Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range

Microplastic Contamination of Seafood Intended for Human Consumption: A Systematic Review and Meta-Analysis

BACKGROUND

Microplastics (MPs) have contaminated all compartments of the marine environment including biota such as seafood; ingestion from such sources is one of the two major uptake routes identified for human exposure.

OBJECTIVES

The objectives were to conduct a systematic review and meta-analysis of the levels of MP contamination in seafood and to subsequently estimate the annual human uptake.

METHODS

MEDLINE, EMBASE, and Web of Science were searched from launch (1947, 1974, and 1900, respectively) up to October 2020 for all studies reporting MP content in seafood species. Mean, standard deviations, and ranges of MPs found were collated. Studies were appraised systematically using a bespoke risk of bias (RoB) assessment tool.

RESULTS

Fifty studies were included in the systematic review and 19 in the meta-analysis. Evidence was available on four phyla: mollusks, crustaceans, fish, and echinodermata. The majority of studies identified MP contamination in seafood and reported MP content < 1  MP / g , with 26% of studies rated as having a high RoB, mainly due to analysis or reporting weaknesses. Mollusks collected off the coasts of Asia were the most heavily contaminated, coinciding with reported trends of MP contamination in the sea. According to the statistical summary, MP content was 0 - 10.5  MPs / g in mollusks, 0.1 - 8.6  MPs / g in crustaceans, 0 - 2.9  MPs / g in fish, and 1  MP / g in echinodermata. Maximum annual human MP uptake was estimated to be close to 55,000 MP particles. Statistical, sample, and methodological heterogeneity was high.

DISCUSSION

This is the first systematic review, to our knowledge, to assess and quantify MP contamination of seafood and human uptake from its consumption, suggesting that action must be considered in order to reduce human exposure via such consumption. Further high-quality research using standardized methods is needed to cement the scientific evidence on MP contamination and human exposures. https://doi.org/10.1289/EHP7171.

Factors associated with a SARS-CoV-2 recurrence after hospital discharge among patients with COVID-19: systematic review and meta-analysis

BACKGROUND

The proportion of recurrences after discharge among patients with coronavirus disease 2019 (COVID-19) was reported to be between 9.1% and 31.0%. Little is known about this issue, however, so we performed a meta-analysis to summarize the demographical, clinical, and laboratorial characteristics of non-recurrence and recurrence groups.

METHODS

Comprehensive searches were conducted using eight electronic databases. Data regarding the demographic, clinical, and laboratorial characteristics of both recurrence and non-recurrence groups were extracted, and quantitative and qualitative analyses were conducted.

RESULTS

Ten studies involving 2071 COVID-19 cases were included in this analysis. The proportion of recurrence cases involving patients with COVID-19 was 17.65% (between 12.38% and 25.16%) while older patients were more likely to experience recurrence (weighted mean difference (WMD)=1.67, range between 0.08 and 3.26). The time from discharge to recurrence was 13.38 d (between 12.08 and 14.69 d). Patients were categorized as having moderate severity (odds ratio (OR)=2.69, range between 1.30 and 5.58), while those with clinical symptoms including cough (OR=5.52, range between 3.18 and 9.60), sputum production (OR=5.10, range between 2.60 and 9.97), headache (OR=3.57, range between 1.36 and 9.35), and dizziness (OR=3.17, range between 1.12 and 8.96) were more likely to be associated with recurrence. Patients presenting with bilateral pulmonary infiltration and decreased leucocyte, platelet, and CD4+ T counts were at risk of COVID-19 recurrence (OR=1.71, range between 1.07 and 2.75; WMD=-1.06, range between -1.55 and -0.57, WMD=-40.39, range between -80.20 and -0.48, and WMD=-55.26, range between -105.92 and -4.60, respectively).

CONCLUSIONS

The main factors associated with the recurrence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) after hospital discharge were older age, moderate severity, bilateral pulmonary infiltration, laboratory findings including decreased leucocytes, platelets, and CD4+ T counts, and clinical symptoms including cough, sputum production, headache, and dizziness. These factors can be considered warning indicators for the recurrence of SARS-CoV-2 and might help the development of specific management strategies.

The association between metabolic syndrome and benign prostatic hyperplasia: a systematic review and meta-analysis

OBJECTIVE

We performed this meta-analysis to assess the association between metabolic syndrome (MetS) and benign prostatic hyperplasia (BPH).

METHOD

We conducted extensive searches on the PubMed, Science and Cochrane Library to identify all articles. Outcomes including annual prostate growth rate, prostate volume (PV), International Prostate Symptom Score (IPSS), IPSS sub-scores (voiding and storage), prostate- specific antigen (PSA), maximum urine flow rate (Qmax), post-void residual urine volume (PVR) and quality of life (QoL) were assessed.

RESULTS

21 studies with 15,317 patients were included. Patients with MetS had higher annual prostate growth rate [weighted mean difference (WMD) = 0.79; p < .001], larger PV (WMD = 2.62; p < .001), lower Qmax (WMD = -0.48; p = .001) and more PVR (WMD = 8.28; p < .001). However, no significant differences were found between two groups in IPSS (WMD = 0.20; p = .37), IPSS-voiding (WMD = -0.05; p = .78), IPSS-storage (WMD = -0.22; p = .26), PSA (WMD = 0.04; p = .43), and QoL (WMD = -0.01; p = .70).

CONCLUSIONS

The study suggested that MetS may be one of the risk factors for the clinical progress of BPH. However, further study is warranted to support these results.

Adjuvant treatment strategies in ovarian stimulation for poor responders undergoing IVF: a systematic review and network meta-analysis

BACKGROUND

Despite great advances in assisted reproductive technology, poor ovarian response (POR) is still considered as one of the most challenging tasks in reproductive medicine.

OBJECTIVE AND RATIONALE

The aim of this systemic review is to evaluate the role of different adjuvant treatment strategies on the probability of pregnancy achievement in poor responders undergoing IVF. Randomized controlled trials (RCTs) comparing 10 adjuvant treatments [testosterone, dehydroepiandrosterone (DHEA), letrozole, recombinant LH, recombinant hCG, oestradiol, clomiphene citrate, progesterone, growth hormone (GH) and coenzyme Q10 (CoQ10)] were included.

SEARCH METHODS

Relevant studies published in the English language were comprehensively selected using PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) until 11 July 2018. We included studies that investigated various adjuvant agents, including androgen and androgen-modulating agents, oestrogen, progesterone, clomiphene citrate, GH and CoQ10, during IVF treatment and reported subsequent pregnancy outcomes. The administration of GnRH analogs and gonadotrophins without adjuvant treatment was set as the control. We measured study quality based on the methodology and categories listed in the Cochrane Collaboration Handbook. This review protocol was registered with PROSPERO (CRD42018086217).

OUTCOMES

Of the 1124 studies initially identified, 46 trials reporting on 6312 women were included in this systematic review, while 19 trials defining POR using the Bologna criteria reporting 2677 women were included in the network meta-analysis. Compared with controls, DHEA and CoQ10 treatments resulted in a significantly higher chance of clinical pregnancy [odds ratio (OR) 2.46, 95% CI 1.16 to 5.23; 2.22, 1.08-4.58, respectively]. With regard to the number of retrieved oocytes, HCG, oestradiol and GH treatments had the highest number of oocytes retrieved [weighted mean difference (WMD) 2.08, 0.72 to 3.44; 2.02, 0.23 to 3.81; 1.72, 0.98 to 2.46, compared with controls, respectively]. With regard to the number of embryos transferred, testosterone and GH treatment led to the highest number of embryos transferred (WMD 0.72, 0.11 to 1.33; 0.67, 0.43 to 0.92; compared with controls, respectively). Moreover, GH resulted in the highest oestradiol level on the HCG day (WMD 797.63, 466.45 to 1128.81, compared with controls). Clomiphene citrate, letrozole and GH groups used the lowest dosages of gonadotrophins for ovarian stimulation (WMD 1760.00, -2890.55 to -629.45; -1110.17, -1753.37 to -466.96; -875.91, -1433.29 to -282.52; compared with controls, respectively). CoQ10 led to the lowest global cancelation rate (OR 0.33, 0.15 to 0.74, compared with controls).

WIDER IMPLICATIONS

For patients with POR, controlled ovarian stimulation protocols using adjuvant treatment with DHEA, CoQ10 and GH showed better clinical outcomes in terms of achieving pregnancy, and a lower dosage of gonadotrophin required for ovulation induction. Furthermore, high-level RCT studies using uniform standards for POR need to be incorporated into future meta-analyses.

Sperm parameters and anti-Müllerian hormone remain stable with Helicobacter pylori infection: a cross-sectional study

BACKGROUND AND AIMS

It has been reported that Helicobacter pylori (HP) infection was more prevalent in infertile populations. HP infection could lead to decreased sperm parameters, and treating the HP infection could improve the quality of sperm. However, studies investigating the relationship between infertility and HP infection are still limited, and more evidence is required. Therefore, we performed the present study to investigate the impact of HP infection on sperm quality in males and on ovarian reserve in females.

METHODS

A total of 16,522 patients who visited the Second Hospital of Zhejiang University from January 2016 to June 2019 due to abdominal discomfort and underwent a 13/14C-urea breath HP test were included in this retrospective cross-sectional study. Among them, 565 had performed sperm analysis or ovarian reserve tests in the past three months and were involved for further analyses. Sperm parameters were examined with a computer-assisted sperm analysis system, and serum anti-Müllerian hormone (AMH) and sex hormones were tested with an electrochemiluminescence method.

RESULTS

Among 363 patients who underwent the sperm test, 136 (37.47%) had HP infection. Among 202 patients who underwent the AMH test, 55 (27.23%) had HP infection. There was no difference in sperm concentration and motility between the HP+ and HP- groups (P > 0.05). Further subgroup analyses stratified into 5-year age groups confirmed that there was no significant difference in sperm parameters (P > 0.05). When pooled with previously published data, no significant difference in sperm concentration or motility was found (P > 0.05). Meanwhile, this study found that the serum AMH level was similar between the HP+ and HP- groups (P > 0.05). Further subgroup analyses confirmed that there was no significant difference in serum AMH level (P > 0.05).

CONCLUSIONS

There were no differences in sperm parameters and AMH levels based on history of HP infection among Chinese patients.

The Clinical Effects of Abdominal Binder on Abdominal Surgery: A Meta-analysis

Objective. We conducted a meta-analysis to quantitatively evaluate the effects of abdominal binder in abdominal surgeries. Methods. Through literature retrieval in globally recognized databases (MEDLINE, EMBASE, and Cochrane Central), trials investigating the application of abdominal binder in abdominal surgeries were systematically reviewed. The main outcomes, namely, 6-minute walk test (6MWT), visual analog scale (VAS) pain score, and symptom distress scale (SDS) score, were pooled to make an overall estimation. I² index was calculated to identify heterogeneity, and sensitivity analysis was performed to validate the stability of main results and explore the source of heterogeneity. A funnel plot and Egger's test were applied to assess publication bias. Results. Ten randomized controlled trials consisting of 968 subjects were ultimately included for the pooled estimation. Abdominal binder significantly increased the distance of 6MWT with standard mean difference (SMD) of .555 (P < .001) and decreased the scores of VAS and SDS with SMD of -.979 (P < .001) and -.716 (P < .001), respectively. Despite of the significant heterogeneity indicated by I² index statistic, the results of sensitivity analysis revealed the reliability of the main conclusions. While we identified no obvious publication bias regarding 6MWT (Egger's test P = .321), it seemed that significant publication biases existed with respect to the estimation of VAS (P < .001) and SDS (P = .006). Conclusion. The current meta-analysis verified that abdominal binder efficiently promoted recovery after abdominal surgeries in terms of facilitating mobilization, alleviating pain, and reducing postoperative distress. More rigorously designed clinical trials with large sample size are expected to further elaborate its clinical value.

Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk

BACKGROUND

Human milk as compared to formula reduces morbidity in preterm infants but requires fortification to meet their nutritional needs and to reduce the risk of extrauterine growth failure. Standard fortification methods are not individualized to the infant and assume that breast milk is uniform in nutritional content. Strategies for individualizing fortification are available; however it is not known whether these are safe, or if they improve outcomes in preterm infants.

OBJECTIVES

To determine whether individualizing fortification of breast milk feeds in response to infant blood urea nitrogen (adjustable fortification) or to breast milk macronutrient content as measured with a milk analyzer (targeted fortification) reduces mortality and morbidity and promotes growth and development compared to standard, non-individualized fortification for preterm infants receiving human milk at < 37 weeks' gestation or at birth weight < 2500 grams.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on September 20, 2019. We also searched clinical trials databases and the reference lists of retrieved articles for pertinent randomized controlled trials (RCTs) and quasi-randomized trials.

SELECTION CRITERIA

We considered randomized, quasi-randomized, and cluster-randomized controlled trials of preterm infants fed exclusively breast milk that compared a standard non-individualized fortification strategy to individualized fortification using a targeted or adjustable strategy. We considered studies that examined any use of fortification in eligible infants for a minimum duration of two weeks, initiated at any time during enteral feeding, and providing any regimen of human milk feeding.

DATA COLLECTION AND ANALYSIS

Data were collected using the standard methods of Cochrane Neonatal. Two review authors evaluated the quality of the studies and extracted data. We reported analyses of continuous data using mean differences (MDs), and dichotomous data using risk ratios (RRs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Data were extracted from seven RCTs, resulting in eight publications (521 total participants were enrolled among these studies), with duration of study interventions ranging from two to seven weeks. As compared to standard non-individualized fortification, individualized (targeted or adjustable) fortification of enteral feeds probably increased weight gain during the intervention (typical mean difference [MD] 1.88 g/kg/d, 95% confidence interval [CI] 1.26 to 2.50; 6 studies, 345 participants), may have increased length gain during the intervention (typical MD 0.43 mm/d, 95% CI 0.32 to 0.53; 5 studies, 242 participants), and may have increased head circumference gain during the intervention (typical MD 0.14 mm/d, 95% CI 0.06 to 0.23; 5 studies, 242 participants). Compared to standard non-individualized fortification, targeted fortification probably increased weight gain during the intervention (typical MD 1.87 g/kg/d, 95% CI 1.15 to 2.58; 4 studies, 269 participants) and may have increased length gain during the intervention (typical MD 0.45 mm/d, 95% CI 0.32 to 0.57; 3 studies, 166 participants). Adjustable fortification probably increased weight gain during the intervention (typical MD 2.86 g/kg/d, 95% CI 1.69 to 4.03; 3 studies, 96 participants), probably increased gain in length during the intervention (typical MD 0.54 mm/d, 95% CI 0.38 to 0.7; 3 studies, 96 participants), and increased gain in head circumference during the intervention (typical MD 0.36 mm/d, 95% CI 0.21 to 0.5; 3 studies, 96 participants). We are uncertain whether there are differences between individualized versus standard fortification strategies in the incidence of in-hospital mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, culture-proven late-onset bacterial sepsis, retinopathy of prematurity, osteopenia, length of hospital stay, or post-hospital discharge growth. No study reported severe neurodevelopmental disability as an outcome. One study that was published after our literature search was completed is awaiting classification.

AUTHORS' CONCLUSIONS

We found moderate- to low-certainty evidence suggesting that individualized (either targeted or adjustable) fortification of enteral feeds in very low birth weight infants increases growth velocity of weight, length, and head circumference during the intervention compared with standard non-individualized fortification. Evidence showing important in-hospital and post-discharge clinical outcomes was sparse and of very low certainty, precluding inferences regarding safety or clinical benefits beyond short-term growth.

Metabolite biomarkers of type 2 diabetes mellitus and pre-diabetes: a systematic review and meta-analysis

BACKGROUND

We aimed to explore metabolite biomarkers that could be used to identify pre-diabetes and type 2 diabetes mellitus (T2DM) using systematic review and meta-analysis.

METHODS

Four databases, the Cochrane Library, EMBASE, PubMed and Scopus were selected. A random effect model and a fixed effect model were applied to the results of forest plot analyses to determine the standardized mean difference (SMD) and 95% confidence interval (95% CI) for each metabolite. The SMD for every metabolite was then converted into an odds ratio to create an metabolite biomarker profile.

RESULTS

Twenty-four independent studies reported data from 14,131 healthy individuals and 3499 patients with T2DM, and 14 included studies reported 4844 healthy controls and a total of 2139 pre-diabetes patients. In the serum and plasma of patients with T2DM, compared with the healthy participants, the concentrations of valine, leucine, isoleucine, proline, tyrosine, lysine and glutamate were higher and that of glycine was lower. The concentrations of isoleucine, alanine, proline, glutamate, palmitic acid, 2-aminoadipic acid and lysine were higher and those of glycine, serine, and citrulline were lower in prediabetic patients. Metabolite biomarkers of T2DM and pre-diabetes revealed that the levels of alanine, glutamate and palmitic acid (C16:0) were significantly different in T2DM and pre-diabetes.

CONCLUSIONS

Quantified multiple metabolite biomarkers may reflect the different status of pre-diabetes and T2DM, and could provide an important reference for clinical diagnosis and treatment of pre-diabetes and T2DM.

An evolution perspective on the urban land carrying capacity in the urbanization era of China

The past few decades witness a typical urbanization era in large developing countries such as China. In line with the urbanization process, land resources have inevitably presented a series of changes. The evolution of urban land carrying capacity (ULCC) is appreciated as a yardstick for guiding towards sustainable urban development. This paper therefore proposes an alternative method from carrier-load perspective for investigating the evolution of ULCC performance in China during the rapid urbanization era of 2012-2017. The data employed for analysis is collected from 290 Chinese prefectural-level cities. Results indicate that ULCC performance in the urbanizing China has been evolving towards a better state, for which 94% of the surveyed cities have made progress. However, significant disparity exists between cities on ULCC evolution performance, in particular, mega cities tend to have better ULCC evolution performance. Some cities may have better evolution performance although they have a poor average ULCC value. Contrarily, some cities may present poor evolution performance but they carry a better average ULCC value. The research findings provide valuable references not only for policy-makers to better understand the state of ULCC across the country, and appreciate inspiring experiences and lessons for implementing effective tailor-made measures to improve the ULCC performance, but also for enriching the literature in land resource management.

Obesity and metabolic syndrome related macrophage promotes PD-L1 expression in TNBC through IL6/JAK/STAT pathway and can be reversed by telmisartan

Breast cancer is the most common malignant tumor in women. Its incidence is associated with obesity and metabolic syndrome (MetS), which are highly prevalent world widely and have been identified as poorer prognosis factors in breast cancer including triple-negative breast cancer (TNBC), which has poorer response to chemotherapy, radiotherapy, and endocrine therapy. Programmed death ligand 1 (PD-L1) is one of the immune checkpoints ligands that facilitates tumor escape and progress. Obesity/MetS could cause systemic inflammation and immune disorders, however, whether and how obesity/MetS affect PD-L1 expression in breast cancer had not been clarified. In the present study, we examined the PD-L1 expression profile in breast cancer either in online database or cell lines. We found higher PD-L1 mRNA level but not DNA copy number in breast cancer than normal breast tissue, and higher PD-L1 expression in TNBC than other subtypes. Moreover, we found a positive relationship between PD-L1 expression in TNBC and metabolic complications in patients. Next, obesity/MetS related M1 macrophage was found to promote the expression of PD-L1 in breast cancer cells cocultured with polarized macrophages derived from either monocyte-like cell line THP-1 or Wistar rat models. IL6/JAK/STAT pathway was further identified to be involved in the process. In addition, we discovered that the PD-L1 expression promoted by obesity/MetS could be restored by telmisartan, one of the angiotensin II receptor blockers (ARBs) and could affect macrophage polarization, through its selective peroxisome proliferator-activated receptor-gamma (PPARG) activation and NFKB p65 inhibition and therefore downregulates IL6 secretion from M1 macrophage.

Repetitive transcranial magnetic stimulation (rTMS) fails to improve cognition in patients with parkinson's disease: a Meta-analysis of randomized controlled trials

BACKGROUND

Cognitive decline is one of the greatest concerns for patients with Parkinson's disease (PD) and their care partners. Repetitive transcranial magnetic stimulation (rTMS) is a nonpharmacological treatment option used to improve cognitive function in PD, but its efficacy is unclear. We performed a meta-analysis to determine whether rTMS improves cognition in PD patients.

METHODS

Eligibility criteria (PICOS) were as follows: (1) 'P': The patients participating were diagnosed with idiopathic PD; (2) 'I': Intervention using rTMS; (3) 'C': Sham stimulation as control; (4) 'O': The outcome of the study included cognitive evaluations; (5) 'S': The study adopted randomized controlled design. The standardized mean difference (SMD) of change of score was applied to measure efficacy, and we used Version 2 of the Cochrane tool to assess risk of bias.

RESULTS

Twelve studies met the inclusion criteria. Compared with sham-controlled group, the pooled result showed a non-significant short-term effect of rTMS on global cognition (SMD: -0.15, 95% CI: -0.59 to 0.29, I² = 36.7%), executive function (SMD: 0.03, 95% CI: -0.21 to 0.26, I² = 0.0%), and attention and working memory (SMD: 0.05, 95% CI: -0.25 to 0.35, I² = 0.0%). Long-term outcomes were either shown to be statistically nonsignificant.

CONCLUSIONS

Based on a limited number of studies, rTMS fails to improve cognition in PD. We call for additional high-quality randomized controlled trials with adequate sample sizes to determine the efficacy of rTMS.

Endoscopic enucleation vs endoscopic vaporization procedures for benign prostatic hyperplasia: how should we choose: A protocol for systematic review and meta-analysis

OBJECTIVE

To assess the safety and efficacy of different endoscopic procedures of the prostate techniques, by comparing endoscopic enucleation (EEP) and endoscopic vaporization procedures (EVP) of the prostate; and laser enucleation procedures (L-EEP) vs laser vaporization procedures (L-EVP) surgeries for benign prostatic hyperplasia.

METHODS

A systematic literature review was performed in December 2019 using PubMed, Embase and the Cochrane Library to identify relevant studies. Two analyses were carried out: (1) EEP vs EVP; and (2) L-EEP vs L-EVP. Efficacy and safety were evaluated using perioperative data, functional outcomes, including maximum urinary flow rate (Qmax), quality of life (QoL), international prostate symptom score (IPSS), postvoiding residual urine volume (PRV), and rate of complications. Meta-analyses were conducted using RevMan5.3.

RESULTS

Sixteen studies (4907 patients) evaluated EEP vs EVP, and 12 of them (4392 patients) evaluated L-EEP vs L-EVP. EEP showed improved functional outcomes compared with EVP. EEP was always presented a better Qmax at various follow-up times. EEP also associated with a reduced PRV and IPSS at 12 months postsurgery, an increased Qmax, and reduced IPSS and QoL score at both 24 and 36 months postsurgery. In addition, EEP was associated with less total energy utilized and retreatment for residual adenoma, but a longer catheterization time. Among other outcomes, there was no significant difference. L-EEP favors total energy used, retreatment for residual adenoma, and functional outcomes. L-EEP was associated with reduced PRV at 1, 6, and 12 months postsurgery, a greater Qmax at 6 and 12 months postsurgery, a lower IPSS at 12 months postsurgery, and higher Qmax and lower IPSS and QoL scores at 24 and 36 months postsurgery. However, there was no difference at 3 months postsurgery. No significant differences were observed for other perioperative data and complications.

CONCLUSIONS

Both EEP and EVP displayed sufficient efficacy and safety for treating benign prostatic hyperplasia. EEP and L-EEP were favored in perioperative data, rate of complications, and functional outcomes. However, the clinical significance of those statistical differences was unclear. Hence, higher-quality randomized controlled trials may be needed to provide a clear algorithm.

Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis

Background

Coronary artery bypass grafting (CABG) is known to improve heart function and quality of life, while rates of surgery‐related mortality are low. However, delirium and cognitive decline are common complications. We sought to identify preoperative, intraoperative, and postoperative risk or protective factors associated with delirium and cognitive decline (across time) in patients undergoing CABG.

Methods and Results

We conducted a systematic search of Medline, PsycINFO, EMBASE, and Cochrane (March 26, 2019) for peer‐reviewed, English publications reporting post‐CABG delirium or cognitive decline data, for at least one risk factor. Random‐effects meta‐analyses estimated pooled odds ratio for categorical data and mean difference or standardized mean difference for continuous data. Ninety‐seven studies, comprising data from 60 479 patients who underwent CABG, were included. Moderate to large and statistically significant risk factors for delirium were as follows: (1) preoperative cognitive impairment, depression, stroke history, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, (2) intraoperative increase in intubation time, and (3) postoperative presence of arrythmia and increased days in the intensive care unit; higher preoperative cognitive performance was protective for delirium. Moderate to large and statistically significant risk factors for acute cognitive decline were as follows: (1) preoperative depression and older age, (2) intraoperative increase in intubation time, and (3) postoperative presence of delirium and increased days in the intensive care unit. Presence of depression preoperatively was a moderate risk factor for midterm (1–6 months) post‐CABG cognitive decline.

Conclusions

This meta‐analysis identified several key risk factors for delirium and cognitive decline following CABG, most of which are nonmodifiable. Future research should target preoperative risk factors, such as depression or cognitive impairment, which are potentially modifiable.

Registration

URL: https://www.crd.york.ac.uk/prosp​ero/; Unique identifier: CRD42020149276.

Rehabilitation therapy for patients with glioma: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Glioma is the most common type of brain tumor because of the destructiveness of the disease itself and the side effects of treatment, patients often leave symptoms of neurological defects. At present, rehabilitation treatment is not popular in glioma patients. There is a lack of definite evidence to prove the benefits of rehabilitation therapy for glioma patients. The purpose of this meta-analysis is to determine whether rehabilitation therapy can significantly improve the prognosis of neurological function and improve the quality of life of patients with glioma.

METHODS

The articles about rehabilitation treatment of glioma in Cochrane, PubMed, and Embase, Web of Science, and Medline database from January 1990 to May 2020 were searched. Before rehabilitation as the control group, after rehabilitation as the experimental group. The Functional Independence Measure (FIM) was used as the outcome index, including total FIM, motor FIM, and cognitive FIM. Use STATA12.0 for meta-analysis.

RESULTS

A total of 8 articles were included in the study, with a total of 375 glioma patients. Meta-analysis of total FIM (SMD = 0.96, 95%CI = 0.66-1.26, P < .001), motor FIM (SMD = 0.75, 95%CI = 0.54-0.96, P < .001) and cognitive FIM (SMD = 0.35, 95%CI = 0.19-0.50, P < .001) indicated that the neurological function of rehabilitation was significantly improved in total, motor and consciousness.

CONCLUSION

The published studies show that rehabilitation therapy can improve the functional prognosis and quality of life of glioma patients. More attention should be paid to the therapeutic value of rehabilitation for glioma patients in the future.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020188740.

Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.

Vitrectomy with fovea-sparing ILM peeling versus total ILM peeling for myopic traction maculopathy: A meta-analysis

PURPOSE

To evaluate the effect and safety of fovea-sparing internal limiting membrane (ILM) peeling (FSIP) for myopic traction maculopathy comparing with that of total ILM peeling (TP).

METHODS

PubMed, Web of science, Embase, Cochrane, EBSCO and CNKI, published until January 2020, were searched. Postoperative best-corrected visual acuity (BCVA), postoperative central foveal thickness (CFT), the rate of visual improvement and anatomic success were the main outcome parameters, and the secondary outcome parameters were postoperative complications. Random-effects models were chosen in regard with multi-studies. Standard mean difference (SMD) with 95% confidence interval (CI) and odds ratio (OR) were applied as effect sizes of continuous and binomial data, respectively.

RESULTS

Six comparative studies involving 193 eyes were included. Better postoperative BCVA was detected in the FSIP group (SMD = -0.39, 95%CI: -0.69 to -0.09, p = 0.01). The FSIP group had a higher rate of vision improvement with statistical significance (OR = 3.86, 95%CI: 1.36 to 10.97, p = 0.01). Both surgical methods had similar outcomes for postoperative CFT (SMD = 0.07, 95%CI: -0.27 to 0.40, p = 0.70). The FSIP group had a higher rate of anatomic success, though there was no obvious significance (OR = 2.54, 95%CI: 0.96 to 6.74, p = 0.06). For the development of postoperative full-thickness macular hole (FTMH), the rate was lower in the FSIP group (OR = 0.18, 95%CI: 0.05 to 0.64, p = 0.008).

CONCLUSION

Vitrectomy with fovea-sparing ILM peeling for myopic traction maculopathy could gain better visual outcomes and decrease incidence of FTMH development, though there was no obvious difference in postoperative CFT and the rate of anatomic success between two groups.

Charlson comorbidity index and a composite of poor outcomes in COVID-19 patients: A systematic review and meta-analysis

BACKGROUND AND AIMS

The ongoing COVID-19 pandemic is disproportionately affecting patients with comorbidities. Therefore, thorough comorbidities assessment can help establish risk stratification of patients with COVID-19, upon hospital admission. Charlson Comorbidity Index (CCI) is a validated, simple, and readily applicable method of estimating the risk of death from comorbid disease and has been widely used as a predictor of long-term prognosis and survival.

METHODS

We performed a systematic review and meta-analysis of CCI score and a composite of poor outcomes through several databases.

RESULTS

Compared to a CCI score of 0, a CCI score of 1-2 and CCI score of ≥3 was prognostically associated with mortality and associated with a composite of poor outcomes. Per point increase of CCI score also increased mortality risk by 16%. Moreover, a higher mean CCI score also significantly associated with mortality and disease severity.

CONCLUSION

CCI score should be utilized for risk stratifications of hospitalized COVID-19 patients.

Treatment of pediatric femoral shaft fractures with elastic stable intramedullary nails versus external fixation: A meta-analysis

BACKGROUND

There is currently a debate about whether elastic stable intramedullary nails (ESIN) or external fixation (EF) is the best surgical method for treating pediatric femoral shaft fractures. We performed a meta-analysis to determine which surgical method leads to higher treatment satisfaction, lower complication rates, and reduced treatment time, to investigate whether ESIN is the preferred surgical method for treatment of pediatric femoral shaft fractures.

PATIENTS AND METHODS

Relevant databases were searched for comparative studies of ESIN versus EF for the treating pediatric femoral shaft fractures. Literature reports and quality evaluations were extracted, followed by a systematic review using RevMan 5.3 software. Treatment satisfaction at the last follow-up, primary complications, secondary complications, and relevant time indicators (operation time, hospital stay, clinical healing time, bone healing time) were analyzed.

RESULTS

A total of 22 reports were included in this meta-analysis. We found no statistical differences in the treatment satisfaction at the last follow-up between ESIN and EF for the treatment of pediatric femoral shaft fractures. A low rate of postoperative re-fracture (RR=3.58, 95% CI (1.85, 6.92), p=0.0001) and postoperative infection (RR=9.25, 95% CI (5.32, 16.11), p<0.00001), and a high risk of skin irritation (RR=0.15, 95% CI (0.06, 0.37), p<0.00001) were found in the ESIN group. No significant differences between the two approaches were found regarding malunion. A low rate of limb-length discrepancy (RR=2.41, 95% CI (1.40, 4.17), p=0.002), hospitalization (SMD=0.84, 95% CI (0.24, 1.43), p=0.006), clinical healing time (SMD=0.95, 95% CI (0.56, 1.33), p<0.00001) and bone healing time (SMD=0.89, 95% CI (0.39, 1.40), p=0.005) were found in the ESIN group, as compared to that in the EF group. No significant differences were found in fixation failure, activity limitation of the joint, and operation time between the two strategies.

DISCUSSION

ESIN should be the primary choice for the treatment of pediatric femoral shaft fractures since it has a reliable curative effect and results in a shorter hospital stay, faster fracture healing, and fewer complications. EF is recommended for fractures with serious injury of the soft tissue to avoid intramedullary infection. Double-blind high-quality randomized studies with larger sample sizes are warranted to confirm our conclusions.

LEVEL OF EVIDENCE

IV.

Acute kidney injury is associated with severe infection and fatality in patients with COVID-19: A systematic review and meta-analysis of 40 studies and 24,527 patients

Currently, coronavirus disease 2019 (COVID-19) is spreading rapidly around the world. This study aimed to investigate whether the presence of acute kidney injury (AKI) might increase the risk of severe infection and fatality in COVID-19 patients. We searched the PubMed, Web of Science, ScienceDirect, MedRxiv and COVID-19 academic research communication platforms for studies reporting severe infection rates and case-fatality rates in COVID-19 patients with and without AKI up to June 20, 2020. The main outcomes were the comparisons of the severe infection rates and fatality rates in COVID-19 patients with and without AKI and the estimation of the odds ratio (OR) and its 95 % confidence interval (CI) for severe infection and mortality. Statistical analyses were performed with R statistical software. A total of 40 studies involving 24,527 patients with COVID-19 were included in our meta-analysis. The incidence of AKI was 10 % (95 % CI 8%-13 %) in COVID-19 patients. The patients had higher severe infection and fatality rates (55.6 % vs. 17.7 % and 63.1 % vs. 12.9 %, respectively, all P < 0.01) with COVID-19. AKI was a predictor of fatality (OR = 14.63, 95 % CI: 9.94-21.51, P < 0.00001) and severe infection (OR = 8.11, 95 % CI: 5.01-13.13, P < 0.00001) in patients with COVID-19. Higher levels of serum creatinine (Scr) and blood urea nitrogen (BUN) were associated with a significant increase in fatality [Scr: mean difference (MD): 20.19 μmol/L, 95 % CI: 14.96-25.42, P < 0.001; BUN: MD: 4.07 mmol/L, 95 % CI: 3.33-4.81, P < 0.001] and severe infection (Scr: MD: 7.78 μmol/L, 95 % CI: 4.43-11.14, P < 0.00001, BUN: MD: 2.12 mmol/L, 95 % CI: 1.74-2.50, P < 0.00001) in COVID-19 patients. In conclusion, AKI is associated with severe infection and higher fatality rates in patients with COVID-19. Clinicians should pay more attention to the monitoring and treatment of COVID-19 patients with AKI.

Effect of obesity and body mass index on coronavirus disease 2019 severity: A systematic review and meta-analysis

We conducted a systematic review of observational studies to examine the effects of body mass index (BMI) and obesity (BMI ≥ 30 kg/m² ) on coronavirus disease 2019 (COVID-19). Medline, Embase, and the Cochrane Library were searched. Sixteen articles were finally included in the meta-analysis, and a random effects model was used. BMI was found to be higher in patients with severe disease than in those with mild or moderate disease (MD 1.6, 95% CI, 0.8-2.4; p = .0002) in China; however, the heterogeneity was high (I² = 75%). Elevated BMI was associated with invasive mechanical ventilation (IMV) use (MD 4.1, 95% CI, 2.1-6.1; p < .0001) in Western countries, and this result was consistent across studies (I² = 0%). Additionally, there were increased odds ratios of IMV use (OR 2.0, 95% CI, 1.4-2.9; p < .0001) and hospitalization (OR 1.4, 95% CI, 1.3-1.60; p < .00001) in patients with obesity. There was no substantial heterogeneity (I² = 0%). In conclusion, obesity or high BMI increased the risk of hospitalization, severe disease and invasive mechanical ventilation in COVID-19. Physicians must be alert to these early indicators to identify critical patients.

Regional similarities and differences in mature human milk fatty acids in Chinese population: A systematic review

Maternal factors such as the diet can impact human milk fatty acid profiles. We hypothesized that mature human milk fatty acid profiles differ among regions of China. To test our hypothesis, we conducted a systematic review to calculate regional average contents of fatty acids and the statistical significance of regional differences in fatty acids. We searched both Chinese and English literature databases and selected 21 articles, including 11 in Chinese and 10 in English. We categorized regions of China by 3 ways: 1) north vs. south; 2) inland vs. coastal; 3) socioeconomic development levels. The ratios of ΣSFAs:ΣMUFAs:ΣPUFAs were similar between regions and the average was 1:1:0.7. Contents of palmitic, oleic, and linoleic acids were also similar between regions and together they accounted for more than 70% of all fatty acids in mature human milk. Conversely, concentrations of ALA and DHA differed more than palmitic, oleic, and linoleic acids. We also found that it might be necessary to reduce maternal dietary contents of potentially harmful fatty acids such as erucic acid to minimize detrimental effects on infant health. To our knowledge, this study represents the first systematic review that quantitatively investigated the regional similarities and differences in mature human milk fatty acid contents and is therefore significant for academia and policy makers.

Circulating Levels of Interleukin-6 and Interleukin-10, But Not Tumor Necrosis Factor-Alpha, as Potential Biomarkers of Severity and Mortality for COVID-19: Systematic Review with Meta-analysis

PURPOSE

Cytokine storm, an uncontrolled overproduction of inflammatory cytokines contributing to an aberrant systemic inflammatory response, is a major pathological feature of acute respiratory distress syndromes being severe manifestations of COVID-19, thus highlighting its potential as a biomarker and therapeutic target for COVID-19. We aimed to determine associations of circulating levels of inflammatory cytokines with severity and mortality of COVID-19 by systematic review and meta-analysis.

METHODS

A comprehensive literature search in electronic databases consisting of PubMed, Scopus, and Cochrane Library and in a hand searching of reference lists from inception to July 31, 2020, was performed using the following search terms: COVID-19, interleukin (IL)-6, IL-10, and tumor necrosis factor-alpha (TNF-α). Mean difference (MD) from individual studies was pooled using a random-effects model. Quality assessment, publication bias, meta-regression, subgroup, and sensitivity analyses were performed.

RESULTS

A total of 6212 COVID-19 patients from 24 eligible studies were included. Compared with non-severe COVID-19 patients, systemic levels of IL-6 and IL-10, but not TNF-α, were significantly elevated in severe COVID-19 patients (MD = 18.63, 95% CI: 10.91, 26.35, P < 0.00001; MD = 2.61, 95% CI: 2.00, 2.32, P < 0.00001; respectively). For COVID-19 mortality, circulating levels of IL-6, IL-10, and TNF-α were found to be significantly increased in non-survivors when compared with survivors (MD = 57.82, 95% CI: 10.04, 105.59, P = 0.02; MD = 4.94, 95% CI: 3.89, 6.00, P < 0.00001; MD = 5.60, 95% CI: 4.03, 7.17, P < 0.00001; respectively).

CONCLUSION

Circulating levels of IL-6 and IL-10 might have great potential as biomarkers for the disease severity and mortality in COVID-19 patients.

Clinical characteristics of COVID-19 with cardiac injury: a systematic review and meta-analysis

Objectives

Cardiac injury is associated with poor prognosis of 2019 novel coronavirus disease 2019 (COVID-19), but the risk factors for cardiac injury have not been fully studied. In this study, we carried out a systematic analysis of clinical characteristics in COVID-19 patients to determine potential risk factors for cardiac injury complicated COVID-19 virus infection.

Methods

We systematically searched relevant literature published in Pubmed, Embase, Europe PMC, CNKI and other databases. All statistical analyses were performed using STATA 16.0.

Results

We analysed 5726 confirmed cases from 17 studies. The results indicated that compared with non-cardiac-injured patients, patients with cardiac injury are older, with a greater proportion of male patients, with higher possibilities of existing comorbidities, with higher risks of clinical complications, need for mechanical ventilation, ICU transfer and mortality. Moreover, C-reactive protein, procalcitonin, D-dimer, NT-proBNP and blood creatinine in patients with cardiac injury are also higher while lymphocyte counts and platelet counts decreased. However, we fortuitously found that patients with cardiac injury did not present higher clinical specificity for chest distress (P = 0.304), chest pain (P = 0.334), palpitations (P = 0.793) and smoking (P = 0.234). Similarly, the risk of concomitant arrhythmia (P = 0.103) did not increase observably either.

Conclusion

Age, male gender and comorbidities are risk factors for cardiac injury complicated COVID-19 infection. Such patients are susceptible to complications and usually have abnormal results of laboratory tests, leading to poor outcomes. Contrary to common cardiac diseases, cardiac injury complicated COVID-19 infection did not significantly induce chest distress, chest pain, palpitations or arrhythmias. Our study indicates that early prevention should be applied to COVID-19 patients with cardiac injury to reduce adverse outcomes.

Effectiveness of computer-based training on post-stroke cognitive rehabilitation: A systematic review and meta-analysis

A systematic review and meta-analysis based on randomized controlled trials (RCTs) from the last 10 years was conducted to identify the effect of computer-based training compared to routine methods on post-stroke cognitive rehabilitation and to provide recommendations for future research. A literature search was performed in the Cochrane Library, EMBASE, PubMed, EBSCO (CINAHL), and Web of Science that focused on studies comparing the effects of computerized cognitive training and routine methods in stroke survivors. After extraction of the study characteristics and methodological quality evaluation, a meta-analysis was conducted using the standard model based on the level of the overall cognitive domain. Ten out of 201 studies were included in the systematic review, with a total of 600 stroke survivors. The average age of the participants ranged from 42.1 to 66 years old, 305 participants used the computer-based training method, and males accounted for approximately 58.5%. All studies compared the baseline characteristics of participants at the onset of their studies, and no significant difference was shown. Six studies that reported the results for the overall cognitive domain were further analyzed by meta-analysis. The outcome of the meta-analysis showed that the effect size was 0.61 with a 95% confidence interval [-0.18, 0.35], and the P value (P = 0.54) indicated no significant difference between the control group and the computer-based cognitive training group. The results of the meta-analysis, based on a limited number of studies, did not show significant superiority of computer-based cognitive training compared to the traditional method in post-stroke patients. More high-quality studies focusing on different illness phases and various types of intervention software should be conducted to improve the meta-analysis and to explore the influence of computer-based cognitive training by subgroup analysis.Abbreviation: CBCT: Computer-based cognitive training; PICOS: Participants, interventions, comparisons, outcomes, and study design.

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.

Reliability of transcranial sonography for assessment of brain midline shift in adult neurocritical patients: a systematic review and meta-analysis

INTRODUCTION

The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients.

EVIDENCE AQUISITION

The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations.

EVIDENCE SYNTHESIS

Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm).

CONCLUSIONS

Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.

Effect of preparative rehabilitation on recovery after cardiac surgery: A systematic review

BACKGROUND

Physical prehabilitation (preparative rehabilitation) programs may have beneficial effects on enhancing physical strength and functional status before surgery, but their effects on postoperative recovery are unclear.

OBJECTIVES

This systematic review investigated the effectiveness of physical prehabilitation programs before cardiac surgery on postoperative recovery and other perioperative outcomes.

METHODS

We searched for reports of randomised controlled trials of any prehabilitation programs that included physical activity or an exercise training component in adults undergoing elective cardiac surgery, published in any language, from six bibliographic databases (last search on June 20, 2019). We assessed trials for risk of bias, overall certainty of evidence and quality of intervention reporting using the Cochrane Risk of Bias Assessment Tool, GRADE system and the Template for Intervention Description and Replication checklist and guide, respectively.

RESULTS

All 7 studies (726 participants) were at high risk of bias because of lack of blinding. The quality of prehabilitation reporting was moderate because program adherence was rarely assessed. The timing of prehabilitation ranged from 5 days to 16 weeks before surgery and from face-to-face exercise prescription to telephone counselling and monitoring. We found uncertain effects of prehabilitation on postoperative clinical outcomes (among the many outcomes assessed): perioperative mortality (Peto odds ratio 1.30, 95% confidence interval [CI] 0.28 to 5.95; I²=0%; low-certainty evidence) and postoperative atrial fibrillation (relative risk 0.75, 95% CI 0.38 to 1.46; I²=50%; very low-certainty evidence). However, prehabilitation may improve postoperative functional capacity and slightly shorten the hospital stay (mean difference -0.66 days, 95% CI -1.29 to -0.03; I²=45%; low-certainty evidence).

CONCLUSION

Despite the high heterogeneity among physical prehabilitation trials and the uncertainty regarding robust clinical outcomes, physical prehabilitation before cardiac surgery seems to enhance selected postoperative functional performance measures and slightly reduce the hospital length of stay after cardiac surgery.

Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis

Our aim was to evaluate the effect of dry needling alone as compared to sham needling, no intervention, or other physical interventions applied over trigger points (TrPs) related with neck pain symptoms. Randomized controlled trials including one group receiving dry needling for TrPs associated with neck pain were identified in electronic databases. Outcomes included pain intensity, pain-related disability, pressure pain thresholds, and cervical range of motion. The Cochrane risk of bias tool and the Physiotherapy Evidence Database (PEDro) score were used to assessed risk of bias (RoB) and methodological quality of the trials. The quality of evidence was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Between-groups mean differences (MD) and standardized mean differences (SMD) were calculated (3) Twenty-eight trials were finally included. Dry needling reduced pain immediately after (MD -1.53, 95% CI -2.29 to -0.76) and at short-term (MD -2.31, 95% CI -3.64 to -0.99) when compared with sham/placebo/waiting list/other form of dry needling and, also, at short-term (MD -0.51, 95% CI -0.95 to -0.06) compared with manual therapy. No differences in comparison with other physical therapy interventions were observed. An effect on pain-related disability at the short-term was found when comparing dry needing with sham/placebo/waiting list/other form of dry needling (SMD -0.87, 95% CI -1.60 to -0.14) but not with manual therapy or other interventions. Dry needling was effective for improving pressure pain thresholds immediately after the intervention (MD 55.48 kPa, 95% CI 27.03 to 83.93). No effect on cervical range of motion of dry needling against either comparative group was found. No between-treatment effect was observed in any outcome at mid-term. Low to moderate evidence suggests that dry needling can be effective for improving pain intensity and pain-related disability in individuals with neck pain symptoms associated with TrPs at the short-term. No significant effects on pressure pain sensitivity or cervical range of motion were observed. Registration number: OSF Registry-https://doi.org/10.17605/OSF.IO/P2UWD.

Intensive Care Versus Nonintensive Care Ward for Postoperative Management of Head and Neck Free Flaps: A Meta-Analysis

Introduction: Although advances in surgical technique and medical management have drastically improved outcomes of free flap reconstructive surgery in head and neck patients, there is no clear consensus on appropriate level of postoperative care. Methods: The literature was searched systematically for all comparative studies of intensive care unit (ICU) and non-ICU admissions for head and neck patients. The primary outcomes were flap failure rate, flap complications, and hospital length of stay (LOS). Secondary outcomes included cost implications, medical complications, and rates of revision surgery, readmission, and mortality. Results: Nine articles (2510 patients) were included. Patients admitted to non-ICU wards were not significantly at increased risk for free flap failure, flap-related complications, or longer LOS. Total medical complications were found to have a pooled relative risk (RR) of 0.57 [95% confidence interval (CI) 0.40 to 0.83], favoring the non-ICU cohort. In particular, the non-ICU cohort was less likely to develop neuropsychiatric complications (RR 0.34 [95% CI 0.24 to 0.48]) and sepsis (RR 0.18 [95% CI 0.05 to 0.68]) with no difference in cardiovascular or pulmonary complications. Discussion: Patients admitted to non-ICU wards did not experience higher rates of adverse flap-related outcomes and had decreased risk of developing medical complications in the studies included in this meta-analysis.

Comparative clinical outcomes of robot-assisted liver resection versus laparoscopic liver resection: A meta-analysis

BACKGROUND

As an emerging technology, robot-assisted surgical system has some potential merits in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted liver resection is still a controversial problem on its advantages compared with laparoscopic liver resection. We aimed to perform the meta-analysis to assess and compare the clinical outcomes of robot-assisted and laparoscopic liver resection.

METHODS

We searched PubMed, Cochrane Library, Embase databases, Clinicaltrials, and Opengrey through March 24, 2020, including references of qualifying articles. English-language, original investigations in humans about robot-assisted and laparoscopic hepatectomy were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Continuous and dichotomous variables were compared by the weighted mean difference (WMD) and odds ratio (OR), respectively.

RESULTS

Of 936 titles identified in our original search, 28 articles met our criteria, involving 3544 patients. Compared with laparoscopy, the robot-assisted groups had longer operative time (WMD: 36.93; 95% CI, 19.74-54.12; P < 0.001), lower conversion rate (OR: 0.63; 95% CI, 0.46-0.87; P = 0.005), higher transfusion rate (WMD: 2.39; 95% CI, 1.51-3.76; P < 0.001) and higher total cost (WMD:0.49; 95% CI, 0.42-0.55; P < 0.001). In addition, the baseline characteristics of patients about largest tumor size was larger (WMD: 0.36; 95% CI, 0.16-0.56; P < 0.001) and malignant lesions rate was higher (WMD: 1.50; 95% CI, 1.21-1.86; P < 0.001) in the robot-assisted versus laparoscopic hepatectomy. The subgroup analysis of minor hepatectomy showed robot-assisted was associated with longer operative time (WMD: 36.00; 95% CI, 12.59-59.41; P = 0.003), longer length of stay (WMD: 0.51; 95% CI, 0.02-1.01; p = 0.04) and higher total cost (WMD: 0.48; 95% CI, 0.25-0.72; P < 0.001) (Table 3); while the subgroup analysis of major hepatectomy showed robot-assisted was associated with lower estimated blood loss (WMD: -122.43; 95% CI, -151.78--93.08; P < 0.001).

CONCLUSIONS

Our meta-analysis revealed that robot-assisted was associated with longer operative time, lower conversion rate, higher transfusion rate and total cost, and robot-assisted has certain advantages in major hepatectomy compared with laparoscopic hepatectomy.

Transurethral laser versus open simple prostatectomy for large volume prostates: a systematic review and meta-analysis of randomized controlled trials

The benefit of transurethral laser prostatectomy over open simple prostatectomy (OSP) is controversial in aged symptomatic benign prostatic hyperplasia (BPH) patients with large volume prostates, and the aim of this study is to compare the safety and efficiency of these two methods. Meta-analysis was applied using the Review Manager V5.3 software and the retrieved randomized controlled clinical trials (RCTs) comparing transurethral laser prostatectomy with OSP were analyzed for the treatment of large volume prostates from 2000 to 2019 in PubMed, Web of Science, Cochrane, and EMBASE datasets. Five RCTs assessing transurethral laser prostatectomy versus OSP were considered suitable for this meta-analysis, which included a total of 448 patients, with 232 patients undergoing laser and 216 patients undergoing OSP. Compared with OSP, although transurethral laser prostatectomy required a longer operative time (weighted mean difference (WMD) 27.49 mins; 95% confidence interval (CI) 16.54-38.44; P < 0.00001) and obtained a less resected prostate weight (WMD - 11.72 g; 95% CI - 21.75 to - 1.70; P = 0.02), patients undergoing laser prostatectomy benefited from significantly less hemoglobin decline (- 0.97 g/dL; 95% CI - 1.31 to - 0.64; P < 0.00001), shorter time of catheterization (WMD - 3.67 days; 95% CI - 5.60 to - 1.75; P = 0.0002), shorter length of hospital stay (WMD - 4.75 days; 95% CI - 6.57 to - 2.93; P < 0.00001), and less blood transfusion (odds ratio 0.10; 95% CI 0.03 to 0.35; P = 0.0003). During postoperative follow-up, no significant difference was observed between the two groups in IPSS, QoL, Q_max, and PVR. Both transurethral laser prostatectomy and OSP are safe and effective for large prostates that require prostate resection. Taking into account of less blood loss, shorter catheterization time and hospital stay, and less blood transfusion, transurethral laser prostatectomy may be a better treatment for patients with large prostates.

A systematic review and meta-analysis of health state utility values for osteoarthritis-related conditions

BACKGROUND

Health state utility values (HSUVs) are a key input in health economic modelling but HSUVs of people with osteoarthritis (OA)-related conditions have not been systematically reviewed and meta-analysed.

OBJECTIVE

To systematically review and meta-analyse the HSUVs for people with OA.

METHODS

Searches within health economic/biomedical databases were performed to identify eligible studies reporting OA-related HSUVs. Data on study design, participant characteristics, affected OA joint sites, treatment type, HSUV elicitation method, considered health states, and the reported HSUVs were extracted. HSUVs for people with knee, hip and mixed OA in pre- and post-treatment populations were meta-analysed using random effects models.

RESULTS

One-hundred and fifty-one studies were included in the systematic review, and 88 in meta-analyses. Of 151 studies, 56% were conducted in Europe, 75% were in people with knee and/or hip OA and 79% were based on the EQ-5D. The pooled mean (95% confidence interval [CI]) baseline HSUVs for knee OA core interventions, medication, injection and primary surgery treatments were 0.64 (0.61-0.66), 0.56 (0.45-0.68), 0.58 (0.50-0.66) and 0.52 (0.49-0.55), respectively. These were 0.71 (0.59-0.84) for hip OA core interventions and 0.52 (0.49-0.56) for hip OA primary surgery. For all knee OA treatments and hip OA primary surgery, pooled HSUVs were significantly higher in the post- than the pre- treatment populations.

CONCLUSION

This study provides a comprehensive summary of OA-related HSUVs and generates a HSUVs database for people with different affected OA joint sites undergoing different treatments to guide HSUV choices in future health economic modelling of OA interventions.

Are thromboelastometric and thromboelastographic parameters associated with mortality in septic patients? A systematic review and meta-analysis

BACKGROUND

Thromboelastometry/elastography (ROTEM/TEG) showed promising results for diagnosis of sepsis-induced coagulopathy, but their association with the outcome is unclear. Our aim was to assess any difference in ROTEM/TEG measurements between septic survivors and non-survivors.

METHODS

Pubmed, Web of Science, Embase and Cochrane Library databases were investigated. The research aimed to include any randomized or observational study: i) on septic adult patients admitted to Intensive Care Unit (ICU) or Emergency Department (ED); ii) including ROTEM/TEG; iii) assessing mortality.

RESULTS

Seven prospective and four retrospective observational studies (952 patients) were included. According to the INTEM/kaolin-assay, clotting time (CT)/R (standardized mean difference(SMD) -0.29, 95% CI -0.49 to -0.09, p = 0.004) and clot formation time (CFT)/K (SMD -0.42, 95% CI -0.78 to -0.06, p = 0.02) were shorter in survivors. According to the EXTEM-assay, CT was shorter (MD -11.66 s, 95% CI -22.59 to -0.73, p = 0.04), while MCF was higher (MD 3.49 mm, 95% CI 0.43 to 6.55, p = 0.03) in survivors. A hypocoagulable profile was more frequent in non-survivors (OR 0.31, 95%CI 0.18 to 0.55, p < 0.0001). Overall, the risk of bias of the included studies was moderate and the quality of evidence low.

CONCLUSIONS

Hypocoagulability and lower MCF in EXTEM may be associated with higher mortality in sepsis.

Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis

Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66-1.06; P = .13; I2  = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46-0.88; P = .007; I2  = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: -384; CI, -640 to -128, P = .003, I2  = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; CI, -3.22 to -0.38; P = .01; I2  = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.

Comparison of Ivor Lewis and Sweet esophagectomy for middle and lower esophageal squamous cell carcinoma: A systematic review and pooled analysis

BACKGROUND

Lack of robust evidence highlights the important need to address the controversy on the clinical safety and effectiveness between Ivor Lewis versus Sweet procedure for middle and lower esophageal squamous cell carcinoma (ESCC).

METHODS

Search results were filtered according to certain criteria and were analyzed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

The inter-study heterogeneity was high. Ivor Lewis procedure might be associated with longer operation time (p < 0.01) and higher lymph node yield (p < 0.01) compared with Sweet procedure. There was no significant difference in the length of hospital stay and postoperative complications with similar reoperation rate between the two procedures (p > 0.05). As the combined analysis of survival data revealed, there was no statistical difference in the oncologic efficacy of them (p = 0.97).

INTERPRETATION

The present study based on retrospective data with high heterogeneity indicated that Ivor Lewis esophagectomy might be associated with increased lymph node yield but longer operation time than Sweet. Prospective studies are warranted to compare the long-term survival of Ivor Lewis esophagectomy versus Sweet for middle and lower ESCC.

Efficacy of Physical Therapy on Nociceptive Pain Processing Alterations in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-analysis

INTRODUCTION

Chronic musculoskeletal pain is a major health, social, and economic problem. Most of the subjects who suffer from chronic musculoskeletal pain present processes of central sensitization. Temporal summation and conditioned pain modulation are the two most commonly used clinical measures of this. The objective of this review is to evaluate the effects of physical therapy on temporal summation (TS) and conditioned pain modulation (CPM) in patients with chronic musculoskeletal pain.

METHODS

This is a systematic review and meta-analysis. We searched the MEDLINE, EMBASE, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews, and SCOPUS databases. Different mesh terms and key words were combined for the search strategy, with the aim of encompassing all studies that have used any type of physical therapy treatment in patients with chronic musculoskeletal pain and have measured both TS and CPM.

RESULTS

Eighteen studies remained for qualitative analysis and 16 for quantitative analysis. Statistically significant differences with a 95% confidence interval (CI) were obtained for TS (-0.21, 95% CI = -0.39 to -0.03, Z = 2.50, P = 0.02, N = 721) and CPM (0.34, 95% CI = 0.12 to 0.56, Z = 2.99, P = 0.003, N = 680) in favor of physical therapy as compared with control. Manual therapy produces a slight improvement in TS, and physical therapy modalities in general improve CPM. No significant differences between the subgroups of the meta-analysis were found. The methodological quality of the studies was high.

CONCLUSIONS

Physical therapy produces a slight improvement in central sensitization (CS)-related variables, with TS decreased and CPM increased when compared with a control group in patients with CMP. Only significant differences in TS were identified in the manual therapy subgroup.

Comparative analysis of laboratory indexes of severe and non-severe patients infected with COVID-19

BACKGROUND

The pandemic coronavirus disease 2019 (COVID-19) has threaten the global health. The characteristics of laboratory findings of coronavirus are of great significance for clinical diagnosis and treatment. We found indicators that may most effectively predict a non-severe COVID-19 patient develop into a severe patient.

METHODS

We conducted a meta-analysis to compare the laboratory findings of severe patients with non-severe patients with COVID-19 from searched articles.

RESULTS

Through the analysis of laboratory examination information of patients with COVID-19 from 35 articles (5912 patients), we demonstrated that severe cases possessed higher levels of leukocyte (1.20-fold), neutrophil (1.33-fold), CRP (3.04-fold), PCT (2.00-fold), ESR (1.44-fold), AST (1.40-fold), ALT (1.34-fold), LDH (1.54-fold), CK (1.44-fold), CK-MB (1.39-fold), total bilirubin (1.14-fold), urea (1.28-fold), creatine (1.09-fold), PT (1.03-fold) and D-dimer (2.74-fold), as well as lower levels of lymphocytes (1.44-fold), eosinophil (2.00-fold), monocyte (1.08-fold), Hemoglobin (1.53-fold), PLT (1.15-fold), albumin (1.15-fold), and APTT (1.02-fold). Lymphocyte subsets and series of inflammatory cytokines were also different in severe cases with the non-severe ones, including lower levels of CD4 T cells (2.10-fold) and CD8 T cells (2.00-fold), higher levels of IL-1β (1.02-fold), IL-6 (1.93-fold) and IL-10 (1.55-fold).

CONCLUSIONS

Some certain laboratory inspections could predict the progress of the COVID-19 changes, especially lymphocytes, CRP, PCT, ALT, AST, LDH, D-dimer, CD4 T cells and IL6, which provide valuable signals for preventing the deterioration of the disease.

Clinical laboratory parameters associated with severe or critical novel coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

To date, several clinical laboratory parameters associated with Coronavirus disease 2019 (COVID-19) severity have been reported. However, these parameters have not been observed consistently across studies. The aim of this review was to assess clinical laboratory parameters which may serve as markers or predictors of severe or critical COVID-19.

METHODS AND FINDINGS

We conducted a systematic search of MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases from 2019 through April 18, 2020, and reviewed bibliographies of eligible studies, relevant systematic reviews, and the medRxiv pre-print server. We included hospital-based observational studies reporting clinical laboratory parameters of confirmed cases of COVID-19 and excluded studies having large proportions (>10%) of children and pregnant women. Two authors independently carried out screening of articles, data extraction and quality assessment. Meta-analyses were done using random effects model. Meta-median difference (MMD) and 95% confidence interval (CI) was calculated for each laboratory parameter. Forty-five studies in 6 countries were included. Compared to non-severe COVID-19 cases, severe or critical COVID-19 was characterised by higher neutrophil count (MMD: 1.23 [95% CI: 0.58 to 1.88] ×109 cells/L), and lower lymphocyte, CD4 and CD8 T cell counts with MMD (95% CI) of -0.39 (-0.47, -0.31) ×109 cells/L, -204.9 (-302.6, -107.1) cells/μl and -123.6 (-170.6, -76.6) cells/μl, respectively. Other notable results were observed for C-reactive protein (MMD: 36.97 [95% CI: 27.58, 46.35] mg/L), interleukin-6 (MMD: 17.37 [95% CI: 4.74, 30.00] pg/ml), Troponin I (MMD: 0.01 [0.00, 0.02] ng/ml), and D-dimer (MMD: 0.65 [0.45, 0.85] mg/ml).

CONCLUSIONS

Relative to non-severe COVID-19, severe or critical COVID-19 is characterised by increased markers of innate immune response, decreased markers of adaptive immune response, and increased markers of tissue damage and major organ failure. These markers could be used to recognise severe or critical disease and to monitor clinical course of COVID-19.

Systematic review with meta-analysis: abnormalities in the international normalised ratio do not correlate with periprocedural bleeding events among patients with cirrhosis

BACKGROUND

Cirrhotic coagulopathy is a delicate interplay comprising deficiencies of both procoagulant and anticoagulant factors.

AIM

To identify the relationship between international normalised ratio [INR] with periprocedural bleeding risk among patients with cirrhosis.

METHODS

Following a thorough database search of the primary literature, 29 studies were targeted for analysis, including 13 276 patients with cirrhosis undergoing indicated procedures.

RESULTS

There was no significant association between periprocedural bleeding events and pre-procedural INR [pooled odds ratio 1.52; 95% CI 0.99, 2.33; P = 0.06]. Furthermore, there was no significant difference in mean INR [pooled mean difference 0.05; 95% CI -0.03, 0.13; P = 0.23] upon comparison of patients who either did or did not experience a periprocedural bleeding event. Significant heterogeneity among some studies was primarily fuelled by significant subgroup effects of both specific procedure types performed. Additionally, there were markedly inconsistent transfusion practices across studies.

CONCLUSIONS

INR fails to serve as a significant correlate for periprocedural bleeding events among patients with cirrhosis. Ideally, these new findings will help serve as a springboard for future studies, as well as to minimize transfusion of blood products, which command a myriad of adverse effects among patients with cirrhosis.

Uric acid levels in subjects with schizophrenia: A systematic review and meta-analysis

The association between schizophrenia (SZ) and uric acid (UA) levels has been suggested for many years, but without solid evidence. Therefore, we conducted a systematic review and meta-analysis of all case-control studies examining the serum and plasma UA levels in SZ subjects in comparison to those in healthy controls. Relevant studies published before October 29, 2018, were searched in the main electronic databases, and 17 studies were finally included into the meta-analysis after screening with the criteria. Our results revealed that there were no statistically significant differences of the UA levels between SZ subjects and healthy controls. Further subgroup analyses of the antipsychotic status reported the same finding. Subgroup analyses of clinical status showed that UA levels were decreased in subjects with first episode psychosis (FEP). The subgroup analyses of gender and ethnicity demonstrated that UA levels were decreased in male subjects and in Americans with SZ. Overall, these findings strengthen the clinical evidence that FEP is accompanied by increased oxidative stress response. Reduced UA levels may be a potential risk factor for SZ in male and in the Americans. However, whether there is a causal relationship between the reduced UA levels and the development of SZ deserves further investigation.

Are the steroids a blanket solution for COVID-19? A systematic review and meta-analysis

Steroids may play a critical role in the current pandemic of coronavirus disease-2019 (COVID-19), given the dearth of specific therapeutic options. This review was conducted to evaluate the impact of glucocorticoid therapy in patients with COVID-19 based on the publications reported to date. A comprehensive screening was conducted using electronic databases up to August 19, 2020. The randomized controlled trials (RCTs) and cohort studies evaluating the effectiveness and safety of steroids in patients with COVID-19 are included for the meta-analyses. Our search retrieved twelve studies, including two RCTs and 10 cohort studies, with a total of 15,754 patients. In patients with COVID-19, the use of systemic glucocorticoid neither reduce mortality (odds ratio [OR] = 1.94, 95% confidence interval [CI]: 1.11-3.4, I²  = 96%), nor the duration of hospital stay (mean difference [MD] = 1.18 days, 95% CI: -1.28 to 3.64, I²  = 93%) and period of viral shedding (MD = 1.42 days, 95% CI: -0.52 to 3.37, I²  = 0%). Systemic steroid therapy may not be effective for reducing mortality, duration of hospitalization, and period of viral shedding. Studies are mostly heterogeneous. Further RCTs are required.

Comparison of efficacy and safety of laparoscopic excision and open operation in children with choledochal cysts: A systematic review and update meta-analysis

Objective

The outcomes of children with Choledochal cyst who undergo laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy versus open cyst excision and Roux-en-Y hepaticojejunostomy have not been adequately compared. We conducted a systematic review and meta-analysis to gain further insight into the efficacy and safety of laparoscopic excision in children with choledochal cysts.

Methods

A systematic search of PubMed, Embase, Cochrane Central Register, and ClinicalTrials.gov databases from January 1973 to January 31, 2020 was performed utilizing the PRISMA guidelines. Short-term, long-term and total postoperative complications were the primary endpoint measurements, whereas intraoperative outcomes and other postoperative outcomes were the secondary endpoints.

Results

The final analysis included 14 retrospective cohorts comprising 1767 patients. There were no significant differences in the patients’ short-term postoperative complications (RR = -1.08; 95% CI = -1.72 to -0.67) between the 2 approaches. However, improvements in long-term (RR = 0.09; 95% CI = 0.01 to 0.18) and total postoperative complications (RR = -0.29; 95% CI = -0.40 to -0.21), estimated intraoperative blood loss and transfusion, time of initial feeding, and length of hospital stay were observed in patients who underwent laparoscopic excision when compared to those who underwent open surgery.

Conclusions

Laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy provides similar or even improved intraoperative, postoperative outcomes when compared to open excision for children with Choledochal cyst.

Evidence of localized and widespread pressure pain hypersensitivity in patients with tension-type headache: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis evaluates pressure pain sensitivity values in symptomatic and distant pain-free areas comparing individuals with tension-type headache to controls.

DATABASES AND DATA TREATMENT

Electronic databases were searched for cross-sectional or prospective case-control studies comparing pressure pain thresholds in patients with tension-type headache to headache-free controls. Data were extracted by three reviewers. The methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of trigeminal, extra-trigeminal (neck) and distant pain-free areas in tension-type headache were compared to headache-free controls. Frequency of tension-type headache and gender were taken into account.

RESULTS

Twenty studies were included. Patients with tension-type headache exhibited lower pressure pain thresholds than headache-free controls: Trigeminal (MD -49.11 kPa, 95% CI -66.05 to -32.17), cervical spine (MD -88.17 kPa, 95% CI -108.43 to -67.92) and distant pain-free areas (MD -98.43 kPa, 95% CI -136.78 to -60.09). Differences were significant for chronic, episodic, and mixed episodic and chronic tension-type headache within the trigeminal and neck (symptomatic areas), but only significant for chronic tension-type headache (MD -102.86, 95% CI -139.47 to -66.25 kPa) for distant pain-free areas. In general, women had lower pressure pain thresholds than men. The methodological quality ranged from fair (45%) to good (40%). The results showed a high heterogeneity and publication bias.

CONCLUSION

This first meta-analysis addressing pressure pain thresholds differences in symptomatic and distant pain-free areas between patients with tension-type headache and controls found low to moderate evidence supporting the presence of pressure pain hypersensitivity in the trigeminal and neck areas in tension-type headache in comparison with headache-free controls. Sensitivity to pressure pain was widespread only in chronic, not episodic, tension-type headache (moderate evidence).Registration number: https://doi.org/10.17605/OSF.IO/R29HY.

Laparoscopic versus robotic right colectomy with extra-corporeal or intra-corporeal anastomosis: a systematic review and meta-analysis

PURPOSE

The aim of the present systematic review and meta-analysis is to compare laparoscopic right colectomy (LRC) versus robotic right colectomy (RRC) using homogeneous subgroup analyses for extra-corporeal anastomosis (EA) and intra-corporeal anastomosis (IA).

METHODS

MEDLINE, Scopus, and Web of Science databases were searched up to April 2020 for prospective or retrospective studies comparing LRC versus RRC on at least one short- or long-term outcome. The primary outcome was the length of hospital stay (LOS). The secondary outcomes included operative and pathological results, survival, and total costs. LRC and RRC were compared using three homogeneous subgroups: without distinction by the type of anastomosis, EA only, and IA only. Pooled data analyses were performed using mean difference (MD) and random effects model.

RESULTS

Thirty-seven of 448 studies were selected. The included patients were 21,397 for the LRC group and 2796 for the RRC group. Regardless for the type of anastomosis, RRC showed shorter LOS, lower blood loss, lower conversion rate, shorter time to flatus, and lower overall complication rate compared with LRC, but longer operative time and higher total costs. In the EA subgroup, RRC showed similar LOS, longer operative time, and higher costs compared with LRC, the other outcomes being similar. In the IA subgroup, RRC showed shorter LOS and longer operative time compared with LRC, with no difference for the remaining outcomes.

CONCLUSIONS

Most included articles are retrospective, providing low-quality evidence and limiting conclusions. The more frequent use of the IA seems to explain the advantages of RRC over LRC.

Immunonutrition for traumatic brain injury in children and adolescents: protocol for a systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) is the leading cause of paediatric trauma death and disability worldwide. The 'Guidelines for the Management of Severe Traumatic Brain Injury (Fourth Edition)' recommend that nutritional goals should be achieved within 5-7 days of injury. Immune-enhancing nutrition or immunonutrition, referring to the addition of specialised nutrients, including glutamine, alanine, omega-3 fatty acids and nucleotides, to standard nutrition formulas, may improve surgical outcomes in the perioperative period. However, the role of immune-enhancing nutritional supplements for patients with paediatric TBI remains unclear. We will conduct a systematic review to determine the efficacy and safety of immunonutrition for patients with paediatric TBI and provide evidence for clinical decision-making.

METHODS AND ANALYSIS

Studies reporting immune-enhancing nutrition treatments for patients with paediatric TBI will be included. Outcomes of interest include the length of hospital stay, wound infections, all-cause mortality, non-wound infection, including pneumonia, urinary tract infection and bacteraemia, and the reports adverse events. Duration of follow-up has no restriction. Primary studies consisting of randomised controlled trials (RCTs) and non-RCTs will be eligible for this review, and only studies published in English will be included. We will search the Medline, Embase and Cochrane Library databases from their inception dates to January 2020. We will also search clinicaltrials.gov and the WHO International Clinical Trials Registry Platform for additional information. Two reviewers will independently select studies and extract data. Risk-of-bias will be assessed with tools based on the Cochrane risk-of-bias criteria and Newcastle-Ottawa Quality Assessment Scale. A meta-analysis will be used to pool data when there are sufficient studies with homogeneity. Heterogeneity of the estimates across studies will be assessed; if necessary, a subgroup analysis will be performed to explore the source of heterogeneity. The Grades of Recommendation, Assessment, Development and Evaluation method will be applied to assess the level of evidence obtained from this systematic review.

ETHICS AND DISSEMINATION

The proposed systematic review and meta-analysis will be based on published data, and thus ethical approval is not required. The results of this review will be published.

PROSPERO REGISTRATION NUMBER

CRD42020154814.