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Environment International Oct 2020As new scientific evidence on health effects of air pollution is generated, air quality guidelines need to be periodically updated. The objective of this review is to... (Meta-Analysis)
Meta-Analysis
As new scientific evidence on health effects of air pollution is generated, air quality guidelines need to be periodically updated. The objective of this review is to support the derivation of updated guidelines by the World Health Organization (WHO) by performing a systematic review of evidence of associations between long-term exposure to particulate matter with diameter under 2.5 µm (PM) and particulate matter with diameter under 10 µm (PM), in relation to all-cause and cause-specific mortality. As there is especially uncertainty about the relationship at the low and high end of the exposure range, the review needed to provide an indication of the shape of the concentration-response function (CRF). We systematically searched MEDLINE and EMBASE from database inception to 9 October 2018. Articles were checked for eligibility by two reviewers. We included cohort and case-control studies on outdoor air pollution in human populations using individual level data. In addition to natural-cause mortality, we evaluated mortality from circulatory diseases (ischemic heart disease (IHD) and cerebrovascular disease (stroke) also specifically), respiratory diseases (Chronic Obstructive Pulmonary Disease (COPD) and acute lower respiratory infection (ALRI) also specifically) and lung cancer. A random-effect meta-analysis was performed when at least three studies were available for a specific exposure-outcome pair. Risk of bias was assessed for all included articles using a specifically developed tool coordinated by WHO. Additional analyses were performed to assess consistency across geographic region, explain heterogeneity and explore the shape of the CRF. An adapted GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessment of the body of evidence was made using a specifically developed tool coordinated by WHO. A large number (N = 107) of predominantly cohort studies (N = 104) were included after screening more than 3000 abstracts. Studies were conducted globally with the majority of studies from North America (N = 62) and Europe (N = 25). More studies used PM (N = 71) as the exposure metric than PM (N = 42). PM was significantly associated with all causes of death evaluated. The combined Risk Ratio (RR) for PM and natural-cause mortality was 1.08 (95%CI 1.06, 1.09) per 10 µg/m. Meta analyses of studies conducted at the low mean PM levels (<25, 20, 15, 12, 10 µg/m) yielded RRs that were similar or higher compared to the overall RR, consistent with the finding of generally linear or supra-linear CRFs in individual studies. Pooled RRs were almost identical for studies conducted in North America, Europe and Western Pacific region. PM was significantly associated with natural-cause and most but not all causes of death. Application of the risk of bias tool showed that few studies were at a high risk of bias in any domain. Application of the adapted GRADE tool resulted in an assessment of "high certainty of evidence" for PM with all assessed endpoints except for respiratory mortality (moderate). The evidence was rated as less certain for PM and cause-specific mortality ("moderate" for circulatory, IHD, COPD and "low" for stroke mortality. Compared to the previous global WHO evaluation, the evidence base has increased substantially. However, studies conducted in low- and middle- income countries (LMICs) are still limited. There is clear evidence that both PM and PM were associated with increased mortality from all causes, cardiovascular disease, respiratory disease and lung cancer. Associations remained below the current WHO guideline exposure level of 10 µg/m for PM. Systematic review registration number (PROSPERO ID): CRD42018082577.
Topics: Air Pollutants; Air Pollution; Cause of Death; Environmental Exposure; Europe; Humans; North America; Particulate Matter
PubMed: 32703584
DOI: 10.1016/j.envint.2020.105974 -
Environmental Health Perspectives Mar 2022Outdoor air pollution is a known lung carcinogen, but research investigating the association between particulate matter (PM) and gastrointestinal (GI) cancers is limited. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Outdoor air pollution is a known lung carcinogen, but research investigating the association between particulate matter (PM) and gastrointestinal (GI) cancers is limited.
OBJECTIVES
We sought to review the epidemiologic literature on outdoor PM and GI cancers and to put the body of studies into context regarding potential for bias and overall strength of evidence.
METHODS
We conducted a systematic review and meta-analysis of epidemiologic studies that evaluated the association of fine PM [PM with an aerodynamic diameter of ()] and (aerodynamic diameter ) with GI cancer incidence or mortality in adults. We searched five databases for original research published from 1980 to 2021 in English and summarized findings for studies employing a quantitative estimate of exposure overall and by specific GI cancer subtypes. We evaluated the risk of bias of individual studies and the overall quality and strength of the evidence according to the Navigation Guide methodology, which is tailored for environmental health research.
RESULTS
Twenty studies met inclusion criteria and included participants from 14 countries; nearly all were of cohort design. All studies identified positive associations between PM exposure and risk of at least one GI cancer, although in 3 studies these relationships were not statistically significant. Three of 5 studies estimated associations with and satisfied inclusion criteria for meta-analysis, but each assessed a different GI cancer and were therefore excluded. In the random-effects meta-analysis of 13 studies, exposure was associated with an increased risk of GI cancer overall [; 95% CI: 1.01, 1.24]. The most robust associations were observed for liver cancer (; 95% CI: 1.07, 1.56) and colorectal cancer (; 95% CI: 1.08, 1.62), for which all studies identified an increased risk. We rated most studies with "probably low" risk of bias and the overall body of evidence as "moderate" quality with "limited" evidence for this association. We based this determination on the generally positive, but inconsistently statistically significant, effect estimates reported across a small number of studies.
CONCLUSION
We concluded there is some evidence of associations between and GI cancers, with the strongest evidence for liver and colorectal cancers. Although there is biologic plausibility for these relationships, studies of any one cancer site were few and there remain only a small number overall. Studies in geographic areas with high GI cancer burden, evaluation of the impact of different PM exposure assessment approaches on observed associations, and investigation of cancer subtypes and specific chemical components of PM are important areas of interest for future research. https://doi.org/10.1289/EHP9620.
Topics: Adult; Air Pollutants; Air Pollution; Environmental Exposure; Gastrointestinal Neoplasms; Humans; Particulate Matter
PubMed: 35234536
DOI: 10.1289/EHP9620 -
Environment International Jun 2022The health effects of traffic-related air pollution (TRAP) continue to be of important public health interest. Following its well-cited 2010 critical review, the Health... (Meta-Analysis)
Meta-Analysis
The health effects of traffic-related air pollution (TRAP) continue to be of important public health interest. Following its well-cited 2010 critical review, the Health Effects Institute (HEI) appointed a new expert Panel to systematically evaluate the epidemiological evidence regarding the associations between long-term exposure to TRAP and selected adverse health outcomes. Health outcomes were selected based on evidence of causality for general air pollution (broader than TRAP) cited in authoritative reviews, relevance for public health and policy, and resources available. The Panel used a systematic approach to search the literature, select studies for inclusion in the review, assess study quality, summarize results, and reach conclusions about the confidence in the evidence. An extensive search was conducted of literature published between January 1980 and July 2019 on selected health outcomes. A new exposure framework was developed to determine whether a study was sufficiently specific to TRAP. In total, 353 studies were included in the review. Respiratory effects in children (118 studies) and birth outcomes (86 studies) were the most commonly studied outcomes. Fewer studies investigated cardiometabolic effects (57 studies), respiratory effects in adults (50 studies), and mortality (48 studies). The findings from the systematic review, meta-analyses, and evaluation of the quality of the studies and potential biases provided an overall high or moderate-to-high level of confidence in an association between long-term exposure to TRAP and the adverse health outcomes all-cause, circulatory, ischemic heart disease and lung cancer mortality, asthma onsetin chilldren and adults, and acute lower respiratory infections in children. The evidence was considered moderate, low or very low for the other selected outcomes. In light of the large number of people exposed to TRAP - both in and beyond the near-road environment - the Panel concluded that the overall high or moderate-to-high confidence in the evidence for an association between long-term exposure to TRAP and several adverse health outcomes indicates that exposures to TRAP remain an important public health concern and deserve greater attention from the public and from policymakers.
Topics: Adult; Air Pollutants; Air Pollution; Asthma; Bias; Child; Environmental Exposure; Humans; Traffic-Related Pollution
PubMed: 35569389
DOI: 10.1016/j.envint.2022.107262 -
The Lancet. Global Health Nov 20203 billion people worldwide rely on polluting fuels and technologies for domestic cooking and heating. We estimate the global, regional, and national health burden... (Meta-Analysis)
Meta-Analysis
BACKGROUND
3 billion people worldwide rely on polluting fuels and technologies for domestic cooking and heating. We estimate the global, regional, and national health burden associated with exposure to household air pollution.
METHODS
For the systematic review and meta-analysis, we systematically searched four databases for studies published from database inception to April 2, 2020, that evaluated the risk of adverse cardiorespiratory, paediatric, and maternal outcomes from exposure to household air pollution, compared with no exposure. We used a random-effects model to calculate disease-specific relative risk (RR) meta-estimates. Household air pollution exposure was defined as use of polluting fuels (coal, wood, charcoal, agricultural wastes, animal dung, or kerosene) for household cooking or heating. Temporal trends in mortality and disease burden associated with household air pollution, as measured by disability-adjusted life-years (DALYs), were estimated from 2000 to 2017 using exposure prevalence data from 183 of 193 UN member states. 95% CIs were estimated by propagating uncertainty from the RR meta-estimates, prevalence of household air pollution exposure, and disease-specific mortality and burden estimates using a simulation-based approach. This study is registered with PROSPERO, CRD42019125060.
FINDINGS
476 studies (15·5 million participants) from 123 nations (99 [80%] of which were classified as low-income and middle-income) met the inclusion criteria. Household air pollution was positively associated with asthma (RR 1·23, 95% CI 1·11-1·36), acute respiratory infection in both adults (1·53, 1·22-1·93) and children (1·39, 1·29-1·49), chronic obstructive pulmonary disease (1·70, 1·47-1·97), lung cancer (1·69, 1·44-1·98), and tuberculosis (1·26, 1·08-1·48); cerebrovascular disease (1·09, 1·04-1·14) and ischaemic heart disease (1·10, 1·09-1·11); and low birthweight (1·36, 1·19-1·55) and stillbirth (1·22, 1·06-1·41); as well as with under-5 (1·25, 1·18-1·33), respiratory (1·19, 1·18-1·20), and cardiovascular (1·07, 1·04-1·11) mortality. Household air pollution was associated with 1·8 million (95% CI 1·1-2·7) deaths and 60·9 million (34·6-93·3) DALYs in 2017, with the burden overwhelmingly experienced in low-income and middle-income countries (LMICs; 60·8 million [34·6-92·9] DALYs) compared with high-income countries (0·09 million [0·01-0·40] DALYs). From 2000, mortality associated with household air pollution had reduced by 36% (95% CI 29-43) and disease burden by 30% (25-36), with the greatest reductions observed in higher-income nations.
INTERPRETATION
The burden of cardiorespiratory, paediatric, and maternal diseases associated with household air pollution has declined worldwide but remains high in the world's poorest regions. Urgent integrated health and energy strategies are needed to reduce the adverse health impact of household air pollution, especially in LMICs.
FUNDING
British Heart Foundation, Wellcome Trust.
Topics: Air Pollution, Indoor; Cost of Illness; Developing Countries; Global Health; Humans
PubMed: 33069303
DOI: 10.1016/S2214-109X(20)30343-0 -
American Journal of Physiology. Heart... Apr 2021Air pollution is a global health concern. Particulate matter (PM), a component of ambient air pollution, has been identified by the World Health Organization as one of...
Air pollution is a global health concern. Particulate matter (PM), a component of ambient air pollution, has been identified by the World Health Organization as one of the pollutants that poses the greatest threat to public health. Cardiovascular health effects have been extensively documented, and these effects are still being researched to provide an overview of recent literature regarding air pollution-associated cardiovascular morbidity and mortality in humans. Additionally, potential mechanisms through which air pollutants affect the cardiovascular system are discussed based on human and additional animal studies. We used the strategy of a narrative review to summarize the scientific literature of studies that were published in the past 7 yr. Searches were carried out on PubMed and Web of Science using predefined search queries. We obtained an initial set of 800 publications that were filtered to 78 publications that were relevant to include in this review. Analysis of the literature showed significant associations between air pollution, especially PM, and the risk of elevated blood pressure (BP), acute coronary syndrome, myocardial infarction (MI), cardiac arrhythmia, and heart failure (HF). Prominent mechanisms that underlie the adverse effects of air pollution include oxidative stress, systemic inflammation, endothelial dysfunction, autonomic imbalance, and thrombogenicity. The current review underscores the relevance of air pollution as a global health concern that affects cardiovascular health. More rigorous standards are needed to reduce the cardiovascular disease burden imposed by air pollution. Continued research on the health impact of air pollution is needed to provide further insight.
Topics: Air Pollutants; Air Pollution; Animals; Cardiovascular Diseases; Cardiovascular System; Environmental Monitoring; Hemodynamics; Humans; Inhalation Exposure; Risk Assessment; Risk Factors; Signal Transduction
PubMed: 33513082
DOI: 10.1152/ajpheart.00706.2020 -
Worldviews on Evidence-based Nursing Apr 2022Pressure injury (PI) is a significant health problem among inpatients that affects their health, quality of life, and expenses. (Review)
Review
BACKGROUND
Pressure injury (PI) is a significant health problem among inpatients that affects their health, quality of life, and expenses.
AIM
This systematic review aimed to compare effects of alternating pressure air mattresses (APMs) with other types of supporting surfaces as a tool for PI prevention.
METHODS
The literature published between 2009 and 2020 was searched using the databases PubMed, EMBASE, CINAHL, and Cochrane. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses process was followed, including independent study selection and data extraction. Quality appraisal was conducted using the Cochrane Risk of Bias Tool (RoB 2.0).
RESULTS
A total of six randomized controlled trials (RCTs) were analyzed. The incidence of hospital-acquired PIs at stage 1 or higher was reported in the APM group from 0.3% to 25%. In one study, APMs were found to be less effective than static air mattresses (SAMs); in contrast, two studies found no difference. In one study, the APM was reported to be more effective than the viscoelastic foam mattress (VFM). On the contrary, in a more recent study, the APM was reported to be less effective than the VFM, and there was no difference compared with high-specification foam mattresses in another study. Using the RoB 2.0 tool, one study was evaluated at "low risk of bias," another as "some concern," and four as "high risk."
LINKING EVIDENCE TO ACTION
There is insufficient evidence to suggest that APM is more effective in preventing PIs than other supporting surfaces. Evidence to date suggests that APM can be used in patients at risk for PIs. It is important to change position regardless of the type of support surface used. Highly controlled RCTs with low risk of bias are needed to provide strong evidence for identifying the most effective PI prevention support surfaces.
Topics: Air; Beds; Humans; Incidence; Pressure Ulcer; Randomized Controlled Trials as Topic
PubMed: 35229980
DOI: 10.1111/wvn.12570 -
Environmental Health Perspectives Dec 2019Particulate air pollution's physical health effects are well known, but associations between particulate matter (PM) exposure and mental illness have not yet been... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Particulate air pollution's physical health effects are well known, but associations between particulate matter (PM) exposure and mental illness have not yet been established. However, there is increasing interest in emerging evidence supporting a possible etiological link.
OBJECTIVES
This systematic review aims to provide a comprehensive overview and synthesis of the epidemiological literature to date by investigating quantitative associations between PM and multiple adverse mental health outcomes (depression, anxiety, bipolar disorder, psychosis, or suicide).
METHODS
We undertook a systematic review and meta-analysis. We searched Medline, PsycINFO, and EMBASE from January 1974 to September 2017 for English-language human observational studies reporting quantitative associations between exposure to PM in aerodynamic diameter (ultrafine particles) and PM and in aerodynamic diameter ( and , respectively) and the above psychiatric outcomes. We extracted data, appraised study quality using a published quality assessment tool, summarized methodological approaches, and conducted meta-analyses where appropriate.
RESULTS
Of 1,826 citations identified, 22 met our overall inclusion criteria, and we included 9 in our primary meta-analyses. In our meta-analysis of associations between long-term () exposure and depression ( studies), the pooled odds ratio was 1.102 per increase (95% CI: 1.023, 1.189; ). Two of the included studies investigating associations between long-term exposure and anxiety also reported statistically significant positive associations, and we found a statistically significant association between short-term exposure and suicide in meta-analysis at a 0-2 d cumulative exposure lag.
DISCUSSION
Our findings support the hypothesis of an association between long-term exposure and depression, as well as supporting hypotheses of possible associations between long-term exposure and anxiety and between short-term exposure and suicide. The limited literature and methodological challenges in this field, including heterogeneous outcome definitions, exposure assessment, and residual confounding, suggest further high-quality studies are warranted to investigate potentially causal associations between air pollution and poor mental health. https://doi.org/10.1289/EHP4595.
Topics: Air Pollutants; Air Pollution; Bipolar Disorder; Depression; Disease Susceptibility; Environmental Exposure; Humans; Psychotic Disorders; Risk Factors; Suicide
PubMed: 31850801
DOI: 10.1289/EHP4595 -
Environment International Sep 2020Air pollution is a leading cause of mortality and morbidity worldwide. Short-term exposure (from one hour to days) to selected air pollutants has been associated with... (Meta-Analysis)
Meta-Analysis
Short-term exposure to particulate matter (PM and PM), nitrogen dioxide (NO), and ozone (O) and all-cause and cause-specific mortality: Systematic review and meta-analysis.
BACKGROUND
Air pollution is a leading cause of mortality and morbidity worldwide. Short-term exposure (from one hour to days) to selected air pollutants has been associated with human mortality. This systematic review was conducted to analyse the evidence on the effects of short-term exposure to particulate matter with aerodynamic diameters less or equal than 10 and 2.5 µm (PM PM), nitrogen dioxide (NO), and ozone (O), on all-cause mortality, and PM and PM on cardiovascular, respiratory, and cerebrovascular mortality.
METHODS
We included studies on human populations exposed to outdoor air pollution from any source, excluding occupational exposures. Relative risks (RRs) per 10 µg/m increase in air pollutants concentrations were used as the effect estimates. Heterogeneity between studies was assessed using 80% prediction intervals. Risk of bias (RoB) in individual studies was analysed using a new domain-based assessment tool, developed by a working group convened by the World Health Organization and designed specifically to evaluate RoB within eligible air pollution studies included in systematic reviews. We conducted subgroup and sensitivity analyses by age, sex, continent, study design, single or multicity studies, time lag, and RoB. The certainty of evidence was assessed for each exposure-outcome combination. The protocol for this review was registered with PROSPERO (CRD42018087749).
RESULTS
We included 196 articles in quantitative analysis. All combinations of pollutants and all-cause and cause-specific mortality were positively associated in the main analysis, and in a wide range of sensitivity analyses. The only exception was NO, but when considering a 1-hour maximum exposure. We found positive associations between pollutants and all-cause mortality for PM (RR: 1.0041; 95% CI: 1.0034-1.0049), PM (RR: 1.0065; 95% CI: 1.0044-1.0086), NO (24-hour average) (RR: 1.0072; 95% CI: 1.0059-1.0085), and O (RR: 1.0043; 95% CI: 1.0034-1.0052). PM and PM were also positively associated with cardiovascular, respiratory, and cerebrovascular mortality. We found some degree of heterogeneity between studies in three exposure-outcome combinations, and this heterogeneity could not be explained after subgroup analysis. RoB was low or moderate in the majority of articles. The certainty of evidence was judged as high in 10 out of 11 combinations, and moderate in one combination.
CONCLUSIONS
This study found evidence of a positive association between short-term exposure to PM, PM, NO, and O and all-cause mortality, and between PM and PM and cardiovascular, respiratory and cerebrovascular mortality. These results were robust through several sensitivity analyses. In general, the level of evidence was high, meaning that we can be confident in the associations found in this study.
Topics: Air Pollutants; Air Pollution; Cause of Death; Environmental Exposure; Humans; Nitrogen Dioxide; Ozone; Particulate Matter; Time Factors
PubMed: 32590284
DOI: 10.1016/j.envint.2020.105876 -
International Journal of Environmental... Dec 2020(1) Background: There is increasing awareness that the quality of the indoor environment affects our health and well-being. Indoor air quality (IAQ) in particular has an...
(1) Background: There is increasing awareness that the quality of the indoor environment affects our health and well-being. Indoor air quality (IAQ) in particular has an impact on multiple health outcomes, including respiratory and cardiovascular illness, allergic symptoms, cancers, and premature mortality. (2) Methods: We carried out a global systematic literature review on indoor exposure to selected air pollutants associated with adverse health effects, and related household characteristics, seasonal influences and occupancy patterns. We screened records from six bibliographic databases: ABI/INFORM, Environment Abstracts, Pollution Abstracts, PubMed, ProQuest Biological and Health Professional, and Scopus. (3) Results: Information on indoor exposure levels and determinants, emission sources, and associated health effects was extracted from 141 studies from 29 countries. The most-studied pollutants were particulate matter (PM and PM); nitrogen dioxide (NO); volatile organic compounds (VOCs) including benzene, toluene, xylenes and formaldehyde; and polycyclic aromatic hydrocarbons (PAHs) including naphthalene. Identified indoor PM sources include smoking, cooking, heating, use of incense, candles, and insecticides, while cleaning, housework, presence of pets and movement of people were the main sources of coarse particles. Outdoor air is a major PM source in rooms with natural ventilation in roadside households. Major sources of NO indoors are unvented gas heaters and cookers. Predictors of indoor NO are ventilation, season, and outdoor NO levels. VOCs are emitted from a wide range of indoor and outdoor sources, including smoking, solvent use, renovations, and household products. Formaldehyde levels are higher in newer houses and in the presence of new furniture, while PAH levels are higher in smoking households. High indoor particulate matter, NO and VOC levels were typically associated with respiratory symptoms, particularly asthma symptoms in children. (4) Conclusions: Household characteristics and occupant activities play a large role in indoor exposure, particularly cigarette smoking for PM, gas appliances for NO, and household products for VOCs and PAHs. Home location near high-traffic-density roads, redecoration, and small house size contribute to high indoor air pollution. In most studies, air exchange rates are negatively associated with indoor air pollution. These findings can inform interventions aiming to improve IAQ in residential properties in a variety of settings.
Topics: Air Pollutants; Air Pollution, Indoor; Child; Humans; Particulate Matter; Polycyclic Aromatic Hydrocarbons; Volatile Organic Compounds
PubMed: 33276576
DOI: 10.3390/ijerph17238972 -
The Cochrane Database of Systematic... May 2021Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Alternating pressure (active) air surfaces are widely used with the aim of preventing pressure ulcers.
OBJECTIVES
To assess the effects of alternating pressure (active) air surfaces (beds, mattresses or overlays) compared with any support surface on the incidence of pressure ulcers in any population in any setting.
SEARCH METHODS
In November 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.
SELECTION CRITERIA
We included randomised controlled trials that allocated participants of any age to alternating pressure (active) air beds, overlays or mattresses. Comparators were any beds, overlays or mattresses.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.
MAIN RESULTS
We included 32 studies (9058 participants) in the review. Most studies were small (median study sample size: 83 participants). The average age of participants ranged from 37.2 to 87.0 years (median: 69.1 years). Participants were largely from acute care settings (including accident and emergency departments). We synthesised data for six comparisons in the review: alternating pressure (active) air surfaces versus: foam surfaces, reactive air surfaces, reactive water surfaces, reactive fibre surfaces, reactive gel surfaces used in the operating room followed by foam surfaces used on the ward bed, and another type of alternating pressure air surface. Of the 32 included studies, 25 (78.1%) presented findings which were considered at high overall risk of bias.
PRIMARY OUTCOME
pressure ulcer incidence Alternating pressure (active) air surfaces may reduce the proportion of participants developing a new pressure ulcer compared with foam surfaces (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.34 to 1.17; I = 63%; 4 studies, 2247 participants; low-certainty evidence). Alternating pressure (active) air surfaces applied on both operating tables and hospital beds may reduce the proportion of people developing a new pressure ulcer compared with reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (RR 0.22, 95% CI 0.06 to 0.76; I = 0%; 2 studies, 415 participants; low-certainty evidence). It is uncertain whether there is a difference in the proportion of people developing new pressure ulcers between alternating pressure (active) air surfaces and the following surfaces, as all these comparisons have very low-certainty evidence: (1) reactive water surfaces; (2) reactive fibre surfaces; and (3) reactive air surfaces. The comparisons between different types of alternating pressure air surfaces are presented narratively. Overall, all comparisons suggest little to no difference between these surfaces in pressure ulcer incidence (7 studies, 2833 participants; low-certainty evidence). Included studies have data on time to pressure ulcer incidence for three comparisons. When time to pressure ulcer development is considered using a hazard ratio (HR), it is uncertain whether there is a difference in the risk of developing new pressure ulcers, over 90 days' follow-up, between alternating pressure (active) air surfaces and foam surfaces (HR 0.41, 95% CI 0.10 to 1.64; I = 86%; 2 studies, 2105 participants; very low-certainty evidence). For the comparison with reactive air surfaces, there is low-certainty evidence that people treated with alternating pressure (active) air surfaces may have a higher risk of developing an incident pressure ulcer than those treated with reactive air surfaces over 14 days' follow-up (HR 2.25, 95% CI 1.05 to 4.83; 1 study, 308 participants). Neither of the two studies with time to ulcer incidence data suggested a difference in the risk of developing an incident pressure ulcer over 60 days' follow-up between different types of alternating pressure air surfaces. Secondary outcomes The included studies have data on (1) support-surface-associated patient comfort for comparisons involving foam surfaces, reactive air surfaces, reactive fibre surfaces and alternating pressure (active) air surfaces; (2) adverse events for comparisons involving foam surfaces, reactive gel surfaces and alternating pressure (active) air surfaces; and (3) health-related quality of life outcomes for the comparison involving foam surfaces. However, all these outcomes and comparisons have low or very low-certainty evidence and it is uncertain whether there are any differences in these outcomes. Included studies have data on cost effectiveness for two comparisons. Moderate-certainty evidence suggests that alternating pressure (active) air surfaces are probably more cost-effective than foam surfaces (1 study, 2029 participants) and that alternating pressure (active) air mattresses are probably more cost-effective than overlay versions of this technology for people in acute care settings (1 study, 1971 participants).
AUTHORS' CONCLUSIONS
Current evidence is uncertain about the difference in pressure ulcer incidence between using alternating pressure (active) air surfaces and other surfaces (reactive water surfaces, reactive fibre surfaces and reactive air surfaces). Alternating pressure (active) air surfaces may reduce pressure ulcer risk compared with foam surfaces and reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds. People using alternating pressure (active) air surfaces may be more likely to develop new pressure ulcers over 14 days' follow-up than those treated with reactive air surfaces in the nursing home setting; but as the result is sensitive to the choice of outcome measure it should be interpreted cautiously. Alternating pressure (active) air surfaces are probably more cost-effective than reactive foam surfaces in preventing new pressure ulcers. Future studies should include time-to-event outcomes and assessment of adverse events and trial-level cost-effectiveness. Further review using network meta-analysis will add to the findings reported here.
Topics: Adult; Aged; Aged, 80 and over; Air; Bedding and Linens; Beds; Bias; Elasticity; Humans; Incidence; Middle Aged; Pressure; Pressure Ulcer; Publication Bias; Quality of Life; Randomized Controlled Trials as Topic; Time Factors
PubMed: 33969911
DOI: 10.1002/14651858.CD013620.pub2