Endoscopic management of biliary strictures post-liver transplantation

Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.

Subcellular expression of maspin – from normal tissue to tumor cells

Maspin or SerpinB5, a member of the serine protease inhibitor family, was shown to function as a tumor suppressor, especially in carcinomas. It seems to inhibit invasion, tumor cells motility and angiogenesis, and promotes apoptosis. Maspin can also induce epigenetic changes such as cytosine methylation, de-acetylation, chromatin condensation, and histone modulation. In this review, a comprehensive synthesis of the literature was done to present maspin function from normal tissues to pathologic conditions. Data was sourced from MEDLINE and PubMed. Study eligibility criteria included: Published in English, between 1994 and 2019, specific to humans, and with full-text availability. Most of the 118 studies included in the present review focused on maspin immunostaining and mRNA levels. It was shown that maspin function is organ-related and depends on its subcellular localization. In malignant tumors, it might be downregulated or negative (e.g., carcinoma of prostate, stomach, and breast) or upregulated (e.g., colorectal and pancreatic tumors). Its subcellular localization (nuclear vs cytoplasm), which can be proved using immunohistochemical methods, was shown to influence both tumor behavior and response to chemotherapy. Although the number of maspin-related papers increased, the exact role of this protein remains unknown, and its interpretation should be done with extremely high caution.

Higher dose of simethicone decreases colonic bubbles and increases prep tolerance and quality of bowel prep: Meta-analysis of randomized controlled trials

BACKGROUND

Antifoaming agents, such as simethicone, may facilitate mucosal inspection during colonoscopy. However, conflicting results have been reported with regard to the impact of simethicone on quality of bowel preparation and adenoma detection rate (ADR).

AIM

To perform a meta-analysis of trials that have compared simethicone vs placebo during colonoscopy.

METHODS

A reproducible literature search of multiple medical databases yielded eleven studies (n = 2605) for inclusion. Studies were compared for quality of bowel preparation, bubbles quality, ADR, and tolerability. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted by both fixed-effects and random-effects models. Relative risk (RR) estimates with a 95% confidence interval (CI) were calculated. Heterogeneity was assessed by I-squared index (I²) statistics.

RESULTS

Patients’ demographic characteristics were comparable in all studies. Of the 2605 patients, 1300 were in the simethicone group, whereas 1305 were in the placebo group. Inadequate bowel preparation was much lower in the simethicone group than in the placebo group [13% vs 24.6%; RR = 0.51 (0.31-0.82); P < 0.0001]. The placebo group was more likely to have significant colonic bubbles than was the simethicone group [35% vs 8%; RR = 1.49 (1.25-1.76); P = 0.0001]. Use of simethicone resulted in a slight, statistically significant increase in ADR compared with the placebo group [26.6% vs 21.6%, RR = 1.07 (1.01-1.13); P = 0.02]. Higher doses of simethicone (> 478 mg) were more likely to result in significant reduction of inadequate bowel preparation, colonic bubbles, and to improve ADR.

CONCLUSION

Adding simethicone improved the quality of bowel preparation, visualization, tolerability, and, eventually, ADR.

Gastrointestinal stress ulcer prophylaxis in the intensive care unit, where is the data?

Stress-induced gastrointestinal ulcers are common among patients admitted to the intensive care unit (ICU). These ulcers impose significant morbidity and mortality, therefore, stress ulcer prophylaxis (SUP) is a common clinical practice among healthcare providers dealing with these critically-ill patients. Several strategies for SUP have been suggested over the past four decades, with acid suppressive therapies being the most commonly used in the ICU. Whether SUP is effective and safe, or not, remains a topic of controversy. The data is still conflicting, and provision of a simple answer is not feasible at the present time. Recently, a large phase IV, multicenter, randomized clinical trial (SUP-ICU), negated the benefits (and harms) of proton pump inhibitors as SUP. This article reviews some of these controversies.

PD-1/PD-L1 antagonists in gastric cancer: Current studies and perspectives

Immune checkpoints release suppressive signals for T cells, which enable the tumors to escape from immune destruction and provide a new concept that uses the capabilities of the immune system as a therapeutic target for tumors. At present, programmed death receptor 1 (PD-1)/programmed death ligand-1 (PD-L1) has become the most promising therapeutic target. PD-1/PD-L1 blockades exhibit long-lasting antitumor efficacy and safety in patients with various cancers, such as melanoma and non-small-cell lung cancer. Moreover, PD-L1 is highly expressed in the peripheral blood and tumor specimens of patients with cancer, and the expression of PD-L1 is positively correlated with various pathological features and may serve as a predictor of poor prognosis or a diagnostic tool. Clinical trials have verified that PD-1/PD-L1 blockade therapy benefits patients with advanced gastric cancer or gastroesophageal junction cancer. Furthermore, there are many molecules involved in the regulation of PD-1/PD-L1 expression, and the modification of these molecules via drugs and combinations with PD-1/PD-L1 inhibitors may further improve the efficacy of immunotherapy for gastric cancer. In this review, the efficacy, safety, and possible combination treatment options of PD-1/PD-L1 in gastric cancer are reviewed in experimental and clinical settings.

Early immune response in post endoscopic retrograde cholangiopancreatography pancreatitis as a model for acute pancreatitis

This opinion review summarizes comparison of clinical presentation and immunology of post-endoscopic pancreatitis and acute pancreatitis (AP) of other etiology. The rationale for this topic was found in studies that mention differences in clinical presentation between these entities, stating that severe form of AP after endoscopic retrograde cholangiopancreatography was more severe than AP of other etiology. Found difference in clinical presentation may have a background in different immunology that needs to be further investigated.

Hepatic regeneration in Greek mythology

The accurate knowledge of surgical anatomy, the amelioration of post-operative processes and the continuously increasing experience of surgeons nowadays allow the performance of severe hepatic operations (e.g., wide liver resections, liver transplantations, etc.). The success of these operations is even more assisted by the great regenerative ability of the liver. Greek mythology, being an important source of information on the beliefs, habits, and phenomena observed during antiquity, reveals that hepatic regeneration was well known to ancient Greeks and this natural ability was established in two tales: the tale of Prometheus and the tale of the Giant Tityus. The main concept of both tales, being the destruction and reconstitution of the liver, is almost the same. Both of the condemned were immortal and their liver regenerated in a night, providing thus, food for the eagles and eternal pain for the sufferers. In conclusion, the tales show that the regenerative ability of the liver was well known from early years and that the trust shown by the Gods in this ability, to cause eternal suffering is on a par with the trust shown by the modern surgeons in it, to assure a successful hepatic operation.

Reproducibility and replicability of systematic reviews

Irreproducibility of research causes a major concern in academia. This concern affects all study designs regardless of scientific fields. Without testing the reproducibility and replicability it is almost impossible to repeat the research and to gain the same or similar results. In addition, irreproducibility limits the translation of research findings into practice where the same results are expected. To find the solutions, the Interacademy Partnership for Health gathered academics from established networks of science, medicine and engineering around a table to introduce seven strategies that can enhance the reproducibility: pre-registration, open methods, open data, collaboration, automation, reporting guidelines, and post-publication reviews. The current editorial discusses the generalisability and practicality of these strategies to systematic reviews and claims that systematic reviews have even a greater potential than other research designs to lead the movement toward the reproducibility of research. Moreover, I discuss the potential of reproducibility, on the other hand, to upgrade the systematic review from review to research. Furthermore, there are references to the successful and ongoing practices from collaborative efforts around the world to encourage the systematic reviewers, the journal editors and publishers, the organizations linked to evidence synthesis, and the funders and policy makers to facilitate this movement and to gain the public trust in research.

Prospects for immunotherapy as a novel therapeutic strategy against hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a highly aggressive malignant disease, with a poor clinical prognosis. Many standard therapies are often considered for HCC treatment today; however, these conventional therapies often fail to achieve sufficiently effective clinical results. Today, HCC therapy is set to undergo a major revolution, owing to rapid developments in cancer immunotherapy, particularly immune checkpoint inhibitor therapy. Cancer immunotherapy is a novel and promising treatment strategy that differs significantly from conventional therapies in its approach to achieve antitumor effects. In fact, many cancer immunotherapies have been tested worldwide and shown to be effective against various types of cancer; HCC is no exception to this trend. For example, we identified a specific cancer antigen called glypican-3 (GPC3) and performed clinical trials of GPC3-targeted peptide vaccine immunotherapy in patients with HCC. Here, we present an overview of the immune mechanisms for development and progression of HCC, our GPC3-based immunotherapy, and immune checkpoint inhibitor therapy against HCC. Finally, we discuss the future prospects of cancer immunotherapy against HCC. We believe that this review and discussion of cancer immunotherapy against HCC could stimulate more interest in this promising strategy for cancer therapy and help in its further development.

Evaluation of tumor response to antiangiogenic therapy in patients with recurrent gliomas using contrast-enhanced perfusion-weighted magnetic resonance imaging techniques: A meta-analysis

BACKGROUND

It is of vital importance to find radiologic biomarkers that can accurately predict treatment response. Usually, the initiation of antiangiogenic therapy causes a rapid decrease in the contrast enhancing tumor. However, the treatment response is observed only in a fraction of patients due to the partial radiological response secondary to stabilization of abnormal vessels which does not essentially indicate a true antitumor effect. Perfusion-weighted magnetic resonance imaging (PW-MRI) techniques have shown implicitness as a strong imaging biomarker for gliomas since they give hemodynamic information of blood vessels. Hence, there is a rapid expansion of PW-MRI related studies and clinical applications.

AIM

To determine the diagnostic performance of PW-MRI techniques including: (A) dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI); and (B) dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) for evaluating response to antiangiogenic therapy in patients with recurrent gliomas.

METHODS

Databases such as PubMed (MEDLINE included), EMBASE, and Google Scholar were searched for relevant original articles. The included studies were assessed for methodological quality with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Medical imaging follow-up or histopathological analysis was used as the reference standard. The data were extracted by two reviewers independently, and then the sensitivity, specificity, summary receiver operating characteristic curve, area under the curve (AUC), and heterogeneity were calculated using Meta-Disc 1.4 software.

RESULTS

This study analyzed a total of six articles. The overall sensitivity for DCE-MRI and DSC-MRI was 0.69 [95% confidence interval (CI): 0.53-0.82], and the specificity was 0.99 (95%CI: 0.93-1) by a random effects model (DerSimonianee-Laird model). The likelihood ratio (LR) +, LR-, and diagnostic odds ratio (DOR) were 12.84 (4.54-36.28), 0.35 (0.22-0.53), and 24.44 (7.19-83.06), respectively. The AUC (± SE) was 0.9921 (± 0.0120), and the Q* index (± SE) was 0.9640 (± 0.0323). For DSC-MRI, the sensitivity was 0.73, the specificity was 0.98, the LR+ was 7.82, the LR- was 0.32, the DOR was 31.65, the AUC (± SE) was 0.9925 (± 0.0132), and the Q* index was 0.9649 (± 0.0363). For DCE-MRI, the sensitivity was 0.41, the specificity was 0.97, the LR+ was 5.34, the LR- was 0.71, the DOR was 8.76, the AUC (± SE) was 0.9922 (± 0.2218), and the Q* index was 0.8935 (± 0.3037).

CONCLUSION

This meta-analysis demonstrated a beneficial value of PW-MRI (DSC-MRI and DCE-MRI) in monitoring the response of recurrent gliomas to antiangiogenic therapy, with reasonable sensitivity, specificity, +LR, and -LR.

Misclassification of smoking habits: An updated review of the literature

BACKGROUND

Misclassification of smoking habits leads to underestimation of true relationships between diseases and active smoking, and overestimation of true relationships with passive smoking. Information on misclassification rates can be obtained from studies using cotinine as a marker.

AIM

To estimate overall misclassification rates based on a review and meta-analysis of the available evidence, and to investigate how misclassification rates depend on other factors.

METHODS

We searched for studies using cotinine as a marker which involved at least 200 participants and which provided information on high cotinine levels in self-reported non-, never, or ex-smokers or on low levels in self-reported smokers. We estimated overall misclassification rates weighted on sample size and investigated heterogeneity by various study characteristics. Misclassification rates were calculated for two cotinine cut points to distinguish smokers and non-smokers, the higher cut point intended to distinguish regular smoking.

RESULTS

After avoiding double counting, 226 reports provided 294 results from 205 studies. A total of 115 results were from North America, 128 from Europe, 25 from Asia and 26 from other countries. A study on 6.2 million life insurance applicants was considered separately. Based on the lower cut point, true current smokers represented 4.96% (95% CI 4.32-5.60%) of reported non-smokers, 3.00% (2.45-3.54%) of reported never smokers, and 10.92% (9.23-12.61%) of reported ex-smokers. As percentages of true current smokers, non-, never and ex-smokers formed, respectively, 14.50% (12.36-16.65%), 5.70% (3.20-8.20%), and 8.93% (6.57-11.29%). Reported current smokers represented 3.65% (2.84-4.45%) of true non-smokers. There was considerable heterogeneity between misclassification rates. Rates of claiming never smoking were very high in Asian women smokers, the individual studies reporting rates of 12.5%, 22.4%, 33.3%, 54.2% and 66.3%. False claims of quitting were relatively high in pregnant women, in diseased individuals who may recently have been advised to quit, and in studies considering cigarette smoking rather than any smoking. False claims of smoking were higher in younger populations. Misclassification rates were higher in more recently published studies. There was no clear evidence that rates varied by the body fluid used for the cotinine analysis, the assay method used, or whether the respondent was aware their statements would be validated by cotinine - though here many studies did not provide relevant information. There was only limited evidence that rates were lower in studies classified as being of good quality, based on the extent to which other sources of nicotine were accounted for.

CONCLUSION

It is important for epidemiologists to consider the possibility of bias due to misclassification of smoking habits, especially in circumstances where rates are likely to be high. The evidence of higher rates in more recent studies suggests that the extent of misclassification bias in studies relating passive smoking to smoking-related disease may have been underestimated.

Empathy assessment in healthcare students is highly heterogeneous: A systematic review and meta-analysis (2012-2016)

BACKGROUND

Clinical empathy leads to improved patient satisfaction and better clinical outcomes. Currently, there are multiple empathy scales with minimal or no efforts to produce an integrated definition of clinical empathy which can be assessed sufficiently by only a few scales. Moreover, there is an unclear overall reliability of these empathy scales, hence limiting comparative evaluation.

AIM

To examine which empathy scales have been used in healthcare students and to estimate their overall internal consistency.

METHODS

A systematic review was performed with inclusion criteria any empirical study with quantitative data examining empathy of healthcare students toward patients between 2012 and 2016. A random effects model was used to produce a pooled estimate of the Cronbach’s alphas. The Hakstian-Whalen transformation was used for analyses based on the Rodriguez-Maeda method. Heterogeneity was quantified using the I² statistic and further investigated with subgroup analysis and meta-regression. Publication bias was assessed using funnel plots, Egger’s test, Begg’s test, and the trim and fill analysis.

RESULTS

Thirteen scales have been used to assess clinical empathy in healthcare students from forty nine studies with total sample size 49384 students. The most frequently used scale is the Jefferson Scale of Physician Empathy followed by Davis’ Interpersonal Reactivity Index. The overall reliability was 0.805 (95%CI 0.786-0.823), which is acceptable, but there was heterogeneity and publication bias. Some heterogeneity was explained by the different countries of the studies under investigation and student types but most heterogeneity remained unexplained.

CONCLUSION

The results indicate that scales have satisfactory internal consistency but there are a multitude of scales, definitions and empathy components. Future research should focus on standardizing scales and creating consensus statements regarding the definition of empathy and use of appropriate scales.

Improving the conduct of meta-analyses of observational studies

The author, who has published numerous meta-analyses of epidemiological studies, particularly on tobacco, comments on various aspects of their content. While such meta-analyses, even when well conducted, are more difficult to draw inferences from than are meta-analyses of clinical trials, they allow greater insight into an association than do simple qualitative reviews. This editorial starts with a discussion of some problems relating to hypothesis definition. These include the definition of the outcome, the exposure and the population to be considered, as well as the study inclusion and exclusion criteria. Under literature searching, the author argues against restriction to studies published in peer-reviewed journals, emphasising the fact that relevant data may be available from other sources. Problems of identifying studies and double counting are discussed, as are various issues in regard to data entry. The need to check published effect estimates is emphasised, and techniques to calculate estimates from material provided in the source publication are described. Once the data have been collected and an overall effect estimate obtained, tests for heterogeneity should be conducted in relation to different study characteristics. Though some meta-analysts recommend classifying studies by an overall index of study quality, the author prefers to separately investigate heterogeneity by those factors which contribute to the assessment of quality. Reasons why an association may not actually reflect a true causal relationship are also discussed, with the editorial describing techniques for investigating the relevance of confounding, and referring to problems resulting from misclassification of key variables. Misclassification of disease, exposure and confounding variables can all produce a spurious association, as can misclassification of the variable used to determine whether an individual can enter the study, and the author points to techniques to adjust for this. Issues relating to publication bias and the interpretation of “statistically significant” results are also discussed. The editorial should give the reader insight into the difficulties of producing a good meta-analysis.

Systematic literature review of the antitumor effect of octreotide in neuroendocrine tumors

AIM

To provide a comprehensive examination of the existing evidence of the antitumor effect of long-acting octreotide in neuroendocrine tumors (NETs).

METHODS

A systematic literature review of clinical trials and observational studies was conducted in PubMed, EMBASE, and Cochrane through January 18, 2017. Conference abstracts for 2015 and 2016 from 5 scientific meetings were also searched.

RESULTS

Of 41 articles/abstracts identified, 13 unique studies compared octreotide with active or no treatment. Two of the 13 studies were clinical trials; the remaining were observational studies. The phase 3 Placebo-Controlled, Double-Blind, Prospective, Randomized Study of the Effect of Octreotide long-acting repeatable (LAR) in the Control of Tumor Growth in Patients with Metastatic Neuroendocrine Midgut Tumors clinical trial showed that long-acting octreotide significantly prolonged time to tumor progression compared with placebo in patients with functionally active and inactive metastatic midgut NETs; no statistically significant difference in overall survival (OS) was observed, possibly due to the crossover of placebo patients to octreotide. Retrospective observational studies found that long-acting octreotide use was associated with significantly longer OS than no octreotide use for patients with distant metastases although not for those with local/regional disease.

CONCLUSION

The clinical trial and observational studies with informative evidence support long-acting octreotide’s antitumor effect on time to tumor progression and OS. This review showed the rarity of existing studies assessing octreotide’s antitumor effect and recommends that future research is warranted.

Genetic studies in irritable bowel syndrome-status quo

AIM

To evaluate the most common studied genetic polymorphisms that may have an etiological role in irritable bowel syndrome (IBS).

METHODS

The data base PubMed was searched for studies analyzing the association between gene polymorphisms and IBS. All original full papers, written in English, were retained for further analysis. The retrieved papers were further systematized according to those polymorphisms that have been detected in IBS.

RESULTS

Considering these criteria, our literature search found 12 polymorphisms, residing in 10 genes, which were reported to be consistently associated with IBS. The initial search identified 189 articles, out of which 48 potentially appropriate articles were reviewed. Of these 48 articles, 41 articles were included in the review. These articles were published between 2002 and 2016. Out of these 41 studies, 17 reported analysis of the serotonin transporter (SERT) gene (SLC6A4), eight on guanine nucleotide-binding protein subunit beta-3 (GNbeta3), six on the serotonin type 3 receptor genes (HTR3A), four on (HTR3E), three on (HTR2A), three the tumor necrosis factor superfamily member TL1A gene (TNFSF15), and ten on genetic polymorphisms with limited evidence.

CONCLUSION

Current evidence for the relation between genetic polymorphisms and IBS is limited owing to the fact that high-quality prospective studies and detailed phenotyping of patients suffering from IBS and matched controls were lacking in the past.

Synthetic vs biologic mesh for the repair and prevention of parastomal hernia

AIM

To outline current evidence regarding prevention and treatment of parastomal hernia and to compare use of synthetic and biologic mesh.

METHODS

Relevant databases were searched for studies reporting hernia recurrence, wound and mesh infection, other complications, surgical techniques and mortality. Weighted pooled proportions (95%CI) were calculated using StatsDirect. Heterogeneity concerning outcome measures was determined using Cochran’s Q test and was quantified using I². Random and fixed effects models were used. Meta-analysis was performed with Review Manager software with the statistical significance set at P ≤ 0.05.

RESULTS

Forty-four studies were included: 5 reporting biologic mesh repairs; 21, synthetic mesh repairs; and 18, prophylactic mesh repairs. Most of the studies were retrospective cohorts of low to moderate quality. The hernia recurrence rate was higher after undergoing biologic compared to synthetic mesh repair (24.0% vs 15.1%, P = 0.01). No significant difference was found concerning wound and mesh infection (5.6% vs 2.8%; 0% vs 3.1%). Open and laparoscopic techniques were comparable regarding recurrences and infections. Prophylactic mesh placement reduced the occurrence of a parastomal hernia (OR = 0.20, P < 0.0006) without increasing wound infection [7.8% vs 8.2% (OR = 1.04, P = 0.91)] and without differences between the mesh types.

CONCLUSION

There is no superiority of biologic over synthetic mesh for parastomal hernia repair. Prophylactic mesh placement during the initial surgery significantly reduces parastomal hernia occurrence regardless of the mesh type.

Different types of mechanical complications after surgical correction of adult spine deformity with osteotomy

AIM

To determine the incidence and risk factors for mechanical complications (MC) after surgical correction of adult spinal deformity (ASD) with osteotomy.

METHODS

A retrospective study was performed. Inclusion criteria: Surgical correction of ASD using osteotomy; male or female; > 20 years old; follow-up ≥ 24 mo or revision. The MC of spine and spinal instrumentation were studied separately. Risk analysis included assessment of the association between more than 50 different characteristics (demographic, clinical, radiographic, and instrumentation) with different types of MC.

RESULTS

The medical records of 94 operations in 88 subjects were analyzed: Female (68%), mean age 58.6 (SD, 12.7) years. Cumulative incidence of MC at 2 year follow-up was 43.6%. Of these, 78% required revision (P < 0.001). The following characteristics had significant (P ≤ 0.05) association with MC: (1) Preoperative: osteoporosis, smoking, previous spinal operation, sagittal vertical axis (SVA) > 100 mm, lumbar lordosis (LL) < 34°; (2) postoperative: SVA > 75 mm; operative correction: SVA > 75 mm, LL > 30°, thoracic kyphosis > 25°, and pelvic tilt > 9°; a fall; pseudarthrosis; and (3) device and surgical technique: use of previously implanted instrumentation; use of domino and/or parallel connectors; type of osteotomy (PSO vs SPO) if preoperative SVA < 100 mm; lumbar osteotomy location; in-situ rod contouring > 60°; and fixation to sacrum/pelvis.

CONCLUSION

Risk of MC after surgical correction of ASD is substantial. To decrease this risk over- and/or insufficient correction of the sagittal imbalance should be avoided.

Complete revascularization reduces adverse outcomes in patients with multivessel coronary artery disease

AIM

To investigate the influence of complete and incomplete revascularization (ICR) in patients with multivessel coronary artery disease undergoing coronary artery bypass or percutaneous coronary intervention.

METHODS

We searched PubMed using the keywords “complete revascularization”, “incomplete revascularization”, “coronary artery bypass”, and “percutaneous coronary intervention”. We selected randomized controlled studies (RCT) and observational studies only for review. The main outcomes of interest were mortality, myocardial infarction (MI) and repeat revascularization. We identified further studies by hand searching relevant publications and included those that met with the inclusion criteria in our final analysis and performed a systematic review.

RESULTS

Ten studies were identified, including 13327 patients of whom, 8053 received complete revascularization and 5274 received ICR. Relative to ICR, CR was associated with lower mortality (RR: 0.755, 95%CI: 0.66 to 0.864, P = 0.765, I² = 0.0%), lower rates of MI (RR: 0.759, 95%CI: 0.615 to 0.937, P = 0.091, I² = 45.1%), lower rates of MACCE (RR: 0.731, 95%CI: 0.668 to 0.8, P = 0.453, I² = 0.0%) and reduced rates of repeat coronary revascularization (RR: 0.691, 95%CI: 0.541 to 0.883, P = 0.0, I² = 88.3%).

CONCLUSION

CR is associated with lower rates of adverse outcomes. CR can be used as a standard in the choice of any particular revascularization strategy.

Thalidomide and thalidomide analogues in treatment of patients with inflammatory bowel disease: Meta-analysis

AIM

To examine the efficacy and safety of thalidomide and thalidomide analogues in induction and maintenance of remission in patients with inflammatory bowel disease (IBD).

METHODS

A literature search was performed in the following databases: PubMed, EMBASE, Web of Science, Ovid and the Cochrane Library, and Chinese databases such as the China National Knowledge Infrastructure, China Science and Technology Journal Database (VIP), Wanfang Data. The randomized controlled analysis was performed to assess the effects of thalidomide therapy on inflammatory bowel disease for patients who did show good response with other therapies.

RESULTS

Three studies (n = 212) met the inclusion criteria were used in this Meta-analysis. No difference was found between thalidomide/thalidomide analogues and placebo in the induction of remission (RR = 1.36, 95%CI: 0.83-2.22, P = 0.22), the induction of clinical response (RR = 1.14, 95%CI: 0.75-1.72, P = 0.54) and the induction of adverse events (RR = 1.41, 95%CI: 0.99-2.02, P = 0.06).

CONCLUSION

Currently, there is not enough evidence to support use of thalidomide or its analogue for the treatment in patients of any age with IBD. However, it warrants a reanalysis when more data become available.

Remission endpoints in ulcerative colitis: A systematic review

AIM

To summarize the current consensus on the definition of remission and the endpoints employed in clinical trials.

METHODS

A bibliogragraphic search was performed from 1946 to 2016 sing online databases (National Library of Medicine’s PubMed Central Medline, OVID SP MEDLINE, OVID EMBASE, the Cochrane Library and Conference Abstracts) with key words: (“ulcerative colitis”) AND (“ulcerative colitis endoscopic index of severity” OR “UCEIS”) AND (“remission”) as well as (“ulcerative colitis”) AND (“ulcerative colitis disease activity index”) OR “UCDAI” OR “UC disease activity index” OR “Sutherland index”) AND (“remission”).

RESULTS

The search returned 37 and 116 articles for the UCEIS and UCDAI respectively. For the UCEIS, 12 articles were cited in the final analysis of which 9 validation studies have been identified. Despite the UCEIS has been more extensively validated in all three aspects (validity, responsiveness and reliability), it has been little employed to monitor disease in randomised clinical trials. For the UCDAI, 37 articles were considered for the final analysis. Although the UCDAI is only partially validated, 29 randomised clinical trials were acknowledged to use the UCDAI to determine endpoints and disease remission, though no clear protocol was identified.

CONCLUSION

Although the UCEIS has been more widely validated than the UCDAI, it has not been reflected in the monitoring of disease activity in clinical trials. Conversely, the UCDAI has been used in numerous large clinical trials to define their endpoints and disease remission, however, it is challenging to determine the best possible outcomes due to a lack of homogeneity of the clinical trial protocols. Before determining a gold standard index, international agreement on remission is urgently needed to advance patient care.

Assessing the quality of studies in meta-analyses: Advantages and limitations of the Newcastle Ottawa Scale

One of the most important points in the meta-analyses is certainly represented by the assessment of the quality of the studies included in such research. The meta-analyses are considered the highest level of evidence in science. Also for this reason, the quality of the studies included should be accurately evaluated by standardized tools. The overall results of the meta-analysis depend indeed also on a rigorous evaluation of the studies quality. Among all the possible tools for this complex evaluation, the Newcastle Ottawa Scale (NOS) is one of the most used worldwide, above all for observational studies. In this review, we will discuss the strengths and limitation of the NOS, also on the basis of the branch of science in which it has been applied.

Medication non-adherence in bipolar disorder: Review of rates, demographic and clinical predictors

AIM

To conduct a systematic search for all studies examining rates and demographic and illness-related determinants of medication non-adherence in bipolar disorder (BD).

METHODS

A comprehensive literature search was undertaken of six English-language databases to identify published articles on medication non-adherence in BD from inception till December 2016. Any article, either a review or an original-research article was examined for its relevance to the subject. All such articles were manually searched to locate any further articles containing relevant information. Studies were included only if they had adequately described the patient sample, assessment methods and statistical procedures, presented their results systematically and their conclusions were congruent with the results.

RESULTS

The initial search yielded 249 articles on the subject; of these 198 articles were included. Of the 162 original-research studies, 132 had provided information on rates of medication non-adherence in BD. There was a wide variation in rates ranging from universal adherence (100%) to almost universal non-adherence (96%); this discrepancy was more due to methodological differences than true variations in rates. Notwithstanding the significant discrepancies in methodology, based on these 132 studies mean rates of 41.5%-43% and median rates of 40%-41% were obtained for medication non-adherence in BD. Rates of adherence with mood stabilizers were significantly lower than those for antipsychotics, or for medications of all classes. None of the demographic attributes were unequivocally linked to medication non-adherence in BD. Similarly, medication-related variables such as type of medications, doses, treatment regimens and side effects did not demonstrate consistent associations with non-adherence. Among clinical characteristics the presence of comorbid substance use disorder and absence of insight were the only two factors clearly linked to non-adherence in BD.

CONCLUSION

Medication non-adherence is prevalent in about a third to half of patients with BD. Demographic, illness and treatment related factors do not predict non-adherence with certainty.

Diffusion tensor imaging beyond brains: Applications in abdominal and pelvic organs

Functional magnetic resonance imaging (MRI) provided critical functional information in addition to the anatomic profiles offered by conventional MRI, and has been enormously used in the initial diagnosis and followed evaluation of various diseases. Diffusion tensor imaging (DTI) is a newly developed and advanced technique that measures the diffusion properties including both diffusion motion and its direction in situ, and has been extensively applied in central nerve system with acknowledged success. Technical advances have enabled DTI in abdominal and pelvic organs. Its application is increasing, yet remains less understood. A systematic overview of clinical application of DTI in abdominal and pelvic organs such as liver, pancreas, kidneys, prostate, uterus, etc., is therefore presented. Exploration of techniques with less artifacts and more normative post-processing enabled generally satisfactory image quality and repeatability of measurement. DTI appears to be more valuable in the evaluation of diffused diseases of organs with highly directionally arranged structures, such as the assessment of function impairment of native and transplanted kidneys. However, the utility of DTI to diagnose focal lesions, such as liver mass, pancreatic and prostate tumor, remains limited. Besides, diffusion of different layers of the uterus and the fiber structure disruption can be depicted by DTI. Finally, a discussion of future directions of research is given. The underlying heterogeneous pathologic conditions of certain diseases need to be further differentiated, and it is suggested that DTI parameters might potentially depict certain pathologic characterization such as cell density. Nevertheless, DTI should be better integrated into the current multi-modality evaluation in clinical practice.

Statin use and risk of cancer: An overview of meta-analyses

AIM

To conduct an overview of meta-analyses to critically appraise the evidence and present a comprehensive evaluation of the association between statin use and risk of site specific cancers.

METHODS

MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and Web of Science databases were searched from inception until 31^st May 2016. The electronic database search was supplemented by a hand search in PROSPERO and relevant journals which are not indexed in above databases. Meta-analyses that examined the association between statin use and risk of site specific cancers were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.

RESULTS

Overall, 38 meta-analyses covered 13 site specific cancers were included. More than half (68%) of the meta-analyses were moderate in quality with an AMSTAR score 4-7 out of a possible 11. Based on current evidence from meta-analyses, use of statin decreases the risk of certain cancers, such as colorectal (8%-12%), gastric (27%-44%), hematological (19%), liver (37%-42%), oesophageal (14%-28%), ovarian (21%) and prostate cancer (7%). On the other side, evidence from meta-analyses also suggests that there is no association between statin use and risk of bladder, breast, endometrial, kidney, lung, pancreatic and skin cancers.

CONCLUSION

This overview of meta-analyses with variable quality has been shown that the statins may have a potential role in cancer chemoprevention and reduce the risk of some site specific cancers, but not all.

Mucin expression and the pancreas: A systematic review and meta-analysis

AIM

To assess mucin expression in pancreatic premalignant and malignant states, and to establish its role as a prognostic marker.

METHODS

English Medical literature searches were conducted for “mucin” and “pancreas”. Observational studies were included. Meta-analysis was performed by using Comprehensive meta-analysis software. Pooled odds ratios and 95%CIs were calculated.

RESULTS

Out of 949 eligible papers we found 20 according to the inclusion criteria, including 4262 patients, published till May 31, 2016. Mucin expression increased in pancreatic lesions with OR 10.206 (95%CI: 4.781-21.781, P < 0.0001). Measure of heterogeneity was high: Q = 296.973, df (Q) = 55.00, I² = 81.48%. We found a significant increase in the expression of MUC2, MUC4 and MUC5AC, 13.39, 118.43 and 13.91 times respectively, in pancreatic lesion in comparison with normal pancreatic tissue, and decreased expression of MUC5B.

CONCLUSION

Mucin expression may serve as prognostic marker for transformation of intraductal papillary mucinous neoplasms to ductal adenocarcinoma, for aggressiveness of the pancreatic tumor, and as targets for potential therapy.