Intravenous administration of dexmedetomidine and quality of recovery after elective surgery in adult patients: A meta-analysis of randomized controlled trials

Study objectiveTo evaluate the efficacy and safety of pre- and perioperative intravenous administration of dexmedetomidine for enhancing quality of recovery (as measured by 40-item quality of recovery questionnaire (QoR-40), ranged from 40 to 200) after surgery.DesignMeta-analysis.SettingAdult patients undergoing elective surgery.InterventionIntravenous administration of dexmedetomidine during pre- and perioperative period.MeasurementsThe primary outcome was quality of recovery after surgery. The secondary outcome was the incidence of dexmedetomidine-related adverse events.Main resultsModerate to low quality evidence suggested that dexmedetomidine (DEX) increased the quality of recovery after surgery (WMD, weighted mean difference 15.71, 95% CI, confidence interval 0.43 to 31.00; 428 participants; 5 RCTs; low quality evidence), decreased the incidence of postoperative nauseas or vomiting (RR, risk ratio 0.60, 95% CI 0.44 to 0.83; 404 participants; 6 RCTs; moderate quality evidence; RR 0.32, 95% CI 0.19 to 0.55; 356 participants; 5 RCTs; moderate quality evidence) without increased risk of bradycardia (RR: 1.78, 95% CI 0.78 to 4.02; 275 participants; 4 RCTs; moderate quality evidence), dizziness (RR 0.78, 95% CI 0.31 to 2.00; 183 participants; 3 RCTs; moderate quality evidence), pruritus (RR 1.32, 95% CI 0.39 to 4.44; 186 participants; 3 RCTs; moderate quality evidence), hypotension requiring an intervention (RR: 1.48, 95% CI, 0.68 to 3.23; 254 participants; 3 RCTs; moderate quality evidence) and longer length of hospital stay (WMD: −0.75 days, 95% CI −1.95 to 0.44; 246 participants; 3 RCTs; low quality evidence) in early postoperative period.ConclusionsDexmedetomidine as an anesthetic adjuvant to general anesthesia was associated with an enhanced quality of recovery (15.71; far more than a clinically significant improvement of 6.3) without increased risk of adverse events in the early postoperative period (moderate to low quality evidence). Further large sample and high quality RCTs are needed to confirm the current findings.     

A systematic review and meta-analysis of efficacy and safety comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for patients with prostate volume less than 100 mL or 100 g

BackgroundTo assess the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for patients with prostate volume less than 100 mL or 100 g.MethodsWe searched PubMed, Embase, Cochrane Library and Web of Science from inception to July 2021 to collect randomized controlled trials. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies by using the Cochrane risk of bias tool. Review Manager 5.3 software was used for meta-analysis. We synthesised effect estimates using risk ratios (RR), mean difference (MD), and standardized mean differences (SMD).ResultsA total of eight studies were included, involving 764 patients, 384 patients in the HoLEP group and 380 patients in the TURP group. The meta-analysis showed that the catheterization time (SMD =−1.44; 95% CI: −2.17 to −0.70; P=0.0001), hospital stay (SMD =−1.01; 95% CI: −1.58 to −0.44; P=0.0005), haemoglobin loss (MD =−0.29; 95% CI: −0.52 to −0.07; P=0.01), and transfusion rate (RR =0.16; 95% CI: 0.05–0.49; P=0.001) in the HoLEP group were lower than those in the TURP group. In addition, the 12-month postvoid residual volume (PVR) of the HoLEP group (MD =−9.93 95% CI: −18.59 to −1.27; P=0.02) were superior to the TURP group. Although the operation time of the HoLEP group was longer (MD =17.89; 95% CI: 9.18–26.60; P<0.0001), more tissues were removed (SMD =0.47; 95% CI: 0.10–0.85; P=0.01).DiscussionCompared with TURP, HoLEP has a shorter catheterization time and hospital stay, with more tissue removed, a lower blood transfusion rate and better results in the short-term follow-up after surgery. Therefore, HoLEP has better efficacy and safety in the treatment of small- and medium-sized benign prostatic obstruction. Our results found that HoLEP is also suitable for patients with prostate volume <100 mL/100 g, suggesting that it is necessary to redefine the prostate size that is best for HoLEP. Overall, the certainty of evidence was assessed to be moderate to low due to potential risk of bias and inconsistent outcome indicators in some studies. More data on the efficacy of HoLEP and TURP on small- and medium-sized prostates are needed to determine the optimal prostate volume of HoLEP.     

Effects of oral alkali drug therapy on clinical outcomes in pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis

BackgroundMetabolic acidosis accelerates the progression of chronic kidney disease (CKD) and increases the mortality rate. Whether oral alkali drug therapy benefits pre-dialysis CKD patients is controversial. We performed a meta-analysis of the effects of oral alkali drug therapy on major clinical outcomes in pre-dialysis CKD patients.MethodsWe systematically searched MEDLINE using the Ovid, EMBASE, and Cochrane Library databases without language restriction. We included all eligible clinical studies that involved pre-dialysis CKD adults and compared those who received oral alkali drug therapy with controls.ResultsA total of 18 eligible studies, including 14 randomized controlled trials and 4 cohort studies reported in 19 publications with 3695 participants, were included. Oral alkali drug therapy led to a 55% reduction in renal failure events (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.25–0.82), a rate of decline in the estimated glomerular filtration rate (eGFR) of 2.59 mL/min/1.73 m² per year (95% CI, 0.88–4.31). There was no significant effect on decline in eGFR events (RR: 0.34; 95% CI: 0.09–1.23), proteinuria (standardized mean difference: −0.32; 95% CI: −1.08 to 0.43), all-cause mortality events (RR: 0.90; 95% CI: 0.40–2.02) and cardiovascular (CV) events (RR: 1.03; 95% CI: 0.32–3.37) compared with the control groups.ConclusionBased on the available and low-to-moderate certainty evidence, oral alkali drug therapy might potentially reduce the risk of kidney failure events, but no benefit in reducing all-cause mortality events, CV events, decline in eGFR and porteninuria.     

The efficacy and safety of dutasteride and finasteride in patients with benign prostatic hyperplasia: a systematic review and meta-analysis

BackgroundAlthough the efficacy and safety of monotherapy in the treatment of benign prostatic hyperplasia (BPH) have been established clinically, the efficacy and safety of dutasteride and finasteride have not been compared. The aim was to systematically evaluate the efficacy and safety of the two drugs in the treatment of BPH to provide medical evidence for clinical treatment.MethodsA search of relevant articles was conducted using the electronic databases PubMed, Embase, Medline, Cochrane Library, China Academic Journals Full-text Database (CJFD), Chinese Science and Technology Journal Database (VIP) and Wanfang Database. Randomized controlled trials (RCTs) comparing the efficacy of finasteride (control group) with that of dutasteride (experimental group) in the treatment of BPH with respect to the International Prostate Symptom Score (IPSS), the maximum urinary flow rate (Qmax), prostate volume (PV), quality of life (QOL), serum prostate-specific antigen (PSA) level and adverse drug reactions (ADRs) after medication were strictly evaluated and considered for inclusion. Rev Man 5.4 software was used for the meta-analysis.ResultsA total of 8 RCTs were included, with a total of 2,116, patients. The meta-analysis showed that compared with finasteride, dutasteride can effectively improve the Qmax of patients with BPH [mean difference (MD) =0.32; 95% confidence interval (CI): (0.01, 0.63); P=0.04]. There was no significant difference in reducing IPSS [MD =0.13; 95% CI: (−0.55, 0.82); P=0.70], improving PV [MD =−1.25; 95% CI: (−3.30, 0.79); P=0.23], reducing QOL [MD =−0.44; 95% CI: (−0.93, 0.05); P=0.08] and serum PSA level [MD =−0.04; 95% CI: (−0.15, 0.07); P=0.50], and the occurrence of ADRs [relative risk (RR) =−0.01; 95% CI: (−0.05, 0.04); P=0.72], there was no significant difference.DiscussionDutasteride is better than finasteride in improving the Qmax of patients with BPH. There was no statistically significant difference in symptoms, PV, PSA, QOL, or adverse reactions. Dutasteride is an effective and safe treatment for BPH. Due to the limitations of the methodological quality and sample size of the included studies, this conclusion needs to be verified by stratified RCTS with high volumes and long follow-up times.     

Optimal acupoint and session of acupuncture for patients with chronic prostatitis/chronic pelvic pain syndrome: a meta-analysis

BackgroundThe study aims to perform a meta-analysis of published trials and evaluate the efficacy of acupuncture on chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) by symptom score reduction, optimal acupuncture session, and most frequently used acupoints.MethodsA literature search was performed for randomized controlled trials (RCTs) comparing efficacy of acupuncture with sham acupuncture or standard medication on CP/CPPS. The primary outcome was the reduction of National Institute of Health-Chronic Prostatitis Index (NIH-CPSI) total score and its subscales. The optimal acupuncture session to reach its clinical efficacy and most common compatibility rule of acupoints were also evaluated.ResultsTen trials involving 770 participants were included. Meta-analysis showed compared with sham acupuncture, acupuncture yielded significant reduction in NIH-CPSI total score [weighted mean difference (WMD): 7.28, 95% confidence interval (95% CI): 5.69–8.86), and provided better pain relief (WMD: 3.57, 95% CI: 2.07–5.08), urinary symptoms improvement (WMD: 1.68, 95% CI: 1.13–2.22), and quality of life (QOL) (WMD: 2.38, 95% CI: 1.41–3.36). Compared with standard medication, acupuncture were more efficacious in reducing NIH-CPSI total score (WMD: 3.36, 95% CI: 1.27–5.45), also showed significant greater pain relief (WMD: 2.36, 95% CI: 1.67–3.06), marginal advantage in improving QOL (WMD: 0.98, 95% CI: 0.12–1.83) but no difference in reducing urinary symptom (WMD: −0.03, 95% CI: −1.30 to 1.24). Four acupuncture sessions were the minimum “dose” to reach clinical efficacy, and prolonged acupuncture sessions continuously improved urinary symptoms and QOL. The majority of acupoint selection strategies were based on the combination of any three acupoints from CV3, CV4, BL32, SP6, and SP9.ConclusionsAcupuncture has promising efficacy for patients with CP/CPPS, especially category IIIB, in aspects of relieving pain and urinary symptoms and improving the QOL. Acupuncture may serve as a standard treatment option when available, and a tailored comprehensive treatment strategy for CP/CPPS is the future trend.     

Efficacy and safety of leflunomide combined with corticosteroids for the treatment of IgA nephropathy: a Meta-analysis of randomized controlled trials

ObjectiveWe performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of leflunomide combined with corticosteroids, compared with corticosteroids alone, for IgA nephropathy.Materials and methodsStudies were retrieved by searching of PubMed, Embase, Cochrane’s Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases on 11 October 2021. A random-effect model incorporating the heterogeneity was used to pool the results. The efficacy outcomes included the complete remission rate of proteinuria, overall response rate (the combined rates of patients with complete and partial remission of proteinuria), changes of urine protein excretion (UPE), serum creatinine (SCr), and estimated glomerular infiltrating rate (eGFR).ResultsNineteen studies were included. Patients receiving the combined therapy had a higher complete remission rate (relative risk [RR]: 1.29, 95% CI: 1.08–1.55, p = 0.006; I² = 0%) and overall response rate (RR: 1.18, 95% CI: 1.10–1.26, p < 0.001, I² = 0%) compared to patients who received CS alone. Besides, combined therapy was associated with significantly reduced levels of UPE (mean difference [MD]: −0.30 g/24h, 95% CI: −0.43 to −0.16, p < 0.001; I² = 34%) and SCr (MD: −7.55 mmol/L, 95% CI: −11.06 to −4.04, p < 0.001; I² = 34%), and increased level of eGFR (MD: 6.51 mL/min/1.73 m², 95% CI: 4.06–8.97, p < 0.001; I² = 0%). The incidence of adverse events was not significantly different.ConclusionsCombined treatment with leflunomide and corticosteroids was more effective than corticosteroids alone for patients with IgA nephropathy.     

Recurrence factors in patients with Keratinizing squamous metaplasia of the bladder after surgical management: a single-center retrospective study

BackgroundKeratinizing squamous metaplasia (KSM) is a clinically heterogeneous disease that lacks research that provide definitive recurrent risk factors. Therefore, we identified the recurrence factors in patients with KSM of the bladder after transurethral resection (TUR). We also attempted to investigate the association between KSM and bladder cancer.MethodsClinical information of 257 patients diagnosed with KSM who underwent TUR in Xiangya Hospital from January 2010 to November 2018 were retrospectively collected. Clinical information was available for follow-up of 223 patients. To determine the risk factors for recurrence, we conducted univariate and multivariate cox regression analysis respectively. To explore the association between KSM and bladder cancer, we used clinical follow-up data.ResultsThe median follow-up time is 49 (IQR, 12–121) months. Five-year recurrence-free rate (RFR) and 1-year RFR were 86.1% and 91.9%, respectively. Thirty-one patients (13.9%) relapsed of KSM after a median follow-up of 49 months (range, 12–121 months), and none of them developed subsequent bladder cancer. Univariate Cox analysis indicated that urinary tract infection [hazard ratio (HR) =2.111; 95% confidence interval (CI): 1.043–4.271; P=0.038], and atypical urothelial hyperplasia of the bladder (HR =4.191; 95% CI: 2.006–8.756; P<0.001) were significant recurrence factors. Multivariate Cox analysis suggested that atypical urothelial hyperplasia of the bladder (HR =3.506; 95% CI: 1.663–7.392; P=0.001) was the independent risk factor for postoperative recurrence of KSM.ConclusionsThe recurrence rate in patients with KSM was about 13.9%, and atypical urothelial hyperplasia of the bladder was the independent risk factor in patients with KSM recurrence. In cases with bladder atypical urothelial hyperplasia, close follow-ups are necessary. Also, we demonstrated that KSM did not increase the subsequent risk of bladder cancer.     

An Updated Meta‐Analysis of Randomized Controlled Trials on Total Hip Arthroplasty through SuperPATH versus Conventional Approaches

The object was to conduct a systematic review and meta‐analysis of randomized controlled trials (RCTs) up to the present to draw reliable conclusions in the comparison between short‐term outcomes of total hip arthroplasty (THA) through supercapsular percutaneously assisted approach in THA (supercapsular percutaneously‐assisted total hip (SuperPATH)) versus conventional approaches (CAs). A systematic literature search was performed to identify RCTs comparing primary and secondary outcomes of THA through SuperPATH vs. CAs. Mean differences (MDs) were calculated for continuous outcomes and odds ratios (ORs) for dichotomous outcomes, using the DerSimonian and Laird method, the Mantel–Haenszel method and random effects model. A total of 14 RCTs involving 1021 patients met the inclusion criteria. Primary outcomes: SuperPATH reduced intraoperative blood loss (MD = −61.4, 95% CI −119.1 to −3.8). SuperPATH increased Harris hip score (HHS) 3, 6 and 12 months postoperatively (MD = 2.4, 95% CI 0.6–4.2; MD = 2.1, 95% CI 0.6–3.6; MD = 0.7, 95% CI 0.1–1.3; resp.). Both approaches did not differ in postoperative complication rates (OR = 0.7, 95% CI 0.2–3.3). Secondary outcomes: SuperPATH reduced pain visual analogue scale (VAS) 1 day and 3 days postoperatively (MD = −1.0, 95% CI −1.8 to −0.2; MD = −1.2, 95% CI −1.8 to −0.5; resp.). SuperPATH reduced incision length (MD = −5.2, 95% CI −7.0 to −3.4). SuperPATH increased operation time (MD = 14.3, 95% CI 3.7–24.8). Both approaches did not differ relevantly in acetabular cup inclination (MD = −1.8, 95% CI −3.8–0.2) and acetabular cup anteversion (MD = −0.6, 95% CI −1.2 to −0.1) angles. The overall findings of this meta‐analysis (Meta‐SuCAs‐2) suggested that the short‐term outcomes of THA through SuperPATH were superior to CAs. In the primary outcome, SuperPATH had a lower intraoperative blood loss and a higher HHS. Both approaches did not differ in postoperative complications. In the secondary outcome, SuperPATH had a lower pain VAS and a shorter incision length. Both approaches showed sufficient results in acetabular cup positioning. CAs had a shorter operation time than SuperPATH.     

Systematic review and meta-analysis on laparoscopic cystectomy in bladder cancer

BackgroundThis study aimed to systematically evaluate the efficacy of laparoscopic radical cystectomy (LRC) surgical therapy in patients with bladder cancer (BC), and to provide evidence for the clinical treatment of BC.MethodsThe Embase, Ovid, PubMed, Medline, Springer, and Web of Sciences database were searched to screen articles with clinical controlled trials on LRC treatment of BC. The Cochrane Handbook 5.0.2 software and Review Manager 5.3 software were adopted to evaluate the risk of bias and to perform a meta-analysis of the included articles in this study.ResultsA total of 12 articles were obtained, including 1,283 research cases. The meta-analysis results showed that relative to the control group (Ctrl), the observation group (Observ group) had significantly lower intraoperative blood loss (IBL) after LRC [mean difference (MD) =−458.75; 95% confidential interval (CI): −505.75 to −411.76; Z=19.13; P<0.00001], blood transfusion rate (BTR) (odds ratio =0.36; 95% CI: 0.13–0.94; Z=2.08; and P=0.04), use of analgesics (MD =−24.53; 95% CI: −39.04 to −10.01; Z=3.31; and P=0.0009), and incidence of postoperative complications (Risk ratio =0.58; 95% CI: 0.39–0.85; Z=2.77; and P=0.006). However, and the length of hospital stay could not be shortened (MD =–2.43; 95% CI: –4.83 to –0.02; Z=1.98; and P=0.05).DiscussionLRC treatment of BC could effectively reduce the amount of IBS, and lower the intraoperative BTR, use of analgesics, and incidence of postoperative complications. Therefore, it could be used in the clinical surgical treatment of BC patients.     

Effects of intensive blood pressure control on mortality and cardiorenal function in chronic kidney disease patients

BackgroundBlood pressure (BP) variability is highly correlated with cardiovascular and kidney outcomes in patients with chronic kidney disease (CKD). However, appropriate BP targets in patients with CKD remain uncertain.MethodsWe searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of CKD patients who underwent intensive BP management. Kappa score was used to assess inter-rater agreement. A good agreement between the authors was observed to inter-rater reliability of RCTs selection (kappa = 0.77; P = 0.005).ResultsTen relevant studies involving 20 059 patients were included in the meta-analysis. Overall, intensive BP management may reduce the incidence of cardiovascular disease mortality (RR: 0.69, 95% CI: 0.53 to 0.90, P: 0.01), all-cause mortality (RR: 0.77, 95% CI: 0.67 to 0.88, P < 0.01) and composite cardiovascular events (RR: 0.84 95% CI: 0.75 to 0.95, P < 0.01) in patients with CKD. However, reducing BP has no significant effect on the incidence of doubling of serum creatinine level or 50% reduction in GFR (RR: 1.26, 95% CI: 0.66 to 2.40, P = 0.48), composite renal events (RR 1.07, 95% CI: 0.81 to 1.41, P = 0.64) or SAEs (RR: 0.97, 95% CI: 0.90 to 1.05, P = 0.48).ConclusionIn patients with CKD, enhanced BP management is associated with reduced all-cause mortality, cardiovascular mortality, and incidence of composite cardiovascular events.     

Association of 5-alpha-reductase inhibitor and prostate cancer incidence and mortality: a meta-analysis

Background5-Alpha-reductase inhibitors (5-ARIs) have been suggested as potential chemopreventive agents for prostate cancer (PCa). This study was conducted to evaluate the effect of 5-ARIs on the incidence and mortality of PCa.MethodsThe PubMed, Embase and Cochrane Library databases were searched comprehensively from database inception to October 2019. The clinical outcomes included the incidence of overall PCa, high-grade (Gleason8-10) PCa, metastatic PCa, overall survival (OS), and cancer-specific survival (CSS).ResultsOverall, 23 studies were included in the present study, representing 11 cohort studies, 5 case-control studies, and 8 randomized controlled trials. The use of 5-ARIs was associated with a decreased risk of overall PCa [relative risk (RR) =0.77; 95% CI: 0.67–0.88; P<0.001] and increased risk of Gleason 8–10 PCa (RR=1.19; 95% CI: 1.01–1.40; P=0.036). In terms of metastatic PCa, there were no significant between-group differences (RR=1.23; 95% CI: 0.69–2.18; P=0.487). Furthermore, we found that prediagnostic 5-ARI usage was not associated with an increased risk of overall or prostate cancer mortality, with HRs of 1.00 (95% CI: 0.92–1.08; P=0.938) and 0.98 (95% CI: 0.80–1.21; P=0.881), respectively.ConclusionsIn conclusion, while male 5-ARI users were associated with a decreased risk of overall prostate cancer and increased risk of high-grade prostate cancer (Gleason 8–10), they were not associated with an increased risk of overall or prostate cancer mortality. 5-ARIs should be recommended carefully for use as chemopreventive agents.     

Paclitaxel coated balloon versus conventional balloon angioplasty in dysfunctional dialysis arteriovenous fistula: a systematic review and meta-analysis of randomized controlled trials

PurposeTo compare the efficacy and safety between paclitaxel coated balloon (PCB) angioplasty and conventional balloon (CB) angioplasty in the treatment of dysfunctional arteriovenous fistula (AVF).MethodsWe searched four major electronic databases (PubMed, EMBASE, Web of Science and the Cochrane Library) for randomized controlled trials (RCTs) published from inception through November 28, 2021. Outcomes of interest included target lesion primary patency (TLPP), technical success and all-cause mortality. The STATA package version 15.1 was utilized to undertake meta-analyses.ResultsFourteen RCTs totaling 1535 patients were analyzed. The available data showed that there were no significant differences of TLPP rates at 3, 6, 9 and 12 months between the PCB group and the CB group (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93–1.07, p = 1.000, I² = 33.5%, Cochrane Q test p = 0.185, fixed-effect model; RR 1.17, 95% CI 0.99–1.39, p = 0.065, I² = 75.4%, Cochrane Q test p = 0.000, random-effect model; RR 0.81, 95% CI 0.35–1.89, p = 0.625, I² = 62.8%, Cochrane Q test p = 0.045, random-effect model; RR 1.19, 95% CI 0.97–1.47, p = 0.096, I² = 40.5%, Cochrane Q test p = 0.071, random-effect model). In addition, two groups had similar technical success rates (RR 1.00, 95% CI 0.97–1.03, p = 1.000, I² = 0.0%, Cochrane Q test p = 0.596, fixed-effect model) and all-cause mortality rates (RR 1.00, 95% CI 0.54–1.84, p = 1.000, I² = 0.0%, Cochrane Q test p = 0.599, fixed-effect model).ConclusionsPCB angioplasty did not appear to convey any obvious advantage over CB angioplasty in the treatment of dysfunctional AVF. However, further multi-center, large-scale and well-designed RCTs are needed to prove outcomes.     

Efficacy and safety of single port robotic radical prostatectomy and multiport robotic radical prostatectomy: a systematic review and meta-analysis

BackgroundThe purpose of this study is to compare the clinical efficacy and safety of single port (SP) robot radical prostatectomy and multiport (MP) robot radical prostatectomy.MethodsUsing the China National Knowledge database, EMBASE, Cochrane library, PubMed, and other databases to obtain relevant research, SP robot radical prostatectomy and MP robot radical prostatectomy were comprehensively evaluated. The software used to evaluate the impact of the results in the selected articles was Review Manager 5.2. Deviation analysis, forest plot analysis, and sensitivity analysis were carried out for the collected data.ResultsA total of 7 related studies that met the criteria were finally included. The data showed that the operation time of MP in the control group was significantly longer than that in the SP group [mean difference (MD) =−13.29; 95% confidence interval (CI): (−17.35, −9.23); P<0.00001; I²=50%]. The duration of intensive care unit (ICU) stay for SP surgery was shorter than that for MP surgery [MD =−18.30; 95% CI: (−29.17, −7.42); P=0.0010; I²=94%]. The blood loss of SP surgery was less than that of MP surgery [MD =−15.54; 95% CI: (−28.37, −2.71); the total effective rate was 0.02; I²=0%]. There was no significant difference in the incidence of postoperative complications between SP and MP surgery [risk ratio (RR) =0.95; 95% CI: (0.55, 1.63); P=0.85; I²=0%]. At the same time, the sensitivity analysis and funnel plot showed that this study was robust and publication bias was limited.DiscussionOur results show that SP robotic radical prostatectomy is superior to MP robotic radical prostatectomy in terms of efficacy and safety. SP robot radical prostatectomy is worthy of wide promotion.     

Drop‐offs in the isoniazid preventive therapy cascade among children living with HIV in western Kenya, 2015–2019

IntroductionIsoniazid preventive therapy (IPT) can reduce the risk of tuberculosis (TB) in children living with HIV (CLHIV), but data on the outcomes of the IPT cascade in CLHIV are limited.MethodsWe evaluated the IPT cascade among CLHIV aged <15 years and newly enrolled in HIV care in eight HIV clinics in western Kenya. Medical record data were abstracted from September 2015 through July 2019. We assessed the proportion of CLHIV completing TB symptom screening, IPT eligibility assessment, IPT initiation and completion. TB incidence rate was calculated stratified by IPT initiation and completion status. Risk factors for IPT non‐initiation and non‐completion were assessed using Poisson regression with generalized linear models.ResultsOverall, 856 CLHIV were newly enrolled in HIV care, of whom 98% ([95% CI 97–99]; n = 841) underwent screening for TB symptoms and IPT eligibility. Of these, 13 (2%; 95% CI 1–3) were ineligible due to active TB and 828 (98%; 95% CI 97–99) were eligible. Five hundred and fifty‐nine (68%; 95% CI 64–71) of eligible CLHIV initiated IPT; median time to IPT initiation was 3.6 months (interquartile range [IQR] 0.5–10.2). Overall, 434 (78%; 95% CI 74–81) IPT initiators completed. Attending high‐volume HIV clinics (aRR = 2.82; 95% CI 1.20–6.62) was independently associated with IPT non‐initiation. IPT non‐initiation had a trend of being higher among those enrolled in the period 2017–2019 versus 2015–2016 (aRR = 1.91; 0.98–3.73) and those who were HIV virally non‐suppressed (aRR = 1.90; 95% CI 0.98–3.71). Being enrolled in 2017–2019 versus 2015–2016 (aRR = 1.40; 1.01–1.96) was independently associated with IPT non‐completion. By 24 months after IPT screening, TB incidence was four‐fold higher among eligible CLHIV who never initiated (8.1 per 1000 person years [PY]) compared to CLHIV who completed IPT (2.1 per 1000 PY; rate ratio [RR] = 3.85; 95% CI 1.08–17.15), with a similar trend among CLHIV who initiated but did not complete IPT (8.2/1000 PY; RR = 4.39; 95% CI 0.82–23.56).ConclusionsDespite high screening for eligibility, timely IPT initiation and completion were suboptimal among eligible CLHIV in this programmatic cohort. Targeted programmatic interventions are needed to address these drop‐offs from the IPT cascade by ensuring timely IPT initiation after ruling out active TB and enhancing completion of the 6‐month course to reduce TB in CLHIV.     

Do androgen-directed therapies improve outcomes in prostate cancer patients undergoing radical prostatectomy? A systematic review and meta-analysis

IntroductionApproximately 50% of patients with non-metastatic prostate cancer are treated with radical prostatectomy (RP). While some men will be cured with surgery alone, a substantial proportion will experience cancer recurrence. Androgen-directed therapy (ADT) is an effective adjuvant therapy for patients treated with prostate radiation. Comparatively, the efficacy of ADT in surgical patients has not been well-studied.MethodsA systematic search of MEDLINE, Embase, and the Cochrane Library from inception to July 2020 was performed. Randomized trials comparing ADT with RP vs. prostatectomy alone in patients with clinically localized prostate cancer were included. Neoadjuvant ADT and adjuvant ADT interventions were assessed separately. The primary outcomes were cancer recurrence-free survival (RFS) and overall survival (OS). Pathological outcomes following neoadjuvant ADT were also evaluated.ResultsFifteen randomized trials met eligibility criteria; 11 evaluated neoadjuvant ADT (n=2322) and four evaluated adjuvant ADT (n=5205). Neoadjuvant ADT (three months of treatment) did not improve RFS (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.74–1.11) or OS (HR 1.22, 95% CI 0.62–2.41). Neoadjuvant ADT significantly decreased the risk of positive surgical margins (relative risk [RR] 0.48, 95% CI 0.41–0.56) and extraprostatic tumor extension (RR 0.75, 95% CI 0.64–0.89). Adjuvant ADT improved RFS (HR 0.65, 95% CI 0.45–0.93) but did not improve OS (HR 1.02, 95% CI 0.84–1.24).ConclusionsNeoadjuvant ADT causes a pathological downstaging of prostate tumors but has not been found to delay cancer recurrence nor extend survival. Few studies have evaluated adjuvant ADT. Trials are needed to determine the benefits and harms of intermediate- or long-term adjuvant ADT for RP patients.     

Intramedullary versus extramedullary fixation in the treatment of subtrochanteric femur fractures: A comprehensive systematic review and meta-analysis

ObjectiveThis meta-analysis aimed to compare the clinical outcomes of intramedullary fixation with the extramedullary fixation in the surgical management of subtrochanteric fractures by analyzing relevant randomized controlled trials (RCTs) and retrospective cohort studies (RCSs).MethodsThe PubMed, Embase, Cochrane Library, Wanfang database, and Chinese National Knowledge Infrastructure (CNKI) were searched from their inception till June 29, 2020. Two reviewers extracted the data, including operation time, intraoperative blood loss, fluoroscopy time, length of stay, union time, nonunion rate, infection rate, implant failure rate, reoperation rate, Harris hip score, and mortality rate. The Cochrane risk-of-bias tool and the Newcastle-Ottawa quality assessment scale were used to evaluate the methodological quality of RCTs and RCSs, respectively. Statistical heterogeneity was quantitatively evaluated with the I2 statistic.ResultsThere were no significant differences in operation time, intraoperative blood loss, average length of stay in hospital, infection rate, implant failure rate, Harris hip scores, and mortality rate. Intramedullary nail could achieve shorter union time (MD=−1.77, 95% CI −3.40~−0.14, p=0.03), lower nonunion rate (RR=0.36, 95%CI 0.14~0.97, p=0.04), and reoperation rate (RR=0.46, 95% CI 0.24~0.89, p=0.02) than extramedullary fixations. The subgroup analysis indicated that intramedullary nail was superior than extramedullary fixations in operation time, reoperation rate, and Harris hip scores in the ≥60-year subgroup. However, the intraoperative blood loss in intramedullary nail group was significantly higher than that of extramedullary fixation group in the <60-year subgroup.ConclusionThe results of this study have revealed that intramedullary fixation can confer shorter union time, lower nonunion, and reoperation rates compared with extramedullary fixations. Therefore, intramedullary fixation should be considered as the first selection for the treatment of patients with subtrochanteric fractures.Level of EvidenceLevel II, Therapeutic study     

Modified ultrafiltration reduces postoperative blood loss and transfusions in adult cardiac surgery: a meta-analysis of randomized controlled trials

 Open in a separate windowOBJECTIVESCardiopulmonary bypass in cardiac surgery has been associated with several deleterious effects including haemodilution and systemic inflammation. Modified ultrafiltration (MUF) has been well established in paediatric cardiac surgery in counteracting postperfusion syndrome. However, MUF is less commonly used in adult cardiac surgery. In this meta-analysis, we compared clinical outcomes in adult patients who underwent cardiopulmonary bypass with and without MUF.METHODSElectronic searches were performed using Pubmed, Ovid Medline, EMBASE and the Cochrane Library until April 2020. Selection criteria were randomized studies of adult cardiac surgery patients comparing MUF versus no MUF. Primary outcomes were postoperative mortality, haematocrit, blood transfusion, chest tube drainage, duration of intensive care unit (ICU) stay and duration of mechanical ventilation.RESULTSThirteen randomized controlled trials were included, comprising 626 patients in the MUF group, and 610 patients in the control (no-MUF) group. There was a significantly improved postoperative haematocrit [mean difference 2.70, 95% confidence interval (CI) 0.68–4.73, P = 0.009], lower chest tube drainage (mean difference −105 ml, 95% CI −202 to −7 ml, P = 0.032), lower postoperative blood transfusion rate (mean difference −0.73 units, 95% CI −0.98 to −0.47 units, P < 0.0001) and shorter duration of ICU stay (mean difference −0.13 days, 95% CI −0.27 to −0.00 days, P = 0.048) in the MUF group. There was no difference in ventilation time (mean difference −0.47 h, 95% CI −2.05 to 1.12 h, P = 0.56) or mortality rates (odds ratio 0.62, 95% CI 0.28–1.33, P = 0.22). There were no reported complications associated with MUF.CONCLUSIONSMUF is a safe and feasible option in adult cardiac patients, with significant benefits including improved postoperative haematocrit, as well as reduced postoperative chest tube bleeding, transfusion requirements and duration of ICU stay.     

Inhaled nitric oxide and acute kidney injury risk: a meta-analysis of randomized controlled trials

PurposeThere are conflicting results as to the effect of inhaled nitric oxide (iNO) therapy on the risk of acute kidney injury (AKI). The aim of this study was to perform a meta-analysis to assess the updated data.MethodsWe systematically searched Web of Science, the Cochrane Library, Wanfang, and PubMed for relevant randomized control trials between database inception and 9/07/2020. Relative risks (RRs) with 95% confidence intervals (CIs) predicting the risk of AKI were extracted to obtain summary estimates using fixed-effects models. The Trim and Fill method was used to evaluate the sensitivity of the results and adjust for publication bias in meta-analysis.Results15 randomized controlled studies from 14 articles involving 1853 patients were included in the study. Analyzing the eligible studies we found: (1) iNO therapy significantly increased the risk of AKI in acute respiratory distress syndrome patients (RR 1.55, 95% CI 1.15–2.10, p = 0.004; I² for heterogeneity 0%; P_het = 0.649). (2) The use of iNO was associated with reduced AKI risk in patients undergoing cardiac surgery (RR 0.80, 95% CI 0.64–0.99, p = 0.037; I² for heterogeneity 0%; P_het = 0.528). (3) For organ transplantation recipients, there was no effect of iNO administration on the risk of AKI (RR 0.50, 95% CI 0.16–1.56, p = 0.233; I² for heterogeneity 0%; P_het = 0.842). The Trim and Fill analysis showed that the overall effect of this meta-analysis was stable.ConclusionsThe effect of iNO on AKI risk might be disease-specific. Future RCTs with larger patient populations should aim to validate our findings.     

Early versus late weightbearing in conservative management of acute achilles tendon rupture: A systematic review and meta-analysis of randomized controlled trials

BackgroundAchilles tendon rupture (ATR) is one of the most frequently encountered injuries in Sports Medicine. ATR can be managed surgically or conservatively followed by early functional rehabilitation or cast immobilization. The aim of the present systematic review and meta-analysis was to provide an update about the role of early weightbearing (WB) versus late WB on the clinical outcomes of adults with acute ATR.MethodsWe performed a systematic literature search in Web of Science, Ovid, Medline/PubMed, and CENTRAL. We included randomized controlled trials (RCTs) that compared early WB, defined as weight-bearing within 4 weeks of treatment, to late WB for individuals with acute (<14 days) ATR. We sought to evaluate the following outcomes: re-rupture rate, Achilles Tendon Rupture Score (ATRS), return to pre-injury sport activity, time to return to work, and adverse event rate. The standardized mean difference (SMD) was used to represent continuous outcomes while the risk ratio (RR) was used to represent dichotomous outcomes.ResultsA total of 9 RCTs that enrolled 1046 participants were deemed eligible. There was no significant difference between early WB and late WB in terms of re-rupture rate (RR=0.75, 95% CI 0.49 to 1.16), ATRS (SMD=0.06, 95% CI –0.03 to 0.16), return to pre-injury sport activity (RR=1.05, 95% CI 0.86 to 1.28), time to return to work (SMD=0.03, 95% CI –0.20 to 0.26), or adverse event rate (RR=1.87, 95% CI 0.53 to 6.63).ConclusionThis meta-analysis shows no difference in the functional outcomes and patient-reported outcomes between early functional rehabilitation and cast immobilization for conservatively treat individuals with acute ATR.