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BackgroundAttributable mortality risk for heat and cold has been investigated in Europe and North America. However, none so far has provided estimates for Latin American, with a whole temperature r...

BackgroundEpidemiological evidence on the short-term effects of ultrafine particles (UFP), with aerodynamic diameter

Background/AimLow and high temperatures have been associated with mortality risk. In addition, the temperature-mortality relationship is different across geographic locations and specific causes. T...

The Paris Agreement binds all nations to undertake ambitious efforts to combat climate change, with the commitment to hold warming well below 2 degrees C in global mean temperature (GMT), relative to pre-industrial levels, and to pursue efforts to limit warming to 1.5 degrees C. The 1.5 degrees C limit constitutes an ambitious goal for which greater evidence on its benefits for health would help guide policy and potentially increase the motivation for action. Here we contribute to this gap with an assessment on the potential health benefits, in terms of reductions in temperature-related mortality, derived from the compliance to the agreed temperature targets, compared to more extreme warming scenarios. We performed a multi-region analysis in 451 locations in 23 countries with different climate zones, and evaluated changes in heat and cold-related mortality under scenarios consistent with the Paris Agreement targets (1.5 and 2 degrees C) and more extreme GMT increases (3 and 4 degrees C), and under the assumption of no changes in demographic distribution and vulnerability. Our results suggest that limiting warming below 2 degrees C could prevent large increases in temperature-related mortality in most regions worldwide. The comparison between 1.5 and 2 degrees C is more complex and characterized by higher uncertainty, with geographical differences that indicate potential benefits limited to areas located in warmer climates, where direct climate change impacts will be more discernible.

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Background Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic agents can prevent PPH, and are routinely recommended. The current World Health Organization (WHO) recommendation for preventing PPH is 10 IU (international units) of intramuscular or intravenous oxytocin. There are several uterotonic agents for preventing PPH but there is still uncertainty about which agent is most effective with the least side effects. This is an update of a Cochrane Review which was first published in April 2018 and was updated to incorporate results from a recent large WHO trial. Objectives To identify the most effective uterotonic agent(s) to prevent PPH with the least side effects, and generate a ranking according to their effectiveness and side-effect profile. Search methods We searched the Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (24 May 2018), and reference lists of retrieved studies. Selection criteria All randomised controlled trials or cluster-randomised trials comparing the effectiveness and side effects of uterotonic agents with other uterotonic agents, placebo or no treatment for preventing PPH were eligible for inclusion. Quasi-randomised trials were excluded. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. Data collection and analysis At least three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for preventing PPH ≥ 500 mL and PPH ≥ 1000 mL as primary outcomes. Secondary outcomes included blood loss and related outcomes, morbidity outcomes, maternal well-being and satisfaction and side effects. Primary outcomes were also reported for pre-specified subgroups, stratifying by mode of birth, prior risk of PPH, healthcare setting, dosage, regimen and route of administration. We performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available agents. Main results The network meta-analysis included 196 trials (135,559 women) involving seven uterotonic agents and placebo or no treatment, conducted across 53 countries (including high-, middle- and low-income countries). Most trials were performed in a hospital setting (187/196, 95.4%) with women undergoing a vaginal birth (71.5%, 140/196). Relative effects from the network meta-analysis suggested that all agents were effective for preventing PPH ≥ 500 mL when compared with placebo or no treatment. The three highest ranked uterotonic agents for prevention of PPH ≥ 500 mL were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. Low-certainty evidence suggests that misoprostol, injectable prostaglandins, and ergometrine may make little or no difference to this outcome compared with oxytocin. All agents except ergometrine and injectable prostaglandins were effective for preventing PPH ≥ 1000 mL when compared with placebo or no treatment. High-certainty evidence suggests that ergometrine plus oxytocin (RR 0.83, 95% CI 0.66 to 1.03) and misoprostol plus oxytocin (RR 0.88, 95% CI 0.70 to 1.11) make little or no difference in the outcome of PPH ≥ 1000 mL compared with oxytocin. Low-certainty evidence suggests that ergometrine may make little or no difference to this outcome compared with oxytocin meanwhile the evidence on carbetocin was of very low certainty. High-certainty evidence suggests that misoprostol is less effective in preventing PPH ≥ 1000 mL when compared with oxytocin (RR 1.19, 95% CI 1.01 to 1.42). Despite the comparable relative treatment effects between all uterotonics (except misoprostol) and oxytocin, ergometrine plus oxytocin, misoprostol plus oxytocin combinations and carbetocin were the highest ranked agents for PPH ≥ 1000 mL. Misoprostol plus oxytocin reduces the use of additional uterotonics (RR 0.56, 95% CI 0.42 to 0.73, high certainty) and probably also reduces the risk of blood transfusion (RR 0.51, 95% CI 0.37 to 0.70, moderate certainty) when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences could be detected between all agents for maternal deaths or severe morbidity as these outcomes were rare in the included randomised trials where they were reported. The two combination regimens were associated with important side effects. When compared with oxytocin, misoprostol plus oxytocin combination increases the likelihood of vomiting (RR 2.11, 95% CI 1.39 to 3.18, high certainty) and fever (RR 3.14, 95% CI 2.20 to 4.49, moderate certainty). Ergometrine plus oxytocin increases the likelihood of vomiting (RR 2.93, 95% CI 2.08 to 4.13, moderate certainty) and may make little or no difference to the risk of hypertension, however absolute effects varied considerably and the certainty of the evidence was low for this outcome. Subgroup analyses did not reveal important subgroup differences by mode of birth (caesarean versus vaginal birth), setting (hospital versus community), risk of PPH (high versus low risk for PPH), dose of misoprostol (≥ 600 mcg versus < 600 mcg) and regimen of oxytocin (bolus versus bolus plus infusion versus infusion only). Authors' conclusions All agents were generally effective for preventing PPH when compared with placebo or no treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional desirable effects compared with the current standard oxytocin. The two combination regimens, however, are associated with significant side effects. Carbetocin may be more effective than oxytocin for some outcomes without an increase in side effects. Which drug is best for reducing excessive blood loss after birth? What is the issue? The aim of this Cochrane Review was to find out which drug is most effective in preventing excessive blood loss at childbirth and has the least side effects. We collected and analysed all the relevant studies to answer this question (date of search: 24 May 2018). Why is this important? Excessive bleeding after birth is the most common reason why mothers die in childbirth worldwide. Although most women will have moderate bleeding at birth, others may bleed excessively, and this can pose a serious risk to their health and life. To reduce excessive bleeding at birth, the routine administration of a drug to contract the uterus (uterotonic) has become standard practice across the world. Different drugs given routinely at birth have been used for reducing excessive bleeding. They include oxytocin, misoprostol, ergometrine, carbetocin, injectable prostaglandins and combinations of these drugs, each with different effectiveness and side effects. Some of the side effects identified include: vomiting, high blood pressure and fever. Currently, oxytocin is recommended as the standard drug to reduce excessive bleeding. We analysed all the available evidence to compare the effectiveness and side-effect profiles for each drug. What evidence did we find? We found 196 studies involving 135,559 women. We compared seven uterotonic agents against each other and against women receiving no uterotonic. Studies were conducted across 53 countries. In most studies women were giving birth normally and in a hospital. The analysis suggests that all drugs are effective for preventing blood loss that equals or exceeds 500 mL when compared with no routine uterotonic treatment. Compared with oxytocin (the standard recommended drug), the three best drugs for this outcome were a combination of ergometrine plus oxytocin, carbetocin, and a combination of misoprostol plus oxytocin. We found the other drugs misoprostol, injectable prostaglandins, and ergometrine may make little or no difference to this outcome compared with oxytocin. All drugs except ergometrine and injectable prostaglandins are effective for preventing blood loss that equals or exceeds 1000 mL when compared with no treatment. Ergometrine plus oxytocin and misoprostol plus oxytocin make little or no difference in this outcome compared with oxytocin. It is uncertain whether carbetocin and ergometrine alone make any difference to this outcome. However, misoprostol is less effective in preventing blood loss that equals or exceeds 1000 mL compared with oxytocin. Misoprostol plus oxytocin reduces the use of additional uterotonics and probably also reduces the risk of blood transfusion when compared with oxytocin. Carbetocin, injectable prostaglandins and ergometrine plus oxytocin may also reduce the use of additional uterotonics but the certainty of the evidence is low. No meaningful differences could be detected between all agents for maternal deaths or severe birth complication as these are rare in such studies. The two combinations of drugs were associated with important side effects. When compared with oxytocin, women receiving misoprostol plus oxytocin combination are more likely to suffer vomiting and fever. Women receiving ergometrine plus oxytocin are also more likely to suffer vomiting and may make little or no difference to the risk of hypertension, however the certainty of the evidence was low for this outcome. The analyses gave similar results irrespective of whether women were giving birth normally or by caesarean, in a hospital or in the community, were at high or low risk for bleeding excessively after birth, whether they received a high or a low dose of misoprostol and whether they received a bolus or an infusion of oxytocin or both. What does this mean? All agents were generally effective for preventing excessive bleeding when compared with no uterotonic drug treatment. Ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination may have some additional benefits compared with the current standard oxytocin. The two combination drugs, however, are associated with significant side effects that women might find disturbing compared with oxytocin. Carbetocin may have some additional benefits compared with oxytocin and appears to be without an increase in side effects.

Objective To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. Design A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). Setting 86 participating Early Pregnancy Units. Population All women diagnosed in the participating units with CSP between November 2013 and January 2015. Methods Cohort study of women identified through the UKEPSS monthly mailing system. Main outcome measures Incidence, clinical outcomes and complications. Results 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. Conclusions Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. Tweetable abstract Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

Background/Aim: Previous studies have shown that temperature-health associations are highly heterogeneous across populations living in different parts of the world. However, little is known about t...

Background: Heatwaves are a critical public health problem. There will be an increase in the frequency and severity of heatwaves under changing climate. However, evidence about the impacts of climate change on heatwave-related mortality at a global scale is limited. Methods and findings: We collected historical daily time series of mean temperature and mortality for all causes or nonexternal causes, in periods ranging from January 1, 1984, to December 31, 2015, in 412 communities within 20 countries/regions. We estimated heatwave–mortality associations through a two-stage time series design. Current and future daily mean temperature series were projected under four scenarios of greenhouse gas emissions from 1971–2099, with five general circulation models. We projected excess mortality in relation to heatwaves in the future under each scenario of greenhouse gas emissions, with two assumptions for adaptation (no adaptation and hypothetical adaptation) and three scenarios of population change (high variant, median variant, and low variant). Results show that, if there is no adaptation, heatwave-related excess mortality is expected to increase the most in tropical and subtropical countries/regions (close to the equator), while European countries and the United States will have smaller percent increases in heatwave-related excess mortality. The higher the population variant and the greenhouse gas emissions, the higher the increase of heatwave-related excess mortality in the future. The changes in 2031–2080 compared with 1971–2020 range from approximately 2,000% in Colombia to 150% in Moldova under the highest emission scenario and high-variant population scenario, without any adaptation. If we considered hypothetical adaptation to future climate, under high-variant population scenario and all scenarios of greenhouse gas emissions, the heatwave-related excess mortality is expected to still increase across all the countries/regions except Moldova and Japan. However, the increase would be much smaller than the no adaptation scenario. The simple assumptions with respect to adaptation as follows: no adaptation and hypothetical adaptation results in some uncertainties of projections. Conclusions: This study provides a comprehensive characterisation of future heatwave-related excess mortality across various regions and under alternative scenarios of greenhouse gas emissions, different assumptions of adaptation, and different scenarios of population change. The projections can help decision makers in planning adaptation and mitigation strategies for climate change. © 2018 Guo et al. http://creativecommons.org/licenses/by/4.0/., We thank relevant institutes/agencies who provided data on mortality and weather conditions.

STUDY QUESTION Is serum vitamin D associated with live birth rates in women undergoing ART? SUMMARY ANSWER Women undergoing ART who are replete in vitamin D have a higher live birth rate than women who are vitamin D deficient or insufficient. WHAT IS KNOWN ALREADY Vitamin D deficiency has been associated with an increased risk of abnormal pregnancy implantation as well as obstetric complications such as pre-eclampsia and fetal growth restriction. However, the effect of vitamin D on conception and early pregnancy outcomes in couples undergoing ART is poorly understood. STUDY DESIGN, SIZE, DURATION A systematic review and meta-analysis of 11 published cohort studies (including 2700 women) investigating the association between vitamin D and ART outcomes. PARTICIPANTS/MATERIALS, SETTINGS, METHODS Literature searches were conducted to retrieve studies which reported on the association between vitamin D and ART outcomes. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL. Eleven studies matched the inclusion criteria. MAIN RESULTS AND THE ROLE OF CHANCE Live birth was reported in seven of the included studies (including 2026 patients). Live birth was found to be more likely in women replete in vitamin D when compared to women with deficient or insufficient vitamin D status (OR 1.33 [1.08-1.65]). Five studies (including 1700 patients) found that women replete in vitamin D were more likely to achieve a positive pregnancy test than women deficient or insufficient in vitamin D (OR 1.34 ([1.04-1.73]). All 11 of the included studies (including 2700 patients) reported clinical pregnancy as an outcome. Clinical pregnancy was found to be more likely in women replete in vitamin D (OR 1.46 [1.05-2.02]). Six studies (including 1635 patients) reported miscarriage by vitamin D concentrations. There was no association found between miscarriage and vitamin D concentrations (OR 1.12 [0.81-1.54]. The included studies scored well on the Newcastle-Ottawa quality assessment scale. LIMITATIONS REASONS FOR CAUTION Although strict inclusion criteria were used in the conduct of the systematic review, the included studies are heterogeneous in population characteristics and fertility treatment protocols. WIDER IMPLICATIONS OF THE FINDINGS The findings of this systematic review show that there is an association between vitamin D status and reproductive treatment outcomes achieved in women undergoing ART. Our results show that vitamin D deficiency and insufficiency could be important conditions to treat in women considering ARTs. A randomized controlled trial to investigate the benefits of vitamin D deficiency treatment should be considered to test this hypothesis. STUDY FUNDING/COMPETING INTERESTS No external funding was either sought or obtained for this study. The authors have no competing interests to declare. REGISTRATION NUMBER N/A.

Daylight Saving Time (DST) is the practice of setting the clocks forward 1 hour from standard time during the summer months, and back again in the fall, in order to make better use of natural daylight. It is applied in a large number of countries worldwide affecting 1.5 billion people. Changes in light hours and sleep disruption occurring during DST changes, have been theorised to increase risk of traffic injuries. However, a recent review found inconclusive results on whether DST increased or decreased the risk of road traffic collision, especially in the short-term. We estimated the risk of daily fatal traffic accidents following summer and fall DST changes in Spain.

Approximately, 20 % of particulate and aerosol emissions into the urban atmosphere are of natural origin (including wildfires and Saharan dust). During these natural episodes, PM10 and PM2.5 levels usually exceed World Health Organisation (WHO) health protection thresholds. This study sought to evaluate the possible effect of advections of particulate matter from biomass fuel combustion on daily specific-cause mortality among the general population and the segment aged ≥ 75 years in Madrid. Ecological time-series study in the city of Madrid from January 01, 2004 to December 31, 2009. The dependent variable analysed was daily mortality due to natural (ICD-10:A00-R99), circulatory (ICD-10:I00-I99), and respiratory (ICD-10:J00-J99) causes in the population, both general and aged ≥ 75 years. The following independent and control variables were considered: a) daily mean PM2.5 and PM10 concentrations; b) maximum daily temperature; c) daily mean O3 and NO2 concentrations; d) advection of particulate matter from biomass combustion ( http://www.calima.ws/ ), using a dichotomous variable and e) linear trend and seasonalities. We conducted a descriptive analysis, performed a test of means and, to ascertain relative risk, fitted a model using autoregressive Poisson regression and stratifying by days with and without biomass advection, in both populations. Of the 2192 days analysed, biomass advection occurred on 56, with mean PM2.5 and PM10 values registering a significant increase during these days. PM10 had a greater impact on organic mortality with advection (RRall ages = 1.035 [1.011-1.060]; RR ≥ 75 years = 1.066 [1.031-1.103]) than did PM2.5 without advection (RRall ages = 1.017 [1.009-1.025]; RR ≥ 75 years = 1.012 [1.003-1.022]). Among specific causes, respiratory-though not circulatory-causes were associated with PM10 on days with advection in ≥ 75 year age group. PM10, rather than PM2.5, were associated with an increase in natural cause mortality on days with advection of particulate matter from biomass combustion, particularly in the ≥ 75 year age group.

ResumenLas revisiones sistemáticas y los metaanálisis se han consolidado como una herramienta fundamental para la práctica clínica basada en la evidencia. Inicialmente, el metaanálisis fue propuesto como una técnica que podría mejorar la precisión y la potencia estadística de la investigación procedente de estudios individuales con pequeño tamaño muestral. Sin embargo, uno de sus principales inconvenientes es que suelen comparar no más de 2 intervenciones alternativas a la vez. Los «metaanálisis en red» utilizan técnicas novedosas de análisis que permiten incorporar la información procedente de comparaciones directas e indirectas a partir de una red de estudios que examina los efectos de diversos tratamientos de una manera más completa. Pese a sus potenciales limitaciones, su aplicación en epidemiología clínica podría ser potencialmente útil en situaciones en las que existen varios tratamientos que se han comparado frente a un comparador común.Además, estas técnicas pueden ser relevantes ante una pregunta clínica o de investigación cuando existen múltiples tratamientos que deben ser considerados, o cuando se dispone tanto de información directa como indirecta en el cuerpo de la evidencia.AbstractSystematic reviews and meta-analyses have long been fundamental tools for evidence-based clinical practice. Initially, meta-analyses were proposed as a technique that could improve the accuracy and the statistical power of previous research from individual studies with small sample size. However, one of its main limitations has been the fact of being able to compare no more than two treatments in an analysis, even when the clinical research question necessitates that we compare multiple interventions. Network meta-analysis (NMA) uses novel statistical methods that incorporate information from both direct and indirect treatment comparisons in a network of studies examining the effects of various competing treatments, estimating comparisons between many treatments in a single analysis. Despite its potential limitations, NMA applications in clinical epidemiology can be of great value in situations where there are several treatments that have been compared against a common comparator. Also, NMA can be relevant to a research or clinical question when many treatments must be considered or when there is a mix of both direct and indirect information in the body of evidence.

Background Evidence on the short-term effects of ultrafine particles (with diameter < 100 nm, UFP) on health is still inconsistent. New particles in ambient urban air are the result of direct emissions and also the formation of secondary UFP from gaseous precursors. We segregated UFP into these two components and investigated their impact on daily mortality in three Spanish cities affected by different sources of air pollution. Methods We separated the UFP using a method based on the high correlation between black carbon (BC) and particle number concentration (N). The first component accounts for aerosol constituents emitted by vehicle exhaust (N1) and the second for the photochemical new particle formation enhancements (N2). We applied city-specific Poisson regression models, adjusting for long-term trends, temperature and population dynamics. Results Mean BC levels were higher in Barcelona and Tenerife (1.8 and 1.2 μg·m− 3, respectively) than in Huelva (0.8 μg·m− 3). While mean UFP concentrations were similar in the three cities, from which N1 was 40% in Barcelona, 46% in Santa Cruz de Tenerife, and 27% in Huelva. We observed an association with N1 and daily mortality in Barcelona, by increasing approximately 1.5% between lags 0 and 2, per an interquartile increase (IQR) of 3277 cm− 3, but not with N2. A similar pattern was found in Santa Cruz de Tenerife, although none of the associations were significant. Conversely, in the industrial city of Huelva mortality was associated with N2 at lag 0, by increasing 3.9% per an IQR of 12,032·cm− 3. Conclusion The pattern and origin of UFP determines their short-term effect on human health. BC is possibly the better parameter to evaluate the health effects of particulate vehicle exhaust emissions, although in areas influenced by domestic solid fuel combustion this should also be taken into account. © 2017 The Authors, This study was supported by the National Plan for I+D+I (project PI15/00515 ) co-funded by the ISCIII Directorate General for Evaluation and the European Regional Development Fund (FEDER), by the Ministry of Economy, Industry and Competitiveness and FEDER funds (project HOUSE, CGL2016-78594-R ) and by the Generalitat de Catalunya (AGAUR 2015 SGR33 and DGQA). ISGlobal is a member of the CERCA Programme by the Generalitat the Catalunya. Appendix A

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Primary To assess the relative effectiveness and produce a clinically meaningful hierarchy of first-line uterotonic drugs for the treatment of postpartum haemorrhage (PPH). Secondary To assess the relative risks and produce side effect hierarchies of first-line uterotonic drugs for the treatment of PPH.

Background and aims Most studies show that probiotics are effective in preventing morbidity and mortality in preterm infants. Using network meta-analysis (NMA) we aim to rank treatments’ efficacy and identify the most effective strain, formulation and dose. Methods Databases searched: CENTRAL, Ovid MEDLINE EMBASE, LILACS and the Cochrane Database of Systematic Reviews. Clinicaltrials.gov; controlled-trials.com; and WHO’s ICTRP were searched for any ongoing studies. Searches completed up to November 2016 without language restriction. Reference checking, citation searching and contact with study authors were done to identify additional studies. Randomised controlled trials evaluating probiotics interventions and combinations of probiotics/strains of the same probiotic of all durations were included. 2 independent, unblinded review authors assessed the trials for inclusion and extracted data. We used standard methodology as per The Cochrane Collaboration. The protocol was registered – Cochrane Database CD012303, PROSPERO CRD42016047640. Main results 53 included trials reported outcomes on 13 630 infants. The period of studies was Jan 1986-Oct 2016. All studies enrolled infants Our preliminary results from 35 studies (10 063 patients) show evidence of significant reduction in global mortality in probiotics group (10 063 patients, RR 0.77, 95% CI 0.66 to 0.91, I2=0%). Data from 38 studies provide information on severe necrotising enterocolitis (NEC), stage 2 or 3, with a significant reduction in the incidence of NEC with prophylactic administration of probiotics (9455 patients, RR 0.52, 95% CI 0.40 to 0.68, I2=22%). And, data from 35 studies with 10 565 patients informed about any culture proven sepsis, showed a significant reduction in rates of confirmed sepsis (RR 0.82, 95% CI 0.74 to 0.92, I2=33%). Conclusion Based on our preliminary results, It seems (moderate quality of evidence) that administration of probiotics in preterm infants could reduce NEC, culture proven sepsis and even global mortality. We are currently analysing the most effective strain of probiotic. Further clinical trials of probiotics head to head will be needed to confirm our data.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: The objectives of this review are: to estimate the relative effectiveness and safety profiles for methods of management of miscarriage; to provide a ranking of the available methods according to their effectiveness and safety profile.

Background: Meta-analysis is very useful to summarize the effect of a treatment or a risk factor for a given disease. Often studies report results based on log-transformed variables in order to achieve the principal assumptions of a linear regression model. If this is the case for some, but not all studies, the effects need to be homogenized. Methods: We derived a set of formulae to transform absolute changes into relative ones, and vice versa, to allow including all results in a meta-analysis. We applied our procedure to all possible combinations of log-transformed independent or dependent variables. We also evaluated it in a simulation based on two variables either normally or asymmetrically distributed. Results: In all the scenarios, and based on different change criteria, the effect size estimated by the derived set of formulae was equivalent to the real effect size. To avoid biased estimates of the effect, this procedure should be used with caution in the case of independent variables with asymmetric distributions that significantly differ from the normal distribution. We illustrate an application of this procedure by an application to a meta-analysis on the potential effects on neurodevelopment in children exposed to arsenic and manganese. Conclusions: The procedure proposed has been shown to be valid and capable of expressing the effect size of a linear regression model based on different change criteria in the variables. Homogenizing the results from different studies beforehand allows them to be combined in a meta-analysis, independently of whether the transformations had been performed on the dependent and/or independent variables. © 2017 The Author(s)., The authors would like to thank Begoña Martínez at the Andalusian School of Public Health, for her comments on and suggestions for the manuscript.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: We aim to assess the clinical effectiveness and safety profile of currently applied controlled ovarian stimulation (COS) protocols, and to generate a clinically-useful ranking of these protocols.

Background: Few studies have examined variation in the associations between heat waves and mortality in an international context. Objectives: We aimed to systematically examine the impacts of heat waves on mortality with lag effects internationally. Methods: We collected daily data of temperature and mortality from 400 communities in 18 countries/regions and defined 12 types of heat waves by combining community-specific daily mean temperature ≥90th, 92.5th, 95th, and 97.5th percentiles of temperature with duration ≥2, 3, and 4 d. We used time-series analyses to estimate the community-specific heat wave–mortality relation over lags of 0–10 d. Then, we applied meta-analysis to pool heat wave effects at the country level for cumulative and lag effects for each type of heat wave definition. Results: Heat waves of all definitions had significant cumulative associations with mortality in all countries, but varied by community. The higher the temperature threshold used to define heat waves, the higher heat wave associations on mortality. However, heat wave duration did not modify the impacts. The association between heat waves and mortality appeared acutely and lasted for 3 and 4 d. Heat waves had higher associations with mortality in moderate cold and moderate hot areas than cold and hot areas. There were no added effects of heat waves on mortality in all countries/regions, except for Brazil, Moldova, and Taiwan. Heat waves defined by daily mean and maximum temperatures produced similar heat wave–mortality associations, but not daily minimum temperature. Conclusions: Results indicate that high temperatures create a substantial health burden, and effects of high temperatures over consecutive days are similar to what would be experienced if high temperature days occurred independently. People living in moderate cold and moderate hot areas are more sensitive to heat waves than those living in cold and hot areas. Daily mean and maximum temperatures had similar ability to define heat waves rather than minimum temperature. Medical Research Council, UK

BACKGROUND: In many places, daily mortality has been shown to increase after days with particularly high or low temperatures, but such daily time-series studies cannot identify whether such increases reflect substantial life shortening or short-term displacement of deaths (harvesting). OBJECTIVES: To clarify this issue, we estimated the association between annual mortality and annual summaries of heat and cold in 278 locations from 12 countries. METHODS: Indices of annual heat and cold were used as predictors in regressions of annual mortality in each location, allowing for trends over time and clustering of annual count anomalies by country and pooling estimates using meta-regression. We used two indices of annual heat and cold based on preliminary standard daily analyses: a) mean annual degrees above/below minimum mortality temperature (MMT), and b) estimated fractions of deaths attributed to heat and cold. The first index was simpler and matched previous related research; the second was added because it allowed the interpretation that coefficients equal to 0 and 1 are consistent with none (0) or all (1) of the deaths attributable in daily analyses being displaced by at least 1 y. RESULTS: On average, regression coefficients of annual mortality on heat and cold mean degrees were 1.7% [95% confidence interval (CI): 0.3, 3.1] and 1.1% (95% CI: 0.6, 1.6) per degree, respectively, and daily attributable fractions were 0.8 (95% CI: 0.2, 1.3) and 1.1 (95% CI: 0.9, 1.4). The proximity of the latter coefficients to 1.0 provides evidence that most deaths found attributable to heat and cold in daily analyses were brought forward by at least 1 y. Estimates were broadly robust to alternative model assumptions. CONCLUSIONS: These results provide strong evidence that most deaths associated in daily analyses with heat and cold are displaced by at least 1 y. https://doi.org/10.1289/EHP1756.

BACKGROUND: Studies have examined the effects of temperature on mortality in a single city, country, or region. However, less evidence is available on the variation in the associations between temperature and mortality in multiple countries, analyzed simultaneously. METHODS: We obtained daily data on temperature and mortality in 306 communities from 12 countries/regions (Australia, Brazil, Thailand, China, Taiwan, Korea, Japan, Italy, Spain, United Kingdom, United States, and Canada). Two-stage analyses were used to assess the nonlinear and delayed relation between temperature and mortality. In the first stage, a Poisson regression allowing overdispersion with distributed lag nonlinear model was used to estimate the community-specific temperature-mortality relation. In the second stage, a multivariate meta-analysis was used to pool the nonlinear and delayed effects of ambient temperature at the national level, in each country. RESULTS: The temperatures associated with the lowest mortality were around the 75th percentile of temperature in all the countries/regions, ranging from 66th (Taiwan) to 80th (UK) percentiles. The estimated effects of cold and hot temperatures on mortality varied by community and country. Meta-analysis results show that both cold and hot temperatures increased the risk of mortality in all the countries/regions. Cold effects were delayed and lasted for many days, whereas heat effects appeared quickly and did not last long. CONCLUSIONS: People have some ability to adapt to their local climate type, but both cold and hot temperatures are still associated with increased risk of mortality. Public health strategies to alleviate the impact of ambient temperatures are important, in particular in the context of climate change.

Few studies have analysed the impact of heat and cold waves on mortality in a given population over the same time period and still fewer studies have analysed this impact in terms of cause-specific mortality. This study analysed the impact of both heat and cold waves on daily all-cause, circulatory-cause and respiratory-cause mortality in the region of Castile-La Mancha (CLM) 1975–2008. The dependent variable was daily all-, circulatory- and respiratory-cause mortality registered in CLM from 01-01-75 to 31-12-08, and the independent variables were maximum, minimum, mean daily temperature daily relative humidity and mean daily air pressure and other related variables, such as heat-wave duration, heat-wave number and pressure trend. Time-series analyses were performed using autoregressive integrated moving average models. The impact of heat on daily mortality was greater than that of cold, with a difference which proved statistically significant for all- and circulatory-cause mortality but not for respiratory-cause mortality. While 16.5 % CI 95 % (15.5–17.4) of summer mortality in CLM was attributable to heat, 12.9 % CI 95 % (12.2–13.8) of daily winter mortality was attributable to low temperatures. The variable, heat-wave duration, was of major importance in all-cause and respiratory-cause mortality, with wave persistence being related to a mean 3.5 % increase in daily organic-cause mortality. Although heat waves have a greater impact on daily mortality than do cold waves, the fact that there were more cold-wave than heat-wave days during the period analysed, coupled with the diseases implicated, means that specific prevention plans should be implemented for both extreme thermal events.

Objectives: To evaluate the impact of road safety interventions, including the penalty point system (PPS) and the reformed Spanish penal code (RPC), on traffic-related occupational injuries in Spain. Methods: The study design was an interrupted time-series with a comparison group. The study group had traffic-related, occupational injuries incurred during working and commuting hours; the comparison group had non-traffic-related injuries incurred at the work site. A negative binomial regression model was used to determine the relative risk (RR) of sustaining occupational injuries for the post-intervention periods compared to the non-intervention period. Results: Non-fatal, traffic-related injuries did not significantly change after the PPS and RPC implementations, except for those occurred in commuting hours, which increased significantly after the PPS. On the other hand, after the RPC, fatal, traffic-related injuries decreased significantly during working hours (0.79; 95%CI 0.65 to 0.97) and commuting hours (RR: 0.63; 95%CI:0,56 to 0.72), although fatal, non-traffic-related injuries also decreased at the work site. Conclusions: Road safety interventions did not clearly affect traffic-related occupational injuries in Spain. Specific occupational risk factors could influence the occurrence of those injuries. (C) 2014 Elsevier Ltd. All rights reserved.

The relationship between occupational noise and cardiovascular outcomes has been widely investigated. Regarding environmental noise levels, the attention is focused on road traffic noise due to the large number of exposed persons and the large periods of exposure. There are few studies assessing the short-term effects of traffic noise on cardiovascular outcomes. The aim of this study was to quantify the short-term effects of urban noise levels on age-specific cardiovascular mortality.A case-crossover design was used. Daily mortality counts in Madrid city due to cardiovascular causes (ICD codes: 390-459) from 1 January 2003 to 31 December 2005 were obtained. Data noise levels were collected as diurnal equivalent noise (Leqd8-22 h), night equivalent noise (Leqn22-8 h), and daily equivalent noise (Leq24 h). Confounding variables as daily levels of air pollutants, temperature, and relative humidity data were controlled. Overdispersed Poisson regression models were adjusted to control for both seasonality and time trends. Estimated effects are reported as percentage increase in the relative risk (IRR) associated with an increase of 1 dBA.The strongest associations between all noise exposure levels and cardiovascular mortality were reported at lag 1: IRR 4.5% (95% CI 0.6, 8.7%), IRR 3.9% (95% CI 0.6, 7.3%), and IRR 6.2% (95% CI 2.1, 10.6%) for Leqd, Leqn, and Leq24, respectively. Analysing by age-specific groups at lag 1, statistically significant associations were found for those aged ≥65: 4.5% (95% CI 0.3, 8.9%), 3.4% (95% CI 0.1, 6.9%), and 6.6% (95% CI 2.2, 11.1%) for Leqd, Leqn, and Leq24, with no substantial changes in the effects of noise exposure levels at lag 1 after adjusting for PM2.5 and NO2.The association found between noise exposure levels and cardiovascular mortality suggests a joint effect of diurnal and night-time noise levels. Our results also reveal independent effects of noise exposure levels and the air pollutants analysed. This strongly suggests the need to seriously consider the high noise exposure levels reported as an important public health issue.

Ferran Catala-Lopez * y Aurelio Tobias d Division de Farmacoepidemiologia y Farmacovigilancia, Agencia Espanola de Medicamentos y Productos Sanitarios (AEMPS), Madrid, Espana b Fundacion Instituto de Investigacion en Servicios de Salud, Valencia, Espana Centro Superior de Investigacion en Salud Publica (CSISP), Red de Investigacion en Servicios de Salud en Enfermedades Cronicas (REDISSEC), Valencia, Espana d Instituto de Diagnostico Ambiental y Estudios del Agua (IDAEA), Centro Superior de Investigaciones Cientificas (CSIC), Barcelona, Espana

This study focuses on the synthesis of merlinoite from Chinese coal fly ashes by KOH direct conversion method, with special emphasis on the application of synthetic merlinoite as fertilizer. These fly ashes were collected from two pulverized-coal combustion (PCC) power plants in Xinjiang, Northwest China. The synthesis results are influenced by fly ash characteristics and different synthesis conditions (KOH solution concentrations, activation temperature, time, and KOH/fly ash ratios). A high quality merlinoite-rich product was synthesized under optimal activation conditions (KOH concentration of 5 M, activation temperature of 150 °C, activation time of 8 h and KOH/fly ash ratio of 2 l/kg), with a cation exchange capacity (CEC) of 160 cmol kg−1. The synthetic merlinoite is proved to be an efficient slow release K-fertilizer for plant growth, indicating that it can be widely used for high-nutrient demanding crops growing in nutrient-limited soils and for large-area poor soil amendment in opencast coal mine areas around the power plants that will substantially grow with the increasing coal combustion in Xinjiang in the near future.

Introduction Desert dust concentrations raise concerns about adverse effects on human health. During the last decade, special attention has been given to mineral dust particles from desert dust and sand storms. However, evidence from previous reviews reported inconclusive results on their health effects and the biological mechanism remains unclear. We aim to systematically synthesise evidence on the health effects of desert dust and sand storms accounting for the relevant desert dust patterns from source areas and emissions, transport and composition. Methods an analysis We will conduct a systematic review that investigated the health effects of desert dust and sand storms in any population. The search will be performed for any eligible studies from previous reviews and selected electronic databases until 2018. Study selection and reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data from individual studies will be extracted using a standardised data extraction form. Quality of the studies will be assessed using a risk of bias tool for environmental exposures developed by experts convened by the WHO. A meta-analysis will be performed by calculating the appropriate effect measures of association for binary and continuous outcomes from individual studies. Subgroup analyses will be performed by geographical areas to account for desert dust patterns. Ethics and dissemination No primary data will be collected. For this reason, no formal ethical approval is required. This systematic review will help to fill the research gaps in the knowledge of desert dust on human health. The results will be disseminated through a WHO peer-reviewed publication and a conference presentation. © 2019 Author(s) (or their employer(s)). Re-use permitted under CC BY. Published by BMJ., Funding The World Health Organization, supported by the Ministry of Foreign Affairs of Norway, has funded this systematic review.

Purpose Atomoxetine is a non-stimulant drug that could be an alternative to methylphenidate, whose benefit:risk balance for the treatment of adults with attention deficit hyperactivity disorder (ADHD) has recently been shown to be unclear. This study aimed to compare all-cause discontinuation rate between atomoxetine and placebo in adults with ADHD. Secondarily, efficacy and safety were investigated. Methods Systematic review and meta-analysis of randomized controlled trials comparing atomoxetine with placebo in adults with ADHD were performed. All-cause treatment discontinuation was the primary endpoint. Efficacy in reducing ADHD symptoms and safety were the secondary endpoints. Odds ratio (OR) and the standardized mean difference (SMD) were calculated for dichotomous and continuous outcomes, respectively. Data were pooled using the fixed and random effects model. The influence of study design-related, intervention-related and patient-related co-variables over the primary endpoint was investigated by means of meta-regression. This study is registered with the international prospective register of systematic reviews (PROSPERO): CRD 42012002042. Results Twelve studies (3375 patients) were included. Treatment discontinuation was larger with atomoxetine than with placebo (OR= 1.39). No co-variable was found to modify the effect of atomoxetine over treatment discontinuation. Atomoxetine showed modest efficacy in reducing ADHD symptoms irrespective of the assessor: patient (SMD=0.33); clinician (SMD=0.40). The rate of adverse events-induced discontinuation was higher with atomoxetine than with placebo (OR=2.57). Conclusion This study suggests that atomoxetine has a poor benefit–risk balance for the treatment of adults with ADHD. The recommendation of atomoxetine use in this population is weak. Copyright © 2013 John Wiley & Sons, Ltd. key words—attention deficit hyperactivity disorder; atomoxetine; discontinuation; efficacy; safety; meta-analysis; meta-regression; pharmacoepidemiology

Saharan dust intrusions make a major contribution to levels of particulate matter (PM) present in the atmosphere of large cities. We analysed the impact of different PM fractions during periods with and without Saharan dust intrusions, using time-series analysis with Poisson regression models, based on: concentrations of coarse PM (PM10 and PM10-2.5) and fine PM (PM2.5); and daily all-, circulatory- and respiratory-cause hospital admissions. While periods without Saharan dust intrusions were marked by a statistically significant association between daily mean PM2.5 concentrations and all- and circulatory-cause hospital admissions, periods with such intrusions saw a significant increase in respiratory-cause admissions associated with fractions corresponding to PM10 and PM10-2.5.

Supplemental Digital Content is available in the text., Background: The minimum mortality temperature from J- or U-shaped curves varies across cities with different climates. This variation conveys information on adaptation, but ability to characterize is limited by the absence of a method to describe uncertainty in estimated minimum mortality temperatures. Methods: We propose an approximate parametric bootstrap estimator of confidence interval (CI) and standard error (SE) for the minimum mortality temperature from a temperature–mortality shape estimated by splines. Results: The coverage of the estimated CIs was close to nominal value (95%) in the datasets simulated, although SEs were slightly high. Applying the method to 52 Spanish provincial capital cities showed larger minimum mortality temperatures in hotter cities, rising almost exactly at the same rate as annual mean temperature. Conclusions: The method proposed for computing CIs and SEs for minimums from spline curves allows comparing minimum mortality temperatures in different cities and investigating their associations with climate properly, allowing for estimation uncertainty.

BACKGROUND: The risk-benefit balance of pharmacological treatment for children and adolescents with ADHD and the factors that moderate this relationship are unclear. METHODS: A systematic review and meta-analysis of randomised, placebo-controlled clinical trials (RPCCTs) investigating the efficacy of pharmacological treatment in children or adolescents with ADHD was carried out. Meta-analysis of treatment discontinuation, clinician-, parent- and teacher-rated efficacy and adverse events was performed. The effect of covariates was studied. RESULTS: Sixty-three studies were included. Ten drugs were investigated, with atomoxetine and methylphenidate the most frequently studied. RPCCTs had mostly a short duration (7.9 weeks). All-cause treatment discontinuation was lower with pharmacological treatment than placebo (OR = 0.68). Pharmacological treatment was more efficacious than placebo independently of the rater (clinician, standardised mean difference (SMD) 0.74; parent, SMD = 0.63; or teacher, SMD = 0.75). Evidence of publication bias was found for clinician-rated efficacy, especially in industry-sponsored RPCCT. Psychostimulants showed a higher efficacy and were associated with a better outcome on treatment discontinuation than non-stimulant drugs. Efficacy was smaller in RPCCTs for which a psychiatric comorbid disorder was an inclusion criterion, was larger in studies with a commercial sponsorship and showed a negative association with treatment length. CONCLUSIONS: In the short term, pharmacological treatment provides moderate-high symptom relief, is safe and shows lower treatment discontinuation than placebo, suggesting a suitable risk-benefit balance, particularly with psychostimulants. The efficacy is lower in patients with a comorbid psychiatric disorder and should be assessed periodically, as it appears to reduce over time. Publication bias of clinician-rated efficacy in studies with a commercial sponsor is suggested.

Epidemiological evidence on the associations between exposure to ultrafine particles (UFP), with aerodynamic electrical mobility diameters, We thank the Consorci Sanitari de Barcelona (Cat-Salut) for providing hospitalisation data for Barcelona and the Agencia Estatal de Meteorologia (Ministerio de Agricultura, Alimentación y Medio Ambiente) for providing the weather data for Spain. We thank the Finnish Meteorological Institute for providing the weather data for Finland and Helsinki Region Environmental Services Authority HSY for providing the air pollution (other than UFP) data for Helsinki, Finland. The study has been conducted as a collaborative effort of the UF&HEALTH Study Group. UF&HEALTH Study Group: S. Breitner, J. Cyrys, R. Hampel, F. Hennig, B. Hoffmann, T. Kuhlbusch; S. Lanzinger, A. Peters, U. Quass, A. Schneider, K. Wolf (Germany); E. Diapouli, K. Elefteriadis, K. Katsouyanni, E. Samoli, S. Vratolis (Greece); T. Ellermann, Z. Ivanovic-Andersen, S. Loft, A. Massling, C. Nordstrøm (Denmark); P.P. Aalto, M. Kulmala, T. Lanki, J. Pekkanen, P. Tiittanen, T. Yli-Tuomi (Finland); G. Cattani, A. Faustini, F. Forastiere, M. Inglessis, M. Renzi, M. Stafoggia (Italy); D. Agis, X. Basagaña, B. Jacquemin, N. Perez, J. Sunyer, A. Tobias (Spain); G. Bero-Bedada, T. Bellander (Sweden).

Background and aim: Vehicle exhaust is the main emission source in urban areas, mainly releasing ultrafine particles ( Methods: We collected daily mortality counts due to respiratory causes (ICD10: J00-J99), COPD (J40-J44,J47), LRTI (J09-J18,J20-J22), bronchitis (J20-J22) and pneumonia (J12-J18) and daily concentrations of UFP between 2009-2012. We segregated the UFP using a method based on the high correlation between black carbon and N (Rodriguez et al, Aerosol Sci 2007;38:1207-19). The first component accounts for aerosol constituents emitted by vehicle exhaust (N1) and the second for photochemical new particle formation enhancements (N2). We evaluated short-term effects up to one week, using a time-stratified case-crossover design. Results: Daily mean UFP concentration (N) was 13,114/cm3, 45% being N1. We observed statistically significant associations for all respiratory causes and COPD, increasing risk of mortality by 6% and 10%, respectively, for 3,950/cm3 rise of N1 at lag 0. We observed positive, but not significant, associations between N1 and the other respiratory outcomes. We did not find any effect of N2. Conclusion: UFP from vehicle exhaust are more harmful for respiratory health than those from photochemical nucleation. This should have an implication for EU regulation of the UFP concentrations in urban air.

Introduction: The evidence is limited for the impacts of temperature variability (TV) within or between days on mortality. In this study, we applied a novel method to calculate TV, and investigated...

Introduction. Epidemiological evidence on the associations between exposure to ultrafine particles (UFP), with electrical mobility diameters

Introduction Several studies provide future projections of the temperature-related mortality in single cities or countries, but few offer a systematic assessment across climates and populations usi...

Few studies have examined the variation in mortality risk associated with heat during the summer. Here, we apply flexible statistical models to investigate the issue by using a large multicountry data set. We collected daily time-series data of temperature and mortality from 305 locations in 9 countries, in the period 1985-2012. We first estimated the heat-mortality relationship in each location with time-varying distributed lag non-linear models, using a bivariate spline to model the exposure-lag-response over lag 0-10. Estimates were then pooled by country through multivariate meta-analysis. Results provide strong evidence of a reduction in risk over the season. Relative risks for the 99th percentile versus the minimum mortality temperature were in the range of 1.15-2.03 in early summer. In late summer, the excess was substantially reduced or abated, with relative risks in the range of 0.97-1.41 and indications of wider comfort ranges and higher minimum mortality temperatures. The attenuation is mainly due to shorter lag periods in late summer. In conclusion, this multicountry analysis suggests a reduction of heat-related mortality risk over the summer, which can be attributed to several factors, such as true acclimatization, adaptive behaviors, or harvesting effects. These findings may have implications on public health policies and climate change health impact projections. © 2016 The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health., This work was supported by the Medical Research Council- United Kingdom (grants MR/M022625/1 and G1002296); the National Institute for Health Research-United Kingdom, Health Protection Research Unit (NIHR HPRU) in Environmental Change and Health; the University of Queensland (Australia); the Ministry of Education (Spain) (grant PRX12/00515); the National Health and Medical Research Council (Australia) (grant 553043); the Australian Research Council (Australia) (grant DP110100651); the Environment Research and Technology Development Fund (Japan) (S-8 & S10); and the National Research Foundation of Korea (grant K21004000001-10A0500-00710).

Background Psychological illness occurring in association with hyperemesis gravidarum (HG) has been widely reported. Objective To determine if there is a higher incidence of psychological morbidity in women with HG compared with women without significant nausea and vomiting in pregnancy. Search strategy PubMed, MEDLINE, Embase and PsychINFO were searched up to September 2015. Selection criteria Articles referring to psychological morbidity in relation to HG. For meta-analysis case–control studies using numerical scales to compare psychological symptoms. Data collection and analysis Articles were independently assessed for inclusion by two reviewers and methodology was appraised using the Newcastle Ottawa Scale. Comparison was made using the standard mean difference (SMD) in symptom scale scores. Main results In all, 59 articles were included in the systematic review, 12 of these were used in the meta-analysis. Meta-analysis of depression scale scores demonstrated a very large effect with statistically significantly higher depression scale scores in women with HG (SMD 1.22; 95% CI 0.80–1.64; P ≤ 0.01) compared with controls. Meta-analysis of anxiety scores demonstrated a large effect with statistically significantly higher anxiety disorder scale scores in women with HG (SMD 0.86; 95% CI 0.53–1.19; P ≤ 0.01). In both analyses significant heterogeneity was identified (depression and HG I2 = 94%, P ≤ 0.01; anxiety and HG I2 = 84%, P = 0.02). Conclusions Our systematic review and meta-analysis have shown a significantly increased frequency of depression and anxiety in women with HG. The findings should prompt service development for women with HG that includes provision of psychological care and support. Tweetable abstract Meta-analysis demonstrates an increase in #PsychologicalMorbidity in women with #HyperemesisGravidarum

La presente revisión trata de describir algunos conceptos fundamentales de los metanálisis en red y las comparaciones indirectas y su aplicación en las ciencias clínicas. Actualmente existe un incremento de revisiones sistemáticas y metanálisis para lo que se requiere la existencia de comparaciones directas entre las diferentes intervenciones, sin embargo, en múltiples ocasiones, esto no es posible dada la carencia de evidencia relacionada con todas las comparaciones posibles. De tal manera que se han desarrollado herramientas estadísticas importantes que permiten hacer comparaciones múltiples e indirectas a partir de las ya existentes. Para concluir, los metanálisis en red son una herramienta novedosa que ayuda a los clínicos, investigadores y a los organismos gubernamentales en la toma de decisiones tanto clínicas como de salud pública. This review describes essential concepts of network meta-analysis and indirect comparisons and their application to clinical science. There are an increasing number of systematic reviews and meta-analyses providing direct comparisons between different interventions, although this is often not feasible when there is a lack of evidence related to all possible comparisons. Thus, important statistical tools that help make indirect comparisons based on previously existing comparisons have been developed. Network meta-analyses are an innovative tool that could assist doctors, researchers, and governmental organizations when making clinical and public health decisions.