Patricia Ghattas Hasbun

Obesity is a growing global epidemic and an established risk factor for chronic kidney disease (CKD). Excess adiposity promotes insulin resistance, hypertension, dyslipidemia, and systemic inflammation, all of which accelerate kidney injury through glomerular hyperfiltration, endothelial dysfunction, and fibrosis. Beyond these indirect mechanisms, obesity can directly cause kidney injury through obesity-related glomerulopathy (ORG), characterized by glomerulomegaly and focal segmental glomerulosclerosis. As the prevalence of both obesity and CKD continues to rise worldwide, strategies that effectively reduce weight and mitigate renal decline have gained increasing clinical relevance. Bariatric surgery, including Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric banding (AGB), and biliopancreatic diversion, is the most effective long-term intervention for severe obesity. Substantial evidence demonstrates that weight loss after bariatric surgery leads to improvements in blood pressure, glycemic control, lipid profiles, and systemic inflammation, translating into kidney protection. Observational studies and meta-analyses have shown that bariatric surgery reduces albuminuria, slows estimated glomerular filtration rate (eGFR) decline, and lowers the risk of incident CKD and kidney failure. Patients with pre-existing CKD stages 3–4 often experience stabilization or improvement in renal function postoperatively. Furthermore, among patients with end-stage renal disease (ESRD), bariatric surgery—particularly SG—can safely reduce body mass index (BMI), increasing eligibility for kidney transplantation and improving postoperative outcomes. Nevertheless, procedure-specific complications must be considered. RYGB offers the greatest metabolic and renal benefits but carries increased risks of nephrolithiasis, hyperoxaluria, and nutritional deficiencies. SG, a metabolic bariatric procedure characterized by gastric remodelling and favorable neurohormonal adaptations, provides a more favorable renal safety profile in many patients. Despite promising results, long-term randomized controlled trials remain scarce, and kidney-specific endpoints are often secondary outcomes. Future research should compare surgical techniques in CKD populations and integrate pharmacologic therapies such as GLP-1 receptor agonists and SGLT2 inhibitors. Bariatric surgery, when carefully selected and monitored, represents a safe and effective strategy to mitigate obesity-related kidney disease progression.

Cardiovascular disease (CVD) remains the leading global cause of death, with a growing interest in modifiable risk factors such as homocysteine. Elevated homocysteine contributes to atherosclerosis through endothelial dysfunction and oxidative stress. Folic acid, a key cofactor in homocysteine metabolism, has been proposed as a preventive strategy. However, recent studies have provided conflicting evidence regarding its effectiveness in preventing cardiovascular outcomes beyond stroke. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we conducted a search in multiple databases, including PubMed, Cochrane, Scopus, Web of Science, CINAHL, and EMBASE, and pre-registered on PROSPERO: CRD42024525945. Data were pooled using a random-effects model in R (version 3.4.3), with relative risks (RRs), mean differences (MD) and 95% confidence intervals (CIs) calculated. Our search yielded a preliminary list of 25,881 articles, with 45 studies that includes 96,962 participants meeting the inclusion criteria. These studies evaluated the effectiveness of folic acid supplementation in preventing cardiovascular disease and related events. The meta-analysis showed that folic acid supplementation reduced the risk of stroke (RR = 0.85, 95% CI: 0.76–0.96, p < 0.01) and modest reduction on overall CVD (RR = 0.95, 95% CI: 0.90–0.99, p = 0.04). No significant effects were found for mortality (RR = 0.98, 95% CI: 0.93–1.02), CHD (RR = 0.98, 95% CI: 0.91–1.06), PAD (RR = 0.94, 95% CI: 0.75–1.17), HDL (MD = 0.31, 95% CI: -0.04–0.65), or LDL (MD = -1.59, 95% CI: -8.82–5.64). These findings reveal the capability of folic acid supplementation in reducing the risk of stroke and cardiovascular disease. However, no benefit was found for other cardiovascular endpoints. These findings support folic acid’s targeted use in primary prevention strategies, but further research is needed to refine patient selection and clarify its role in broader cardiovascular risk management. 1. Stroke Risk Reduction: Folic acid supplementation significantly reduces stroke risk but has no significant effect on cardiovascular disease, coronary heart disease, or peripheral arterial disease. 2. No Effect on Lipid Profiles: Folic acid supplementation does not significantly impact high-density lipoprotein (HDL) or low-density lipoprotein (LDL) levels. 3. Study Variability and Bias: There is substantial heterogeneity and some high-risk biases across the studies included, which suggests the need for careful interpretation of the results. 4. Further Research Needed: The findings underscore the necessity for additional research to better understand how folic acid supplementation might more broadly influence cardiovascular health.

Background Anxiety is a common concern among patients undergoing endoscopic procedures, affecting up to 70% of individuals. Increased anxiety can heighten pain perception, reduce procedural tolerance, and negatively impact patient satisfaction. Non-pharmacological interventions, such as music therapy, virtual reality, aromatherapy, relaxation techniques, and others, have been explored as alternatives to pharmacological anxiolytics.. This systematic review and network meta-analysis (NMA) provides an evaluation of these interventions in reducing anxiety and their impact on secondary outcomes, including pain, patient satisfaction, and procedure duration. Methods Following PRISMA guidelines, we systematically searched seven databases for randomized controlled trials (RCTs) evaluating non-pharmacological interventions for anxiety reduction in endoscopy and colonoscopy. A network meta-analysis was conducted using a random-effects model to compare intervention effectiveness, with standardized mean differences (SMDs) and 95% confidence intervals (CIs) calculated. Surface under the cumulative ranking (SUCRA) probabilities determined the rank order of interventions. Subgroup analyses were performed by type of procedure (upper vs. lower endoscopy) and sedation status. Results A total of 48 RCTs comprising 6014 participants and evaluating 12 non-pharmacological interventions were included. In the network meta-analysis (NMA) for anxiety, Reiki (SMD = − 1.51, 95% CI − 3.01 to − 0.01, p = 0.04), aromatherapy (SMD = − 1.31, 95% CI − 2.47 to − 0.14, p = 0.02), and music therapy (SMD = − 1.09, 95% CI − 1.50 to − 0.67, p < 0.01) significantly reduced anxiety compared to standard care. These interventions also ranked highest in terms of SUCRA values Reiki (0.77), aromatherapy (0.73), and music therapy (0.67). The NMA for secondary outcomes showed that music therapy significantly improved patient satisfaction (SMD = 2.21, 95% CI 1.20 to 3.22, p < 0.01), while no intervention had a statistically significant impact on pain or procedure duration. Subgroup analyses showed that music therapy was most consistent in lower endoscopic and sedated procedures, while aromatherapy and Reiki demonstrated stronger effects in upper and non-sedated procedures. Conclusion Music therapy demonstrated the strongest evidence for anxiety reduction, with potential benefits for patient satisfaction. Reiki and aromatherapy also ranked highly, though their significance varied. No intervention significantly influenced pain or procedure duration. Subgroup analyses suggested that effectiveness may vary by procedure type and sedation status, underscoring the importance of tailoring interventions to clinical context. Future research should prioritize direct intervention trials with standardized methodologies to enhance the robustness of findings and establish causal relationships.

Systematic reviews and meta-analyses are essential tools in medical research. Systematic reviews are a type of literature review that uses a systematic process to identify and assess all available literature on a specific research question. A meta-analysis is a statistical method of synthesizing the results of a systematic review by quantitatively combining data. The process begins with formulating a well-defined research question using frameworks. Comprehensive literature searches across multiple databases, including PubMed, Embase, and Cochrane, to ensure the inclusion of diverse studies. Tools like EndNote and Covidence streamline reference management and study selection, enhancing efficiency and accuracy. Quality assessment using tools like the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale is crucial to evaluate the methodological rigor. Data extraction, using standardized forms to ensure consistent information capture. Qualitative synthesis is one method that integrates the results of a systematic review focusing on textual data. Meta-analysis employs statistical software such as R and RevMan to compute effect sizes, confidence intervals, and assess heterogeneity. Visual representations, including forest and funnel plots, facilitate the interpretation of results. Challenges such as publication bias and heterogeneity are addressed using statistical methods like Egger regression and the trim-and-fill technique. Sensitivity analyses further validate the robustness of findings. Common errors, including data entry mistakes and inappropriate pooling, are mitigated through rigorous methodological adherence and critical self-evaluation. Meticulously conducted, systematic reviews and meta-analyses represent the pinnacle of the evidence hierarchy, driving advancements in medical research and practice.