Cumulative Ranking Area Research Articles

Effect of acupuncture and moxibustion on post-stroke constipation: a network Meta-analysis

To systematically review the therapeutic effect of acupuncture-moxibustion therapies on post-stroke constipation based on the network Meta-analysis. The randomized controlled trials of acupuncture and moxibustion for post-stroke constipation were retrieved from the databases, starting from the time of establishment through to June, 2019, i.e. the PubMed, EMbase, Cochrane Library, Web of Science, SinoMed, CNKI, Wanfang and VIP. The literature was selected according to inclusion and exclusion criteria, the quality of literature was evaluated by bias risk assessment tool of Cochrane Review Manual 5.3 and the data was statistically analyzed by softwares of Stata 13.1 and R Language. A total of 28 trails were included, involving 9 intervention methods. The therapeutic effect was arranged from high to the low according to the surface under cumulative ranking area (SUCRA), i.e. acupuncture combined with medication (0.86), warm needling (0.83), electroacupuncture combined with medication (0.68), electroacupuncture (0.68), moxibustion (0.50), auricular point sticking (0.44), acupuncture (0.31), Chinese herbal medicine (0.12) and western medication (0.04). Acupuncture- moxibustion therapies have superiority on treating post-stroke constipation, acupuncture combined with medication has the most optimum therapeutic effect and the therapeutic effect of acupuncture-moxibustion combined with medication is superior to the single treatment of medication.

Efficacy and Safety of Peripherally Acting Mu-Opioid Receptor Antagonists for the Treatment of Opioid-Induced Constipation: A Bayesian Network Meta-analysis.

To assess the efficacy and safety of peripherally acting mu-opioid receptor antagonists (PAMORAs) for the treatment of opioid-induced constipation (OIC). Randomized controlled trials (RCTs) were searched for OIC therapy comparing PAMORAs with placebo. Both a pairwise and network meta-analysis were performed. The surface under the cumulative ranking area (SUCRA) was used to determine the efficacy and safety of OIC treatment using different PAMORAs. The primary target outcome was a response that achieves an average of three or more bowel movements (BMs) per week. In the network meta-analysis, four PAMORAs (naldemedine, naloxone, methylnaltrexone, and alvimopan) showed a better BM response than the placebo. Naldemedine was ranked first (odds ratio [OR] = 2.8, 95% credible interval [CrI] = 2-4.5, SUCRA = 89.42%), followed by naloxone (OR = 2.9, 95% CrI = 1.6-5.3, SUCRA = 87.44%), alvimopan (OR = 2.2, 95% CrI = 1.3-3.5, SUCRA = 68.02%), and methylnaltrexone (OR = 1.7, 95% CrI = 1.0-2.8, SUCRA = 46.09%). There were no significant differences in safety found between the PAMORAs and the placebo. We found that PAMORAs are effective and can be safely used for the treatment of OIC. In network meta-analysis, naldemedine and naloxone appear to be the most effective PAMORAs for the treatment of OIC.

Efficacy and safety of over-the-counter analgesics for primary dysmenorrhea

Background:Primary dysmenorrhea is common and troublesome. The comparative efficacy of over-the-counter analgesics (OTCAs) for dysmenorrhea is unclear. This study was aimed at conducting a network meta-analysis to assess the efficacy and safety of 5 OTCAs – naproxen, ibuprofen,diclofenac, aspirin, and ketoprofen – in patients with primary dysmenorrhea.Methods:The study was registered with PROSPERO (number: CRD42019133556). The search strategy involved a review of PubMed, Embase, Cochrane Library, Web of Science, and CINAHL for relative randomized controlled trials of the 5 analgesics from the date of database establishment to July 2019. The outputs are presented as odds ratios (ORs), their corresponding 95% confidence intervals (CIs), and the surface under the cumulative ranking area (SUCRA) probabilities.Results:Thirty-five trials with 4383 participants were included in our study. As for efficacy outcomes, all the included analgesics except aspirin were more effective than placebo in treating dysmenorrhea [naproxen (OR 3.99, 95% CI 2.18–7.30), ibuprofen (OR 10.08, 95% CI 3.29–30.85), diclofenac (OR 11.82, 95% CI 2.66–52.48), and ketoprofen (OR 5.12, 95% CI 1.57–16.69). The OTCAs were superior to the placebo in terms of pain relief in primary dysmenorrhea. Aspirin was less effective than ibuprofen (OR 0.17, 95% CI 0.04–0.73) and diclofenac (OR 1.17, 95% CI 0.02–0.85). The SUCRA curves showed that diclofenac and ibuprofen were the most and second most effective (85.1% and 83.8%, respectively), followed by ketoprofen, naproxen, and aspirin. Regarding safety, there was no significant difference between the 5 OTCAs included and the placebo. Diclofenac versus ibuprofen (OR 4.31, 95% CI 1.18–15.67), ketoprofen versus diclofenac (OR 0.18, 95% CI 0.04–0.78), and ketoprofen versus aspirin (OR 0.41, 95% CI 0.18–0.97) presented statistically significant differences. Ketoprofen and ibuprofen were ranked the best (SUCRA 90.6% and 79.6%), followed by naproxen, aspirin, and diclofenac.Conclusion:Considering the efficacy and safety, ibuprofen is recommended as the optimal OTCA for primary dysmenorrhea. Further well-designed studies that directly compare these analgesics are needed to support our conclusion.

The Impact of Iron Supplementation for Treating Anemia in Patients with Chronic Kidney Disease: Results from Pairwise and Network Meta-Analyses of Randomized Controlled Trials.

After relative erythropoietin deficiency, iron deficiency is the second most important contributing factor for anemia in chronic kidney disease (CKD) patients. Iron supplementation is a crucial part of the treatment of anemia in CKD patients, and intravenous (IV) iron supplementation is considered to be superior to per os (PO) iron supplementation. The differences between the available formulations are poorly characterized. This report presents results from pairwise and network meta-analyses carried out after a comprehensive search in sources of published and unpublished studies, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) recommendations (International prospective register of systematic reviews PROSPERO reference ID: CRD42020148155). Meta-analytic calculations were performed for the outcome of non-response to iron supplementation (i.e., hemoglobin (Hgb) increase of <0.5–1.0 g/dL, or initiation/intensification of erythropoiesis-stimulating agent (ESA) therapy, or increase/change of iron supplement, or requirements of blood transfusion). A total of 34 randomized controlled trials (RCT) were identified, providing numerical data for analyses covering 93.7% (n = 10.097) of the total study population. At the network level, iron supplementation seems to have a more protective effect against the outcome of non-response before the start of dialysis than once dialysis is initiated, and some preparations seem to be more potent (e.g., ferumoxytol, ferric carboxymaltose), compared to the rest of iron supplements assessed (surface under the cumulative ranking area (SUCRA) > 0.8). This study provides parameters for adequately following-up patients requiring iron supplementation, by presenting the most performing preparations, and, indirectly, by making it possible to identify good responders among all patients treated with these medicines.

ACE Inhibitor Benefit to Kidney and Cardiovascular Outcomes for Patients with Non-Dialysis Chronic Kidney Disease Stages 3-5: A Network Meta-Analysis of Randomised Clinical Trials.

BackgroundThe advantages of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) in reducing risk of cardiovascular events (CVEs) and delaying end-stage kidney disease (ESKD) in patients with chronic kidney disease (CKD) is well-known. However, the efficacy and safety of these agents in non-dialysis CKD stages 3–5 patients are still a controversial issue.MethodsTwo investigators (Yaru Zhang and Dandan He) independently searched and identified relevant studies from MEDLINE (from 1950 to October 2018), EMBASE (from 1970 to October 2018), and the Cochrane Library database. Randomised clinical trials in non-dialysis CKD3–5 patients treated with renin-angiotensin system (RAS) inhibitors were included. We used standard criteria (Cochrane risk of bias tool) to assess the inherent risk of bias of trials. We calculated the odds ratio (OR) and 95% confidence interval (CI) for each outcome by random-effects model. A 2-sided p value < 0.05 was considered statistically significant, and all statistical analyses were performed using STATA, version 15.0. This network meta-analysis was undertaken by the frequency model.ResultsForty-four randomised clinical trials with 42,319 patients were included in our network meta-analysis. ACEIs monotherapy significantly decreased the odds of kidney events (OR 0.54, 95% CI 0.41–0.73), cardiovascular events (OR 0.73, 95% CI 0.64–0.84), cardiovascular death (OR 0.73, 95% CI 0.63–0.86) and all-cause death (OR 0.77, 95% CI 0.66–0.91) when compared to placebo. According to the cumulative ranking area (SUCRA), ACEI monotherapy had the highest probabilities of their protective effects on outcomes of kidney events (SUCRA 93.3%), cardiovascular events (SUCRA 77.2%), cardiovascular death (SUCRA 86%), and all-cause death (SUCRA 94.1%), even if there were no significant differences between ACEIs and other antihypertensive drugs, including calcium channel blockers (CCBs), β-blockers and diuretics on above outcomes except for kidney events. ARB monotherapy and combination therapy of an ACEI plus an ARB showed no more advantage than CCBs, β-blockers and diuretics in all primary outcomes. In the subgroup of non-dialysis diabetic kidney disease patients, no drugs, including ACEIs or ARBs, significantly lowered the odds of cardiovascular events and all-cause death. However, ACEIs were still better than other antihypertensive drugs including ARBs in all-cause death but not ARBs in cardiovascular events according to the SUCRA. Only ARBs had significant differences in preventing the occurrence of kidney events compared with placebo (OR 0.82, 95% CI 0.72–0.95). Both ACEI/ARB monotherapy and combination therapy had higher odds of hyperkalaemia. ACEIs had 3.81 times higher odds than CCBs (95% CI 1.58–9.20), ARBs had 2.08–5.10 times higher odds than placebo and CCBs and combination therapy of an ACEI and an ARB had 4.80–24.5 times higher odds than all other treatments. Compared with placebo, CCBs and β blockers, ACEI therapy significantly increased the odds of cough (OR 2.90, 95% CI 1.76–4.77; OR 8.21, 95% CI 3.13–21.54 and OR 1.80, 95% CI 1.08–3.00). There were no statistical differences in hypotension among all comparisons except ACEIs versus placebo.ConclusionsAlthough ACEIs increased the odds of hyperkalaemia, cough and hypotension, they were still superior to ARBs and other antihypertensive drugs and had the highest benefits for the prevention of kidney events, cardiovascular outcomes, cardiovascular death and all-cause mortality in non-dialysis CKD3–5 patients. In patients with advanced diabetic kidney disease, ACEIs were superior to ARBs in lowering risk of all-cause death but not in kidney events and cardiovascular events.Electronic supplementary materialThe online version of this article (10.1007/s40265-020-01290-3) contains supplementary material, which is available to authorized users.

Endocrine therapies in postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative, pretreated, advanced breast cancer: A network meta-analysis.

Recently, many endocrine therapies have become available for hormone receptor-positive, human epidermal growth factor receptor 2-negative, pretreated, advanced breast cancer. Direct comparisons of these novel treatments to assess their added value, however, are lacking METHODS:: Our aim was to synthesize available evidence to compare all current endocrine treatments for hormone receptor-positive / human epidermal growth factor receptor 2-negative advanced breast cancer. We performed a systematic review to identify available randomized controlled trial evidence. We searched Embase, MEDLINE, and the Cochrane Central Register of Controlled Clinical Trials. Two trials presented at international oncology congresses (American Society of Clinical Oncology [ASCO]) were added to include the most recent evidence. A frequent network meta-analysis was used, and the surface under cumulative ranking area (SUCRA) was calculated to determine the best treatment RESULTS:: In total, 32 trials and 12,726 patients were identified, including 27 arms. Compared with fulvestrant 500 mg alone, novel target inhibitors combined with fulvestrant or exemestane had significantly prolonged progression-free survival with hazard ratios ranging from 0.62 to 0.82. Fulvestrant 500 mg plus palbociclib 125 mg and exemestane 25 mg plus entinostat 5 mg similarly extended progression-free survival (hazard ratio: 0.64 and 0.62 with SUCRA values of 91% and 92%, respectively). The exemestane 25 mg plus everolimus 10 mg combination had the best clinical benefit rate (risk ratio: 1.84, SUCRA: 91%) and overall response rate (risk ratio: 6.05, SUCRA: 97%) CONCLUSIONS:: On the basis of this analysis, the 2 combinations of exemestane plus everolimus and fulvestrant plus palbociclib were the best treatment options.

Efficacy and safety of oral anticoagulants in atrial fibrillation patients with cancer-a network meta-analysis.

There are no guideline recommendations for the use of anticoagulant therapy in atrial fibrillation (AF) patients with cancer, which creates uncertainty about the optimal antithrombotic treatment in these patients. We conducted a network meta-analysis for the first time to assess the efficacy and safety of anticoagulant drugs in patients with AF and concurrent cancer. The PubMed, EMBASE, and Cochrane databases were searched up to March 2019. A search was made for the main anticoagulant drugs (warfarin, dabigatran, apixaban, rivaroxaban, and edoxaban). Outputs were presented as odds ratios (ORs), their corresponding 95% confidence intervals (CIs), and the surface under the cumulative ranking area (SUCRA) probabilities. We identified 414 relevant studies and included 5 trials involving 31,660 participants. In reducing the risk of stroke or systemic embolism, rivaroxaban and apixaban ranked the best and second best (SUCRA, 25.2% and 29.3%, respectively), followed by dabigatran, edoxaban, and warfarin. Apixaban and dabigatran were associated with lower probability of achieving at venous thromboembolism (VTE) (OR 0.12, 95% CI 0.05-0.52, SUCRA, 0.1%; and OR 0.24, 95% CI 0.07-1.00, SUCRA, 33.3%, respectively) than warfarin (SUCRA, 100.0%). For the prevention of all-cause death, apixaban was nonsignificantly less likely than warfarin. In addition, there were nonsignificant differences among all interventions in major bleeding, with the exception of apixaban vs. warfarin (OR 0.39, 95% CI 0.18-0.79; SUCRA 4.9%). In AF patients with cancer, nonvitamin K antagonist oral anticoagulants showed a lower incidence of stroke/systemic embolism, VTE, all-cause death, and major bleeding than warfarin, with apixaban being the best of those studied.

Simultaneous, Delayed and Liver-First Hepatic Resections for Synchronous Colorectal Liver Metastases: A Systematic Review and Network Meta-Analysis.

BackgroundSystematic reviews and meta-analyses that compare simultaneous, delayed and liver-first approach for synchronous colorectal liver metastases have found no significant differences. The aim of this study was to determine the best treatment strategy on the basis of effect sizes and the probabilities of treatment ranking by using a network meta-analysis. Moreover, first-time pairwise and network meta-analyses were used to estimate the existing evidence, and their results were compared to detect any discrepancies between them.MethodsSystematic review, pairwise meta-analysis and network meta-analysis were performed. The primary and secondary outcomes were 5-year overall survival and postoperative major morbidity, respectively.ResultsNo significant differences in long-term survival and major morbidity were found amongst the three approaches. The hazard ratios (95% confidence interval) for 5-year overall survival for the simultaneous, delayed and liver-first approaches were 0.93 (0.69 - 1.24, P = 0.613), 0.97 (0.87 - 1.07, P = 0.596) and 0.90 (0.67 - 1.22, P = 0.499), respectively. Moreover, the liver-first approach with a surface under the cumulative ranking area score of 89% was ranked as the potentially best treatment option based on probabilities of treatment ranking.ConclusionsOn the basis of the relative ranking of treatments, the liver-first approach ranked first, followed by the delayed and simultaneous approaches. Therefore, a three-arm randomized controlled trial that compares the liver-first, simultaneous and delayed approaches needs to shed further light as to which is the best treatment option.

Pharmacologic interventions for preventing delirium in adult patients after cardiac surgery: Protocol of a systematic review and network meta-analysis.

Delirium is common in adult patients undergoing cardiac surgery and related to a high morbidity and mortality. Although a variety of pharmacologic interventions have been applied in delirium prevention, there is still uncertainty concerning which drug is optimal. Thus, we plan to conduct a systematic review and network meta-analysis (NMA) of published studies to assess the efficacy and safety of pharmacologic interventions for preventing delirium among those patients. A systematic literature search will be conducted in Embase, PubMed, and the Cochrane Library. The primary outcome will be the incidence of postoperative delirium. Secondary outcomes will include all-cause mortality and length of hospital or intensive care unit stay. A frequentist NMA will be conducted using Stata version 14.0. The inconsistency between direct and indirect comparisons will be evaluated using a node splitting method. In addition, surface under the cumulative ranking area will be used to evaluate superiority of different treatments. The findings of our review will be submitted to a peer-reviewed publication. Our study will generate convincing evidence regarding the effectiveness and safety of different pharmacologic interventions for delirium prevention in cardiac surgery patients.

Network Meta-Analysis of Adjuvant Chemotherapy following Resection of Colorectal Liver Metastases

Objective: Six principal adjuvant chemotherapy treatments (ACTs) are currently available for patients with resected colorectal liver metastases. This meta-analysis was designed to determine the optimal ACT, as evaluated by 2-year disease-free survival (DFS) and 5-year overall survival (OS) rates as well as by hepatic recurrences and adverse events (AEs). Methods: A systematic literature search of the PubMed, EMBASE, Medline, Cochrane Library, and Google Scholar databases was performed. The probability of the optimal therapeutic scheme and the mean ranking were estimated for each treatment using network meta-analysis. Results: Systemic chemotherapy (SCT) had the best 2-year DFS rate (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.48–1.27, 95% prediction interval [PI] = 0.17–3.56, surface under the cumulative ranking area [SUCRA] = 73) and the lowest AE rate (estimated SUCRA = 65 and predicted SUCRA = 62). Hepatic arterial infusion (HAI) plus SCT had the best 5-year OS rate (HR = 0.81, 95% CI = 0.64–1.01, 95% PI = 0.50–1.29) and the lowest hepatic recurrence rate (odds ratio = 2.87, 95% CI = 1.56–5.30, 95% PI = 0.61–13.62). Conclusion: Both SCT and HAI plus SCT showed superior efficacy and safety. Clinical trials in homogeneous populations with strict selection criteria are needed to compare these two ACTs.

Efficacy and Safety of Agents in IgA Nephropathy: An Update Network Meta-Analysis

Background/Aims: The present network meta-analysis of randomized controlled trials (RCTs) was to explore the efficacy and safety of different pharmacologic interventions in IgA nephropathy with proteinuria more than 0.75 g/d. Methods: We systematically searched the Cochrane Library, Embase, and PubMed database for studies compared the rate of clinical remission and/or serious adverse events in IgA nephropathy patients with proteinuria (> 0.75 g/d) up to August 1, 2018. We ranked the comparative effects of all drugs against placebo on the surface under the cumulative ranking area (SUCRA) probabilities. Results: There were 29 RCTs comprising 2517 participants included for the comparisons of 9 interventions. The rank of the most effective treatments for inducing clinical remission was renin-angiotensin system inhibitors (RASi) in combination with steroid, tonsillectomy combined with steroid pulse therapy, and azathioprine plus RASi with SUCRA of 82.9%, 80.5%, and 67.6%, respectively. RASi in combination with steroid (SUCRA 3.9%) was the most effective in prevention of end-stage renal disease or doubling serum creatinine, followed by RASi monotherapy (SUCRA 38.4%) and azathioprine combined with steroid (SUCRA 49.0%). As for the occurrence of serious adverse events, azathioprine combined with RASi (SUCRA 88.0%) and steroid plus RASi (SUCRA 74.6%) showed the first and second highest incidence of adverse events, respectively. Conclusion: RASi combined with steroid demonstrated the most effective therapeutic approach for IgA nephropathy patients in terms of reducing proteinuria and stabilizing renal function.

Efficacy and safety of rectal 5-aminosalicylic acid versus corticosteroids in active distal ulcerative colitis: a systematic review and network meta-analysis

Topical 5-aminosalicylic acid (5-ASA) and corticosteroids are used frequently in the treatment of active distal ulcerative colitis (UC). Our study aimed to determine the efficacy and safety of different topical drugs used to treat active distal UC. A random-effects model within a Bayesian framework was utilized to compare treatment effects and safety as odds ratios (ORs) with corresponding 95% credible intervals (CrI). The surface under the cumulative ranking area (SUCRA) and median rank (MR) with corresponding 95% CrI were calculated to rank the treatment outcomes. In the induction of clinical and endoscopic remission, most regimens showed significant advantages over placebo except topical budesonide 0.5 mg/d and hydrocortisone 100 mg/d. According to SUCRA and MR values, rectal 5-ASA 1.5 to 2.0 g/d + Beclomethasone dipropionate (BDP) 3 mg/d rendered the highest probability of being the best regimen to achieve clinical and endoscopic remission, followed by the separate use of 5-ASA 4 g/d and BDP 3 mg/d. The occurrence of adverse events was not significantly different between each treatments and placebo. In conclusion, the combined use of topical 5-ASA and BDP proved to be the best choice for active distal UC and further well-designed researches are warranted to assess its efficacy and safety.

Efficacy and safety of medical therapy for low bone mineral density in patients with Crohn disease: A systematic review with network meta-analysis.

Low bone mineral density (BMD) is a frequent complication of inflammatory bowel disease (IBD), particularly in patients with Crohn disease (CD). The aim of our study is to determine the efficacy and safety of different drugs used to treat low BMD in patients with CD. PUBMED/MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as standardized mean difference (SMD) with their corresponding 95% credible interval (CrI), while odds ratio (OR) was applied to compare adverse events with 95% CrI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes. Twelve randomized controlled trials (RCTs) were eligible. Compared with placebo, zoledronate (SMDs 2.74, 95% CrI 1.36-4.11) and sodium-fluoride (SMDs 1.23, 95% CrI 0.19-2.26) revealed statistical significance in increasing lumbar spine BMD (LSBMD). According to SUCRA ranking, zoledronate (SUCRA = 2.5%) might have the highest probability to be the best treatment for increasing LSBMD in CD patients among all agents, followed by sodium-fluoride (27%). For safety assessment, the incidence of adverse events (AEs) demonstrated no statistical difference between agents and placebo. The corresponding SUCRA values indicated that risedronate (SUCRA = 77%) might be the most safe medicine for low BMD in CD patients and alendronate ranked the worst (SUCRA = 16%). Zoledronate might have the highest probability to be the best therapeutic strategy for increasing LSBMD. For the safety assessment, risedronate showed the greatest trend to decrease the risk of AEs. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.