Carvedilol vs endoscopic variceal ligation for primary and secondary prevention of variceal bleeding: Systematic review and metaanalysis

BACKGROUND Variceal hemorrhage is associated with high mortality and is the cause of death for 20–30% of patients with cirrhosis. Nonselective β blockers(NSBBs) or endoscopic variceal ligation(EVL) are recommended for primary prevention of variceal bleeding in patients with medium to large esophageal varices.Meanwhile, combination of EVL and NSBBs is the recommended approach for the secondary prevention. Carvedilol has greater efficacy than other NSBBs as it decreases intrahepatic resistance. We hypothesized that there was no difference between carvedilol and EVL intervention for primary and secondary prevention of variceal bleeding in cirrhosis patients.AIM To evaluate the efficacy of carvedilol compared to EVL for primary and secondary prevention of variceal bleeding in cirrhotic patients METHODS We searched relevant literatures in major journal databases(CENTRAL,MEDLINE, and EMBASE) from March to August 2018. Patients with cirrhosis and portal hypertension, regardless of aetiology and severity, with or without a history of variceal bleeding, and aged ≥ 18 years old were included in this review.Only randomized controlled trials(RCTs) that compared the efficacy of carvedilol and that of EVL for primary and secondary prevention of variceal bleeding and mortality in patients with cirrhosis and portal hypertension were considered, irrespective of publication status, year of publication, and language.RESULTS Seven RCTs were included. In four trials assessing the primary prevention, no significant difference was found on the events of variceal bleeding(RR: 0.74,95%CI: 0.37-1.49), all-cause mortality(RR: 1.10, 95%CI: 0.76-1.58), and bleedingrelated mortality(RR: 1.02, 95%CI: 0.34-3.10) in patients who were treated with carvedilol compared to EVL. In three trials assessing secondary prevention, there was no difference between two interventions for the incidence of rebleeding(RR:1.10, 95%CI: 0.75-1.61). The fixed-effect model showed that, compared to EVL,carvedilol decreased all-cause mortality by 49%(RR: 0.51, 95%CI: 0.33-0.79), with little or no evidence of heterogeneity.CONCLUSION Carvedilol had similar efficacy to EVL in preventing the first variceal bleeding in cirrhosis patients with esophageal varices. It was superior to EVL alone for secondary prevention of variceal bleeding in regard to all-cause mortality reduction.     

抗血小板与抗凝治疗预防非瓣膜性心房颤动缺血性卒中的疗效评价

目的 评价抗血小板治疗与抗凝治疗预防非瓣膜性心房颤动(房颤)缺血性卒中疗效及安全性.方法 采用Cochrane系统评价方法,计算机检索PubMed、Embase、CENTREN及其下属各临床注册试验数据中心、中国生物医学文献数据库、中文科技期刊数据库、中国期刊全文数据库,检索时间截至2009年12月,纳入中外文抗血小板治疗与抗凝治疗预防非瓣膜性房颤缺血性卒中随机对照试验(RCT).由两名评价者独立评价纳入研究质量、提取资料并交叉核对.采用RevMan 5.0软件进行荟萃分析.结果 共纳入14个RCT,包括15 880例患者.荟萃分析结果显示:与对照组比较,抗血小板治疗不减少非瓣膜性房颤缺血性卒中(RR=0.83,95%CI0.68～1.00,P=0.05),不减少房颤全因死亡(RR=0.88,95% CI 0.73～1.07,P=0.21),可能增加房颤患者严重出血1.9倍(RR=2.88,95%CI1.21～6.86,P=0.02),不减少房颤体循环栓塞(RR=0.71,95%CI0.34～1.51,P=0.38),不增加房颤患者颅内出血(RR=3.25,95%CI0.84～12.62,P=0.09).抗血小板治疗与抗凝治疗比较显示:抗凝治疗显著降低房颤缺血性卒中发生率(RR=1.84,95%CI1.48～2.28,P＜0.01),房颤全因病死率二者差异无统计学意义(RR=1.06,95%CI0.90～1.23,P=0.50),严重出血发生率二者差异无统计学意义(RR=0.95,95%CI0.76～1.19,P=0.66),抗凝治疗显著降低房颤体循环栓塞发生率(RR=1.94,95%CI1.24～3.03,P=0.004),抗凝治疗显著增加颅内出血发生率(RR=0.49,95%CI0.31～0.78,P=0.003).结论 与对照组比较,抗血小板治疗不减少非瓣膜性房颤缺血性卒中及体循环栓塞,并可能增加房颤严重出血事件1.9倍;抗血小板治疗与抗凝治疗比较,抗凝治疗显著降低房颤缺血性卒中及体循环栓塞发生率,不增加房颤严重出血但显著增加颅内出血发生率.由于纳入的研究有限,结局指标不够统一,得出的结论尚需更多设计严谨、使用统一结局指标、随访时间较长的大样本RCT来进一步证实.

Abstract：

Objective To evaluate the efficacy and security of anti-platelet and anticoagulant therapy on prevention of ischemic stroke in patients with nonvalvular atrial fibrillation ( NAF). Methods We searched PubMed, EMbase, CENTREN and its affiliated clinical trial registration data center, CBMdisc,VIP,and CNKI databases from establishment to Dec 2009 to identify randomized controlled trials (RCTs)covering the use of anti-platelet agents and anticoagulants for patients with NAF. Meta-analysis was performed by using RevMan 5.0 software after the strict evaluation of the methodological quality of the included RCTs. Results Fourteen RCTs involving 15 880 patients were include. Compared with placebo or no use of anti-platelet drugs, antiplatelet therapy didn't reduce ischemic stroke (RR = 0. 83,95% CI0. 68 to 1.00, P = 0. 05 ), systemic emboli ( RR= 0. 71, 95% CI0. 34 to 1.51, P = 0. 38 ) and all-cause mortality (RR = 0. 88, 95% CI0. 73 to 1.07, P= 0. 21 ) while significantly increased the major bleeding ( RR = 2. 88, 95% CI 1.21 to 6. 86, P= 0. 02 ) in patients with NAF, intracranial hemorrhage was not affected by antiplatelet therapy in patients with atrial fibrillation ( RR= 3. 25, 95% CI0. 84 to 12.62, P =0. 09). Compared with anti-platelet therapy, anticoagulant therapy significantly reduced the incidence of ischemic stroke (RR = 1.84,95% CI 1.48 to 2. 28 ,P ＜0. 01 ) and systemic emboli (RR= 1.94, 95% CI 1.24 to 3.03, P = 0. 004 ) but significantly increased the incidence of intracranial hemorrhage ( RR =0. 49, 95% CI0. 31 to 0. 78, P= 0. 003 ), did not affect all-cause mortality ( RR = 1.06, 95% CI0. 90 to 1.23, P = 0. 50) and the incidence of major bleeding ( RR = 0. 95, 95 % CI0. 76 to 1.19, P = 0. 66) in NAF patients. Conclusions Compared with the placebo and no use of anti-platelet drugs, anti-platelet therapy didn't reduce ischemic stroke and systemic emboli but increased the risk of major bleeding in NAF patients. Compared with anti-platelet therapy, anticoagulant therapy significantly reduced the ischemic stroke and systemic emboli without increasing the risk of major bleeding, but significantly increased the incidence of intracranial hemorrhage in NAF patients. Since the study included RCTs with limited and less uniform outcome endpoints, the conclusions should be verified with RCTs with more uniform endpoints and longer follow-up time.     

Is the advantage of coronary bypass surgery over percutaneous coronary intervention in diabetic patients with severe multivessel disease influenced by the status of insulin requirement?

Several studies have shown that coronary artery bypass graft surgery （CABG） is superior to percutaneous coronary intervention （PCI） in patients with diabetes and multi-vessel disease. Whether this advantage of CABG over PCI is confined to diabetics who require insulin is unknown. We review the published literature comparing CABG with PCI in diabetics including 8 cohorts and 4,786 patients. There was a lower rate for all-cause mortality （Relative risk （RR）： 0.78, 95% confidence interval （CI）： 0.62-0.99）, and for major adverse cardiac and cerebrovascular events （MACCE, RR： 0.59, 95% CI： 0.47-0.75） for CABG compared to PCI. Composite outcome of mortality, myocardial infarction and stoke was similar between CABG and PCI （RR： 0.87, 95% CI： 0.54-1.42）. Visual inspection of the forest plots showed that in most analyses, the point estimates of the RR are similar between the insulin requiring group and non-insulin requiring group. On meta-regression, there was no interaction between status of insulin requirement and revascularization strategies （P 〉 0.05 for all）. The pre- sented data on the still unpublished analysis of the FREEDOM trial showed similar results. Thus, in the current era, CABG is superior to PCI with lower mortality and MACCE rates, but the state of insulin requirement had no effect on the outcomes from the two revascularization strategies.     

Systematic review of D2 lymphadenectomy versus D2 with para-aortic nodal dissection for advanced gastric cancer

AIM:To evaluate the feasibility and therapeutic effects of para-aortic nodal dissection (PAND) for advanced gastric cancer.METHODS:Randomized controlled trials (RCTs) and non-randomized studies comparing D2 + PAND with D2 lymphadenectomy were identified using a predefined search strategy.Five-year overall survival rate,post-operative mortality,and wound degree of surgery between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions.RESULTS:Four RCTs (1120 patients) and 4 nonrandomized studies (901 patients) were identif ied.Metaanalysis showed that there was no signif icant difference between these two groups in 5-year overall survival rate [risk ratio (RR) 1.04 (95% CI:0.93-1.16) for RCTs and 0.96 (95% CI:0.83-1.10) for non-randomized studies] and post-operative mortality [RR 0.99 (95% CI:0.44-2.24) for RCTs and 2.06 (95% CI:0.69-6.15) for non-randomized studies].There was a significant difference between these two groups in wound degree of surgery,operation time was significantly longer [weighted mean difference (WMD) 195.32 min (95% CI:114.59-276.05) for RCTs and 126.07 min (95% CI:22.09-230.04) for non-randomized studies] and blood loss was signif icantly greater [WMD 301 mL (95% CI:151.55-450.45) for RCTs and 302.86 mL (95% CI:127.89-477.84) for non-randomized studies] in D2 + PAND.CONCLUSION:D2 + PAND can be performed as safely as standard D2 resection without increasing post-operative mortality but fail to benefit overall survival in patients with advanced gastric cancer.     

Effect of probiotic treatment on cirrhotic patients with minimal hepatic encephalopathy: A meta-analysis

Background: Minimal hepatic encephalopathy(MHE) is an early and reversible form of hepatic encephalopathy. The documentations on the treatment with probiotics are inconsistent. The present meta-analysis was to verify the role of probiotics in the treatment of cirrhotic patients with MHE.Data sources: Seven electronic databases were searched for relevant randomized controlled trials(RCTs)published until July 2015. The effects of probiotics on serum ammonia, endotoxin, and MHE were evaluated.Results: A total of 14 RCTs(combined n = 1132) were included in the meta-analysis. When probiotics were compared to placebo or no treatment, probiotics were more likely to reduce values in the number connection test(NCT; week 4: MD =-30.25, 95% CI:-49.85 to-10.66), improve MHE(week 4: OR = 0.18,95% CI: 0.07 to 0.47; week 12: OR = 0.15, 95% CI: 0.07 to 0.32), and prevent overt HE progression(week4: OR = 0.22, 95% CI: 0.07 to 0.67) in patients with liver cirrhosis. When probiotics was compared to lactulose, probiotics tended to reduce serum ammonia levels(week 4: MD =-0.33 μmol/L, 95% CI:-5.39 to 4.74; week 8: MD = 6.22 μmol/L, 95% CI:-24.04 to 36.48), decrease NCT(week 8: MD = 3.93, 95% CI:-0.72 to 8.58), improve MHE(week 4: OR = 0.93, 95% CI: 0.45 to 1.91; week 12: OR = 0.73, 95% CI: 0.35 to 1.51) and prevent the development of overt HE(week 4: OR = 0.96, 95% CI: 0.17 to 5.44; week 12:OR = 2.7, 95% CI: 0.50 to 14.64) in patients with liver cirrhosis. However, lactulose appears to be more effective in reducing NCT values as compared to probiotics(week 4: MD = 6.7, 95% CI: 0.58 to 12.82).Conclusion: Probiotics can decrease serum ammonia and endotoxin levels, improve MHE, and prevent overt HE development in patients with liver cirrhosis.     

Bivalirudin versus heparin with or without glycoprotein Ⅱb/Ⅲa inhibitors in?patients with STEMI undergoing primary percutaneous coronary intervention:Pooled patient-level analysis from the

Background In the HORIZONS-AMI(Harmonizing Outcomes with Revasculari Zati ON and Stents in Acute Myocardial Infarction) trial, 3,602 patients undergoing primary percutaneous coronary intervention(PCI) for ST-segment elevation myocardial infarction(STEMI) treated with bivalirudin had lower bleeding and mortality rates, but higher acute stent thrombosis rates compared with heparin + a glycoprotein Ⅱb / Ⅲa inhibitor(GPI). Subsequent changes in primary PCI, including the use of potent P2Y12 inhibitors, frequent radial intervention, and pre-hospital medication administration, were incorporated into the EUROMAX(European Ambulance Acute Coronary Syndrome Angiography) trial, which assigned 2,218 patients to bivalirudin versus heparin ± GPI before primary PCI.Objectives The goal of this study was to examine the outcomes of procedural anticoagulation with bivalirudin versus heparin ± GPI for primary PCI, given the evolution in primary PCI.Methods Databases from HORIZONS-AMI and EUROMAX were pooled for patient-level analysis. The Breslow-Day test evaluated heterogeneity between trials.Results A total of 5,800 patients were randomized to bivalirudin(n = 2,889) or heparin ± GPI(n = 2,911). The radial approach was used in 21.3% of patients, prasugrel / ticagrelor was used in 18.1% of patients, and GPI was used in 84.8% of the control group. Bivalirudin compared with heparin ± GPI resulted in reduced 30-day rates of major bleeding(4.2% vs. 7.8%; relative risk [RR]: 0.53; 95% confidence interval [CI]: 0.43 to0.66; P 0.0001), thrombocytopenia(1.4% vs. 2.9%, RR: 0.48; 95% CI: 0.33 to 0.71; P = 0.0002), and cardiac mortality(2.0% vs. 2.9%; RR: 0.70; 95% CI: 0.50 to 0.97; P = 0.03), with nonsignificantly different rates of reinfarction, ischemia-driven revascularization, stroke, and all-cause mortality. Bivalirudin resulted in increased acute( 24 h) stent thrombosis rates(1.2% vs. 0.2%; RR: 6.04; 95% CI: 2.55 to 14.31;P 0.0001), with nonsignificantly different rates of subacute stent thrombosis. Composite net adverse clinical events were lower with bivalirudin(8.8% vs. 11.9%; RR: 0.74; 95% CI: 0.63 to 0.86; P 0.0001). There was no significant heterogeneity between the 2 trials for these outcomes, and results were consistent across major subgroups.Conclusions Despite increased acute stent thrombosis, primary PCI with bivalirudin improved 30-day net clinical outcomes, with significant reductions in major bleeding, thrombocytopenia, and transfusions compared? with heparin ± GPI, results that were consistent with evolution in PCI technique and pharmacotherapy.(Harmonizing Outcomes with Revasculari Zati ON and Stents in Acute Myocardial Infarction [HORIZONS-AMI];NCT00433966)(European Ambulance Acute Coronary Syndrome Angiography [EUROMAX]; NCT01087723)(From: Journal of the American College of Cardiology Volume 65, Issue 1, 6-13 January 2015, Pages 27-38)     

A systematic review and meta-analysis of the Chinese literature for the treatment of achalasia

AIM： To evaluate the effect of different approaches in the treatment of achalasia in China. METHODS： We performed a systematic review and meta-analysis of Chinese literature by searching the Chinese Biomedical Database and Chinese scientific Journals database （up to March 2008）. All cohort studies （controlled or uncontrolled） in which the patients were observed for more than a year were reviewed in detail. Dichotomous outcomes were reported as relative risks （RR） with 95% confidence interval （CI） for controlled trials. The efficacy in uncontrolled trials was assessed by a pooled estimate of response rate with individual studies weighted in proportion to the sample size. RESULTS： Seven controlled trials compared the effect of botulinum toxin injection （BoTx） with pneumatic dilation （PD）. PD was superior to BoTx [65.2% vs 45.3%; RR 1.47 （95% CI 1.23-1.77）, P 〈 0.0001], and had a lower clinical relapse rate （BoTx 30.2% vs PD 10%, RR 0.32 （0.16-0.65）, P = 0.001）. Heller myotomy （HM） had superior remission rate compared to PD [HM 94.0% vs PD 64.1%, RR 1.48 （1.15-1.99）, P = 0.002]. In uncontrolled trials, the effectiveness of PD was 86.6% （23.9%） vs 94.8% （10.6%） for HM. The main complications of PD were perforation and gastroesophageal reflux disease. CONCLUSION： HM is the most effective long-term treatment for patients with achalasia in China. In the future, controlled clinical trials on the treatment of achalasia should focus on comparing laparoscopic myotomy with or without antireflux procedure,including different partial and total fundoplication techniques.     

Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndromeaTitle and subTitle Breakaaaaaaaa randomized controlled trial

Objectives This study sought to determine the risk versus benefit ratio of an early aggressive(EA)approach in elderly patients with non-ST-segment elevation acute coronary syndromes(NSTEACS).Background Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.Methods A total of 313 patients ≥75 years of age(mean 82 years)with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy(coronary angiography and,when indicated,revascularization within 72 h)or an initially conservative(IC)strategy(angiography and revascularization only for recurrent ischemia).The primary endpoint was the composite of death,myocardial infarction,disabling stroke,and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.Results During admission,88% of the patients in the EA group underwent angiography(55% revascularization),compared with 29%(23% revascularization)in the IC group.The primary outcome occurred in 43 patients(27.9%)in the EA group and 55(34.6%)in the IC group(hazard ratio [HR]0.80;95% confidence interval [CI]0.53 to 1.19;P = 0.26).The rates of mortality(HR0.87;95% CI0.49 to 1.56),myocardial infarction(HR0.67;95% CI0.33 to 1.36),and repeat hospital stay(HR0.81;95% CI0.45 to 1.46)did not differ between groups.The primary endpoint was significantly reduced in patients with elevated troponin on admission(HR0.43;95% CI0.23 to 0.80),but not in those with normal troponin(HR1.67;95% CI 0.75 to 3.70;p for interaction = 0.03).Conclusions The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS.The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial.     

Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis

Background: Common bile duct(CBD) stones may occur in up to 3%–14.7% of all patients with cholecystectomy. Various approaches of laparoscopic CBD exploration plus primary duct closure(PDC) are the most commonly used and the best methods to treat CBD stone. This systematic review was to compare the effectiveness and safety of the various approaches of laparoscopic CBD exploration plus PDC for choledocholithiasis.Data sources: Randomized controlled trials(RCTs) and non-randomized controlled trials(NRCTs)(casecontrol studies or cohort studies) were searched from Cochrane library(until Issue 2, 2015), Web of Science(1980-January 2016), Pub Med(1966-January 2016), and Baidu search engine. After independent quality assessment and data extraction, meta-analysis was conducted using Rev Man 5.1 software.Results: Four RCTs and 18 NRCTs were included. When compared with choledochotomy exploration(CE) plus T-tube drainage(TTD)(CE + TTD), CE plus PDC(CE + PDC) and CE + PDC with biliary drainage(BD)(CE + PDC + BD) had a lower rate of postoperative biliary peritonitis(OR = 0.22; 95% CI: 0.06, 0.88;P 0.05; OR = 0.27; 95% CI: 0.08, 0.84; P 0.05; respectively) where T-tubes were removed more than3 weeks. The operative time of CE + PDC was significantly shorter(WMD =-24.82; 95% CI:-27.48,-22.16; P 0.01) than that of CE + TTD in RCTs. Cystic duct exploration(CDE) plus PDC(CDE + PDC) has a lower rate of postoperative complications(OR = 0.39; 95% CI: 0.23, 0.67; P 0.01) when compared with CE + PDC. Confluence part micro-incision exploration(CME) plus PDC(CME + PDC) has a lower rate of postoperative bile leakage(OR = 0.17; 95% CI: 0.04, 0.74; P 0.05) when compared with CE + PDC.Conclusion: PDC with other various approaches are better than TTD in the treatment of choledocholithiasis.     

Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding： A meta-analysis

AIM： TO systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate（BB ＋ ISMN） and endoscopic band ligation （EBL） on prophylaxis of esophageal variceal rebleeding.METHODS： Randomized controlled trials （RCTs）comparing the efficacy and safety of BB ＋ ISMN and EBL on prophylaxis of esophageal variceal rebleedingwere gathered from Medline, Embase, Cochrane Controlled Trial Registry and China Biological Medicine database between January 1980 and August 2007.Data from five trials were extracted and pooled. The analyses of the available data using the Revman 4.2 software were based on the intention-to-treat principle.RESULTS： Four RCTs met the inclusion criteria. Incomparison with BB ＋ ISMN with EBL in prophylaxisof esophageal variceal rebleeding, there was nosignificant difference in the rate of rebleeding [relativerisk （RR）, 0.79; 95% CI： 0.62-1.00; P = 0.05], bleeding-related mortality （RR, 0.76; 95% CI： 0.31-1.42;P = 0.40）, overall mortality （RR, 0.81; 95% CI：0.61-1.08; P = 0.15） and complications （RR, 1.26;95% CI： 0.93-1.70; P = 0.13）.CONCLUSION：In the prevention of esophagealvariceal rebleeding, BB ＋ ISMN are as effective as EBL.There are few complications with the two treatment modalities. Both BB ＋ ISMN and EBL would be considered as the first-line therapy in the prevention of esophageal variceal rebleeding.     

Continuous regional arterial infusion for the treatment of severe acute pancreatitis: a meta-analysis

BACKGROUND: Continuous regional arterial infusion(CRAI) is a drug delivery system, which dramatically increases the drug concentration in the pancreas. Previous clinical and basic studies have demonstrated the possible therapeutic efficacy of CRAI for severe acute pancreatitis(SAP). This meta-analysis of all published randomized controlled trials(RCTs) was conducted to assess the efficacy and safety of CRAI for the treatment of SAP. DATA SOURCES: Up to August 10, 2014, RCTs comparing CRAI with intravenous infusion for SAP in PubM ed, Embase, EBSCO, MEDLINE, Science Citation Index Expanded, Cochrane Library, China Academic Journals Full-Text Database, Chinese Biomedical Literature Database, and Chinese Scientific Journals Database were selected by two independent reviewers. The relative risk(RR) and their 95% confidence intervals(CI) for duration of elevated serum amylase and urine amylase, duration of abdominal pain, infection rate, incidence of complication, overall mortality, curative rate, hospital stay and details of subgroup analysis were extracted. Meta-analyses were made using the software Review Manager(RevM an version 5.10).RESULTS: Six RCTs with 390 patients meeting the inclusion criteria were included in the final analysis. Compared with intravenous infusion route, CRAI significantly shortened the duration of elevated urine amylase(MD=-2.40, 95% CI=-3.20,-1.60; P0.00001) and the duration of abdominal pain(MD=-1.46, 95% CI=-1.94,-0.98; P0.00001), decreased the incidence of complication(RR=0.35, 95% CI=0.15, 0.81; P=0.01) and overall mortality(RR=0.25, 95% CI=0.08, 0.78;P=0.02), shortened the duration of hospital stay(MD=-10.36, 95% CI=-17.05,-3.68; P=0.002), and increased the curative rate(RR=1.66, 95% CI=1.13, 2.46; P=0.01). No mortality and catheter-related infections due to CRAI administration was reported in these studies. Subgroup analysis showed that the combination of drug administration via CRAI did not significantly improve the outcomes.CONCLUSION: CRAI is effective for the treatment of SAP, and the combination of drug administration via CRAI did not have a significant effect on the improvement of the outcomes.     

Glutamine dipeptide for parenteral nutrition in abdominal surgery： A meta-analysis of randomized controlled trials

INTRODUCTION Glutamine (Gln) is the most abundant free amino acid in the body and plays a vital role in amino acid transport and nitrogen balance. Gln is also a primary fuel for rapidly dividing cells such as enterocytes and lymphocytes, which protect muc…     

Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials

BACKGROUND: While the role of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) in secondary prevention of cardiovascular (CV) events and mortality is established, their value for primary prevention is less clear. To clarify the role of statins for patients without CV disease, we performed a meta-analysis of randomized controlled trials (RCTs). METHODS: MEDLINE, EMBASE, Cochrane Collaboration, and American College of Physicians Journal Club databases were searched for RCTs published between 1966 and June 2005. We included RCTs with follow-up of 1 year or longer, more than 100 major CV events, and 80% or more of the population without CV disease. From each trial, demographic data, lipid profile, CV outcomes, mortality, and adverse outcomes were recorded. Summary relative risk (RR) ratios with 95% confidence intervals (CIs) were calculated using a random effects model. RESULTS: Seven trials with 42,848 patients were included. Ninety percent had no history of CV disease. Mean follow-up was 4.3 years. Statin therapy reduced the RR of major coronary events, major cerebrovascular events, and revascularizations by 29.2% (95% CI, 16.7%-39.8%) (P<.001), 14.4% (95% CI, 2.8%-24.6%) (P = .02), and 33.8% (95% CI, 19.6%-45.5%) (P<.001), respectively. Statins produced a nonsignificant 22.6% RR reduction in coronary heart disease mortality (95% CI, 0.56-1.08) (P = .13). No significant reduction in overall mortality (RR, 0.92 [95% CI, 0.84-1.01]) (P = .09) or increases in cancer or levels of liver enzymes or creatine kinase were observed. CONCLUSION: In patients without CV disease, statin therapy decreases the incidence of major coronary and cerebrovascular events and revascularizations but not coronary heart disease or overall mortality.     

Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis.

AIMS: Clinical trials comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA) for patients with symptomatic carotid artery disease have produced conflicting results. We performed a meta-analysis to systematically evaluate currently available data by comparing CAS with CEA in patients with symptomatic carotid artery disease. METHODS AND RESULTS: We searched MEDLINE, Embase, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts databases, the Cochrane Central Register of Controlled Trials, and scientific meeting abstracts up to 31 October 2006 and then calculated summary risk ratios (RRs) for mortality, stroke, disabling stroke, and death using random- and fixed-effect models. Data from five trials with 2122 patients were pooled. There was no difference in risk of 30-day mortality (summary RR 0.57, 95% CI 0.22-1.47, P = 0.25), stroke (summary RR 1.64, 95% CI 0.67-4.00, P = 0.34), disabling stroke (summary RR 1.67, 95% CI 0.50-5.62, P = 0.50), death and stroke (summary RR 1.54, 95% CI 0.81-2.92, P = 0.19), or death and disabling stroke (summary RR 1.19, 95% CI 0.57-2.51, P = 0.64) among patients randomized to CAS, compared with CEA. CONCLUSIONS: No significant differences could be identified between CAS and CEA in the treatment of patients with symptomatic carotid artery disease. Larger randomized controlled trials are warranted to compare the two strategies.     

Timing of Percutaneous Coronary Intervention in Non-ST Elevation Acute Coronary Syndrome - Meta-Analysis and Systematic Review of Literature

BackgroundPercutaneous coronary intervention (PCI) is the standard procedure of care for most patients with non-ST elevation acute coronary syndrome (NSTE-ACS). However, the timing of PCI remains unclear. We performed this meta-analysis with available randomized controlled trials (RCTs) to compare early versus late coronary intervention in patients with NSTE-ACS.MethodA total of 13 RCTs were selected through PubMed/MEDLINE via OVID, EMBASE via OVID and Cochrane Central Register of Controlled Trials (inception to October 2018) search. Outcomes were analyzed using the relative risk (RR) and 95% CI. Pooled RRs were determined using M-H random-effects model, which can account for between study heterogeneity.ResultsWe included 13 RCTs with 11,972 patients were included. There were 7101 patients were randomized into early invasive group and 4871 in late invasive group. There was a significant decrease in myocardial infarction with long-term follow up in early invasive group compared to the delayed invasive group (RR 0.847 [95% CI 0.74–0.95], p = 0.009) with no difference in mortality between early and late invasive group (5.41% vs 6.49%, RR 0.882 [95% CI, 0.76–1.02]). On subgroup analysis, data was available from 6 RCTs for GRACE (Global Registry of Acute Coronary Events) score and 8 RCTs for elevated troponin. Early intervention led to decrease in adverse events in patients with elevated GRACE score > 140 (Mantel-Haenszel pooled RR 0.88 [95% CI 0.82–0.95], p-value 0.002) but no difference was seen in patients with elevated troponin.ConclusionIt can be postulated from these results that early invasive strategy leads to decrease in myocardial infarction but without significant decrease in mortality. In patients with elevated GRACE score (>140), early intervention did show a trend towards decrease in major adverse cardiac events, whereas in patients with elevated troponin alone, similar association was not observed. However, adequately powered randomized controlled trial is necessary to validate these findings.     

导丝引导胆管选择性插管对ERCP术后胰腺炎影响的系统评价

目的 系统评价导丝引导胆管选择性插管与传统地造影剂辅助插管相比,能否降低ERCP术后胰腺炎(post-ERCP panereatitis,PEP)的发生率.方法 检索Cochrane临床对照试验资料库、MEDLINE、EMBASE、Science Citation Index、中国生物医学文献数据库,以及2002-2008年相关会参考文献,全面收集关于导丝引导胆管选择性插管对PEP影响的文摘,并且手工检索入选文献的议随机对照试验进行Meta分析.结果 共7篇随机对照试验包括2474例胆管选择性插管的ERCP患者被纳入评价.Meta分析结果显示,导丝引导胆管选择性插管和造影剂辅助插管比较,可降低PEP发生率(RR=0.46,95%可信区间0.25～0.85,P=0.01).但是,排除摘要和分配隐藏不清楚的试验进行敏感性分析后,两个插管方法 对PEP发生率差异无统计学意义(RR=0.66,95%可信区间0.28～1.54,P=0.33).结论 导丝引导胆管选择性插管可能是减少PEP发生的有效方法 ,但由于纳入系统评价的试验有限,还需开展随机对照试验证实.     

导丝引导胆管选择性插管对ERCP术后胰腺炎影响的系统评价

目的 系统评价导丝引导胆管选择性插管与传统地造影剂辅助插管相比,能否降低ERCP术后胰腺炎(post-ERCP panereatitis,PEP)的发生率.方法 检索Cochrane临床对照试验资料库、MEDLINE、EMBASE、Science Citation Index、中国生物医学文献数据库,以及2002-2008年相关会参考文献,全面收集关于导丝引导胆管选择性插管对PEP影响的文摘,并且手工检索入选文献的议随机对照试验进行Meta分析.结果 共7篇随机对照试验包括2474例胆管选择性插管的ERCP患者被纳入评价.Meta分析结果显示,导丝引导胆管选择性插管和造影剂辅助插管比较,可降低PEP发生率(RR=0.46,95%可信区间0.25～0.85,P=0.01).但是,排除摘要和分配隐藏不清楚的试验进行敏感性分析后,两个插管方法 对PEP发生率差异无统计学意义(RR=0.66,95%可信区间0.28～1.54,P=0.33).结论 导丝引导胆管选择性插管可能是减少PEP发生的有效方法 ,但由于纳入系统评价的试验有限,还需开展随机对照试验证实.     

导丝引导胆管选择性插管对ERCP术后胰腺炎影响的系统评价

目的 系统评价导丝引导胆管选择性插管与传统地造影剂辅助插管相比,能否降低ERCP术后胰腺炎(post-ERCP panereatitis,PEP)的发生率.方法 检索Cochrane临床对照试验资料库、MEDLINE、EMBASE、Science Citation Index、中国生物医学文献数据库,以及2002-2008年相关会参考文献,全面收集关于导丝引导胆管选择性插管对PEP影响的文摘,并且手工检索入选文献的议随机对照试验进行Meta分析.结果 共7篇随机对照试验包括2474例胆管选择性插管的ERCP患者被纳入评价.Meta分析结果显示,导丝引导胆管选择性插管和造影剂辅助插管比较,可降低PEP发生率(RR=0.46,95%可信区间0.25～0.85,P=0.01).但是,排除摘要和分配隐藏不清楚的试验进行敏感性分析后,两个插管方法 对PEP发生率差异无统计学意义(RR=0.66,95%可信区间0.28～1.54,P=0.33).结论 导丝引导胆管选择性插管可能是减少PEP发生的有效方法 ,但由于纳入系统评价的试验有限,还需开展随机对照试验证实.     

导丝引导胆管选择性插管对ERCP术后胰腺炎影响的系统评价

目的 系统评价导丝引导胆管选择性插管与传统地造影剂辅助插管相比,能否降低ERCP术后胰腺炎(post-ERCP panereatitis,PEP)的发生率.方法 检索Cochrane临床对照试验资料库、MEDLINE、EMBASE、Science Citation Index、中国生物医学文献数据库,以及2002-2008年相关会参考文献,全面收集关于导丝引导胆管选择性插管对PEP影响的文摘,并且手工检索入选文献的议随机对照试验进行Meta分析.结果 共7篇随机对照试验包括2474例胆管选择性插管的ERCP患者被纳入评价.Meta分析结果显示,导丝引导胆管选择性插管和造影剂辅助插管比较,可降低PEP发生率(RR=0.46,95%可信区间0.25～0.85,P=0.01).但是,排除摘要和分配隐藏不清楚的试验进行敏感性分析后,两个插管方法 对PEP发生率差异无统计学意义(RR=0.66,95%可信区间0.28～1.54,P=0.33).结论 导丝引导胆管选择性插管可能是减少PEP发生的有效方法 ,但由于纳入系统评价的试验有限,还需开展随机对照试验证实.     

导丝引导胆管选择性插管对ERCP术后胰腺炎影响的系统评价

目的系统评价导丝引导胆管选择性插管与传统地造影剂辅助插管相比，能否降低ERCP术后胰腺炎（post—ERCP panereatitis，PEP）的发生率。方法检索Cochrane临床对照试验资料库、MEDLINE、EMBASE、Science Citation Index、中国生物医学文献数据库，以及2002—2008年相关会议文摘，并且手工检索人选文献的参考文献，全面收集关于导丝引导胆管选择性插管对PEP影响的随机对照试验进行Meta分析。结果共7篇随机对照试验包括2474例胆管选择性插管的ERCP患者被纳入评价。Meta分析结果显示，导丝引导胆管选择性插管和造影剂辅助插管比较，可降低PEP发生率（RR=0．46，95％可信区间0．25～0．85，P=0．01）。但是，排除摘要和分配隐藏不清楚的试验进行敏感性分析后，两个插管方法对PEP发生率差异无统计学意义（RR=0．66，95％可信区间0．28～1．54，P=0．33）。结论导丝引导胆管选择性插管可能是减少PEP发生的有效方法，但由于纳入系统评价的试验有限，还需开展随机对照试验证实。