Dexmedetomidine for preventing sevoflurane‐related emergence agitation in children: a meta‐analysis of randomized controlled trials

Emergence agitation (EA) is a common problem after sevoflurane anesthesia in children. Prophylactic dexmedetomidine has been directed at this issue; however, the efficacy remains controversial. We therefore conducted a meta‐analysis of randomized controlled trials (RCTs) to evaluate the effectiveness of dexmedetomidine on the incidence of sevoflurane‐related EA. A comprehensive literature search was performed to identify RCTs that compared dexmedetomidine with placebo about the reduction in the incidence of sevoflurane‐related EA for children. Heterogeneity between studies was anticipated; therefore, random effects models were chosen to calculate the pooled risk ratio (RR) and 95% confidence interval (CI), and I² statistics were used to assess statistical heterogeneity. The funnel plot and Egger test were used to assess potential publication bias. Subgroup analysis was run to explore the possible effects of age, surgical procedure, regional block/local anesthetics, supplemental analgesic, propofol, N₂O, pre‐medication and methodological quality on the incidence of EA using dexemedetomidine. Totally, 15 RCTs were included (518 patients received dexmedetomidine and 413 had placebo). Dexmedetomidine reduced the incidence of sevofurane‐related EA (pooled RR = 0.351; 95% CI: 0.275–0.449; P = 0.965; heterogeneity test, I² = 0.0%), and it also resulted in a lower incidence of severe EA (pooled RR = 0.119; 95% CI: 0.033–0.422; P = 0.962; heterogeneity test, I² = 0.0%). All subgroup analyses for potential sources of heterogeneity showed a lower incidence of sevoflurane‐related EA after dexmedetomidine administration. This meta‐analysis demonstrated that dexemedetomidine was effective in reducing the incidence of sevoflurane‐induced EA in children as compared with placebo.     

Prognostic value of pathologic fracture in patients with high grade localized osteosarcoma: A systemic review and meta‐analysis of cohort studies

Consensus has not been reached regarding the ability of pathologic fracture to predict local recurrence and survival in osteosarcoma. We aim to review the available evidence to examine the association between pathologic fracture and osteosarcoma prognosis. A comprehensive literature search for relevant studies published until March 2014 was performed using PubMed, Cochrane and Web of Science. The studies investigating pathologic fracture of osteosarcoma patients were systematically analyzed. The overall relative risk (RR) was estimated using a fixed‐effect model or random‐effect model according to heterogeneity between the trials. We included nine cohort studies involving 2,187 patients (311 with pathologic fracture and 1,876 without fracture) for the analysis of survival rate and local recurrence. Studies were assessed for quality using the Newcastle–Ottawa Assessment Scale. In the fixed‐effects model, the meta‐analysis showed that pathologic fracture in osteosarcoma patients predicted poor 3‐year overall survival (OS) (RR = 1.86, 95% CI: 1.37–2.53, p < 0.001) and 5‐year OS (RR = 1.34, 95% CI: 1.06–1.70, p = 0.016). Similarly, pathologic fracture was significantly correlated with worse 3‐year event free survival (EFS) (RR = 1.52, 95% CI: 1.21–1.92, p < 0.001) and 5‐year EFS (RR = 1.24, 95% CI: 1.03–1.49, p = 0.021), whereas no significant association was noted with local recurrence (RR = 1.30, 95% CI: 0.84–2.02, p = 0.233). The meta‐analysis confirmed that pathologic fracture in osteosarcoma was a prognostic marker for both OS and EFS but not for local recurrence. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:131–139, 2015.     

High inspired oxygen versus low inspired oxygen for reducing surgical site infection: a meta‐analysis

To perform a meta‐analysis of published literature to assess the role of high‐concentration inspired oxygen in reducing the incidence of surgical site infections (SSIs) following all types of surgery, a comprehensive search for published randomized controlled trials (RCTs) comparing high‐ with low‐concentration inspired oxygen for SSIs was performed. The related data were extracted by two independent authors. The fixed and random effects methods were used to combine data. Twelve RCTs involving 6750 patients were included. Our pooled result found that no significant difference in the incidence of SSIs was observed between the two groups, but there was high statistic heterogeneity across the studies [risk ratio (RR): 0·91; 95% confidence interval (CI): 0·72–1·14; P = 0·40; I² = 54%]. The sensitivity analysis revealed the superiority of high‐concentration oxygen in decreasing the SSI rate (RR: 0·86; 95% CI: 0·75–0·98; P = 0·02). Moreover, a subgroup analysis of studies with intestinal tract surgery showed that patients experienced less SSI when high‐concentration inspired oxygen was administrated (RR: 0·53; 95% CI: 0·37–0·74; P = 0·0003). Our study provided no direct support for high‐concentration inspired oxygen in reducing the incidence of SSIs in patients undergoing all types of surgery.     

Incidence and risk factors for venous thromboembolism following surgical treatment of fractures below the hip: a meta‐analysis

Venous thromboembolism (VTE) is a common complication after surgical treatment of fractures, which is associated with significant morbidity and mortality. Identifying the risk factors for VTE is important for preventive strategies to reduce the incidence of VTE. Therefore, we conducted a meta‐analysis to evaluate the incidence of VTE and the risk factors influencing the development of VTE in patients who underwent surgery for fractures below the hip. PubMed, Embase, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China) and CNKI (National Knowledge Infrastructure, China) databases were systematically searched to identify cohort or case–control studies that investigated the incidence and risk factors for VTE following surgical treatment of fractures below the hip. VTE risk ratios (RRs) were pooled by use of a fixed‐effect model or a random‐effect model, depending on the heterogeneity among the included studies. Heterogeneity between the studies was assessed by I² statistics. Twenty‐three studies with a total of 191 294 patients who met the inclusion criteria were included in this meta‐analysis. Our results demonstrated that age (≥60 years) (RR = 1·85, 95% confidence interval (CI): 1·34, 2·55; P = 0·000), previous VTE(RR = 5·25, 95% CI: 2·77, 9·96; P = 0·000), heart failure (RR = 1·74, 95% CI: 1·34, 2·27; P = 0·000), current smoking status (RR = 1·23, 95% CI: 1·07, 1·41; P = 0·004), hypertension (RR = 1·62, 95% CI: 1·27, 2·06; P = 0·000), hyperlipidaemia (RR = 2·16, 95% CI: 1·79, 2·62; P = 0·000), diabetes mellitus (RR = 1·46, 95% CI: 1·27, 1·68; P = 0·000), obesity (RR = 1·58, 95% CI: 1·35,·1·85; P = 0·000), multiple fractures (RR = 2·14, 95% CI: 1·00, 4·60; P = 0·050), varicose veins (RR = 3·07, 95% CI: 1·12, 8·47; P = 0·030), prolonged operation time (weighted mean differences (WMD) = 1·22, 95% CI: 0·63, 1·81; P = 0·000) and prolonged bed rest time (WMD = 3·12, 95% CI: 2·96, 3·29; P = 0·000) were associated with an increased risk of developing VTE. The other variables, including age (<60 years), previous smoking, immobility, pregnancy, cancer, open fractures and combination with trauma were not identified as significant risk factors for VTE. Almost all the risk factors mentioned above are in line with the known risk factors for VTE following surgery for fractures below the hip. Thus, surgeons should pay close attention to patients with these medical conditions in order to reduce the incidence of VTE following surgical treatment of fractures below the hip.     

Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure

Aim The study analyzed clinical trials investigating the effectiveness of diltiazem (DTZ) and glyceryltrinitrate (GTN) for the nonsurgical management of chronic anal fissure (CAF). Method Randomized trials on the effectiveness of DTZ and GTN were analyzed systematically using RevMan^® where combined outcome was expressed as risk ratio (RR). Results Seven randomized controlled trials that included 481 patients were analyzed. Two‐hundred and thirty‐eight patients were treated with DTZ and 243 patients were treated with GTN. There was significant heterogeneity [Tau² = 0.24, χ2 = 13.16, d.f. = 6 (P < 0.05); I² = 54%] among the included trials. In the random‐effects model, DTZ was associated with a lower incidence of side effects (RR = 0.48; 95% CI = 0.27, 0.86; z = 2.46; P < 0.01), headache (RR = 0.39; 95% CI = 0.24, 0.66; z = 3.54; P < 0.004) and recurrence (RR = 0.68; 95% CI = 0.52, 0.89; z = 2.77; P < 0.006) of CAF. Both GTN and DTZ were equally effective (RR = 1.10; 95% CI = 0.90, 1.34; z = 0.92; P = 0.36) in the nonsurgical management of CAF. Conclusion This systematic review of seven trials validates and strengthens the finding of a previously published meta‐analysis of two randomized trials. Both DTZ and GTN are equally effective in the management of CAF. However, DTZ is associated with a lower incidence of headache and recurrent fissure. Therefore DTZ should be the preferred first line of treatment for CAF.     

Plasma cell infiltrates and renal allograft outcomes in indigenous and non-indigenous people of the Northern Territory of Australia

Introduction: Plasma cell‐rich rejection is a distinct histological phenomenon associated with poor renal allograft outcomes. Aboriginal and Torres Straight Islander (ATSI) transplant recipients have poorer allograft survival and higher rates of acute rejection. We sought to determine whether a higher incidence of plasma cell‐rich infiltrates (PCIR) could account for poorer survival. Methods: Renal transplant biopsies performed in recipients from the Northern Territory of Australia between 1985 and 2007 were reviewed and correlated with outcome. Biopsies were designated PCIR positive when plasma cells constituted >10% of the interstitial infiltrate. Results: Four hundred and seventy‐seven biopsies from 177 recipients (108 ATSI) were performed. Median graft survival was shorter for recipients with PCIR: 4.0 years (interquartile range 2.18–6.41) versus 5.4 years (2.0–9.99) (P = 0.013). ATSI recipients had higher rates of plasma cell‐rich rejection (RR 1.76, 95% CI 1.43–2.17, P < 0.0001), which occurred earlier (251 vs 869 days, P = 0.03) compared with non‐indigenous recipients. On multivariate analysis, PCIR did not independently influence allograft survival. There was a correlation between PCIR and panel reactive antibody peak >20% (RR 1.29, 95% CI 1.03–1.56, P = 0.025), ≥5 human leukocyte antigen mismatches (RR 1.91, 1.41–2.58, p < 0.0001), increasing post‐transplant infection rate (>10 infections RR 5.11, 1.69–15.5, P = 0.004), and subsequent death from septicaemia (RR 1.6, 1.17–2.18, P = 0.003). Conclusion: PCIR is associated with infection and markers of chronic immunological stimulation but does not independently contribute to inferior renal allograft outcomes, even in ATSI recipients.     

Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and susceptibility to diabetic nephropathy in Chinese type 2 diabetic patients: a meta-analysis

Abstract

The association between methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and diabetic nephropathy (DN) or diabetes mellitus (DM) risk has been widely reported, but the results are still debatable. To investigate the role of MTHFR C677T polymorphism on DM or DN, 13 separate studies in the Chinese population on the relation between MTHFR C677T polymorphism and DM or DN were analyzed by a meta-analysis. Five genetic models were used to estimate the association between MTHFR C677T polymorphism and the risk of DM or DN. Overall, our meta-analysis for DN versus healthy controls produced significant results for all genetic contrasts except for the co-dominant model (allele contrast: OR?=?2.24, 95%CI: 1.88–2.65, p?<?0.00001, P_{heterogeneity}?=?0.49). However, the meta-analysis for DM versus healthy controls produced non-significant results for all contrasts (allele contrast: OR?=?1.12, 95%CI: 0.92–1.35, p?=?0.25, P_{heterogeneity}?=?0.07). In addition, the meta-analysis for DM versus DN produced significant results for all contrasts (allele contrast: OR?=?1.88, 95%CI: 1.65–2.15, p?<?0.00001, P_{heterogeneity}?=?0.83). The current meta-analysis suggested that MTHFR C677T polymorphism might influence DN risk, but not for DM in the Chinese population.     

A Study of Incidence of AKI in Critically Ill Patients

Background: There have been many studies to estimate the incidence of acute kidney injury (AKI) in critically ill patients. However, results were variable due to the non-usage of uniform criteria and retrospective design of most studies. There are no new studies from the developing countries looking at AKI in these patients since adoption of uniform Acute Kidney Injury Network (AKIN) criteria. Methods: In this prospective observational study from a tertiary care hospital in India, we enrolled 100 consecutively admitted critically ill patients and followed them during hospital stay. AKI was defined by AKIN criteria. Both the groups of patients, those who developed AKI and those who did not develop AKI, were then followed during the course of their hospital stay. Results: AKI occurred in 33 patients with an incidence rate of 17.3 per person year. Thirty-one out of 33 (93.9%) patients died in the AKI group, whereas 31 out of 67 (53.7%) patients died in the non-AKI group. Independent risk factors for AKI were older age (adjusted relative risk (RR) = 4.42, 95% CI = 2.57–5.23), septic shock (adjusted RR = 2.82, 95% CI = 1.43–3.80), prolonged duration of mechanical ventilation (adjusted RR = 2.35, 95% CI = 1.09–3.6), higher acute physiology and chronic health evaluation II (APACHE II) score (adjusted RR = 2.74, 95% CI = 1.28–4.13), and higher sequential organ failure assessment (SOFA) score (adjusted RR = 2.53, 95% CI = 1.04–4.08). Development of AKI was an independent risk factor for mortality (adjusted RR = 1.76, 95% CI = 1.25–1.84). Conclusion: Older patients, those with septic shock, and those requiring prolonged mechanical ventilation had increased risk for AKI. AKI was an independent predictor of mortality.     

Renal resistance thresholds during hypothermic machine perfusion and transplantation outcomes – a retrospective cohort study

Renal resistance (RR), of allografts undergoing hypothermic machine perfusion (HMP), is considered a measure of organ quality. We conducted a retrospective cohort study of adult deceased donor kidney transplant (KT) recipients whose grafts underwent HMP. Our aim was to evaluate whether RR is predictive of death‐censored graft failure (DCGF). Of 274 KT eligible for analysis, 59% were from expanded criteria donor. RR was modeled as a categorical variable, using a previously identified terminal threshold of 0.4, and 0.2 mmHg/ml/min (median in our cohort). Hazard ratios (HR) of DCGF were 3.23 [95% confidence interval (CI): 1.12–9.34, P = 0.03] and 2.67 [95% CI: 1.14–6.31, P = 0.02] in univariable models, and 2.67 [95% CI: 0.91–7.86, P = 0.07] and 2.42 [95% CI: 1.02–5.72, P = 0.04] in multivariable models, when RR threshold was 0.4 and 0.2, respectively. Increasing risk of DCGF was observed when RR over the course of HMP was modeled using mixed linear regression models: HR of 1.31 [95% CI: 1.07–1.59, P < 0.01] and 1.25 [95% CI: 1.00–1.55, P = 0.05], in univariable and multivariable models, respectively. This suggests that RR during HMP is a predictor of long‐term KT outcomes. Prospective studies are needed to assess the survival benefit of patients receiving KT with higher RR in comparison with staying wait‐listed.     

Evaluating the Prognostic Factors Associated with Cancer-specific Survival of Differentiated Thyroid Carcinoma Presenting with Distant Metastasis

Background

Because patients with differentiated thyroid carcinoma (DTC) presenting with distant metastasis (DM) have a particularly poor prognosis, examining the prognostic factors in this group is essential. We aimed to evaluate the prognostic factors affecting cancer-specific survival (CSS) in DTC patients presenting with DM.

Methods

Of the 1227 DTC patients, 51 (4.2 %) presented with DM at diagnosis. All patients underwent a total thyroidectomy, followed by radioiodine (RAI) ablation and postablation whole body scan (WBS). Patients were considered to have an osseous metastasis if one of the metastatic sites involved a bone, while RAI avidity was determined by any visual uptake in a known metastatic site on the first WBS. Factors predictive of CSS were determined by univariate and multivariate analyses by the Cox proportional hazard model.

Results

In univariate analysis, older age (relative risk [RR] 1.050, 95 % confidence interval [CI] 1.010–1.091, P = 0.014), DM discovered before WBS (RR 3.401, 95 % CI 1.127–10.309, P = 0.030), follicular thyroid carcinoma (RR 3.095, 95 % CI 1.168–8.205, P = 0.025), osseous metastasis (RR 4.695, 95 % CI 1.379–15.873, P = 0.013), non-RAI avidity (RR 3.355, 95 % CI 1.280–8.772, P = 0.014), and external beam radiotherapy to DM (RR 3.241, 95 % CI 1.093–9.614, P = 0.034) were significant poor prognostic factors for CSS. In the multivariate analysis, after adjusting for other factors, osseous metastasis (RR 6.849, 95 % CI 1.495–31.250, P = 0.013) and non-RAI avidity (RR 7.752, 95 % CI 2.198–27.027, P = 0.001) were the two independent poor prognostic factors for CSS. Older age almost reached statistically significance (RR 1.055, 95 % CI 0.996–1.117, P = 0.068).

Conclusions

DTC patients presenting with DM accounted for 4.2 % of all patients. Because osseous metastasis and RAI avidity were independent prognostic factors, future therapy should be directed at improving the treatment efficacy of osseous and/or non-RAI-avid metastases.     

Antioxidants in the chemoprevention of colorectal cancer and colorectal adenomas in the general population: a systematic review and meta‐analysis

Aim Antioxidants, such as vitamin A, C and E, selenium and β‐carotene, have been proposed as possible agents in the chemoprevention of colorectal cancer and have been the subject of recent trials and reviews. This review aimed to assess the present evidence on the effect of antioxidants on the incidence of colorectal neoplasms in the general population. Method A systematic review of randomized controlled trials was undertaken comparing antioxidants alone or in combination with other agents vs placebo. The following databases were searched for published and unpublished literature: Cochrane Library, MEDLINE, PreMEDLINE, CINAHL, EMBASE, Web of Science, and Biological Abstracts and Research Registers. Studies were quality appraised and extracted. Meta‐analysis was performed. Results Twelve studies were identified as relevant. In the nine comparing antioxidants with no antioxidants (n = 148 922), there was no difference in the incidence of colorectal cancer [relative risk (RR) 1.00, 95% confidence interval (CI) 0.88–1.13]. One study assessed the effect of antioxidants on adenoma formation (n = 15 538) and did not demonstrate a statistically significant effect (RR 1.47, 95% CI 0.97–2.23). Of 14 discrete analyses for different combinations of antioxidants, only one reported a statistically significant increase in relative risk of adenoma formation in participants receiving vitamin E (RR 1.74, 95% CI 1.09–1.79, P = 0.02) or vitamin E plus β‐carotene (RR 1.63, 95% CI 1.01–2.63, P = 0.04). Effectiveness did not seem to differ between healthy populations, participants with cardiovascular risk factors or populations exposed to smoking or asbestos. Conclusion The review demonstrates that antioxidants (vitamin A, C and E, selenium and β‐carotene), as single agents, in combination with other antioxidants or in combination with other agents, are not effective in the chemoprevention of colorectal neoplasia in the general population. This questions their involvement in future randomized controlled trials of chemoprevention in colorectal cancer.     

Risk of Colorectal Carcinoma in Post‐Liver Transplant Patients: A Systematic Review and Meta‐analysis

Liver transplant patients (LTx) have an increased risk for developing de novo malignancies, but for colorectal cancer (CRC) this risk is less clear. We aimed to determine whether the CRC risk post‐LTx was increased. A systematic search was performed in MEDLINE and Cochrane databases to identify studies published between 1986 and 2008 reporting on the risk of CRC post‐LTx. The outcomes were (1) CRC incidence rate (IR per 100 000 person‐years (PY)) compared to a weighted age‐matched control population using SEER and (2) relative risk (RR) for CRC compared to the general population. If no RR data were available, the RR was estimated using SEER. Twenty‐nine studies were included. The overall post‐LTx IR was 119 (95% CI 88–161) per 100 000 PY. The overall RR was 2.6 (95% CI 1.7–4.1). The non‐primary sclerosing cholangitis (PSC) IR was 129 per 100 000 PY (95% CI 81–207). Compared to SEER (71 per 100 000 PY), the non‐PSC RR was 1.8 (95% CI 1.1–2.9). In conclusion, the overall transplants and the subgroup non‐PSC transplants have an increased CRC risk compared to the general population. However, in contrast to PSC, non‐PSC transplants do not need an intensified screening strategy compared to the general population until a prospective study further defines recommendations.     

Effects of high versus low inspiratory oxygen fraction on postoperative clinical outcomes in patients undergoing surgery under general anesthesia: A systematic review and meta-analysis of randomized controlled trials

ObjectivesTo determine whether high perioperative inspired oxygen fraction (FiO₂) compared with low FiO₂ has more deleterious postoperative clinical outcomes in patients undergoing non-thoracic surgery under general anesthesia.DesignMeta-analysis of randomized controlled trials.SettingOperating room, postoperative recovery room and surgical ward.PatientsSurgical patients under general anesthesia.InterventionHigh perioperative FiO₂ (≥0.8) vs. low FiO₂ (≤0.5).MeasurementsThe primary outcome was mortality within 30 days. Secondary outcomes were pulmonary outcomes (atelectasis, pneumonia, respiratory failure, postoperative pulmonary complications [PPCs], and postoperative oxygen parameters), intensive care unit (ICU) admissions, and length of hospital stay. A subgroup analysis was performed to explore the treatment effect by body mass index (BMI).Main resultsTwenty-six trials with a total 4991 patients were studied. The mortality in the high FiO₂ group did not differ from that in the low FiO₂ group (risk ratio [RR] 0.91, 95% confidence interval [CI] 0.42–1.97, P = 0.810). Nor were there any significant differences between the groups in such outcomes as pneumonia (RR 1.19, 95% CI 0.74–1.92, P = 0.470), respiratory failure (RR 1.29, 95% CI 0.82–2.04, P = 0.270), PPCs (RR 1.05, 95% CI 0.69–1.59, P = 0.830), ICU admission (RR 0.94, 95% CI 0.55–1.60, P = 0.810), and length of hospital stay (mean difference [MD] 0.27 d, 95% CI -0.28–0.81, P = 0.340). The high FiO₂ was associated with postoperative atelectasis more often (risk ratio 1.27, 95% CI 1.00–1.62, P = 0.050), and lower postoperative arterial partial oxygen pressure (MD −5.03 mmHg, 95% CI -7.90– -2.16, P < 0.001)_. In subgroup analysis of BMI >30 kg/m², these parameters were similarly affected between the groups.ConclusionsThe use of high FiO₂ compared to low FiO₂ did not affect the short-term mortality, although it may increase the incidence of atelectasis in adult, non-thoracic patients undergoing surgical procedures. Nor were there any significant differences in other secondary outcomes.     

The incidence and outcome of brain metastases after liver resection for colorectal cancer metastases

Aim Brain metastases from colorectal cancer are rare, with an incidence of 0.6–4%. The risk and outcome of brain metastases after hepatic and pulmonary metastasectomy have not been previously described. This study aimed to determine the incidence, predictive factors, treatment and survival of patients developing colorectal brain metastases, who had previously undergone resection of hepatic metastases. Method A retrospective review was carried out of a prospectively maintained database of patients undergoing liver resection for colorectal metastases. Results Fifty‐two (4.0%) of 1304 patients were diagnosed with brain metastases. The annual incidence rate was 1.03% per person‐year. In the majority of cases brain metastases were found as part of multifocal disease. Median survival was 3.2 months (95% CI: 2.3–4.1), but was best for six patients treated with potentially curative resection [median survival = 13.2 (range, 4.9–32.1) months]. Multivariate analysis showed that a lymph node‐positive primary tumour [hazard ratio (HR) = 2.7, 95% CI: 1.8–6.19; P = 0.019], large liver metastases (> 6 cm) [HR = 2.23, 95% CI: 1.19–2.33; P = 0.012] and recurrent intrahepatic and extrahepatic disease [HR = 2.11, 95% CI: 1.2–4.62; P = 0.013] were independent predictors for the development of brain metastases. Conclusion The annual risk of developing brain metastases following liver resection for colorectal metastases is low, but highest for patients presenting with a Dukes’ C primary tumour, large liver metastases or who subsequently develop disseminated disease. The overall survival from colorectal brain metastases is poor, but resection with curative intent offers patients their best chance of medium‐term survival.     

Efficacy of Carbon Dioxide Insufflation for Cerebral and Cardiac Protection During Open Heart Surgery: A Systematic Review and Meta‐Analysis

In spite of widespread application around the world, there has been controversy on the cerebral and cardiac protection efficacy of carbon dioxide insufflation (CDI) during open heart surgery. To make a comprehensive evaluation, we screened all relevant published randomized controlled trials to perform the first systematic review and meta‐analysis for CDI during open heart surgery. We searched PubMed, EMBASE, the Cochrane Controlled Clinical Trial register, WANFAN, CQVIP, and CNKI database for published articles. Randomized controlled trials were included when the research provided data of neurological complications postoperatively, creatinine kinase, MB isoenzyme (CK‐MB) on the first postoperative day, or all‐cause mortality. We chose a fixed‐effects model when the trials showed low heterogeneity, otherwise a random effects model was used. The quality of studies was assessed by modified Jadad scale. Four studies were included in this meta‐analysis. The overall pooled relative risk (RR) for neurological complications was 1.59, 95% confidence interval (CI) = [0.57, 4.46], and the z‐score for overall effect was 0.89 (P = 0.37). The standardized mean difference of the CK‐MB between groups was 1.15, 95% CI = [?1.27, 3.56], and the z‐score for overall effect was 0.93 (P = 0.35). The overall pooled RR for all‐cause mortality was 0.5, 95% CI = [0.16, 1.64], and the z‐score for overall effect was 1.14 (P = 0.25). There was no significant difference between groups. Because of the insufficiency of powerful evidences, the cerebral and cardiac protection efficacy of CDI during open heart surgery needs to be further verified by more high‐quality trials.     

The impact of lymph node yield on Duke’s B and C colorectal cancer survival

Aim The number of positive lymph nodes retrieved following colorectal cancer (CRC) resection impacts on the staging and further treatment of the disease. We compared 5‐year survival by lymph node yield for Duke’s B and C patients to assess the impact on prognosis. Method A retrospective methodology was employed to review patients who underwent operative resection for Duke’s B or C CRC between 1999 and 2003. Results A total of 351 patients were included in our analyses. Lymph node yield, N‐stage and extramural vascular invasion were independent predictors of overall 5‐year survival. A significant difference in 5‐year survival by lymph node yield was seen among Duke’s B patients (< 9 nodes vs≥ 9 nodes, 45.2%vs 68.4%; P = 0.0043) and Duke’s C patients (< 10 nodes vs≥ 10 nodes, 25.6%vs 48.8%; P = 0.0099). There was a significant reduction in the relative risk of 2.8% in mortality for each additional node sampled in Duke’s B and C patients (RR 0.972, 95% confidence interval 0.949–0.994, P = 0.0102). Duke’s B patients who had < 9 lymph node yield and no neoadjuvant/adjuvant treatment had a similar survival to all Duke’s C patients (47.8%vs 41.7%, P = 0.5136). Conclusion Lymph node yield independently predicts for survival in patients with Duke’s B and C CRC. Duke’s B patients with < 9 lymph node yield have no better survival than patients with Duke’s C disease. Therefore, prospective randomized studies are required to examine if inadequate lymph node yield could be one of the deciding factors in offering adjuvant therapy among Duke’s B cancer patients.     

Cinacalcet versus standard treatment for chronic kidney disease: a systematic review and meta-analysis

Background: Chronic kidney disease-mineral and bone disorders (CKD-MBD) have been associated with poor health outcomes, including diminished quality and length of life. Standard management for CKD-MBD includes phosphate restricted diet, vitamin D and phosphate binders. Persistently elevated parathyroid hormone levels may require the addition of cinacalcet hydrochloride (cinacalcet), which sensitizes calcium receptors in the parathyroid gland.

Purpose: The objective of this systematic review is to compare, in patients with CKD-MBD the effect of cinacalcet versus standard treatment on patient-important outcomes, including parathyroidectomy, fractures, hospitalizations due to cardiovascular events, cardiovascular mortality, all-cause mortality, and intermediate outcomes, in particular Kidney Disease Outcome Quality Initiative targets.

Methods: Data sources included MEDLINE, EMBASE, the Cochrane Register of Controlled Trials and Web of Science from 1996 to June 2015. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility, and subsequently abstracted data and assessed risk of bias in eligible trials. We calculated the effect estimates (risk ratios or mean differences) and 95% confidence intervals, as well as statistical measures of variability in results across studies using random effect models. We used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to rate quality of evidence about estimates of effect on an outcome-by-outcome basis for all outcomes. We presented our results with a GRADE summary table.

Results: Twenty-four trials including 8311 CKD patients proved eligible. The results left considerable uncertainty regarding the impact of cinacalcet on reducing fractures (relative risk [RR] 0.59, 95% confidence interval [CI] 0.13–2.60; heterogeneity: p?=?0.03, I²=?78%; very low quality evidence), and indicated that cinacalcet did not reduce hospitalizations due to cardiovascular events (RR 0.93, 95% CI 0.85–1.02, moderate quality of evidence), cardiovascular mortality (RR 0.95, 95% CI 0.84–1.07; heterogeneity p=?0.61, high quality evidence) or all-cause mortality (RR 0.96, 95% CI 0.89–1.04; heterogeneity: p=?0.98, I²=?0%; moderate quality evidence). Cinacalcet reduced the need for parathyroidectomy (RR 0.30, 95% CI 0.22–0.42; heterogeneity: p=?0.70, I²=?0%; absolute effect 55 fewer per 1000 [95% CI 61 fewer to 45 fewer], high quality of evidence). The most common adverse event associated with cinacalcet therapy was gastrointestinal side effects. Cinacalcet increased nausea (RR 2.16, 95% CI 1.46–3.21, absolute effect 158 more per 1000 [95% CI 82 more to 302 more]) and vomiting (RR 2.15, 95% CI 1.66–2.80, absolute effect 63 more per 1000 [95% CI 109 more to 171 more]). Cinacalcet treatment increased the rate of hypocalcemia (RR 6.0, 95% CI 3.65–9.87; heterogeneity: p=?0.71, I²=?0%, absolute effect 20 more per 1000 [95% CI 11 more to 36 more], high quality of evidence).

Conclusions: In the hands of clinicians participating in these studies, cinacalcet decreased the rate of parathyroidectomy but had no influence on mortality. Patients and clinicians can trade of the benefit of fewer parathyroidectomies against the adverse effects.     

Once‐yearly zoledronic acid and days of disability,bed rest,and back pain: Randomized,controlled HORIZON Pivotal Fracture Trial

The objective of this study was to determine the effect of once‐yearly zoledronic acid on the number of days of back pain and the number of days of disability (ie, limited activity and bed rest) owing to back pain or fracture in postmenopausal women with osteoporosis. This was a multicenter, randomized, double‐blind, placebo‐controlled trial in 240 clinical centers in 27 countries. Participants included 7736 postmenopausal women with osteoporosis. Patients were randomized to receive either a single 15‐minute intravenous infusion of zoledronic acid (5 mg) or placebo at baseline, 12 months, and 24 months. The main outcome measures were s elf‐reported number of days with back pain and the number of days of limited activity and bed rest owing to back pain or a fracture, and this was assessed every 3 months over a 3‐year period. Our results show that although the incidence of back pain was high in both randomized groups, women randomized to zoledronic acid experienced, on average, 18 fewer days of back pain compared with placebo over the course of the trial (p = .0092). The back pain among women randomized to zoledronic acid versus placebo resulted in 11 fewer days of limited activity (p = .0017). In Cox proportional‐hazards models, women randomized to zoledronic acid were about 6% less likely to experience 7 or more days of back pain [relative risk (RR) = 0.94, 95% confidence interval (CI) 0.90–0.99] or limited activity owing to back pain (RR = 0.94, 95% CI 0.87–1.00). Women randomized to zoledronic acid were significantly less likely to experience 7 or more bed‐rest days owing to a fracture (RR = 0.58, 95% CI 0.47–0.72) and 7 or more limited‐activity days owing to a fracture (RR = 0.67, 95% CI 0.58–0.78). Reductions in back pain with zoledronic acid were independent of incident fracture. Our conclusion is that in women with postmenopausal osteoporosis, a once‐yearly infusion with zoledronic acid over a 3‐year period significantly reduced the number of days that patients reported back pain, limited activity owing to back pain, and limited activity and bed rest owing to a fracture. © 2011 American Society for Bone and Mineral Research.     

Comparison of the Efficiency and Safety of Total Ankle Replacement and Ankle Arthrodesis in the Treatment of Osteoarthritis: An Updated Systematic Review and Meta‐analysis

While osteoarthritis is a common degenerative disease, ankle osteoarthritis is a subdivision that has received little attention. Two effective ways to treat osteoarthritis of the ankle are total ankle replacement (TAR) and ankle arthrodesis (AAD). Whether TAR or AAD is more beneficial for treatment is controversial. The purpose of this meta‐analysis was to compare the efficiency (clinical outcome and patient satisfaction) and safety (complications and survival) of these two procedures. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement was performed as a guideline for this study. Three electronic databases, PubMed, Web of Science, and Cochrane Library, were searched up to May 2019, with no language restrictions. Prospective or retrospective comparative studies were identified. The outcomes included clinical outcome, patient satisfaction, complications, and survival. Review Manager (Revman) 5.3 software was used to conduct the data analysis. We only selected literature from the past 5 years (no earlier than 2015). Seven comparative studies were included. There were six cohort studies and one cross‐sectional study. The Newcastle–Ottawa Scale (NOS) was used to assess the quality of cohort studies, and The Agency for Healthcare Research and Quality (AHRQ) checklist was chosen to assess the quality of cross‐sectional studies. No significant difference was observed for efficiency and safety. Clinical outcome was included in five studies with four different scoring systems. Two of them used the American Orthopaedic Foot & Ankle Society (AOFAS) questionnaire scores to assess the two procedures (mean difference, ?4.26; 95% confidence interval [CI], ?11.37–2.85; P = 0.24; I² = 1%). Patient satisfaction (risk ratio [RR], 0.96; 95% CI, 0.65–1.40; P = 0.82; I² = 54%), complications (RR, 1.15; 95% CI, 0.16–8.21; P = 0.89; I² = 84%), and survival (RR, 1.91; 95% CI, 0.33–11.08; P = 0.47; I² = 90%) showed no significant difference between the TAR group and the AAD group. This meta‐analysis showed no statistically significant difference between TAR and AAD in clinical outcome, patient satisfaction, complications, and survival. This revealed that TAR and AAD could appear to have similar results in these aspects. Therefore, the present results are not sufficient to conclude which of these two methods is better. Further studies are needed to obtain more clues.