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The Physician and Sportsmedicine Dec 2023Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic... (Review)
Review
OBJECTIVE
Identifying risk factors for Achilles Tendon Rupture (ATR) is one of the first necessary steps for its prevention. This systematic review aimed to update the systematic review published in 2014 in ATR etiology.
METHODOLOGY
A systematic review was carried out using PubMed, EBSCO, and ScienceDirect databases. All types of research studies (Randomized Control Trials - RCTs, Cohort studies, Case-control studies and Cross-sectional studies) that considered ATR, were eligible. The inclusion criteria for eligibility of the studies were to be written in the English language, and to include populations of men and/or women, both athletes, and non-athletes, healthy individuals, and patients. Two independent reviewers used the assessment instrument Newcastle-Ottawa Scale independently, to evaluate the quality of each selected study. Further, two reviewers worked independently to extract the study characteristics, and the GRADE methodology was used to assess the level of certainty of each risk factor.
RESULTS
From 9526 studies initially identified, 19 studies were eligible for further analysis to identify risk factors for ATR. Seventeen studies were considered good quality, and two studies fair quality. Low to very low certainty of evidence was found for the following medications: steroids, quinolones, and oral bisphosphonate, as well as for other factors such as chronic tendon inflammation and Achilles' tendinopathy, spring season, diabetes, previous musculoskeletal injury, regular participation in athletic activity, hyperparathyroidism, renal failure, and genetic factors.
CONCLUSIONS
The risk factors found prove that ATR is a multifactorial injury. Appropriate methodologies and well-designed studies are needed to determine the factors and their significance in ATR risk. Finally, the role of biomechanical and psychological aspects in the ATR etiology may be of interest in future studies, as we could not extract relative data in our review.
Topics: Male; Humans; Female; Achilles Tendon; Cross-Sectional Studies; Tendon Injuries; Risk Factors; Musculoskeletal Diseases; Rupture
PubMed: 35670156
DOI: 10.1080/00913847.2022.2085505 -
JAMA Network Open Sep 2023Current rehabilitation guidelines for patients with post-COVID-19 condition (PCC) are primarily based on expert opinions and observational data, and there is an urgent... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Current rehabilitation guidelines for patients with post-COVID-19 condition (PCC) are primarily based on expert opinions and observational data, and there is an urgent need for evidence-based rehabilitation interventions to support patients with PCC.
OBJECTIVE
To synthesize the findings of existing studies that report on physical capacity (including functional exercise capacity, muscle function, dyspnea, and respiratory function) and quality of life outcomes following rehabilitation interventions in patients with PCC.
DATA SOURCES
A systematic electronic search was performed from January 2020 until February 2023, in MEDLINE, Scopus, CINAHL, and the Clinical Trials Registry. Key terms that were used to identify potentially relevant studies included long-covid, post-covid, sequelae, exercise therapy, rehabilitation, physical activity, physical therapy, and randomized controlled trial.
STUDY SELECTION
This study included randomized clinical trials that compared respiratory training and exercise-based rehabilitation interventions with either placebo, usual care, waiting list, or control in patients with PCC.
DATA EXTRACTION AND SYNTHESIS
This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A pairwise bayesian random-effects meta-analysis was performed using vague prior distributions. Risk of bias was assessed using the Cochrane risk of bias tool version 2, and the certainty of evidence was evaluated using the GRADE system by 2 independent researchers.
MAIN OUTCOMES AND MEASURES
The primary outcome was functional exercise capacity, measured at the closest postintervention time point by the 6-minute walking test. Secondary outcomes were fatigue, lower limb muscle function, dyspnea, respiratory function, and quality of life. All outcomes were defined a priori. Continuous outcomes were reported as standardized mean differences (SMDs) with 95% credible intervals (CrIs) and binary outcomes were summarized as odds ratios with 95% CrIs. The between-trial heterogeneity was quantified using the between-study variance, τ2, and 95% CrIs.
RESULTS
Of 1834 identified records, 1193 were screened, and 14 trials (1244 patients; 45% female participants; median [IQR] age, 50 [47 to 56] years) were included in the analyses. Rehabilitation interventions were associated with improvements in functional exercise capacity (SMD, -0.56; 95% CrI, -0.87 to -0.22) with moderate certainty in 7 trials (389 participants). These improvements had a 99% posterior probability of superiority when compared with current standard care. The value of τ2 (0.04; 95% CrI, 0.00 to 0.60) indicated low statistical heterogeneity. However, there was significant uncertainty and imprecision regarding the probability of experiencing exercise-induced adverse events (odds ratio, 1.68; 95% CrI, 0.32 to 9.94).
CONCLUSIONS AND RELEVANCE
The findings of this systematic review and meta-analysis suggest that rehabilitation interventions are associated with improvements in functional exercise capacity, dyspnea, and quality of life, with a high probability of improvement compared with the current standard care; the certainty of evidence was moderate for functional exercise capacity and quality of life and low for other outcomes. Given the uncertainty surrounding the safety outcomes, additional trials with enhanced monitoring of adverse events are necessary.
Topics: Humans; Adult; Female; Middle Aged; Male; Quality of Life; Post-Acute COVID-19 Syndrome; Bayes Theorem; COVID-19; Dyspnea; Randomized Controlled Trials as Topic
PubMed: 37725376
DOI: 10.1001/jamanetworkopen.2023.33838 -
JAMA Oct 2023The effect of continuous positive airway pressure (CPAP) on secondary cardiovascular disease prevention is highly debated. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
The effect of continuous positive airway pressure (CPAP) on secondary cardiovascular disease prevention is highly debated.
OBJECTIVE
To assess the effect of CPAP treatment for obstructive sleep apnea (OSA) on the risk of adverse cardiovascular events in randomized clinical trials.
DATA SOURCES
PubMed (MEDLINE), EMBASE, Current Controlled Trials: metaRegister of Controlled Trials, ISRCTN Registry, European Union clinical trials database, CENTRAL (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov databases were systematically searched through June 22, 2023.
STUDY SELECTION
For qualitative and individual participant data (IPD) meta-analysis, randomized clinical trials addressing the therapeutic effect of CPAP on cardiovascular outcomes and mortality in adults with cardiovascular disease and OSA were included.
DATA EXTRACTION AND SYNTHESIS
Two reviewers independently screened records, evaluated potentially eligible primary studies in full text, extracted data, and cross-checked errors. IPD were requested from authors of the selected studies (SAVE [NCT00738179], ISAACC [NCT01335087], and RICCADSA [NCT00519597]).
MAIN OUTCOMES AND MEASURES
One-stage and 2-stage IPD meta-analyses were completed to estimate the effect of CPAP treatment on risk of recurrent major adverse cardiac and cerebrovascular events (MACCEs) using mixed-effect Cox regression models. Additionally, an on-treatment analysis with marginal structural Cox models using inverse probability of treatment weighting was fitted to assess the effect of good adherence to CPAP (≥4 hours per day).
RESULTS
A total of 4186 individual participants were evaluated (82.1% men; mean [SD] body mass index, 28.9 [4.5]; mean [SD] age, 61.2 [8.7] years; mean [SD] apnea-hypopnea index, 31.2 [17] events per hour; 71% with hypertension; 50.1% receiving CPAP [mean {SD} adherence, 3.1 {2.4} hours per day]; 49.9% not receiving CPAP [usual care], mean [SD] follow-up, 3.25 [1.8] years). The main outcome was defined as the first MACCE, which was similar for the CPAP and no CPAP groups (hazard ratio, 1.01 [95% CI, 0.87-1.17]). However, an on-treatment analysis by marginal structural model revealed a reduced risk of MACCEs associated with good adherence to CPAP (hazard ratio, 0.69 [95% CI, 0.52-0.92]).
CONCLUSIONS AND RELEVANCE
Adherence to CPAP was associated with a reduced MACCE recurrence risk, suggesting that treatment adherence is a key factor in secondary cardiovascular prevention in patients with OSA.
Topics: Female; Humans; Male; Middle Aged; Cardiovascular Diseases; Continuous Positive Airway Pressure; Hypertension; Proportional Hazards Models; Sleep Apnea, Obstructive; Risk; Aged; Secondary Prevention; Patient Compliance
PubMed: 37787793
DOI: 10.1001/jama.2023.17465 -
Prevention Science : the Official... May 2024Parenting and family environment have significant impact on child development, including development of executive function, attention, and self-regulation, and may... (Meta-Analysis)
Meta-Analysis Review
All in the Family? A Systematic Review and Meta-analysis of Parenting and Family Environment as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children.
Parenting and family environment have significant impact on child development, including development of executive function, attention, and self-regulation, and may affect the risk of developmental disorders including attention-deficit/hyperactivity disorder (ADHD). This paper examines the relationship of parenting and family environment factors with ADHD. A systematic review of the literature was conducted in 2014 and identified 52 longitudinal studies. A follow-up search in 2021 identified 7 additional articles, for a total of 59 studies that examined the association of parenting factors with ADHD outcomes: ADHD overall (diagnosis or symptoms), ADHD diagnosis specifically, or presence of the specific ADHD symptoms of inattention and hyperactivity/impulsivity. For parenting factors that were present in three or more studies, pooled effect sizes were calculated separately for dichotomous or continuous ADHD outcomes, accounting for each study's conditional variance. Factors with sufficient information for analysis were parenting interaction quality (sensitivity/warmth, intrusiveness/reactivity, and negativity/harsh discipline), maltreatment (general maltreatment and physical abuse), parental relationship status (divorce, single parenting), parental incarceration, and child media exposure. All factors showed a significant direct association with ADHD outcomes, except sensitivity/warmth which had an inverse association. Parenting factors predicted diagnosis and overall symptoms as well as inattentive and hyperactive symptoms when measured, but multiple factors showed significant heterogeneity across studies. These findings support the possibility that parenting and family environment influences ADHD symptoms and may affect a child's likelihood of being diagnosed with ADHD. Prevention strategies that support parents, such as decreasing parenting challenges and increasing access to parent training in behavior management, may improve children's long-term developmental health.
Topics: Humans; Attention Deficit Disorder with Hyperactivity; Parenting; Child; Risk Factors
PubMed: 35438451
DOI: 10.1007/s11121-022-01358-4 -
The Lancet. Neurology Aug 2023Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by...
BACKGROUND
Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by 2030, and assessing trends in the global meningitis burden can help track progress and identify gaps in achieving these goals. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to assess incident cases and deaths due to acute infectious meningitis by aetiology and age from 1990 to 2019, for 204 countries and territories.
METHODS
We modelled meningitis mortality using vital registration, verbal autopsy, sample-based vital registration, and mortality surveillance data. Meningitis morbidity was modelled with a Bayesian compartmental model, using data from the published literature identified by a systematic review, as well as surveillance data, inpatient hospital admissions, health insurance claims, and cause-specific meningitis mortality estimates. For aetiology estimation, data from multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature studies were analysed by use of a network analysis model to estimate the proportion of meningitis deaths and cases attributable to the following aetiologies: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococcus, Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, viruses, and a residual other pathogen category.
FINDINGS
In 2019, there were an estimated 236 000 deaths (95% uncertainty interval [UI] 204 000-277 000) and 2·51 million (2·11-2·99) incident cases due to meningitis globally. The burden was greatest in children younger than 5 years, with 112 000 deaths (87 400-145 000) and 1·28 million incident cases (0·947-1·71) in 2019. Age-standardised mortality rates decreased from 7·5 (6·6-8·4) per 100 000 population in 1990 to 3·3 (2·8-3·9) per 100 000 population in 2019. The highest proportion of total all-age meningitis deaths in 2019 was attributable to S pneumoniae (18·1% [17·1-19·2]), followed by N meningitidis (13·6% [12·7-14·4]) and K pneumoniae (12·2% [10·2-14·3]). Between 1990 and 2019, H influenzae showed the largest reduction in the number of deaths among children younger than 5 years (76·5% [69·5-81·8]), followed by N meningitidis (72·3% [64·4-78·5]) and viruses (58·2% [47·1-67·3]).
INTERPRETATION
Substantial progress has been made in reducing meningitis mortality over the past three decades. However, more meningitis-related deaths might be prevented by quickly scaling up immunisation and expanding access to health services. Further reduction in the global meningitis burden should be possible through low-cost multivalent vaccines, increased access to accurate and rapid diagnostic assays, enhanced surveillance, and early treatment.
FUNDING
Bill & Melinda Gates Foundation.
Topics: Child; Humans; Global Burden of Disease; Bayes Theorem; Meningitis; Risk Factors; Global Health
PubMed: 37479374
DOI: 10.1016/S1474-4422(23)00195-3 -
Journal of Affective Disorders Oct 2023Despite a surge in research on self-injury in the last decade, a summary of research findings about the development of Non-Suicidal Self-Injury (NSSI) over time in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Despite a surge in research on self-injury in the last decade, a summary of research findings about the development of Non-Suicidal Self-Injury (NSSI) over time in community youth samples is not yet present in the scientific literature. This study aims to summarize the empirical literature on this topic, examining both the occurrence (Study 1) and frequency (Study 2) of NSSI over time, and for this reason, a Systematic Review and Bayesian Meta-Analysis were conducted.
METHODS
Following the PRISMA guidelines, the longitudinal studies included in the systematic review consisted of 41 papers (Study 1 = 16; Study 2 = 25). Only studies with available data were included in the meta-analysis (Study 1 = 12; Study 2 = 11).
RESULTS
First, the findings highlight limits related to methodological aspects, the design of the studies, and the availability of data. Meta-analytic results shows that across development, the frequency (i.e., not the occurrence) of NSSI increases for the group of younger adolescents, remains stable in the group of middle adolescents, and it decreases for older adolescents.
LIMITATIONS
This study highlights some limitations that can be summarized in three different macro categories: the first refers to methodological aspects (e.g., the lifetime prevalence of NSSI), the second to the design of the studies (e.g., not homogeneous cohort; short-term covered), and the third to the availability of data.
CONCLUSIONS
The current meta-analysis tries to shed light on the longitudinal research on NSSI behavior and how this behavior develops in terms of both occurrence and frequency, providing practical and methodological indications for future research.
Topics: Adolescent; Humans; Bayes Theorem; Self-Injurious Behavior; Prevalence; Suicidal Ideation
PubMed: 37479039
DOI: 10.1016/j.jad.2023.07.091 -
Diabetes Care Feb 2024The optimal dose or type of physical activity to control glycosylated hemoglobin (HbA1c) in people with diabetes remains unknown. Current guidelines do not include... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The optimal dose or type of physical activity to control glycosylated hemoglobin (HbA1c) in people with diabetes remains unknown. Current guidelines do not include consideration of baseline HbA1c for activity prescription.
PURPOSE
To examine the dose-response relationship between physical activity and HbA1c (%) in individuals with type 2 diabetes.
DATA SOURCES
A systematic search was performed in Embase, MEDLINE, Scopus, CINAHL, SPORTDiscus, and Web of Science.
STUDY SELECTION
We included trials that involved participants diagnosed with type 2 diabetes that included any type of physical activity as intervention.
DATA EXTRACTION
Pre- and postintervention HbA1c data, population and interventions characteristics, and descriptive statistics were collected to calculate change scores for each study arm.
DATA SYNTHESIS
We used Bayesian random-effects meta-analyses to summarize high-quality evidence from 126 studies (6,718 participants). The optimal physical activity dose was 1,100 MET min/week, resulting in HbA1c reductions, ranging from -1.02% to -0.66% in severe uncontrolled diabetes, from -0.64% to -0.49% in uncontrolled diabetes, from -0.47% to -0.40% in controlled diabetes, and from -0.38% to -0.24% in prediabetes.
LIMITATIONS
The time required to achieve these HbA1c reductions could not be estimated due to the heterogeneity between interventions' duration and protocols and the interpersonal variability of this outcome.
CONCLUSIONS
The result of this meta-analysis provide key information about the optimal weekly dose of physical activity for people with diabetes with consideration of baseline HbA1c level, and the effectiveness of different types of active interventions. These results enable clinicians to prescribe tailored physical activity programs for this population.
Topics: Humans; Diabetes Mellitus, Type 2; Glycated Hemoglobin; Glycemic Control; Bayes Theorem; Exercise
PubMed: 38241499
DOI: 10.2337/dc23-0800 -
BMC Public Health Aug 2023During the COVID-19 epidemic, the prevalence of neck pain among college students has increased due to the shift from offline to online learning and increasing academic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
During the COVID-19 epidemic, the prevalence of neck pain among college students has increased due to the shift from offline to online learning and increasing academic and employment pressures. Therefore, this systematic review aimed to identify the personal, occupational, and psychological factors associated with the development of neck pain to promote the development of preventive strategies and early intervention treatment.
METHODS
Seven electronic databases were searched from inception to December 2022 for cross-sectional studies, cohort studies, case----control studies, and randomized controlled trials (RCTs) on neck pain. The quality of the selected studies were assessed by American Agency for Healthcare Research and Quality (AHRQ) or the Newcastle-Ottawa Scale (NOS). Pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated to evaluate the effects of the included risk factors on neck pain.
RESULTS
Thirty studies were included, including 18,395 participants. And a total of 33 potentially associated risk factors were identified. Ultimately, 11 risk factors were included in the meta-analysis after assessing, and all results were statistically significant (P < 0.05). The factors supported by strong evidence mainly include the improper use of the pillow (OR = 2.20, 95% CI: 1.39 to 3.48), lack of exercise (OR = 1.88, 95% CI: 1.53 to 2.30), improper sitting posture (OR = 1.97, 95% CI: 1.39 to 2.78), history of neck and shoulder trauma (OR = 2.32, 95% CI: 1.79 to 3.01), senior grade (OR = 2.86, 95% CI: 2.07 to 3.95), staying up late (OR = 1.80, 95% CI: 1.35 to 2.41), long-time electronic product usage daily (OR = 1.53, 95% CI: 1.33 to 1.76), long-time to bow head (OR = 2.04, 95% CI: 1.58 to 2.64), and emotional problems (OR = 2.09; 95% CI: 1.66 to 2.63). Risk factors supported by moderate evidence were high stress (OR = 1.61, 95% CI: 1.02 to 2.52) and female gender (OR = 1.69, 95% CI: 1.52 to 1.87).
CONCLUSION
This study obtained 11 main risk factors affecting college students neck pain, including improper use of the pillow, lack of exercise, improper sitting posture, history of neck and shoulder trauma, senior grade, staying up late, long-term electronic product usage daily, long time to bow head, high stress, emotional problems and female gender.
Topics: Female; Humans; Neck Pain; COVID-19; Neck; Risk Factors; Students
PubMed: 37553622
DOI: 10.1186/s12889-023-16212-7 -
JAMA Pediatrics Aug 2023Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support... (Meta-Analysis)
Meta-Analysis
Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis.
IMPORTANCE
Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown.
OBJECTIVE
To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT).
DATA SOURCES
MEDLINE, Embase, and CINAHL Complete through May 2022.
STUDY SELECTION
Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS.
DATA EXTRACTION AND SYNTHESIS
Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA).
MAIN OUTCOMES AND MEASURES
The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury.
RESULTS
A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension.
CONCLUSIONS AND RELEVANCE
The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.
Topics: Infant; Child; Humans; Child, Preschool; Continuous Positive Airway Pressure; Oxygen; Cannula; Airway Extubation; Bayes Theorem; Critical Illness; Network Meta-Analysis; Oxygen Inhalation Therapy; Randomized Controlled Trials as Topic
PubMed: 37273226
DOI: 10.1001/jamapediatrics.2023.1478 -
RMD Open Jul 2023To conduct a systematic review of the literature on the association between fibromyalgia and mortality and to pool the results in a meta-analysis. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To conduct a systematic review of the literature on the association between fibromyalgia and mortality and to pool the results in a meta-analysis.
METHODS
The authors searched the PubMed, Scopus, and Web of Science databases using the key words 'fibromyalgia' and 'mortality' to identify studies that addressed an association between fibromyalgia and mortality. Original papers that assessed associations between fibromyalgia and mortality (all or specific causes) and provided an effect measure (hazard ratio (HR), standardised mortality ratio (SMR), odds ratio (OR)) quantifying the relationship between fibromyalgia and mortality were included in the systematic review. Of 557 papers that were initially identified using the search words, 8 papers were considered eligible for the systematic review and meta-analysis. We used a Newcastle-Ottawa scale to assess the risk of bias in the studies.
RESULTS
The total fibromyalgia group included 188 751 patients. An increased HR was found for all-cause mortality (HR 1.27, 95% CI 1.04 to 1.51), but not for the subgroup diagnosed by the 1990 criteria. There was a borderline increased SMR for accidents (SMR 1.95, 95% CI 0.97 to 3.92), an increased risk for mortality from infections (SMR 1.66, 95% CI 1.15 to 2.38), and suicide (SMR 3.37, 95% CI 1.52 to 7.50), and a decreased mortality rate for cancer (SMR 0.82, 95% CI 0.69 to 0.97). The studies showed significant heterogeneity.
CONCLUSIONS
These potential associations indicate that fibromyalgia should be taken seriously, with a special focus on screening for suicidal ideation, accident prevention, and the prevention and treatment of infections.
Topics: Humans; Databases, Factual; Fibromyalgia; Odds Ratio
PubMed: 37429737
DOI: 10.1136/rmdopen-2023-003005