, none of the variances were associated with specific dosage in frequency, time, or exercise duration, nor with the severity of the disability. ConclusionActive physiotherapy seems effective in increasing objective physical activity among stroke survivors living in the community. However, the evidence supporting the efficacy of active physiotherapy was found to be of low certainty. Thus, further evidence is required. Registration PROPEROCRD42022315639.

The COVID-19 pandemic has highlighted the need for improved air flow in hospitals, to reduce the transmission of airborne infections such as COVID-19. The aim of this review was to map the existing literature on intervention used to improve air flow in hospitals, understanding challenges in implementation and the findings of any evaluations. We reviewed peer-reviewed articles identified on three databases, MEDLINE, Web of Science and the Cochrane Library with no restriction on date. 5846 articles were identified, 130 were reviewed and 18 were included: ten articles were from databases and eight articles were identified through hand searching. Results were discussed in terms of three categories: (i) concentration of aerosol particles, (ii) changes in/effect of air speed and ventilation and (iii) improvements or reduction in health conditions. Eight studies included an evaluation, the majority only had one comparator condition however three had multiple conditions. The most common device or method that was outlined by researchers was HEPA filters, which can remove particles with a size of 3 microns. Articles outline different interventions to improve air flow and some demonstrate their effectiveness in terms of improving health outcomes for patients, they also suggest either mechanical and natural ventilation are the best methods for dispersing particulate matter as well as perhaps two air cleaning units rather than one. With different methods comes different strengths and weaknesses however, the key finding is that air flow improvement measures reduce the likelihood of nosocomial infections.

BackgroundAvenues of treatment currently implemented for Covid-19 pandemic are largely supportive in nature. Non-availability of an effective antiviral treatment makes supportive care for acute hypoxic respiratory failure is the most crucial intervention. Highly contagious nature of Covid-19 had created stress and confusion among front line Health Care Workers (HCWs) regarding infectious risk of supportive interventions and best preventive strategies. PurposeTo analyze and summarize key evidence from published literature exploring the risk of transmission of Covid-19 related to common supportive care interventions in hospitalized patients and effectiveness of currently used preventive measures in hospital setting. Data SourcesCurated Covid-19 literature from NCBI Computational Biology Branch, Embase and Ovid till May 20,2020.Longitudinal and reference search till June 28,2020 Study SelectionStudies pertaining to risk of infection to HCWs providing standard supportive care of hospitalized Covid-19 mainly focusing on respiratory support interventions. Indirect studies from SARS,MERS or other ARDS pathology caused by infectious agents based on reference tracking and snow ball search. Clinical, Healthy volunteer and mechanistic studies were included. Two authors independently screened studies for traditional respiratory supportive-care (Hypoxia management, ventilatory support and pulmonary toileting) related transmission of viral or bacterial pneumonia to HCWs. Data ExtractionTwo authors (TK and SP) independently screened articles and verified for consensus. Quality of studies and level of evidence was assessed using Oxford Center for Evidence Based Medicine (OCEBM), Newcastle - Ottawa quality assessment Scale for observational studies and Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence. Data Synthesis22 studies were eligible for inclusion. In 11 mechanistic studies, 7 were manikin based,1 was in the setting of GNB pneumonia, 2 were healthy volunteer study and 1 was heterogenous setting.Out of 11 clinical studies, 5 were case controlled and 6 were cohort studies. Risk of corona virus transmission was significantly high in HCWs performing or assisting endotracheal intubation or contact with respiratory secretion.(Moderate certainty evidence, GRADE B) Safety of nebulization treatment in corona virus pneumonia patients are questionable(Low certainty evidence, GRADE C).Very low certainty evidence exist for risk of transmission with conventional HFNC (GRADE D) and NIV (GRADE D),CPR (GRADE D),Bag and mask ventilation(GRADE D).Moderate certainty evidence exist for protective effect of wearing a multilayered mask, gown, eye protection and formal training for PPE use (GRADE B).Low certainty evidence exist for transmission risk with bag and mask ventilation, suctioning before and after intubation and prolonged exposure (GRADE C).Certainty of evidence for wearing gloves,post exposure hand washing and wearing N 95 mask is low(GRADE C). LimitationsThis study was limited to articles with English abstract. Highly dynamic nature of body of literature related to Covid-19, frequent updates were necessary even during preparation of manuscript and longitudinal search was continued even after finalizing initial search. Due to the heterogeneity and broad nature of the search protocol, quantitative comparisons regarding the effectiveness of included management strategies could not be performed. Direct evidence was limited due to poor quality and non-comparative nature of available Covid-19 reporting. ConclusionsMajor risk factors for transmission of corona virus infection were, performing or assisting endotracheal intubation and contact with respiratory secretion. Risk of transmission with HFNC or NIV can be significantly decreased by helmet interface, modified exhalation circuit or placing a properly fitting face mask over patient interface of HFNC. Evidence for risk of transmission with CPR, suctioning before or after intubation or bag and mask ventilation of very low certainty. Significant protective factors are Formal training for PPE use, consistently wearing mask, gown and eye protection.

ObjectiveThis scoping review protocol outlines the steps to conduct a scoping review to assess the health experiences of female head porters and their unique health challenges and needs. The review aims to broaden our understanding of the occupational health challenges facing head porters in sub-Saharan Africa and identify any gaps in the health literature related to this population. IntroductionHead portering is an informal occupation predominantly undertaken by women and girls in sub-Saharan Africa. Female head porters often lack education and skills, which makes head portering an appealing yet laborious occupation to improve income and associated social conditions and support families left behind. Inclusion criteriaStudies were included in the review if they included females of all ages engaging in head-portering activities as a livelihood in sub-Saharan Africa. Methods and AnalysisThe six stages of the Arksey and OMalley (2005) framework guided the design and reporting of this scoping review. The methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for scoping reviews. Relevant articles and grey literature were identified through searches of health-related databases. The extracted data will be presented using a narrative summary to complement a data table. Ethics and disseminationThe ethical approval submission for this scoping review protocol was not completed as it is not required. Formal knowledge translation and dissemination activities will include publishing findings in African-based high-impact journals and conference presentations to reach relevant audiences. The final recommendations for practice, policy, and research will be shared and distributed through toolkits for healthcare professionals and stakeholder information leaflets. RegistrationThe review has been registered with Open Science Framework Registries: https://osf.io/c3q7as Strengths and LimitationsThis scoping review explores the literature on the health implications of head portering among female head porters, encompassing a broad range of studies and evidence. It aims to identify research gaps, highlight key health concerns requiring further investigation, and serve as a foundation for future reviews and primary studies. However, this review does not include a formal quality assessment of the included studies, which may impact the reliability of the findings. Due to its broad scope, detailed analyses of specific health issues may be limited. Additionally, the risk of selection and interpretation bias may constrain the depth of analytic synthesis, reducing its applicability for precise policy and practice recommendations.

ObjectivesTo investigate the effectiveness of adding a brief vocational advice intervention to usual care in reducing the number of days absent from work over a period of 6 months in adults given a fit note by their general practice. DesignMulticentre, pragmatic, two parallel-arm, randomised controlled trial with health economic analyses and nested qualitative study. A computer-generated stratified block randomisation (ratio 1:1) was used to allocate arms. SettingParticipants will be recruited from general practices in the UK. Participants720 adults consulting in general practice, for any health condition, and receiving a fit note who have been absent from work for more than two-weeks but less than six months. InterventionsParticipants in the intervention arm will be offered usual care and vocational advice delivered by a Vocational Support Worker (VSW) remotely via phone or videoconferencing. Participants in the control arm will be offered usual care. Main outcome measureNumber of days off work over 6 months. Follow-up data collection is via questionnaires at 6 weeks and 6 months. ConclusionsThis paper presents the rationale, design and methods of the Work And Vocational advicE (WAVE) trial. The results of this trial will provide evidence to inform primary care practice and guide the development of services to provide support for patients with work absence. Trial registration: Clinical Trials: NCT04543097 Protocol number: Version 5.1

BackgroundWe aimed to systematically review the evidence for causal associations between the known modifiable risk factors and dementia based on Mendelian randomization (MR) studies. MethodFive databases were searched from inception to April 2024 investigating the association between the twelve risk factors identified in the Lancet Commission and dementia. Evaluable analyses were categorised into one of four levels (robust, probable, suggestive, insufficient) based on estimate significance level and concordance of direction of effect between main and sensitivity analyses. Results47 articles were included representing 160 separate analyses (136 unique; 104 evaluable) for ten risk factors and six dementia outcomes. There were no valid analyses for air pollution and traumatic brain injury. Of the unique and evaluable analyses over half (59.3%) were evaluated as providing insufficient evidence of causal links. There was no evidence that genetically predicted liability to hearing loss was associated with dementia and limited genetic evidence for social contact. Evidence for education, obesity, depression, alcohol consumption and physical activity was inconclusive. There was probable evidence that smoking was protective against dementia risk however this may be an artefact of survivor bias. The two risk factors with the strongest genetic evidence for links with dementia were diabetes (probable evidence) and blood pressure (probable and suggestive evidence). ConclusionGenetic evidence for eight of the risk factors examined was insufficient or inconclusive. However, the null findings should be interpreted in the light of the biases inherent to MR studies. The strongest genetic evidence supported a causal link between diabetes and dementia.

BackgroundThe pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a serious worldwide public health emergency. This systematic review aims to summarize the available evidence regarding the role of face mask in community settings in slowing the spread of respiratory viruses such as SARS-CoV-2. MethodsThe preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used for this review. Literature search using PUBMED, Google Scholar and Cochrane database was performed using Medical subject heading (MeSH) words from the year 2000-2020. The articles focused on the use of masks and N95 respirators in healthcare workers were excluded. ResultsA total of 305 records were identified, out of which 14 articles were included in the review based upon quality and eligibility criteria. All the articles mentioned about role of face masks in preventing the spread of respiratory viruses like influenza, SARS and SARS-CoV-2, in the community or experimental setting. Studies also suggested that early initiation of face mask usage was more effective. Masks were also reported to be more effective in viruses which transmit easily from asymptomatic individuals, as is now known in SARS-CoV-2. ConclusionTheoretical, experimental and clinical evidence suggested that usage of face masks in general population offered significant benefit in preventing the spread of respiratory viruses especially in the pandemic situation, but its utility is limited by inconsistent adherence to mask usage.