Smoking and Glioma Risk: Evidence From a Meta-Analysis of 25 Observational Studies

To systematically assess the relationship between smoking and glioma risk.A dose–response meta-analysis of case–control and cohort studies was performed. Pertinent studies were identified by searching database and reference lists. Random-effects model was employed to pool the estimates of the relative risks (RRs) with corresponding 95% confidence intervals (CIs).A total of 19 case–control and 6 cohort studies were included. Overall, compared with those who never smoked, the pooled RR and 95% CI was 0.98 (0.92–1.05) for ever smoker. The subgroups were not significantly different regarding risk of glioma except the group of age at start smoking (RR = 1.17, 95% CI: 0.93–1.48 for age < 20; RR = 1.25, 95% CI: 1.02–1.52 for age ≥ 20). Dose–response analysis also suggested no significant association between smoking and the risk of glioma, although some evidence for a linear relationship between smoking and glioma risk was observed.In conclusion, this meta-analysis provides little support for a causal relationship between smoking and risk of glioma.     

Target Lesion Failure With Current Drug-Eluting Stents: Evidence From a Comprehensive Network Meta-Analysis

ObjectivesThe aim of this study was to investigate the efficacy and safety of currently used drug-eluting stents (DES).BackgroundHead-to-head comparisons among newer DES have shown conflicting results.MethodsFor this network meta-analysis, randomized controlled trials comparing different types of currently used DES were searched in PubMed, Scopus, and proceedings of international meetings. The primary endpoint was target lesion failure (TLF) at 1 year and at long-term follow-up.ResultsSeventy-seven trials with 99,039 patients were selected for this network meta-analysis. Among the 10 DES included in the meta-analysis, 4 received the most extensive investigation: Orsiro, XIENCE, Nobori/BioMatrix, and Resolute. At 1 year, the Orsiro stent was associated with lower rates of TLF compared with XIENCE (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.03), Resolute (OR: 0.81; 95% CI: 0.68 to 0.95; p = 0.01), and Nobori/BioMatrix (OR: 0.81; 95% CI: 0.67 to 0.98; p = 0.03). Orsiro had the highest probability to be the best (70.8%), with a surface under the cumulative ranking curve value of 95.9%. However, after a median follow-up period of 50 months (range: 24 to 60 months), no significant difference was apparent in the rates of TLF between any DES, although Orsiro still ranked as the best stent (58.6% probability to be the best). In addition, Orsiro had a lower rate of long-term definite stent thrombosis compared with Nobori/BioMatrix (OR: 0.60; 95% CI: 0.36 to 0.98; p = 0.04) and lower rates of definite and probable stent thrombosis compared with Resolute (OR: 0.66; 95% CI: 0.45 to 0.99; p = 0.04). No differences in cardiac mortality between any DES were observed.ConclusionsOrsiro is associated with a lower 1-year rate of TLF compared with XIENCE, Resolute, and Nobori/BioMatrix but with an attenuation of the efficacy signal at long-term follow-up.     

Diagnostic Performance of Diffusion-weighted Magnetic Resonance Imaging in Bone Malignancy: Evidence From a Meta-Analysis

Current state-of-the-art nuclear medicine imaging methods (such as PET/CT or bone scintigraphy) may have insufficient sensitivity for predicting bone tumor, and substantial exposure to ionizing radiation is associated with the risk of secondary cancer development. Diffusion-weighted MRI (DW-MRI) is radiation free and requires no intravenous contrast media, and hence is more suitable for population groups that are vulnerable to ionizing radiation and/or impaired renal functions. This meta-analysis was conducted to investigate whether whole-body DW-MRI is a viable means in differentiating bone malignancy.Medline and Embase databases were searched from their inception to May 2015 without language restriction for studies evaluating DW-MRI for detection of bone lesions. Methodological quality was assessed by the quality assessment of diagnostic studies (QUADAS-2) instrument. Sensitivities, specificities, diagnostic odds ratio (DOR), and areas under the curve (AUC) were used as measures of the diagnostic accuracy. We combined the effects by using the random-effects mode. Potential threshold effects and publication bias were investigated.We included data from 32 studies with 1507 patients. The pooled sensitivity, specificity, and AUC were 0.95 (95% CI, 0.90–0.97), 0.92 (95% CI, 0.88–0.95), and 0.98 on a per-patient basis, and they were 0.91 (95% CI, 0.87–0.94), 0.94 (95% CI, 0.90–0.96), and 0.97 on a per-lesion basis. In subgroup analysis, there is no statistical significance found in the sensitivity and specificity of using DWI only and DWI combined with other morphological or functional imaging sequence in both basis (P > 0.05). A b value of 750 to 1000 s/mm² enables higher AUC and DOR for whole-body imaging purpose when compared with other values in both basis either (P < 0.01). The ROC space did not show a curvilinear trend of points and a threshold effect was not observed. According to the Deek''s plots, there was no publication bias on both basis.Our results support the use of DWI as an effective means for distinguishing malignant bone lesions; however, various imaging parameters need to be standardized prior to its broad use in clinical practice.     

体外反搏在冠心病治疗中的应用及其循证医学证据

体外反搏的原理是在心脏的舒张期反肢体血液驱回心脏,增加心脏舒张期灌注,改善心肌缺血。迄今为止,在美国和我国已相继开展了多个与体外反搏有关的、观察体外反搏治疗冠心病和心功能不全效果和安全性的大型临床试验（MUST-EECP、RECC、PEECH和IEPR）,取得了很多具有重要科研价值的学术资料。2002年美国ACC/AHA正式将体外反搏疗法纳入冠心病心绞痛的临床治疗指南。体外反搏适应于急性冠状动脉综合征、心源性休克、稳定型心绞痛和稳定性心力衰竭的患者。绝对禁忌证不多,主要包括中至重度的主动脉瓣关闭不全、需要手术的腹主动脉瘤、最近发生的静脉血栓形成、严重肺动脉高压、收缩压控制不佳及显著的出血倾向者。     

The Efficacy of Surgical Treatment for the Secondary Prevention of Stroke in Symptomatic Moyamoya Disease: A Meta-Analysis

The treatment of moyamoya disease (MMD) is controversial and often depends on the doctor''s experience. In addition, the choice of surgical procedure to treat MMD can differ in many ways. In this study, we performed a meta-analysis to determine whether surgical treatment of MMD is superior to conservative treatment and to provide evidence for the selection of an appropriate surgical treatment.The human case–control studies regarding the association of MMD treatment were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized.This meta-analysis included 16 studies. Surgical treatment significantly reduced the risk of stroke (odds ratio (OR) of 0.17, 95% confidence interval (CI), 0.12–0.26, P < 0.01). A subgroup analysis showed that surgical treatment was more beneficial to hemorrhagic MMD (OR of 0.23, 95% CI, 0.15–0.38, P < 0.01), but there was no significant difference between surgical treatment and conservative treatment on ischemic MMD treatment (OR of 0.45, 95% CI, 0.15–1.29, P = 0.14). Further analysis indicated that compared to direct bypass surgery, indirect bypass surgery had a lower efficacy on secondary stroke risk reduction (OR of 1.79, 95% CI, 1.14–2.82, P = 0.01), while no significant difference was detected for perioperative complications.Surgery is an effective treatment for symptomatic MMD patients, and direct bypass surgery may bring more benefits for these patients.     

Moxibustion is an Alternative in Treating Knee Osteoarthritis: The Evidence From Systematic Review and Meta-Analysis

Knee osteoarthritis (KOA) is a common disorder in elderly. There is no known cure for KOA, and thus therapeutic strategies of alleviating symptoms are increasingly emphasized. Moxibustion has been widely used to treat KOA; however, results are inconclusive. The aim of our study is to critically reassess the effects of moxibustion on KOA.We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedical Literature database (CBM) through 25 November 2015. Two independent reviewers selected studies and abstracted information, as well as assessed the risk of bias using Cochrane risk of bias tool. The random-effects meta-analyses were performed based on abstracted data.We initially captured 163 citations and added 4 records through checking review. After critical appraisal, 13 RCTs were included. Meta-analyses indicated that moxibustion is not statistically different from oral drug in improving the response rate (MD = 1.09; 95% CI = 1.00, 1.20; P = 0.05), alleviating pain and improving physical function. Our meta-analysis also found that moxibustion is superior to usual care and sham moxibustion in reducing WOMAC score (MD = 7.56; 95% CI = 4.11, 11.00; P = 0.00), pain and function, as well as increasing QoL. Moreover, most AEs caused by moxibustion can heal without medical care.We concluded that moxibustion treatment is equal to the oral drugs and intra-articular injections and may be an alternative in treating patients with KOA.     

The Evidence Base for Diabetes Technology: Appropriate and Inappropriate Meta-Analysis

When we are interested in making decisions about best use, comparative therapeutic efficacy, or cost-effectiveness of diabetes technologies such as insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] or continuous glucose monitoring, meta-analysis for the purpose of literature summary is inappropriate and may be misleading. Instead, “decision-making meta-analysis” is more appropriate and should involve either preselection of trials based on intended use [e.g., elevated baseline hemoglobin A1c or hypoglycemia rate for trials of multiple daily injections (MDI) versus CSII] or metaregression of summary effect sizes in different trials against potential effect-modifying covariates such as baseline risk, or models of the covariates that determine effect size using individual patient data. Appropriate meta-analysis should also only include trials that are of sufficient duration to accurately measure outcomes such as severe hypoglycemia, and they should not use obsolete technology that is of proven inferiority to current technology. The use of appropriate decision-making meta-analysis is illustrated by the change in the rate ratio for severe hypoglycemia in randomized controlled trials of MDI versus CSII in type 1 diabetes from 1.56 (95% confidence interval 0.96–2.55; p = .074) for literature-summary meta-analysis to 2.0 (1.08–3.69; p = .027) for decision-making meta-analysis of all patients and 3.91 (1.35–11.36; p = .01) for trials in children.     

Lipophilic Statin Versus Rosuvastatin (Hydrophilic) Treatment for Heart Failure: a Meta-Analysis and Adjusted Indirect Comparison of Randomised Trials

Objectives

This study aims to compare lipophilic and hydrophilic statin therapy on clinical outcomes of heart failure (HF) using a systematic review and an adjusted indirect comparison meta-analysis. Outcomes were all-cause mortality, cardiovascular mortality, cardiovascular hospitalization and hospitalization for worsening HF.

Methods

We conducted a search of PubMed, EMBASE and Cochrane databases until 31st December 2014 for randomized control trials (RCTs) in HF evaluating statins versus placebo. Identified RCTs and their respective abstracted information were grouped according to statin type evaluated and analyzed separately. Outcomes were initially pooled with the Peto’s one-step method, producing odd ratios (OR) and 95 % confidence intervals (CI) for each statin type. Using these pooled estimates, we performed adjusted indirect comparisons of lipophilic versus hydrophilic statin for each outcome.

Results

Thirteen studies involving 10,966 patients were identified and analyzed. Lipophilic statins were superior to hydrophilic rosuvastatin regarding all-cause mortality (OR 0?·?50; 95 % CI, 0?·?11–0?·?89; p?=?0?·?01), cardiovascular mortality (OR 0?·?61; 0?·?25–0?·?97; p?=?0?·?009), and hospitalization for worsening HF (OR 0?·?52; 0?·?21–0?·?83; p?=?0?·?0005). However, both statins were comparable with regards to cardiovascular hospitalization [OR 0?·?80 (0?·?31, 1?·?28); p?=?0?·?36].

Conclusions

Lipophilic statin treatment shows significant decreases in all-cause mortality, cardiovascular mortality and hospitalization for worsening HF compared with rosuvastatin treatment. This meta-analysis provides preliminary evidence that lipophilic statins offer better clinical outcomes in HF till data from head to head comparisons are available.

     

Biosimilars in the Treatment of Inflammatory Bowel Disease: Supporting Evidence in 2017

Purpose of Review

Monoclonal antibodies targeting tumor necrosis factor-alpha, integrin molecules, and interleukin-12/23 have become backbone therapies for Crohn’s disease and ulcerative colitis. While clinically effective, these biologic therapies come with significant expense, contributing to overall healthcare spending in the USA. Biosimilars have the potential to significantly reduce expenditures secondary to the use of biologic medications such as infliximab and adalimumab, though their complicated manufacturing process results in inherent differences in structure when compared to the originator compounds. In this article, we review the available literature regarding biosimilars in IBD.

Recent Findings

Several biosimilar agents to infliximab and adalimumab are currently FDA-approved, with many more currently in development. Initial clinical trials for approval have been conducted in one of the original indications for each originator biologic. There are growing data demonstrating similar clinical efficacy, immunogenicity, and safety of each of the approved infliximab and adalimumab biosimilars, both through indication extrapolation from other diseases such as rheumatoid arthritis and ankylosing spondylitis, as well observational data in patients with inflammatory bowel disease. Further research is ongoing regarding the efficacy and safety of substitution and interchangeability of biosimilars, as well as therapeutic drug monitoring for biosimilar agents.

Summary

Research to date supports the utilization of reference biologics and biosimilars for new initiators, while additional data are being accrued regarding the interchangeability between these agents.

     

Asthma: Versatile Treatment for a Variable Disease

Objective. This review describes factors contributing to the variable nature of asthma and the versatile treatment strategies required for the clinical management of the disease. Data Sources. A comprehensive review of the literature using MEDLINE was conducted. Study Selection. Included articles were selected for their relevance to variability or severity of asthma. Bibliographies of selected articles served as additional sources of considered publications. Results. Asthma severity can vary substantially among patients and within individual patients because of physiologic, environmental, or behavioral factors. Inhaled corticosteroids are an effective and versatile treatment option for special populations with asthma and for patients with varying degrees of asthma severity. Inhaled corticosteroids are now the preferred treatment for all three severity levels of persistent asthma, especially in young children and pregnant women. Treatment regimens may be adjusted up or adjusted down when appropriate to maintain optimal symptom control and limit potential adverse systemic effects. Conclusions. The clinical management of asthma is challenging given the day-to-day variability of the disease. Variability in pulmonary function and asthma symptoms may be minimized through increased awareness of the factors contributing to asthma variability as well as the effective use of inhaled corticosteroid therapy. Flexible treatment strategies that consider the different severities of asthma and account for variability within individual patients may be particularly useful in improving adherence and patient outcomes.     

Laparoscopic-Assisted Rectal Foreign Body Removal: Report of a Case

PURPOSE Rectal foreign bodies are not an uncommon presentation to the emergency department. Frequently they can be removed in the department through the transanal approach. However, this often is not well tolerated by the patient or can force the foreign body more proximal. We present a case of a difficult rectal foreign body in an obese patient that was successfully removed transanally in the operating room with laparoscopic assistance. METHODS Under general anesthesia, with the patient in Trendelenburg position, laparoscopy was used to push the rectal foreign body from above while it was removed transanally from below. This was performed with one 10-mm and two 5-mm incisions. RESULTS The foreign body was successfully removed transanally with laparoscopic assistance, and the patient was discharged within 12 hours from the operation. CONCLUSIONS The laparoscopic approach to assist in rectal foreign body removal is a good treatment choice for difficult cases. It allows for easy removal, detection of rectal injury, and early discharge.