Reporting 'number needed to treat' in meta-analyses: a cross-sectional study

Aggressive hydration for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis: trial sequential analysis

BACKGROUND

Randomized controlled trials (RCTs) have demonstrated that aggressive hydration with lactated Ringer's (LR) solution reduces the frequency and severity of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In this trial sequential analysis (TSA), we aimed to evaluate the prophylactic effect of aggressive hydration on PEP in specific patient subgroups and to determine the need for additional RCTs.

METHODS

We conducted a systematic and comprehensive search to identify all randomized controlled studies published through August 2021 that examined the effectiveness of aggressive hydration for preventing PEP. The primary outcome was the frequency of PEP. We also performed TSA to calculate the required information size and assess whether our results were conclusive.

RESULTS

The analysis included 12 studies involving 2,501 patients. According to the TSA, the overall frequency of PEP was significantly lower in the aggressive hydration group (5.6%; 74 of 1,327 patients) than in the control group (13.1%; 154 of 1,174 patients) (risk ratio [RR]: 0.458; 95% confidence interval [CI]: 0.350-0.599). In the subgroup analysis of patients with average risk, the cumulative Z curve crossed both the conventional test boundary and the trial sequential monitoring boundary. However, in the high-risk group and in patients with moderate-to-severe PEP, the Z curve did not cross the trial sequential monitoring boundary.

CONCLUSIONS

This TSA indicates that aggressive hydration is effective in the overall prevention of PEP. However, additional RCTs are required to examine the prophylactic effect of aggressive hydration with LR on PEP in high-risk populations.

Comparison of the Effectiveness of Palonosetron and Ramosetron in Preventing Postoperative Nausea and Vomiting: Updated Systematic Review and Meta-Analysis with Trial Sequential Analysis

This updated systematic review and meta-analysis with trial sequential analysis aimed to compare the efficacy of the perioperative administration of palonosetron with that of ramosetron in preventing postoperative nausea and vomiting (PONV). A total of 17 randomized controlled trials comparing the efficacy of the perioperative administration of palonosetron to that of ramosetron for preventing PONV were included. The primary outcomes were the incidences of postoperative nausea (PON), postoperative vomiting (POV), and PONV, which were measured in early, late, and overall phases. Subgroup analysis was performed on the basis of the administration time of the 5-HT3 receptor antagonist and divided into two phases: early phase and the end of surgery. A total of 17 studies with 1823 patients were included in the final analysis. The incidence of retching (relative risk [RR] = 0.525; 95% confidence interval [CI] = 0.390 to 0.707) and late POV (RR = 0.604; 95% CI = 0.404 to 0.903) was significantly lower in the palonosetron group than in the ramosetron group. No significant differences were demonstrated in the incidence of PON, PONV, complete response, use of antiemetics, and adverse effects. Subgroup analysis showed that palonosetron was superior to ramosetron in terms of early PON, late PON, overall POV, and use of rescue antiemetics when they were administered early; in terms of retching, regardless of the timing of administration. Ramosetron was superior to palonosetron in terms of early PON when they were administered late. The prophylactic administration of palonosetron was more effective than that of ramosetron in preventing the development of retching and late POV. In this meta-analysis, no significant differences in PONV prevention between the two drugs were demonstrated. Further studies are required to validate the outcomes of our study.

Effect of intravenous dexmedetomidine and remifentanil on neonatal outcomes after caesarean section under general anaesthesia: A systematic review and meta-analysis

BACKGROUND

Various strategies have been used to mitigate haemodynamic instability during general anaesthesia for caesarean section. However, the safety of these strategies for neonates remains controversial.

OBJECTIVE

To investigate the effects of intravenous dexmedetomidine and remifentanil on neonatal outcomes during caesarean section under general anaesthesia.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Databases of PubMed, EMBASE and CENTRAL were searched until March 2020 and updated in February 2021.

ELIGIBILITY CRITERIA

Randomised controlled trials were included if they compared dexmedetomidine and remifentanil infusion on neonatal outcomes after elective caesarean section under general anaesthesia. Primary outcomes were 1 and 5 min Apgar scores. Secondary outcomes were the incidence of neonatal mask ventilation or endotracheal intubation, and pH of the umbilical artery and vein. Studies that did not report primary outcomes were excluded.

RESULTS

Five studies with 258 patients in total were included. The Apgar score at 1 min in the remifentanil group was lower than that in the dexmedetomidine group for both quantitative [weighted mean difference (WMD): 0.75; 95% CI, 0.44 to 1.07; τ2 = 0.00] and categorical outcomes (≥Apgar 7 vs.

CONCLUSION

In our study, Apgar score at 1 min reported using both quantitative and categorical variables were lower in the remifentanil group than in the dexmedetomidine group but TSA showed that these differences were inconclusive for categorical variables. Data for other outcomes were scarce and did not allow any conclusions to be drawn. Thus, further studies with larger numbers of parturients and with neonatal outcomes as a primary endpoint are warranted to clarify the effects of intravenous dexmedetomidine and remifentanil.

TRIAL REGISTRATION

The protocol of this study has been registered in PROSPERO (CRD42019141102).

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MESH Headings

• Anesthesia, General/adverse effects
• Cesarean Section
• Dexmedetomidine/adverse effects
• Female
• Humans
• Infant, Newborn
• Piperidines/adverse effects
• Pregnancy
• Remifentanil

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Affiliation(s)

Myeongjong Lee From the Department of Anesthesiology and Pain Medicine (ML), Research Institute of Medical Science, Konkuk University School of Medicine, Chungju (ML), Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul (HK), Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Muwang-ro, Iksan (CL) and Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Heukseok-ro, Dongjak-gu, Seoul, Republic of Korea (HK)
Hyungtae Kim
Cheol Lee
Hyun Kang

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Prognostic Significance of Tumor Location in T2 Gallbladder Cancer: A Systematic Review and Meta-Analysis

(1) Background: The AJCC Cancer Staging Manual, Eighth Edition, subdivided T2 GBC into T2a and T2b. However, there still exist a lack of evidence on the prognostic significance of tumor location. The aim of the present study was to examine the existing evidence to determine the prognostic significance of tumor location of T2 gallbladder cancer (GBC) and to evaluate the optimal surgical extent according to tumor location. (2) Methods: We searched for relevant literature published in the electronic databases PubMed, MEDLINE, Web of Science, Cochrane Library, and Embase before September 2020 using search terms related to gallbladder, cancer, and stage. Data were weighted and pooled using random-effects modeling. (3) Results: Seven studies were deemed eligible for inclusion, representing a cohort of 1789 cases of resected T2 GBC. The overall survival for T2b tumor was significantly worse than that for T2a tumor (HR, 2.141; 95% confidence interval (CI), 1.140 to 4.023; I² = 71.4%; P_chⁱ² = 0.007). The rate of lymph node metastasis was lower in the T2a group (26.6%) than in the T2b group (36.6%) (OR, 2.164; 95% CI, 1.309 to 3.575). There was no evidence of a survival difference between the patients who underwent extended cholecystectomy and simple cholecystectomy in T2a GBC (OR, 0.802; 95% CI, 0.618 to 1.042) and T2b GBC (OR, 0.820; 95% CI, 0.620 to 1.083). (4) Conclusions: Hepatic side tumor was a significant poor prognostic factor in T2 GBC. Extended cholecystectomy and simple cholecystectomy showed comparable survival outcomes in T2 GBC, and additional large-scale prospective studies are warranted to establish evidence-based treatment guidelines for T2 GBC.

Comparison of procedural sequence in same-day bidirectional endoscopy: a systematic review and meta-analysis

BACKGROUND/AIMS

To compare the efficacy and safety of procedural sequence in same-day bidirectional endoscopy.

METHODS

We searched OVID-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar to identify randomized controlled trials that compared the procedural sequences in same-day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy. The sedative and analgesic doses required, discomfort and satisfaction scores, procedure time, recovery time, adenoma detection rate, and failed cecal intubation were evaluated. Adverse effects, including respiratory and cardiovascular complications, were also assessed.

RESULTS

We included six studies, with 1,848 patients in total. The requirement for sedative treatment was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (standardized mean difference [SMD], -0.39; 95% confidence interval [CI], -0.54 to -0.24; p = 0.12; I2 = 49%). Discomfort, scored by patients during the EGD procedure, was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, -0.45; 95% CI, -0.80 to -0.09; p = 0.02; I2 = 73%), while it was comparable during colonoscopy between the two sequences. Recovery time was significantly shorter in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, -0.47; 95% CI, -0.65 to -0.30; p = 0.28; I2 = 21%). Total procedure duration, EGD, colonoscopy, cecal intubation time and incidence, incidences of pathologic findings, and adenoma detection were comparable between the two sequences. There was no significant difference in the incidences of desaturation, hypotension, hypertension, bradycardia, and tachycardia between the two sequences.

CONCLUSION

When conducting same-day bidirectional endoscopy, EGD followed by colonoscopy is the most beneficial sequence to be used because patients require lower sedative doses, recover faster, and report lesser discomfort.

Vonoprazan versus proton pump inhibitors for the management of gastric endoscopic submucosal dissection-induced artificial ulcer: A systematic review with meta-analysis

BACKGROUND

Vonoprazan, a novel potassium-competitive acid blocking agent, has been used in the management of endoscopic submucosal dissection (ESD)-induced artificial ulcers. This study aimed to perform a systematic review and meta-analysis for the comparison of the effects of vonoprazan and proton pump inhibitors (PPIs) in treating ESD-induced artificial ulcers and preventing delayed bleeding in randomized controlled trial and cohort studies.

METHODS

We searched OVID-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and clinical trial registries in April 2018 to identify all studies that assess and compare the effects of vonoprazan and PPI in treating ESD-induced artificial ulcers and preventing delayed bleeding. Primary outcome of ulcer healing rate and secondary outcomes of shrinkage rate, ulcer size, and delayed bleeding were studied.

RESULTS

A total of 1265 patients from 12 studies were included in the final analysis. Healing rate at 4 weeks post-ESD was significantly higher in the vonoprazan group than in the PPI group (relative ratio [RR] 1.20 [1.03-1.40]). However, healing rate at 8 weeks post-ESD was significantly higher in the PPI group than in the vonoprazan group (RR 0.68 [0.48-0.97]).There was no evidence of significant difference between groups in shrinkage rate at 4 weeks post-ESD, shrinkage rate at 8 weeks post-ESD, delayed bleeding, ulcer size at 0 weeks post-ESD, and ulcer size at 8 weeks post-ESD.

CONCLUSIONS

There was no substantial difference in ulcer healing and post-ESD bleeding between vonoprazan and PPIs. However, vonoprazan more rapidly and effectively treated artificial ulcers after ESD than did PPIs.

Moderate versus deep sedation in adults undergoing colonoscopy: systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis comparing effectiveness and safety of moderate and deep sedation during colonoscopy.

RESEARCH DESIGN AND METHODS

We searched Medline, Embase, Central and Google scholar in May 2017 and updated in March 2018 to identify all randomized controlled trials that compared the effectiveness and safety of moderate and deep sedation during colonoscopy. The quality of studies was assessed using the "Risk of bias" tool. The primary endpoints were defined as patient satisfaction, physician satisfaction, incidence of recall and incidence of desaturation. Recovery time was also evaluated. Review Manager and Comprehensive Meta-Analysis software were used for statistical analysis.

RESULTS

A total of 919 patients from three studies were included in the final analysis. The combined analysis did not reveal any differences in patient satisfaction between moderate and deep sedation (RR = 0.94; 95% CI: 0.86 to 1.04; P_chi² = 0.06; I² = 65%; number needed to treat to harm [NNTH] = 15.6; 95% CI: NNTH 7.8 to ∞ to number needed to treat to benefit [NNTB] = 3078.0), physician satisfaction (RR = 0.35; 95% CI: 0.02 to 6.95; P_chi² < 0.001; I² = 100%; NNTB = 1.6; 95% CI: 1.5 to 1.8), incidence of recall (RR = 5.82; 95% CI: 0.51 to 66.48; P_chi² = 0.11; I² = 60%; NNTH = 11.0; 95% CI: 7.5 to 20.5) or recovery time (mean difference = -6.77; 95% CI: -16.21 to 2.67; P_chi² < 0.001; I² = 99%). However, incidence of desaturation was higher in the deep group than in the moderate group (RR = 0.18; 95% CI: 0.01 to 0.99; P_chi² = 0.48; I² = 0%; NNTB = 56.7; 95% CI: 31.6 to 273.1).

CONCLUSIONS

Moderate sedation showed comparable safety and effectiveness to deep sedation with respect to patient satisfaction, physician satisfaction, incidence of recall and recovery time.

Etomidate versus propofol sedation for electrical external cardioversion: a meta-analysis

OBJECTIVE

To compare the efficacy and safety of etomidate vs propofol sedation for electrical cardioversion.

METHODS

The authors searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, Google Scholar, Koreamed, and KMBASE databases to identify all randomized controlled trials that compared etomidate and propofol sedation for cardioversion in adult patients. Induction and recovery time, success rate, number of shocks, and cumulative energy were evaluated. Adverse effects, including respiratory and cardiovascular complications, myoclonus, and nausea and vomiting, were also assessed.

RESULTS

A total of nine studies, involving a total of 430 patients, were included. Induction and recovery time, success rate, number of shocks, and cumulative energy were similar. The incidences of hypotension and respiratory depression were significantly higher in the propofol group than in the etomidate group (risk ratio [RR] = 0.11, 95% confidence interval (CI) = 0.02-0.74, I² = 0%; RR = 0.50, 95% CI = 0.32-0.77, I² = 47%, respectively). The incidences of myoclonus and nausea or vomiting were significantly higher in the etomidate group than in the propofol group (RR = 8.89, 95% CI  =  4.59-17.23, I² = 9%; RR = 5.13, 95% CI = 1.72-15.31, I² = 31%, respectively).

CONCLUSIONS

Issues affecting efficacy, including induction and recovery time, success rate, number of shocks, and cumulative energy, were comparable between etomidate and propofol sedation. Regarding safety issues, propofol sedation resulted in hypotension and respiratory depression more frequently; however, initiation of positive pressure ventilation was comparable. Etomidate sedation caused myoclonus and nausea or vomiting more frequently.

Vonoprazan versus proton pump inhibitors for the management of gastroesophageal reflux disease: A protocol for a systematic review with meta-analysis

BACKGROUND AND AIM

Vonoprazan, a novel potassium-competitive acid blocking agent, is used in the management of gastroesophageal reflux disease (GERD). We aim to perform a systematic review and meta-analysis for the comparison of the effects of vonoprazan and proton pump inhibitors (PPIs) in GERD in randomized controlled trials (RCTs).

METHODS

A systematic and comprehensive search will be performed using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and clinical trial registries, for studies published up to September 2018. Only randomized clinical trials will be included. Primary outcomes of symptoms and esophageal erosion improvement in the intention-to-treat analysis, and secondary outcomes of symptoms and esophageal erosion improvement rate in the per protocol analysis, the comparative efficacy in terms of healing rate of esophageal erosion on endoscopy, the comparative efficacy in terms of improvement of esophageal impedance-pH study, adverse events, long-term safety, and the comparative efficacy in terms of CYP2C19 metabolite levels will be studied. The quality of included studies will be assessed using the modified risk of bias tool. Heterogeneity of estimates across studies as well as publication bias will be assessed. This systematic review and meta-analysis will be performed according to the protocol recommended by the Cochrane Collaboration and reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. All statistical analyses will be conducted using Stata SE version 15.0.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

To our knowledge, this systematic review and meta-analysis will be the first to evaluate existing research comparing Vonoprazan and PPIs in GERD. Our study will provide information about the effect of vonoprazan and PPIs in GERD in RCTs. The review will benefit patients, healthcare providers, and policymakers.

Comparison of propofol monotherapy and propofol combination therapy for sedation during gastrointestinal endoscopy: A systematic review and meta-analysis

BACKGROUND AND AIM

Previous randomized controlled trials have reported conflicting findings comparing propofol combination therapy (PCT) with propofol monotherapy (PMT) for sedation of patients undergoing gastrointestinal endoscopy. Therefore, a systematic review was carried out to compare the efficacy and safety of PCT and PMT in such patients.

METHODS

We searched MEDLINE, EMBASE and CENTRAL databases to identify all randomized controlled trials that compared the efficacy and safety of PCT and PMT for sedation of patients undergoing gastrointestinal endoscopy. Primary endpoints were incidence of respiratory complications, hypotension and arrhythmia, dose of propofol used, and recovery time. Procedure duration and the satisfaction of patients and doctors were also evaluated.

RESULTS

A total of 2250 patients from 22 studies were included in the final analysis. The combined analysis did not show any difference between PCT and PMT in the incidence of respiratory complications (risk ratio [RR], 0.80; 95% CI, 0.52 to 1.23; I2 = 58.34%), hypotension (RR, 1.06; 95% CI, 0.63 to 1.78; I2 = 72.13%), arrhythmia (RR,1.40; 95% CI, 0.74 to 2.64; I2 = 43.71%), recovery time (standardized mean difference [SMD], 0.16; 95% CI, -0.49 to 0.81; I2 = 95.9%), procedure duration (SMD, 0.04; 95% CI, -0.05 to 0.14; I2 = 0.0%), patient satisfaction (SMD, 0.13; 95% CI, -0.26 to 0.52; I2 = 89.63%) or doctor satisfaction (SMD, 0.01; 95% CI, -0.15 to 0.17; I2 = 0.00%). However, the dose of propofol used was significantly lower in PCT than in PMT (SMD, -1.38; 95% CI, -1.99 to -0.77; I2 = 97.70%).

CONCLUSION

PCT showed comparable efficacy and safety to PMT with respect to respiratory complications, hypotension and arrhythmia, recovery time, procedure duration, patient satisfaction, and doctor satisfaction. However, the average dose of propofol used was higher in PMT.

Palonosetron and Ramosetron Compared for Effectiveness in Preventing Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis

Previous randomized controlled trials have reported conflicting findings on the superiority of palonosetron over ramosetron for preventing postoperative nausea and vomiting (PONV). Therefore, the present systematic review was registered in PROSPERO (CRD42016038120) and performed to compare the efficacy of perioperative administration of palonosetron to that of ramosetron for preventing PONV. We searched MEDLINE, EMBASE, and CENTRAL to identify all randomized controlled trials that compared the effectiveness of perioperative administration of palonosetron to that of ramosetron. The primary endpoints were defined as the incidence of postoperative nausea (PON), postoperative vomiting (POV), and PONV. A total of 695 patients were included in the final analysis. Subgroup analysis was performed through administration times which were divided into two phases: the early phase of surgery and the end of surgery. Combined analysis did not show differences between palonosetron and ramosetron in the overall incidence of PON, POV or PONV. Palonosetron was more effective than ramosetron, when the administration time for the 5-HT3 receptor antagonist was during the early phase of the operation. Otherwise, ramosetron was more effective than palonosetron, when the administration time was at the end of surgery. However, the quality of evidence for each outcome was low or very low and number of included studies was small, limiting our confidence in findings.

Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis

BACKGROUND

Comparisons between the efficacies of supraglottic airway devices (SGAs) and endotracheal tubes (ETTs) in patients undergoing laparoscopic surgeries have yielded conflicting results. Therefore, in this meta-analysis, we compared the clinical performance and incidence of complications between SGAs and ETT intubation in laparoscopic surgery.

METHODS

A comprehensive search was conducted using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar to identify randomized controlled trials that compared SGAs with ETTs in laparoscopic surgery.

RESULTS

In total, 1433 patients from 17 studies were included in the final analysis. SGAs and ETTs showed no difference in insertion success rate on the first attempt (relative risk [RR] 1.01, 95% confidence interval [CI] 0.99-1.03), insertion time (standardized mean difference 1.57, 95% CI -3.74 to 0.61), and oropharyngeal leak pressure (OLP) (mean difference -2.54, 95% CI -7.59 to 2.50). The incidence of desaturation (RR 3.65, 95% CI 1.39-9.62), gastric insufflations (RR 0.90, 95% CI 0.48-1.71), regurgitation (RR 0.98, 95% CI 0.02-49.13), and aspiration (RR 0.99, 95% CI 0.01-78.4) also showed no intergroup differences. However, the incidence of laryngospasm (RR 3.12, 95% CI 1.29-7.52), cough at removal (RR 6.68, 95% CI 4.70-9.48), dysphagia (RR 1.47, 95% CI 1.12-1.95) or dysphonia (RR 4.41, 95% CI 1.25-15.55), sore throat (RR 1.60, 95% CI 1.33-1.93), and hoarseness (RR 1.53, 95% CI 1.29-1.81) was higher in the ETT group than in the SGA group.

CONCLUSIONS

The incidence of laryngospasm, cough at removal, dysphagia or dysphonia, sore throat, and hoarseness were higher in the ETT group than in the SGA group. However, the groups showed no differences in the rate of insertion success on the first attempt, insertion time, OLP, and other complications. Therefore, SGAs might be clinically more useful as effective airways in laparoscopic surgery.