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Purpose The use of virtual reality (VR) based rehabilitation has increased substantially within orthopedic surgery, particularly in the field of total knee arthroplasty (TKA). The objective of this systematic review and meta-analysis was to compare patient-reported outcomes and cost analyses from randomized controlled trials (RCT) utilizing VR-based rehabilitation in patients following TKA. Methods MEDLINE, EMBASE, and Cochrane databases were searched for RCTs involving VR-based rehabilitation following TKA. Quantitative synthesis was conducted for pain scores and functional outcomes. Narrative outcomes were reported for results not amenable to quantitative synthesis. Results A total of 9 RCTs with 835 patients were included with follow-up ranging from 10 days to 6 months postoperatively. No differences in pain scores were demonstrated between VR-based and traditional rehabilitation at 2 weeks and 3 months postoperatively. VR-based rehabilitation demonstrated improved functional outcomes at 12 weeks ( n  = 353) postoperatively [mean difference (MD) − 3.32, 95% confidence interval (CI) − 5.20 to − 1.45, moderate certainty evidence] and 6 months ( n  = 66) postoperatively [MD − 4.75, 95% CI − 6.69 to − 2.81, low certainty evidence], compared to traditional rehabilitation. One trial demonstrated significant cost savings with the use of VR-based rehabilitation. Conclusions VR-based rehabilitation for patients undergoing TKA represents an evolving field that may have advantages over traditional therapy for some patients. The current review is limited by the low quality of evidence in the literature. This is a rapidly evolving field with more trials needed to determine the impact of VR-based rehabilitation on patients undergoing TKA. Level of evidence Level I; meta-analysis of randomized controlled trials.

To provide Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidance for assessing inconsistency, imprecision, and other domains for the certainty of evidence about the relative importance of outcomes. We applied the GRADE domains to rate the certainty of evidence in the importance of outcomes to several systematic reviews, iteratively reviewed draft guidance, and consulted GRADE members and other stakeholders for feedback. We describe the rationale for considering the remaining GRADE domains when rating the certainty in a body of evidence for the relative importance of outcomes. As meta-analyses are not common in this context, inconsistency and imprecision assessments are challenging. Furthermore, confusion exists about inconsistency, imprecision, and true variability in the relative importance of outcomes. To clarify this issue, we suggest that the true variability is neither equivalent to inconsistency nor imprecision. Specifically, inconsistency arises from population, intervention, comparison and outcome and methodological elements that should be explored and, if possible, explained. The width of the confidence interval and sample size inform judgments about imprecision. We also provide suggestions on how to detect publication bias and discuss the domains to rate up the certainty. We provide guidance and examples for rating inconsistency, imprecision, and other domains for a body of evidence describing the relative importance of outcomes.

Persistent pain after breast cancer surgery affects up to 60% of patients. Early identification of those at higher risk could help inform optimal management. We conducted a systematic review and meta-analysis of observational studies to explore factors associated with persistent pain among women who have undergone surgery for breast cancer. We searched the MEDLINE, Embase, CINAHL and PsycINFO databases from inception to Mar. 12, 2015, to identify cohort or case–control studies that explored the association between risk factors and persistent pain (lasting ≥ 2 mo) after breast cancer surgery. We pooled estimates of association using random-effects models, when possible, for all independent variables reported by more than 1 study. We reported relative measures of association as pooled odds ratios (ORs) and absolute measures of association as the absolute risk increase. Thirty studies, involving a total of 19 813 patients, reported the association of 77 independent variables with persistent pain. High-quality evidence showed increased odds of persistent pain with younger age (OR for every 10-yr decrement 1.36, 95% confidence interval [CI] 1.24–1.48), radiotherapy (OR 1.35, 95% CI 1.16–1.57), axillary lymph node dissection (OR 2.41, 95% CI 1.73–3.35) and greater acute postoperative pain (OR for every 1 cm on a 10-cm visual analogue scale 1.16, 95% CI 1.03–1.30). Moderate-quality evidence suggested an association with the presence of preoperative pain (OR 1.29, 95% CI 1.01–1.64). Given the 30% risk of pain in the absence of risk factors, the absolute risk increase corresponding to these ORs ranged from 3% (acute postoperative pain) to 21% (axillary lymph node dissection). High-quality evidence showed no association with body mass index, type of breast surgery, chemotherapy or endocrine therapy. Development of persistent pain after breast cancer surgery was associated with younger age, radiotherapy, axillary lymph node dissection, greater acute postoperative pain and preoperative pain. Axillary lymph node dissection provides the only high-yield target for a modifiable risk factor to prevent the development of persistent pain after breast cancer surgery.

The retreat of glaciers has altered hydrological processes in cryospheric regions and affects water resources at the basin scale. It is necessary to elucidate the contributions of environmental changes to evapotranspiration (ET) variation in cryospheric-dominated regions. Considering the upper reach of the Shule River Basin as a typical cryospheric-dominated watershed, an extended Budyko framework addressing glacier change was constructed and applied to investigate the sensitivity and contribution of changes in environmental variables to ET variation. The annual ET showed a significant upward trend of 1.158 mm yr−1 during 1982–2015 in the study area. ET was found to be the most sensitive to precipitation (P), followed by the controlling parameter (w), which reflects the integrated effects of landscape alterations, potential evapotranspiration (ET0), and glacier change (∆W). The increase in P was the dominant factor influencing the increase in ET, with a contribution of 112.64%, while the decrease in w largely offset its effect. The contributions of P and ET0 to ET change decreased, whereas that of w increased when considering glaciers using the extended Budyko framework. The change in glaciers played a clear role in ET change and hydrological processes, which cannot be ignored in cryospheric watersheds. These findings are helpful for better understanding changes in water resources in cryospheric regions.

Accurately understanding flood evolution and its attribution is crucial for watershed water resource management as well as disaster prevention and mitigation. The source region of the Yellow River (SRYR) has experienced several severe floods over the past few decades, but the driving factor influencing flood volume variation in the SRYR remains unclear. In this study, the Budyko framework was used to quantify the effects of climate change, vegetation growth, and permafrost degradation on flood volume variation in six basins of the SRYR. The results showed that the flood volume decreased before 2000 and increased after 2000, but the average value after 2000 remained lower than that before 2000. Flood volume is most sensitive to changes in precipitation, followed by changes in landscape in all basins. The decrease in flood volume was primarily influenced by changes in active layer thickness in permafrost-dominated basins, while it was mainly controlled by other landscape changes in non-permafrost-dominated basins. Meanwhile, the contributions of changes in potential evapotranspiration and water storage changes to the reduced flood volume were negative in all basins. Furthermore, the impact of vegetation growth on flood volume variation cannot be neglected due to its regulating role in the hydrological cycle. These findings can provide new insights into the evolution mechanism of floods in cryospheric basins and contribute to the development of strategies for flood control, disaster mitigation, and water resource management under a changing climate.

Diurnal variation of land surface temperature (LST) is essential for land surface energy and water balance at regional or global scale. Diurnal temperature cycle (DTC) model with least parameters and high accuracy is the key issue in estimating the spatial–temporal variation of DTC. The alpine meadow is the main land cover in the Tibetan Plateau (TP). However, few studies have been reported on the performance of different DTC models over alpine meadows in the TP. Four semi-empirical types of DTC models were used to generate nine 4-parameter (4-para) models by fixing some of free parameters. The performance of the nine 4-para DTC models were evaluated with four in situ and MODIS observations. All models except GOT09-dT-ts (dT means the temperature residual between T0 and T (t→∞); ts means the time when free attenuation begins) had higher correlation with in situ data (R2 > 0.9), while the INA08-ts model performed best with NSE of 0.99 and RMSE of 2.04 K at all sites. The GOT09-ts-τ (τ is the total optical thickness), VAN06-ts-ω1 (ω1 means the half-width of the cosine term in the morning), and GOT01-ts models had better performance, followed by GOT09-dT-τ, GOT01-dT, and VAN06-ts-ω2 (ω2 means the half-width of the cosine term in the afternoon) models. All models had higher accuracy in summer than in other seasons, while poorer performance was produced in winter. The INA08-ts model showed best performance among all seasons. Models with fixing ts could produce higher accuracy results than that with fixing dT. The comparison of INA08-ts model driven by in situ and Moderate Resolution Imaging Spectroradiometer (MODIS) data indicated that the simulation accuracy mainly depended on the accuracy of MODIS LST. The daily maximum temperature generated by the nine models had high accuracy when compared with in situ data. The sensitivity analysis indicated that the INA08-dT and GOT09-dT-ts models were more sensitive to parameter dT, while all models were insensitive to parameter ts, and all models had weak relationship with parameters ω and τ. This study provides a reference for exploring suitable DTC model in the TP.

ObjectiveA systematic review and meta-analysis to investigate the impact of electronic nicotine delivery systems (ENDS) and/or electronic non-nicotine delivery systems (ENNDS) versus no smoking cessation aid, or alternative smoking cessation aids, in cigarette smokers on long-term tobacco use.Data sourcesSearches of MEDLINE, EMBASE, PsycInfo, CINAHL, CENTRAL and Web of Science up to December 2015.Study selectionRandomised controlled trials (RCTs) and prospective cohort studies.Data extractionThree pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence by outcome.Data synthesisThree randomised trials including 1007 participants and nine cohorts including 13 115 participants proved eligible. Results provided by only two RCTs suggest a possible increase in tobacco smoking cessation with ENDS in comparison with ENNDS (RR 2.03, 95% CI 0.94 to 4.38; p=0.07; I2=0%, risk difference (RD) 64/1000 over 6 to 12 months, low-certainty evidence). Results from cohort studies suggested a possible reduction in quit rates with use of ENDS compared with no use of ENDS (OR 0.74, 95% CI 0.55 to 1.00; p=0.051; I2=56%, very low certainty).ConclusionsThere is very limited evidence regarding the impact of ENDS or ENNDS on tobacco smoking cessation, reduction or adverse effects: data from RCTs are of low certainty and observational studies of very low certainty. The limitations of the cohort studies led us to a rating of very low-certainty evidence from which no credible inferences can be drawn. Lack of usefulness with regard to address the question of e-cigarettes' efficacy on smoking reduction and cessation was largely due to poor reporting. This review underlines the need to conduct well-designed trials measuring biochemically validated outcomes and adverse effects.

Accurate information on snow cover extent plays a crucial role in understanding regional and global climate change, as well as the water cycle, and supports the sustainable development of socioeconomic systems. Remote sensing technology is a vital tool for monitoring snow cover’ extent, but accurate identification of shallow snow cover on the Tibetan Plateau has remained challenging. Focusing on the Three-Rivers Headwater Region (THR), this study addressed this issue by developing a snow cover discrimination model (SCDM) using a random forests (RF) algorithm. Using daily observed snow depth (SD) data from 15 stations in the THR during the period 2001–2013, a comprehensive analysis was conducted, considering various factors influencing regional snow cover distribution, such as land surface reflectance, land surface temperature (LST), Normalized Difference Snow Index (NDSI), Normalized Difference Vegetation Index (NDVI), and Normalized Difference Forest Snow Index (NDFSI). The key results were as follows: (1) Optimal model performance was achieved with the parameters Ntree, Mtry, and ratio set to 1000, 2, and 19, respectively. The SCDM outperformed other snow cover products in both pixel-scale and local spatial-scale discrimination. (2) Spectral information of snow cover proved to be the most influential auxiliary variable in discrimination, and the combined inclusion of NDVI and LST improved model performance. (3) The SCDM achieved accuracy of 99.04% for thick snow cover (SD > 4 cm) and 98.54% for shallow snow cover (SD ≤ 4 cm), significantly (p < 0.01) surpassing the traditional dynamic threshold method. This study can offer valuable reference for monitoring snow cover dynamics in regions with limited data availability.

The non-vitamin K antagonist oral anticoagulants (NOACs) have been increasingly prescribed in clinical practice for stroke prevention in patients with nonvalvular atrial fibrillation (AF). Direct comparisons between NOACs in trials are lacking, leaving an important clinical decision-making gap. We aimed to perform a systematic review and meta-analysis to summarize the evidence of observational studies for direct comparative effectiveness and safety amongst NOACs in patients with AF. Conference proceedings and electronic databases including MEDLINE, CINAHL, EMBASE and PUBMED were systematically searched. We included observational studies directly comparing individual NOACs in patients with nonvalvular AF who were aged ≥ 18 years for stroke prevention. Primary outcome included effectiveness outcome (stroke or systemic embolism) and safety outcome (major bleeding). Data were extracted in duplicated by two reviewers independently. A random-effects meta-analysis was conducted to synthesize the data from included observational studies. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to rate the overall quality of evidence for each outcome. Fifteen studies were included for qualitative synthesis, twelve studies for meta-analyses. It was found that rivaroxaban and dabigatran were similar with regard to risk of stroke or systemic embolism (Hazard ratio [HR] = 1.00, 95 % CI 0.91–1.10; evidence quality: low), but rivaroxaban was associated with higher risk of major bleeding (HR = 1.39, 95 % CI 1.28–1.50; evidence quality: moderate). Compared with apixaban, a significantly higher risk of major bleeding was observed with rivaroxaban (HR = 1.71, 95 % CI 1.51–1.94; evidence quality: low). Apixaban was associated with lower risk of major bleeding, in comparison with dabigatran (HR = 0.80, 95 % CI 0.68–0.95; evidence quality: low). No differences in risk of stroke or systemic embolism was observed between rivaroxaban versus apixaban, and apixaban versus dabigatran. In this study, apixaban was found to have the most favorable safety profile amongst the three NOACs. No significant difference was observed in risk of stroke or systemic embolism between the NOACs. Such findings may provide some decision-making support for physicians regarding their choices amongst NOACs in patients with AF.

To determine the effectiveness and safety of amino acids in preventing the mortality and morbidity among preterm infants. We conducted a systematic review and network meta-analysis. We searched MEDLINE, EMBASE, Web of Science, CINAHL, Scopus, Cochrane, and Google Scholar, and grey literature, from databases inception to January 2021. We included randomized trials that evaluated any amino acids on preterm or low-birth weight infants. We performed frequentist pairwise and network meta-analyses and used the GRADE methodology to assess the certainty of the evidence and provide a summary of the results.We included 18 trials (3702 infants). Low certainty evidence showed that there seems to be no benefit for arginine, glutamine, or N-acetylcysteine in reducing all-cause mortality. Oral arginine likely results in reduction of necrotizin enterocolitis (NEC) stage ≥ II (OR 0.48; 95% CI 0.26–0.90; moderate certainty). Oral glutamine may reduce the likelihood of developing late-onset sepsis (LOS) compared to placebo (OR 0.62; 95% CI 0.47–0.82; low certainty); and likely reduces time to reach full enteral feeding (MD = − 2.63 days; 95% CI − 4.99 to − 0.27; moderate certainty). Amino acids may have no effect on mortality. Oral arginine may reduce severe NEC, and oral glutamine may reduce LOS and the time to reach full feeding. Systematic review registration : PROSPERO registration number: CRD4201603873.