Small studies may overestimate the effect sizes in critical care meta-analyses: a meta-epidemiological study

Mu-opioid antagonists for opioid-induced bowel dysfunction in people with cancer and people receiving palliative care

BACKGROUND

Opioid-induced bowel dysfunction (OIBD) is characterised by constipation, incomplete evacuation, bloating, and gastric reflux. It is one of the major adverse events of treatment for pain in cancer and in palliative care, resulting in increased morbidity and reduced quality of life.This is an update of two Cochrane reviews. One was published in 2011, Issue 1 on laxatives and methylnaltrexone for the management of constipation in people receiving palliative care; this was updated in 2015 and excluded methylnaltrexone. The other was published in 2008, Issue 4 on mu-opioid antagonists (MOA) for OIBD. In this updated review, we only included trials on MOA (including methylnaltrexone) for OIBD in people with cancer and people receiving palliative care.

OBJECTIVES

To assess the effectiveness and safety of MOA for OIBD in people with cancer and people receiving palliative care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, and Web of Science to August 2017. We also searched clinical trial registries and regulatory websites. We contacted manufacturers of MOA to identify further data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed the effectiveness and safety of MOA for OIBD in people with cancer and people at a palliative stage irrespective of the type of terminal disease they experienced.

DATA COLLECTION AND ANALYSIS

Two review authors assessed risk of bias and extracted data. The appropriateness of combining data from the trials depended upon sufficient homogeneity across the trials. Our primary outcomes were laxation, impact on pain relief, and adverse events. Impact on pain relief was a primary outcome because a possible adverse effect of MOAs is a reduction in pain relief from opioids. We assessed the evidence on these outcomes using GRADE.

MAIN RESULTS

We identified four new trials for this update, bringing the total number included in this review to eight. In total, 1022 men and women with cancer irrespective of stage or at a palliative care stage of any disease were randomised across the trials. The MOAs evaluated were oral naldemedine and naloxone (alone or in combination with oxycodone), and subcutaneous methylnaltrexone. The trials compared with MOA with a placebo or with the active intervention administered at different doses or in combination with other drugs. The trial of naldemedine and the two of naloxone in combination with oxycodone were in people with cancer irrespective of disease stage. The trial on naloxone alone was in people with advanced cancer. The four trials on methylnaltrexone were undertaken in palliative care where most participants had cancer. All trials were vulnerable to biases; four were at a high risk as they involved a sample of fewer than 50 participants per arm.In the trial of naldemedine compared to placebo in 225 participants, there were more spontaneous laxations over the two-week treatment for the intervention group (risk ratio (RR) 1.93, 95% confidence intervals (CI) 1.36 to 2.74; moderate-quality evidence). In comparison with higher doses, lower doses resulted in fewer spontaneous laxations (0.1 mg versus 0.2 mg: RR 0.73, 95% CI 0.55 to 0.95; 0.1 mg versus 0.4 mg: RR 0.69, 95% CI 0.53 to 0.89; moderate-quality evidence). There was moderate-quality evidence that naldemedine had no effect on opiate withdrawal. There were five serious adverse events. All were in people taking naldemedine (low-quality evidence). There was an increase in the occurrence of other (non-serious) adverse events in the naldemedine groups (RR 1.36, 95% CI 1.04 to 1.79, moderate-quality evidence). The most common adverse event was diarrhoea.The trials on naloxone taken either on its own, or in combination with oxycodone (an opioid) compared to oxycodone only did not evaluate laxation response over the first two weeks of administration. There was very low-quality evidence that naloxone alone, and moderate-quality evidence that oxycodone/naloxone, had no effect on analgesia. There was low-quality evidence that oxycodone/naloxone did not increase the risk of serious adverse events and moderate-quality evidence that it did not increase risk of adverse events.In combined analysis of two trials of 287 participants, we found methylnaltrexone compared to placebo induced more laxations within 24 hours (RR 2.77, 95% CI 1.91 to 4.04. I² = 0%; moderate-quality evidence). In combined analysis, we found methylnaltrexone induced more laxation responses over two weeks (RR 9.98, 95% CI 4.96 to 20.09. I² = 0%; moderate-quality evidence). The proportion of participants who had a rescue-free laxation response within 24 hours of the first dose was 59.1% in the methylnaltrexone arms and 19.1% in the placebo arm. There was moderate-quality evidence that the rate of opioid withdrawal was not affected. Methylnaltrexone did not increase the likelihood of a serious adverse event; there were fewer in the intervention arm (RR 0.59, 95% CI 0.38 to 0.93; I² = 0%; moderate-quality evidence). There was no difference in the proportion of participants experiencing an adverse event (RR 1.17, 95% CI 0.94 to 1.45; I² = 74%; low-quality evidence). Methylnaltrexone increased the likelihood of abdominal pain and flatulence.Two trials compared differing methylnaltrexone schedules of higher doses with lower doses. For early laxation, there was low-quality evidence of no clear difference between doses on analgesia and adverse events. Both trials measured laxation response within 24 hours of first dose (trial one: RR 0.82, 95% CI 0.41 to 1.66; trial two: RR 1.07, 95% CI 0.81 to 1.42).

AUTHORS' CONCLUSIONS

In this update, the conclusions for naldemedine are new. There is moderate-quality evidence to suggest that, taken orally, naldemedine improves bowel function over two weeks in people with cancer and OIBD but increases the risk of adverse events. The conclusions on naloxone and methylnaltrexone have not changed. The trials on naloxone did not assess laxation at 24 hours or over two weeks. There is moderate-quality evidence that methylnaltrexone improves bowel function in people receiving palliative care in the short term and over two weeks, and low-quality evidence that it does not increase adverse events. There is a need for more trials including more evaluation of adverse events. None of the current trials evaluated effects in children.

Local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis

Background

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of local infiltration anesthesia (LIA) versus epidural analgesia (EPA) for postoperative pain control in total knee arthroplasty (TKA).

Methods

In December 2017, a systematic computer-based search was conducted in Pubmed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. RCTs of patients prepared for spine surgery that compared LIA versus EPA for postoperative pain control in TKA were retrieved. The primary endpoint was the VAS score with rest or mobilization at 12, 24 and 48, and 72 h. The secondary outcomes were the range of motion, the length of stay, and the occurrence of infection and nausea. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

Results

Seven clinical studies with 251 patients (LIA = 124, EPA = 127) were included in the meta-analysis. There was no significant difference between LIA and EPA group in terms of the VAS score with rest at 12 and 24 h. LIA was associated with a reduction of the VAS score with rest at 48 and 72 h than EPA (P < 0.05). There was no significant difference between the LIA group and EPA group in terms of the VAS with mobilization at 24, 48, and 72 h (P > 0.05). And LIA was associated with an increase of the range of motion at 24 and 48 h (P < 0.05) and a reduction of the length of hospital stay (P < 0.05). What is more, LIA was associated with a reduction of the occurrence of the nausea.

Conclusions

LIA has equivalent efficacy as EPA for pain control after TKA and shows an increase of the range of motion and a reduction of the occurrence of nausea and length of hospital stay. Due to the limited number of the included studies, more high-quality RCTs are still needed to identify the long-term effects of LIA for pain control after TKA.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0770-9) contains supplementary material, which is available to authorized users.

Lenalidomide and the risk of serious infection in patients with multiple myeloma: a systematic review and meta-analysis

The immunomodulatory drug lenalidomide is highly effective against newly diagnosed and relapsed/refractory multiple myeloma (MM), but serious and even fatal infections have been associated with its use. In this meta-analysis, we assessed the overall risk of infection to MM patients treated with lenalidomide. Eleven phase II or III clinical trials, comprising 3,210 subjects, were selected from the Embase, Pubmed, and Cochrane Library databases, from the Clinical Trial Registration website, and from meeting abstracts and virtual presentations at the American Society of Clinical Oncology. Main outcome measures were overall incidence, relative risk (RR), and 95% confidence intervals (CIs) of reported infection events. Fixed-effect or random-effect models were used in the statistical analyses, depending on the between-study heterogeneity. The overall incidence of high-grade infection was 14.32% (95% CI: 12.08%-16.90%) and high-grade infection's pooled RR was 2.23 (95% CI: 1.71-2.91, P < 0.0001) for all 11 studies evaluated. No evidence of publication bias for the incidence of high-grade infection was detected using Begg's funnel plot and Egger's test (P = 0.2; 95% CI: -1.70, 1.23). From this meta-analysis, it appears lenalidomide use is associated with an increased risk of high-grade infection. Moreover, fatal infection events occurred only in patients treated with lenalidomide; no infection-related deaths were observed among controls. These data indicate that accurate diagnosis and optimal management of infection in MM patients treated with lenalidomide could be critical for treatment efficacy.

Incidence of menopausal symptoms in postmenopausal breast cancer patients treated with aromatase inhibitors

Aromatase inhibitors (AIs) are the standard of care for postmenopausal women with estrogen receptor-positive breast cancer. Here, we performed a meta-analysis to evaluate the occurrence of menopausal symptoms in breast cancer patients receiving the AI therapy. Patients treated with AIs had an increased risk of all-grade arthralgia (1.63 [95% CI: 1.34–1.98]) and insomnia (1.24 [95% CI: 1.14–1.34]). The overall incidence of hot flashes, fatigue, arthralgia, sweating, and insomnia in patients receiving AIs was 30.47% (95% CI: 25.51%–35.93%), 17.16% (95% CI: 14%–20.85%), 17.91% (95% CI: 11.29%–27.22%), 14.64% (95% CI: 11.46%–18.52%), and 16.52% (95% CI: 12.45%–21.6 %), respectively. Both arthralgia (RR = 0.34, 95% CI: 0.16–0.75) and sweating (RR = 11.02, 95% CI: 4.11–29.57) differed between patients with early- and advanced-stage breast cancer. Our findings indicates that AIs are associated with a significant risk of developing arthralgia and insomnia in breast cancer patients. Effective early detection and management of menopausal symptoms would likely lead to safer use of AIs in breast cancer patients.

Comparison of treatment effect sizes from pivotal and postapproval trials of novel therapeutics approved by the FDA based on surrogate markers of disease: a meta-epidemiological study

BACKGROUND

The U.S. Food and Drug Administration (FDA) often approves new drugs based on trials that use surrogate markers for endpoints, which involve certain trade-offs and may risk making erroneous inferences about the medical product's actual clinical effect. This study aims to compare the treatment effects among pivotal trials supporting FDA approval of novel therapeutics based on surrogate markers of disease with those observed among postapproval trials for the same indication.

METHODS

We searched Drugs@FDA and PubMed to identify published randomized superiority design pivotal trials for all novel drugs initially approved by the FDA between 2005 and 2012 based on surrogate markers as primary endpoints and published postapproval trials using the same surrogate markers or patient-relevant outcomes as endpoints. Summary ratio of odds ratios (RORs) and difference between standardized mean differences (dSMDs) were used to quantify the average difference in treatment effects between pivotal and matched postapproval trials.

RESULTS

Between 2005 and 2012, the FDA approved 88 novel drugs for 90 indications based on one or multiple pivotal trials using surrogate markers of disease. Of these, 27 novel drugs for 27 indications were approved based on pivotal trials using surrogate markers as primary endpoints that could be matched to at least one postapproval trial, for a total of 43 matches. For nine (75.0%) of the 12 matches using the same non-continuous surrogate markers as trial endpoints, pivotal trials had larger treatment effects than postapproval trials. On average, treatment effects were 50% higher (more beneficial) in the pivotal than the postapproval trials (ROR 1.5; 95% confidence interval CI 1.01-2.23). For 17 (54.8%) of the 31 matches using the same continuous surrogate markers as trial endpoints, pivotal trials had larger treatment effects than the postapproval trials. On average, there was no difference in treatment effects between pivotal and postapproval trials (dSMDs 0.01; 95% CI -0.15-0.16).

CONCLUSIONS

Many postapproval drug trials are not directly comparable to previously published pivotal trials, particularly with respect to endpoint selection. Although treatment effects from pivotal trials supporting FDA approval of novel therapeutics based on non-continuous surrogate markers of disease are often larger than those observed among postapproval trials using surrogate markers as trial endpoints, there is no evidence of difference between pivotal and postapproval trials using continuous surrogate markers.

Meta-analytic review of the effects of a single dose of intranasal oxytocin on threat processing in humans

BACKGROUND

Heightened threat sensitivity is a transdiagnostic feature in several psychiatric disorders. The neuropeptide oxytocin has been shown to reduce fear related behaviours and facilitated fear extinction in animals. These findings have led to increasing interest to explore the effects of intranasal oxytocin on threat processing in humans.

METHODS

The review included 26 studies (N = 1173), nine of which included clinical populations (N = 234). The clinical groups included were people with borderline personality disorder (BPD), anorexia nervosa, bulimia nervosa, depression, anxiety, and alcohol dependence disorder. We examined the effects of a single dose of intranasal oxytocin on startle response, attentional responses, and behavioural responses to threat.

RESULTS

A single dose of intranasal oxytocin significantly increased the physiological startle response to threat in healthy people with a small effect size. However, oxytocin did not have significant effects on attentional bias towards social or disorder-specific threat, fixation towards threatening stimuli among healthy or clinical populations, or on threat related behavioural approach or avoidance responses.

LIMITATIONS

No studies investigated the effects of oxytocin on the startle response to threat among clinical populations. Additionally, only one of the reviewed studies had sufficient power to detect at least a moderate effect of oxytocin according to our criterion.

DISCUSSION

The synthesis of literature suggest that oxytocin may influence the salience of threatening stimuli among healthy individuals, increasing the startle response to threat. It would be of interest to investigate the effects of oxytocin on the startle response to threat among clinical populations.

Predictive value of GGN and CAG repeat polymorphisms of androgen receptors in testicular cancer: a meta-analysis

The risk of testicular cancer (TC) is markedly increased in subjects with androgen insensitivity, and previous studies have proposed that GGN and CAG repeats in androgen receptors (AR) could be related to the risk of TC. To evaluate the association between the length of GGN and CAG repeats in AR and TC, a meta-analysis involving 3255 TC cases and 2804 controls was performed. The results suggested that long GGN repeats are associated with an increased risk of TC compared with those < 23 [odds ratio (OR) = 1.22, 95% confidence interval (CI) = 1.05–1.41]; similarly, a subgroup analysis revealed that this association occurred in studies with case sizes > 200, and in the mid-latitude, and seminoma subgroups. The subgroup analysis based on populations, high-latitude, and seminomas/non-seminomas suggested that AR CAG repeat polymorphisms with > 25 and < 21 + > 25 repeats might confer a protective effect to the patients with TC (in the high-latitude subgroup analysis, for > 25 vs. 21–25: OR = 0.54, 95% CI = 0.41–0.70). In contrast, an increased risk of TC was observed for AR CAG repeat polymorphisms with > 25 and < 21 + > 25 repeats in the mid-latitude subgroup (for > 25 vs. 21–25: OR = 1.65, 95% CI = 1.09–2.50). In addition, no associations between the remaining subgroups and male infertility were observed. In short, this meta-analysis suggested that AR GGN and CAG repeat polymorphisms may be involved in the etiology of TC.

Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery.

METHODS

Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA.

RESULTS

We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension.

CONCLUSIONS

There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.

Outcomes after liver transplantation in accordance with ABO compatibility: A systematic review and meta-analysis

AIM

To evaluate the differences in outcomes between ABO-incompatible (ABO-I) liver transplantation (LT) and ABO-compatible (ABO-C) LT.

METHODS

A systematic review and meta-analysis were performed by searching eligible articles published before No-vember 28, 2016 on MEDLINE (PubMed), EMBASE, and Cochrane databases. The primary endpoints were graft survival, patient survival, and ABO-I-related complications.

RESULTS

Twenty-one retrospective observational studies with a total of 8247 patients were included in this meta-analysis. Pooled results of patient survival for ABO-I LT were comparable to those for ABO-C LT. However, ABO-I LT showed a poorer graft survival than ABO-C LT (1-year: OR = 0.66, 95%CI: 0.57-0.76, P < 0.001; 3-year: OR = 0.74, 95% CI 0.64-0.85, P < 0.001; 5-yearr: OR =0.75, 95%CI: 0.66-0.86, P < 0.001). Furthermore, ABO-I LT was associated with more incidences of antibody-mediated rejection (OR = 74.21, 95%CI: 16.32- 337.45, P < 0.001), chronic rejection (OR =2.28, 95%CI: 1.00-5.22, P = 0.05), cytomegalovirus infection (OR = 2.64, 95%CI: 1.63-4.29, P < 0.001), overall biliary complication (OR = 1.52, 95%CI: 1.01-2.28, P = 0.04), and hepatic artery complication (OR = 4.17, 95%CI: 2.26-7.67, P < 0.001) than ABO-C LT. In subgroup analyses, ABO-I LT and ABO-C LT showed a comparable graft survival in pediatric patients and those using rituximab, and ABO-I LT showed an increased acute cellular rejection in cases involving deceased donor grafts.

CONCLUSION

Although patient survival in ABO-I LT was comparable to that in ABO-C LT, ABO-I LT was inferior to ABO-C LT in graft survival and several complications. Graft survival of ABO-I LT could be comparable to that of ABO-C LT in pediatric patients and those using rituximab.

Clinical research in critical care. Difficulties and perspectives

In the field of Intensive Care Medicine, improved survival has resulted from better patient care, the early detection of clinical deterioration, and the prevention of iatrogenic complications, while research on new treatments has been followed by an overwhelming number of disappointments. The origins of these fiascos must be sought in the conjunction of methodological problems - common to other disciplines - and the particularities of critically ill patients. The present article discusses both aspects and suggests some options for progress.

Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults: A Systemic Review and Meta-Analysis

BACKGROUND

Endotracheal intubation (EI) in ICU patients is associated with an increased risk of life-threatening adverse events due to unstable conditions, rapid deterioration, limited preparation time, and variability in the expertise of operators. The goal of this study was to compare the effect of video laryngoscopy (VL) and direct laryngoscopy (DL) in ICU patients requiring EI.

METHODS

We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception through January 30, 2017. Randomized controlled trials were included if they reported data on any of the predefined outcomes in ICU patients requiring EI and managed with VL or DL. Results were expressed as risk ratios (RRs) or mean differences (MDs) with accompanying 95% CIs.

RESULTS

Five randomized controlled trials with 1,301 patients were included. Despite better glottic visualization with VL (RR = 1.24; 95% CI, 1.07 to 1.43; P = .003), use of VL did not result in a significant increase in the first-attempt success rate (RR = 1.08; 95% CI, 0.92-1.26; P = .35) compared with DL. In addition, time to intubation (MD = 4.12 s; 95% CI, -15.86-24.09; P = .69), difficult intubation (RR = 0.72; 95% CI, 0.30-1.70; P = .45), mortality (RR = 1.02; 95% CI, 0.84-1.25; P = .83), and most other complications were similar between the VL and DL groups.

CONCLUSIONS

The VL technique did not increase the first-attempt success rate during EI in ICU patients compared with DL. These findings do not support routine use of VL in ICU patients.

Effects of levosimendan on mortality in patients with septic shock: systematic review with meta-analysis and trial sequential analysis

Object

Several studies have investigated a survival benefit for levosimendan treatment in patients with septic shock. However, data are conflicting. We conducted a meta-analysis to evaluate the effect of levosimendan treatment on mortality in patients with septic shock.

Materials and Methods

We searched PubMed, EMBASE and Cochrane Library Databases up to March 27, 2017, without language restrictions. We searched for terms related to septic shock, levosimendan, randomized clinical trial. Randomized controlled trials reported the effect of levosimendan on mortality were included. Moreover, we constructed the trial sequential analysis (TSA) to determine the reliability of the outcomes. Furthermore, secondary outcomes were cardiac index(CI), mean arterial pressure (MAP), blood lactate, norepinephrine dose and length of ICU stay.

Results

Ten studies with a total of 816 patients were included in this meta-analysis. There was no significant difference in the mortality between the levosimendan group and the standard inotropic therapy group [RR = 0.96, 95% CI (0.81–1.12), I² = 0]. However, methods adapted from formal interim monitoring boundaries applied to TSA indicated that the cumulative evidence was unreliable and inconclusive. Blood lactate was significantly reduced in the levosimendan group while there was no difference in MAP, CI, norepinephrine dose and length of ICU stay.

Conclusions

Findings from this meta-analysis demonstrated that levosimendan treatment may not reduce mortality in patients with septic shock. The result remains inclusive and further randomized controlled trials were needed to confirm these conclusions.

Intravenous fish oil in critically ill and surgical patients - Historical remarks and critical appraisal

The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated.

Guidelines for reporting meta-epidemiological methodology research

Published research should be reported to evidence users with clarity and transparency that facilitate optimal appraisal and use of evidence and allow replication by other researchers. Guidelines for such reporting are available for several types of studies but not for meta-epidemiological methodology studies. Meta-epidemiological studies adopt a systematic review or meta-analysis approach to examine the impact of certain characteristics of clinical studies on the observed effect and provide empirical evidence for hypothesised associations. The unit of analysis in meta-epidemiological studies is a study, not a patient. The outcomes of meta-epidemiological studies are usually not clinical outcomes. In this guideline, we adapt items from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) to fit the context of meta-epidemiological studies.

Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis

We aimed to investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in evaluating blunt abdominal trauma for patients presenting to the emergency department. Electronic search of Scopus and Pubmed was performed from inception to September 2016. Human studies investigating the diagnostic accuracy of CEUS in identifying abdominal solid organ injuries were included. Risk of bias was assessed using the QUADAS tool. A total of 10 studies were included in the study and 9 of them were included for meta-analysis. The log(DOR) values ranged from 3.80 (95% CI: 2.81-4.79) to 8.52 (95% CI: 4.58-12.47) in component studies. The combined log(DOR) was 6.56 (95% CI: 5.66-7.45). The Cochran's Q was 11.265 (p = 0.793 with 16 degrees of freedom), and the Higgins' I² was 0%. The CEUS had a sensitivity of 0.981 (95% CI: 0.868-0.950) and a false positive rate of 0.018 (95% CI: 0.010-0.032) for identifying parenchymal injuries, with an AUC of 0.984. CEUS performed at emergency department had good diagnostic accuracy in identifying abdominal solid organ injuries. CEUS can be recommended in monitoring solid organ injuries, especially for patients managed with non-operative strategy.

Polymorphisms of protamine genes contribute to male infertility susceptibility in the Chinese Han population

Protamine (PRM) plays important roles in the packaging of DNA within the sperm nucleus. To investigate the role of PRM1/2 and transition protein 1 (TNP1) polymorphisms in male infertility, 636 infertile men and 442 healthy individuals were recruited into this case-controlled study of the Chinese Han population, using MassARRAY technology to analyze genotypes. Our analysis showed that there were no significant differences between controls and infertile cases among the five single nucleotide polymorphisms identified in PRM1, PRM2 and TNP1 [rs737008 (G/A), rs2301365 (C/A), rs2070923 (C/A), rs1646022 (C/G) and rs62180545 (A/G)]. However, we found that the PRM1 and PRM2 haplotypes GCTGC, TCGCA and TCGCC exhibited significant protective effects against male infertility compared to fertile men, while TCGGA, GCTCC and TCGGC represented significant risk factors for spermatogenesis. Our data showed that rs737008 and rs2301365 in PRM1, and rs1646022 in PRM2, were significantly associated with male infertility and that gene–gene interaction played a role in male infertility. A linkage disequilibrium plot for the five SNPs showed that rs737008 was strongly linked with both rs2301365 and rs2070923. These findings are likely to help improve our understanding of the etiology of male infertility. Further studies should include a larger number of genes and SNPs, particularly growing critical genes; such studies will help us to unravel the effect of individual genetic factors upon male infertility.

Different research designs and their characteristics in intensive care

Different research designs have various advantages and limitations inherent to their main characteristics. Knowledge of the proper use of each design is of great importance to understanding the applicability of research findings to clinical epidemiology.

In intensive care, a hierarchical classification of designs can often be misleading if the characteristics of the design in this context are not understood. One must therefore be alert to common problems in randomized clinical trials and systematic reviews/meta-analyses that address clinical issues related to the care of the critically ill patient.

Sedation of mechanically ventilated adults in intensive care unit: a network meta-analysis

Sedatives are commonly used for mechanically ventilated patients in intensive care units (ICU). However, a variety of sedatives are available and their efficacy and safety have been compared in numerous trials with inconsistent results. To resolve uncertainties regarding usefulness of these sedatives, we performed a systematic review and network meta-analysis. Randomized controlled trials comparing sedatives in mechanically ventilated ICU patients were included. Graph-theoretical methods were employed for network meta-analysis. A total of 51 citations comprising 52 RCTs were included in our analysis. Dexmedetomidine showed shorter MV duration than lorazepam (mean difference (MD): 68.7; 95% CI: 18.2-119.3 hours), midazolam (MD: 10.2; 95% CI: 7.7-12.7 hours) and propofol (MD: 3.4; 95% CI: 0.9-5.9 hours). Compared with dexmedetomidine, midazolam was associated with significantly increased risk of delirium (OR: 2.47; 95% CI: 1.17-5.19). Our study shows that dexmedetomidine has potential benefits in reducing duration of MV and lowering the risk of delirium.

Can NGAL be employed as prognostic and diagnostic biomarker in human cancers? A systematic review of current evidence

BACKGROUND

Some studies have reported differentially altered neutrophil gelatinase-associated lipocalin (NGAL) levels in several malignancies. We evaluated NGAL measured in plasma or urine as both prognostic and diagnostic marker for different types of human tumors.

METHODS

We performed systematic electronic searches in Medline, Embase and CRDTAS. Studies were included if they evaluated NGAL as a prognostic or diagnostic marker for human cancers. The selection of the studies, screening of the full texts and data extraction were conducted independently by 2 authors. We used the random-effects model for the meta-analyses. A methodological assessment was completed.

RESULTS

We included 35 studies dedicated to colorectal, pancreas, breast, thyroid, gastric, kidney, endometrial, brain, liver, lung, esophageal, oral and ovarian cancers. Our meta-analyses showed that, in patients with colorectal and breast cancer, positive NGAL expression was associated with a decrease of disease-free survival (hazard ratio [HR] = 2.27, 95% confidence interval [95% CI], 1.54-3.36; HR = 1.78, 95% CI, 1.33-2.38, respectively). NGAL was a negative prognostic marker of overall survival in colorectal (HR = 2.37, 95% CI, 1.68-3.34) and endometrial (HR = 4.38, 95% CI, 1.9-10.12) cancers. Discriminative power of NGAL between cancer patients and control was moderate in colorectal cancer (area under the curve [AUC] = 0.6; pooled sensitivity 0.56; pooled specificity 0.72), acceptable in pancreatic cancer (AUC = 0.8; pooled sensitivity 0.6; pooled specificity 0.8) and good in thyroid cancer (AUC = 0.9; pooled sensitivity 0.85; pooled specificity 0.96).

CONCLUSIONS

NGAL determination in plasma and urine could be useful in the prognosis of colorectal and breast cancer, but its prognostic accuracy remains uncertain for other human tumors.

Prognostic role of copeptin with all-cause mortality after heart failure: a systematic review and meta-analysis

BACKGROUND

As the C-terminal section of vasopressin precursor, copeptin has been recently suggested as a new prognostic biomarker after heart failure (HF). Thus, the aim of this study was to evaluate the prognostic value of plasma copeptin level with all-cause mortality in patients with HF.

METHODS

Comprehensive strategies were used to search relevant studies from electronic databases. Pooled hazard ratios (HRs) and standardized mean differences (SMDs) together with their 95% confidence intervals (CIs) were calculated. Subgroup analysis and sensitivity analysis were performed to find the potential sources of heterogeneity.

RESULTS

A total of 5,989 participants from 17 prospective studies were included in this meta-analysis. A significant association was observed between circulating copeptin levels and risk of all-cause mortality in patients with HF (categorical copeptin: HR =1.69, 95% CI =1.42-2.01; per unit copeptin: HR =1.03, 95% CI =1.00-1.07; log unit copeptin: HR =3.26, 95% CI =0.95-11.25). Pooled SMD showed that copeptin levels were significantly higher in patients with HF who died during the follow-up period than in survivors (SMD =1.19, 95% CI =0.81-1.57). Subgroup analyses also confirmed this significant association, while sensitivity analyses indicated that the overall results were stable.

CONCLUSION

This study demonstrated that circulating copeptin seemed to be a novel biomarker to provide better prediction of all-cause mortality in patients with HF.

Perioperative statin therapy in cardiac surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Several studies suggest beneficial effects of perioperative statin therapy on postoperative outcome after cardiac surgery. However, recent randomized controlled trials (RCTs) show potential detrimental effects. The objective of this systematic review is to examine the association between perioperative statin therapy and clinical outcomes in cardiac surgery patients.

METHODS

Electronic databases were searched up to 1 November 2016 for RCTs of preoperative statin therapy versus placebo or no treatment in adult cardiac surgery. Postoperative outcomes were acute kidney injury, atrial fibrillation, myocardial infarction, stroke, infections, and mortality. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using fixed-effects meta-analyses. Primary analysis was restricted to trials with low risk of bias according to Cochrane methodology, and sensitivity analyses examined whether the risk of bias of included studies was associated with different results. We performed trial sequential analysis (TSA) to test the strength of the results.

RESULTS

We included data from 23 RCTs involving 5102 patients. Meta-analysis of trials with low risk of bias showed that statin therapy was associated with an increase in acute kidney injury (314 of 1318 (23.82%) with statins versus 262 of 1319 (19.86%) with placebo; OR 1.26 (95%CI 1.05 to 1.52); p = 0.01); these results were supported by TSA. No difference in postoperative atrial fibrillation, myocardial infarction, stroke, infections, or mortality was present. On sensitivity analysis, statin therapy was associated with a slight increase in hospital mortality. Meta-analysis including also trials with high or unclear risk of bias showed no beneficial effects of statin therapy on any postoperative outcomes.

CONCLUSIONS

There is no evidence that statin therapy in the days prior to cardiac surgery is beneficial for patients' outcomes. Particularly, statins are not protective against postoperative atrial fibrillation, myocardial infarction, stroke, or infections. Statins are associated with a possible increased risk of acute kidney injury and a detrimental effect on hospital survival could not be excluded. Future RCTs should further evaluate the safety profile of this therapy in relation to patients' outcomes and assess the more appropriate time point for discontinuation of statins before cardiac surgery.

Noninvasive Positive Pressure Ventilation in Chronic Heart Failure

Instruction and Objectives. Noninvasive positive pressure ventilation (NPPV) alleviates sleep-disordered breathing (SDB) and it may improve cardiac function in SDB patients. Because large randomized controlled trials directly evaluating the impact of NPPV on cardiac function are lacking, we conducted a meta-analysis of published data on effectiveness of NPPV in improving cardiac function in patients with chronic heart failure regardless of SDB presence. Methods. Controlled trials were identified in PubMed, OVID, and EMBASE databases. Both fixed and randomized models were used in meta-analysis with primary outcomes of left ventricular ejection fraction (LVEF). Results. Nineteen studies were included with a total of 843 patients. Compared to standard medical treatment (SMT) plus sham-NPPV or SMT only, NPPV plus SMT was associated with improvement in LVEF (weighted mean difference 5.34, 95% CI, [3.85,6.82]; P < 0.00001) and plasma brain natriuretic peptide (BNP) level (weighted mean difference -117.37, 95% CI, [-227.22, -7.52]; P = 0.04) and no influence on overall mortality (RR 1.00, 95% CI, [0.96,1.04]; P = 0.95). Conclusions. In the present meta-analysis, use of NPPV plus SMT improved LVEF and reduced plasma BNP level but did not improve overall mortality in patients with chronic heart failure.

Noninvasive Ventilation with Heliox for Respiratory Distress Syndrome in Preterm Infant: A Systematic Review and Meta-Analysis

Objectives. To assess whether noninvasive ventilation with Heliox reduces the need for endotracheal ventilation and subsequent complications in preterm infants with respiratory distress syndrome (RDS). Methods. A search of major electronic databases, including MEDLINE and the Cochrane Central Register of Controlled Trials, for randomized or quasi-randomized controlled trials that compared noninvasive ventilation with Heliox versus noninvasive ventilation with standard gas for preterm infants with RDS was performed. The primary outcome was the incidence of intubation. The secondary outcomes were the level of PaCO₂, the use of surfactant, and other complications. Results. Two randomized and one quasi-randomized controlled trials including 123 preterm infants were assessed. Heliox was found to significantly decrease the incidence of intubation (RR: 0.42; 95% CI: 0.23 to 0.78), the level of PaCO₂ (MD: −9.61; 95% CI: −15.76 to −03.45), and the use of surfactant (RR: 0.25; 95% CI: 0.10 to 0.61) as compared with standard gas. No significant differences were found in other secondary outcomes. Conclusions. Noninvasive ventilation with Heliox decreases the incidence of intubation in preterm infants suffering from RDS. However, data on clinical outcomes are limited. Larger trials are needed to verify the beneficial effects.

Current Treatments for Breast Cancer-Related Lymphoedema: A Systematic Review

Background and objective: Breast cancer-related lymphoedema (BCRL) is a disabling complication with long term impact on quality on life after breast cancer treatment. Its management remains a major challenge for patients and health care professionals; the goal of this overview was to summarize effects of different treatment strategies for patients with BCRL. Methods: A thorough search was undertaken to allow a systematic review or meta-analysis of treatments for BCRL. Two investigators independently selected studies and abstracted the data. Results: Combined physical therapy (CPT) with different combinations of surgery, oral pharmaceuticals, low-level laser therapy, weight reduction, mesenchymal stem cell therapy, kinesio tex taping, and acupuncture might be effective in reducing lymphoedema, but exercise demonstrated no obvious benefit. The results of direct comparisons showed CPT might be more effective than standard physiotherapy (ST). Manual lymphatic drainage (MLD) may not offer additional benefits to ST for swelling reduction, but could facilitate compression bandaging. MLD seemed to have similar effects with self-administered simple lymphatic drainage (SLD) or using an intermittent pneumatic compression pump (IPC). IPC might also not be associated with additional effectiveness for CPT. Efficacy of stem cell therapy vs. compression sleeve or CPT, as well as the effects of daflon and coumarin could not be established. Conclusion: Although many treatments for BCRL might reduce lymphoedema volume, their effects were not well established. The quality of many of the original studies in the included reviews was not optimal, so that in future randomized control trials are a high priority.

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

INTRODUCTION

The Surviving Sepsis Campaign guidelines recommend early goal-directed therapy (EGDT) for the resuscitation of patients with sepsis; however, the recent evidences quickly evolve and convey conflicting results. We performed a meta-analysis to evaluate the effect of EGDT on mortality in adults with severe sepsis and septic shock.

METHODS

We searched electronic databases to identify randomized controlled trials that compared EGDT with usual care or lactate-guided therapy in adults with severe sepsis and septic shock. Predefined primary outcome was all-cause mortality at final follow-up.

RESULTS

We included 13 trials enrolling 5268 patients. Compared with usual care, EGDT was associated with decreased mortality (risk ratio [RR]: 0.87, 95% CI: 0.77-0.98; 4664 patients, 8 trials; Grading of Recommendations Assessment, Development, and Evaluation [GRADE] quality of evidence was moderate). Compared with lactate clearance-guided therapy, EGDT was associated with increased mortality (RR: 1.60, 95% CI: 1.24-2.06; 604 patients, 5 trials; GRADE quality of evidence was low). Patients assigned to EGDT received more intravenous fluid, red cell transfusion, vasopressor infusion, and dobutamine use within the first 6 hours than those assigned to usual care (all P values < .00001).

CONCLUSION

Adults with severe sepsis and septic shock who received EGDT had a lower mortality than those given usual care, the benefit may mainly be attributed to treatments administered within the first 6 hours. However, the underlying mechanisms by which lactate clearance-guided therapy benefits these patients are yet to be investigated.

Condom-Insistence Conflict in Women's Alcohol-Involved Sexual Encounters with a New Male Partner

First-time sexual intercourse with a new male partner, relative to other sexual encounters, is associated with heightened risk to women for contracting sexually transmitted infections. Little is known, however, about women's condom-related decision-making processes during these first-time sexual encounters. In the present study, we surveyed a community sample of 179 women aged 18-30 about their alcohol consumption, desire to use a condom, perception of their partner's desire to use a condom, condom-insistence conflict, and condom-decision abdication and use during their most recent alcohol-involved first-time sexual encounter with a new partner. With structural equation modeling we tested a cognitive mediation model with various configurations of alcohol effects on abdication and condom use (direct, indirect, moderator). A moderated mediation model fit the data best. Women experienced elevated condom-insistence conflict when they wanted to use a condom and perceived their partner did not; conflict, in turn, was associated with higher likelihood of abdication and lower likelihood of condom use. Higher alcohol intoxication attenuated the associations of desire to use a condom, and perceived partner's desire to use a condom, with conflict. Results support an alcohol myopia-conflict inhibition-reduction model and emphasize the importance of sex education programs that teach young women not only about condom-related assertiveness and the effects of alcohol, but also prepare them to respond to experiences of conflict that arise during sexual encounters.

Impact of including or excluding both-armed zero-event studies on using standard meta-analysis methods for rare event outcome: a simulation study

OBJECTIVES

There is no consensus on whether studies with no observed events in the treatment and control arms, the so-called both-armed zero-event studies, should be included in a meta-analysis of randomised controlled trials (RCTs). Current analytic approaches handled them differently depending on the choice of effect measures and authors' discretion. Our objective is to evaluate the impact of including or excluding both-armed zero-event (BA0E) studies in meta-analysis of RCTs with rare outcome events through a simulation study.

METHOD

We simulated 2500 data sets for different scenarios varying the parameters of baseline event rate, treatment effect and number of patients in each trial, and between-study variance. We evaluated the performance of commonly used pooling methods in classical meta-analysis-namely, Peto, Mantel-Haenszel with fixed-effects and random-effects models, and inverse variance method with fixed-effects and random-effects models-using bias, root mean square error, length of 95% CI and coverage.

RESULTS

The overall performance of the approaches of including or excluding BA0E studies in meta-analysis varied according to the magnitude of true treatment effect. Including BA0E studies introduced very little bias, decreased mean square error, narrowed the 95% CI and increased the coverage when no true treatment effect existed. However, when a true treatment effect existed, the estimates from the approach of excluding BA0E studies led to smaller bias than including them. Among all evaluated methods, the Peto method excluding BA0E studies gave the least biased results when a true treatment effect existed.

CONCLUSIONS

We recommend including BA0E studies when treatment effects are unlikely, but excluding them when there is a decisive treatment effect. Providing results of including and excluding BA0E studies to assess the robustness of the pooled estimated effect is a sensible way to communicate the results of a meta-analysis when the treatment effects are unclear.

Tanezumab for Patients with Osteoarthritis of the Knee: A Meta-Analysis

OBJECTIVE

Tanezumab is a new therapeutic intervention for patients with osteoarthritis (OA) of the knee. We performed the present meta-analysis to appraise the efficacy and safety of tanezumab for patients with knee OA.

METHODS

We systematically searched randomized controlled trials from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL). The primary outcomes were mean change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, the WOMAC physical function and patient's global assessment (PGA). Outcomes were reported as the standard mean difference (SMD) or relative risk (RR) with 95% confidence interval (CI). We assessed the pooled data using a random-effects model.

RESULTS

Of the identified studies, four were eligible and were included in this meta-analysis (N = 1839 participants). Compared with the placebo groups, tanezumab yielded a significant reduction in mean change in the WOMAC pain (SMD = 0.51, 95% CI 0.34 to 0.69, P<0.00001), the WOMAC physical function (SMD = 0.56, 95% CI 0.38 to 0.74, P<0.00001) and PGA (SMD = 0.34, 95% CI 0.22 to 0.47, P<0.00001). There was no significant difference in serious adverse events (RR = 1.06, 95% CI 0.59 to 1.92, P = 0.84) between the tanezumab and placebo groups. Tanezumab significantly increased discontinuations due to adverse events (RR = 2.89, 95% CI 1.59 to 5.26, P = 0.0005), abnormal peripheral sensations (RR = 3.14, 95% CI 2.12 to 4.66, P<0.00001), and peripheral neuropathy (RR = 6.05, 95% CI 2.32 to 15.81, P = 0.0002).

CONCLUSION

Tanezumab can alleviate pain and improve function for patients with OA of the knee. However, considering the limited number of studies, this conclusion should be interpreted cautiously and more clinical randomized controlled trials are needed to verify the efficacy and safety of tanezumab for OA of the knee.

Intravenous immune globulin and thromboembolic adverse events: A systematic review and meta-analysis of RCTs

Prior case reports and observational studies indicate that intravenous immune globulin (IVIg) products may cause thromboembolic events (TEEs), leading the FDA to require a boxed warning in 2013. The effect of IVIg treatment on the risk of serious TEEs (acute myocardial infarction, ischemic stroke, or venous thromboembolism) was assessed using adverse event data reported in randomized controlled trials (RCTs) of IVIg. RCTs of IVIg in adult patients from 1995 to 2015 were identified from Pubmed, Embase, ClinicalTrials.Gov, and two large prior reviews of IVIg's therapeutic applications. Trials at high risk of detection or reporting bias for serious adverse events were excluded. 31 RCTs with a total of 4,129 participants (2,318 IVIg-treated, 1,811 control) were eligible for quantitative synthesis. No evidence was found of increased TEE risk among IVIg-treated patients compared with control patients (odds ratio = 1.10, 95% CI: 0.44, 2.88; risk difference = 0.0%, 95% CI: -0.7%, 0.7%, I(2)  = 0%). No significant increase in risk was found when arterial and venous TEEs were analyzed as separate endpoints. Trial publications provided little specific information concerning the methods used to ascertain potential adverse events. Care should be taken in extrapolating the results to patients with higher baseline risks of TEE. Am. J. Hematol. 91:594-605, 2016. © 2016 Wiley Periodicals, Inc.

Meta-epidemiological study: a step-by-step approach by using R

The results of meta-analysis are usually influenced by characteristics of component trials. These characteristics include but are not limited to sample size, publication language, quality of study design and the number of participating centers. Because systematic review and meta-analysis is considered to be evidence of the highest quality in the era of evidence-based medicine, characteristics that may bias the results of meta-analysis should be fully investigated. Meta-epidemiological study aims to investigate the impact of study design characteristics on treatment effect. The article introduces how to perform meta-epidemiological study by using R software. There are several methodological approaches to perform meta-epidemiological study, depending on whether there is heterogeneity between meta-analyses and between trials. When there is no significant heterogeneity, these results would be similar.

Pulmonary Toxicities of Gefitinib in Patients With Advanced Non-Small-Cell Lung Cancer: A Meta-Analysis of Randomized Controlled Trials

Gefitinib is a selective tyrosine kinase inhibitor of the epidermal growth factor receptor (EGFR) used to treat adults with EGFR mutation-positive non-small-cell lung cancer (NSCLC). Clinical benefits of gefitinib administration in NSCLC patients have been observed in clinical practice, but the extent of the pulmonary toxicity of gefitinib in patients with advanced NSCLC remains unclear. The aim of this systematic review was to evaluate the overall incidence and risk of gefitinib-related pulmonary toxicity in advanced NSCLC patients. Relevant trials were identified from the databases of Pubmed, Embase, Cochrane Library, and the clinicaltrials.gov of the U.S. National Institutes of Health. The outcomes included the overall incidence, odds ratios (ORs), and 95% confidence intervals (CIs). Fixed-effects models were used in the statistical analyses according to the heterogeneity of the included studies. According to the data from the included trials, the overall incidence of high-grade hemoptysis, pneumonia, pneumonitis, and interstitial lung disease (ILD) was 0.49% (95% CI: 0.24%-0.99%), 2.33% (95% CI: 1.47%-3.66%), 2.24% (95% CI: 1.34%-3.72%), and 1.43% (95% CI: 0.98%-2.09%), respectively. The pooled ORs of high-grade hemoptysis, pneumonia, pneumonitis, and ILD were 1.73 (95% CI: 0.46-6.52; P = 0.42), 0.99 (95% CI: 0.66-1.49; P = 0.95), 4.70 (95% CI: 1.48-14.95; P = 0.0087), and 2.64 (95% CI: 1.22-5.69; P = 0.01), respectively. Gefitinib was associated with a significantly increased risk of high-grade/fatal ILD and pneumonitis compared with the controls, whereas the risk of other high-grade pulmonary events (pneumonia and hemoptysis) was not significant. Careful surveillance of gefitinib-related pulmonary toxicity is critical for the safe use of this drug.

Interventions for sexual dysfunction following treatments for cancer in women

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life, including sexual function, in those affected by cancer. Sexual dysfunction is a potential long-term complication of many cancer treatments. This includes treatments that have a direct impact on the pelvic area and genitals, and also treatments that have a more generalised (systemic) impact on sexual function.This is an update of the original Cochrane review published in Issue 4, 2007, on interventions for treating sexual dysfunction following treatments for cancer for men and women. Since publication in 2007, there has been an increase in the number of trials for both men and women and this current review critiques only those for women. A review in press will present those for men.

OBJECTIVES

To evaluate the effectiveness of interventions for treating sexual dysfunction in women following treatments for cancer. To assess adverse events associated with interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9), MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, Dissertation Abstracts and the NHS Research Register. The searches were originally run in January 2007 and we updated these to September 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed the effectiveness of a treatment for sexual dysfunction. The trial participants were women who had developed sexual dysfunction as a consequence of a cancer treatment. We sought evaluations of interventions that were pharmaceutical, mechanical, psychotherapeutic, complementary or that involved physical exercise.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. We considered meta-analysis for trials with comparable key characteristics.

MAIN RESULTS

Since the original version of this review we have identified 11 new studies in women. The one study identified in the earlier version of this review was excluded in this update as it did not meet our narrower inclusion criteria to include only interventions for the treatment, not prevention, of sexual dysfunction.In total 1509 female participants were randomised across 11 trials. All trials explored interventions following treatment either for gynaecological or breast cancer. Eight trials evaluated a psychotherapeutic or psycho-educational intervention. Two trials evaluated a pharmaceutical intervention and one pelvic floor exercises. All involved heterosexual women. Eight studies were at a high risk of bias as they involved a sample of fewer than 50 participants per trial arm. The trials varied not only in intervention content but in outcome measurements, thereby restricting combined analysis. In the trials evaluating a psychotherapeutic intervention the effect on sexual dysfunction was mixed; in three trials benefit was found for some measures of sexual function and in five trials no benefit was found. Evidence from the other three trials, two on different pharmaceutical applications and one on exercise, differed and was limited by small sample sizes. Only the trial of a pH-balanced vaginal gel found significant improvements in sexual function. The trials of pharmaceutical interventions measured harm: neither reported any. Only one psychological intervention trial reported that no harm occurred because of the intervention; the other trials of psychological support did not measure harm.

AUTHORS' CONCLUSIONS

Since the last version of this review, the new studies do not provide clear information on the impact of interventions for sexual dysfunction following treatments for cancer in women. The sexual dysfunction interventions in this review are not representative of the range that is available for women, or of the wider range of cancers in which treatments are known to increase the risk of sexual problems. Further evaluations are needed.

Efficacy and Safety of Bisphosphonates for Low Bone Mineral Density After Kidney Transplantation: A Meta-Analysis

In patients with low bone mineral density (BMD) after kidney transplantation, the role of bisphosphonates remains unclear. We performed a systematic review and meta-analysis to investigate the efficacy and safety of bisphosphonates.We retrieved trials from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception through May 2015. Only randomized controlled trials that compared bisphosphonate-treated and control groups of patients with low bone mineral density after kidney transplantation were included. The primary outcomes were the percent change in BMD, the absolute change in BMD, and the BMD at the end of study at the lumbar spine. The results were expressed as the mean difference (MD) or relative risk (RR) with the 95% confidence interval (CI). We used a random-effects model to pool the outcomes.We included 17 randomized controlled trials with 1067 patients. Only 1 included trial was found to be at low risk of bias. The rest of the included studies were found to have high to uncertain risk of bias. Compared with the control group, those who received bisphosphonates had a significant increase in percent change in BMD (mean difference [MD] = 5.51, 95% confidence interval [CI] 3.22-7.79, P < 0.00001) and absolute change in BMD (MD = 0.05, 95% CI 0.04-0.05, P < 0.00001), but a nonsignificant increase in BMD at the end of the study (MD = 0.02, 95% CI -0.01 to 0.05, P = 0.25) at the lumbar spine. Bisphosphonates resulted in a significant improvement in percent change in BMD (MD = 4.95, 95% CI 2.57-7.33, P < 0.0001), but a nonsignificant improvement in absolute change in BMD (MD = 0.03, 95% CI -0.00 to 0.06, P = 0.07) and BMD at the end of the study (MD = -0.01, 95% CI -0.04 to 0.02, P = 0.40) at the femoral neck. No significant differences were found in vertebral fractures, nonvertebral fractures, adverse events, and gastrointestinal adverse events.Bisphosphonates appear to have a beneficial effect on BMD at the lumbar spine and do not significantly decrease fracture events in recipients. However, the results should be interpreted cautiously due to the lack of robustness and the heterogeneity among studies.

Systematic review with meta-analysis: the risk of major gastrointestinal bleeding with non-vitamin K antagonist oral anticoagulants

BACKGROUND

Gastrointestinal (GI) bleeding is a common complication among anticoagulated patients. Non-vitamin K antagonist oral anticoagulants (NOACs) are associated with increased risk of GI (major and clinically relevant non-major) bleeding. However, more information is needed regarding severe events.

AIM

To evaluate the risk of NOACs major GI bleeding.

METHODS

We searched for phase III randomised clinical trials (RCT) evaluating NOACs (apixaban, dabigatran, edoxaban and rivaroxaban) and reporting major GI bleeding events, in MEDLINE, Cochrane Library, SciELO collection and Web of Science databases (July 2015). Meta-analysis was performed to estimate risk ratio (RR) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with the I(2) test.

RESULTS

A total of 23 studies were included. Among patients with atrial fibrillation, the risk of major GI bleeding was not different between NOACs and vitamin K antagonists (VKA) (RR 1.08, 95% CI 0.85-1.36, I(2)  = 78%; 5 RCTs) or acetylsalicylic acid (RR 0.78, 95% CI 0.36-1.72; 1 RCT). Similar results were found for patients undergoing orthopaedic surgery and those with venous thromboembolism. NOACs were not found to increase the risk compared to low-molecular-weight heparin (LWMH) alone (RR 1.42, 95% CI 0.55-3.71, I(2)  = 7%; 8 RCTs), the sequential treatment with LMWH-VKA (RR 0.77, 95% CI 0.49-1.21, I(2)  = 43%; 7 RCTs) or placebo (RR 1.48, 95% CI 0.15-14.84, I(2)  = 21%; 2 RCTs).

CONCLUSION

Despite previous evidence supporting the association of non-vitamin K antagonist oral anticoagulants and overall GI bleeding, non-vitamin K antagonist oral anticoagulants are not associated with increased risk of major GI bleeding compared to other anticoagulant drugs (with known increased risk of these events).

Nebulised dornase alfa versus placebo or hypertonic saline in adult critically ill patients: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

BACKGROUND

Nebulised dornase alfa is used off-label in critically ill patients. We aimed to assess the benefits and harms of nebulised dornase alfa versus placebo, no prophylaxis, or hypertonic saline on patient-important outcome measures in adult critically ill patients.

METHODS

We performed a systematic review with meta-analysis and trial sequential analysis (TSA) using the Cochrane Collaboration methodology. Eligible trials were randomised clinical trials comparing nebulised dornase alfa with placebo, no prophylaxis, or hypertonic saline. The predefined outcome measures were all-cause mortality, duration of mechanical ventilation, length of stay, and adverse events. Two reviewers independently assessed trials for inclusion, data extraction, and risk of bias. Risk ratios (RRs) with 95 % confidence intervals (CIs) were estimated by conventional cumulative meta-analysis, and the robustness of the primary estimate was assessed by TSA.

RESULTS

Two trials (n = 63) were included; both were judged to have high risk of bias. There was no statistically significant difference in mortality (random effects model RR (95 % CI) 0.73 (0.09-5.77); P = 0.24; I (2) = 30 %). TSA could not be conducted because less than 1 % of the required information size had been accrued. None of the two trials reported adequate and detailed data on any of the secondary outcome measures.

CONCLUSIONS

We found very low quantity and quality of evidence for use of nebulised dornase alfa in adult critically ill patients in this systematic review with meta-analysis.

SYSTEMATIC REVIEW REGISTRATION

The International Prospective Register of Systematic Reviews (PROSPERO), no. CRD442015016047.

Polymorphisms in Protamine 1 and Protamine 2 predict the risk of male infertility: a meta-analysis

Several studies have investigated the association between polymorphisms in protamine 1 and 2 genes and male infertility risk, with inconsistent results to date. This meta-analysis based on the 13 published case-control studies, including 7350 cases and 6167 controls, was performed to further establish the potential association between the 6 common single nucleotide polymorphisms (rs35576928, rs737008, rs35262993, rs2301365, rs1646022, rs2070923) in protamines 1 and 2 and male infertility. The -190C > A (rs2301365) polymorphism was identified as a risk factor for male infertility under all models. Interestingly, rs1646022 and rs737008 polymorphisms exerted protective effects against male sterility in Asian and population-based under some models. No associations between the remaining SNPs and male sterility were observed.

Lung protective ventilation in patients undergoing major surgery: a systematic review incorporating a Bayesian approach

OBJECTIVE

Protective ventilation (PV) has been validated in patients with acute respiratory distress syndrome. However, the effect of PV in patients undergoing major surgery is controversial. The study aimed to explore the beneficial effect of PV on patients undergoing a major operation by systematic review and meta-analysis.

SETTING

Various levels of medical centres.

PARTICIPANTS

Patients undergoing general anaesthesia.

INTERVENTIONS

PV with low tidal volume.

PRIMARY AND SECONDARY OUTCOME MEASURES

Study end points included acute lung injury (ALI), pneumonia, atelectasis, mortality, length of stay (LOS) in intensive care unit (ICU) and hospital.

METHODS

Databases including PubMed, Scopus, EBSCO and EMBASE were searched from inception to May 2015. Search strategies consisted of terms related to PV and anaesthesia. We reported OR for binary outcomes including ALI, mortality, pneumonia, atelectasis and other adverse outcomes. Weighted mean difference was reported for continuous outcomes such as LOS in the ICU and hospital, pH value, partial pressure of carbon dioxide, oxygenation and duration of mechanical ventilation (MV).

MAIN RESULTS

A total of 22 citations were included in the systematic review and meta-analysis. PV had protective effect against the development of ALI as compared with the control group, with an OR of 0.41 (95% CI 0.19 to 0.87). PV tended to be beneficial with regard to the development of pneumonia (OR 0.46, 95% CI 0.16 to 1.28) and atelectasis (OR 0.68, 95% CI 0.46 to 1.01), but statistical significance was not reached. Other adverse outcomes such as new onset arrhythmia were significantly reduced with the use of PV (OR 0.47, 95% CI 0.48 to 0.93).

CONCLUSIONS

The study demonstrates that PV can reduce the risk of ALI in patients undergoing major surgery. However, there is insufficient evidence that such a beneficial effect can be translated to more clinically relevant outcomes such as mortality or duration of MV.

TRIAL REGISTRATION NUMBER

The study was registered in PROSPERO (http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42013006416.

Incidence and risk of hypertension with bevacizumab in non-small-cell lung cancer patients: a meta-analysis of randomized controlled trials

Aim

A study was conducted to determine the overall risk and incidence of hypertension with bevacizumab in non-small-cell lung cancer (NSCLC) patients.

Materials and methods

Electronic databases such as the Embase, PubMed, and Cochrane Library were searched for related trials. Statistical analyses were conducted to calculate the overall incidence rates, odds ratios (ORs), and 95% confidence intervals (CIs) by using either random-effect or fixed-effect models depending on the heterogeneity.

Results

A total of 3,155 subjects from nine studies were included. The overall incidences of all-grade and high-grade hypertension in NSCLC patients were 19.55% (95% CI 10.17%–34.3%) and 6.95% (95% CI 5.81%–8.30%). Bevacizumab use was associated with a significantly increased risk in all-grade hypertension (OR 8.07, 95% CI 3.87–16.85; P=0.0002) and high-grade hypertension (OR 5.93, 95% CI 3.41–10.32; P<0.0001). No evidence of publication bias was determined for the ORs of hypertension in our meta-analysis.

Conclusion

Bevacizumab is associated with a significantly increased risk of hypertension development in NSCLC patients. Early monitoring and effective management of hypertension might be important steps for the safe use of this drug.

Tolerability and Acceptability of Non-Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation: Systematic Review and Meta-Analysis

BACKGROUND

The non-vitamin K antagonist oral anticoagulants (NOACs) overcame some limitations of vitamin K antagonists (VKAs), and are at least as effective in stroke prevention, with an additional decrease of intracranial bleeding risk. The transferability of these benefits to the real world requires tolerability (related to adverse events) and acceptability (drug discontinuation) profiles at least similar to VKAs.

METHODS

We performed a systematic review with meta-analysis of randomized controlled trials (RCTs) evaluating NOACs versus VKAs in patients with non-valvular atrial fibrillation (AF). Studies were searched in April 2015 through MEDLINE, the Cochrane Collaboration's Database, Health Technology Assessment (HTA), Web of Science, and regulatory agencies' documents. Serious adverse events (SAEs) as well as drug-related and patient-related discontinuation rates were the outcomes of interest. Random-effects meta-analysis was performed, and the results expressed as risk ratios (RRs) and 95 % confidence intervals (CIs). Heterogeneity was evaluated with I (2) test.

RESULTS

Five RCTs evaluating four NOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) and 72,720 patients were included. Overall, NOACs were associated with a 4 % risk reduction of SAEs (95 % CI 2-6; I (2) = 0 %). Drug-related and patient-related discontinuation rates were similar between NOACs and VKAs (RR 1.03 [0.88-1.21] and RR 0.99 [0.89-1.10], respectively). Significant heterogeneity (I (2) ≥ 75 %) was found among studies results, which could be, at least partially, explained by the findings of the open-label dabigatran trial.

CONCLUSIONS

NOACs were associated with a small, yet significant, risk reduction of SAEs in patients with AF. NOACs' drug-related and patient-related acceptability profiles were similar to those for VKAs. The results were heterogeneous mainly because of the increased rate of discontinuation associated with dabigatran. Pragmatic trials and cohort studies should be conducted to further address these important clinical questions.

Doppler-based renal resistive index for prediction of renal dysfunction reversibility: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Doppler-based renal resistive index (RI) might help in distinguishing transient from persistent acute kidney injury (AKI). The main objective of these systematic review and meta-analysis was to investigate the diagnostic performance of RI in predicting short-term reversibility of AKI.

STUDY DESIGN

A systematic review of the literature was performed. Relevant studies were identified in Pubmed and Cochrane databases covering the years 1985 to 2013 and reviewed independently by 3 authors. Renal transplant recipients were excluded from this analysis. The summary estimates were computed using a random-effects model based on the DerSimonian and Lair meta-analytic method.

RESULTS

Among the 154 unique articles identified, 9 studies were included. Of the 176 patients in these studies with elevated RI or pulsatility index, 146 (83%) had a persistent AKI vs 44 (16%) of the 273 patients with normal values. Elevated RI or pulsatility index was associated with an increased risk of persistent AKI (odds ratio, 29.85; 95% confidence interval [CI], 8.73-102.16; P < .00001) with significant heterogeneity (I(2) = 75.0%, P < .0001). The pooled sensitivity and specificity were 0.83 (95% CI, 0.77-0.88) and 0.84 (95% CI, 0.79-0.88). The summary positive and negative likelihood ratios were 4.9 (95% CI, 2.44-9.87) and 0.21 (95% CI, 0.11-0.41).

CONCLUSION

These results suggest that an elevated RI may be a predictor of persistent AKI in critically ill patients. Further studies are warranted, however, to clarify the exact test performance given the marked heterogeneity among the included studies.

Do negative symptoms of schizophrenia change over time? A meta-analysis of longitudinal data

BACKGROUND

Negative symptoms are a core component of schizophrenia which can severely impact quality of life and functional outcomes. These symptoms are understood to be highly stable but this has not been tested in a meta-analysis, despite the wealth of longitudinal data available.

METHOD

A systematic review of the literature was conducted, with eligible studies pooled into a random-effects meta-analysis. Planned meta-regressions were conducted to evaluate the impact of factors known to induce secondary negative symptoms, in addition to other possible sources of heterogeneity.

RESULTS

The main analysis included 89 samples from 41 studies, totalling 5944 participants. Negative symptoms were found to significantly reduce in all treatment interventions, including in placebo and treatment as usual conditions, with a medium effect size (ES) present across all study conditions (ES = 0.66, 95% confidence interval 0.56-0.77, I(2) = 94.0%). In a multivariate meta-regression, only the type of scale used was found to significantly influence negative symptom change. No difference in outcome was found between studies that excluded patients with a high level of positive or depressive symptoms, compared to those that did not.

CONCLUSIONS

Negative symptoms were found to reduce in almost all schizophrenia outpatient samples. A reduction was found across all conditions, with effect sizes ranging from small to large depending upon the condition type. These findings challenge the convention that negative symptoms are highly stable and suggest that they may improve to a greater extent than what has previously been assumed.