Pooled Effect Estimates Research Articles

Intermittent epidural bolus versus continuous epidural infusions for labor analgesia: A meta-analysis of randomized controlled trials

There are inconsistent results regarding the efficacy and safety of intermittent epidural bolus (IPB) versus continuous epidural infusions (CPI) for labor analgesia. This study used a meta-analytic approach to assess the safety and treatment efficacy of IPB versus CPI for labor analgesia based on randomized controlled trials (RCTs). Four electronic databases were used to identify eligible RCTs. Pooled effect estimates at 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-two RCTs with 2,573 parturients were selected for final analysis. The findings revealed no significant differences between IPB and CPI for the incidences of cesarean and instrumental delivery. IPB was shown to be associated with shorter total duration of labor [weighted mean difference (WMD): −21.46; 95% CI: −25.07 to −17.85; P < 0.001], duration of the first of stage of labor (WMD: −13.41; 95% CI: −21.01 to −5.81; P = 0.001), and duration of the second stage of labor (WMD: −4.98; 95% CI: −9.32 to −0.63; P = 0.025). Furthermore, IPB significantly reduced the incidences of required anesthetic interventions compared with CPI [relative risk (RR): 0.61; 95% CI: 0.39–0.95; P = 0.030], whereas there was no significant difference between IPB and CPI for the time required in the first anesthetic intervention (WMD: 7.73; 95% CI: −33.68–49.15; P = 0.714). The local anesthetic IPB (bupivacaine equivalents) was associated with lower milligrams per hour of local anesthetic (WMD: −0.89; 95% CI: −1.41 to −0.36; P = 0.001) and better maternal satisfaction (WMD: 8.76; 95% CI: 4.18–13.35; P < 0.001). There were no significant differences between IPB and CPI for the risk of adverse events. This study found that parturients with IPB have short total duration of labor and duration of the first and second stage of labor, reduced requirements for additional anesthetic interventions, and improved maternal satisfaction.

Effects of isoflavone interventions on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials.

This study aimed to determine the efficacy of isoflavone interventions on bone density outcomes and the safety of isoflavone interventions in postmenopausal women by means of systematic review and meta-analysis. A systematic search was performed on three databases (PubMed, Scopus, and Cochrane Library). Included studies were limited to randomized controlled trials (RCTs) assessing the effects of isoflavone intervention on bone mineral density (BMD) in postmenopausal women. Mean difference (MD) in BMD or relative risk for adverse outcomes was used as a summary effect measure; pooled-effect estimates were calculated using a random-effects model. A total of 63 RCTs, involving 6427 postmenopausal women, were included in the meta-analysis. Statistically significant differences in BMD at the last follow-up visit between the two groups (isoflavones vs. control) were found at the lumbar spine (MD = 21.34 mg/cm2, 95% CI = 8.21 to 34.47 mg/cm2, p = 0.001), the femoral neck (MD = 28.88 mg/cm2, 95% CI = 15.05 to 42.71 mg/cm2, p < 0.0001), and the distal radius (MD = 19.27 mg/cm2, 95% CI = 5.65 to 32.89 mg/cm2, p = 0.006). The positive effects in improved BMD were primarily associated with two formulations, i.e., genistein 54 mg/day and ipriflavone 600 mg/day. Isoflavone interventions were generally safe and well tolerated. Isoflavone interventions, genistein (54 mg/day) and ipriflavone (600 mg/day) in particular, have beneficial effects on BMD outcomes and are safe in postmenopausal women. They may be considered as a complementary or alternative option in the prevention and treatment of menopause-related osteoporosis.

Chronic Hepatitis C Virus Infection is Associated with an Increased Risk of Lung Cancer: A Systematic Review and Meta-analysis.

Chronic hepatitis C virus (HCV) infection is associated with increased risk of hepatocellular carcinoma. However, whether HCV infection also increases the risk of extra-hepatic cancer is still not well-established. This systematic review and meta-analysis was conducted in order to investigate the relationship between chronic HCV infection and lung cancer. A systematic review was performed using MEDLINE and EMBASE databases from inception to November 2019 with search strategy that included the terms for "hepatitis C virus" and "cancer". Eligible studies must be cohort studies that included patients with chronic HCV infection and comparators without HCV infection, then followed them for incident lung cancer. Relative risk, incidence rate ratio, standardized incidence ratio or hazard risk ratio of this association along with associated 95% confidence interval (CI) were extracted from each eligible study and combined for the calculation of the pooled effect estimate using the random effect, generic inverse variance method. A total of 20,459 articles were identified using the aforementioned search strategy. After two rounds of review, eight studies fulfilled the inclusion criteria and were included into the meta-analysis. Chronic HCV infection was significantly associated with an increased risk of lung cancer with the pooled relative risk of 1.94 (95% CI 1.56-2.42; I2 = 87%). Funnel plot was fairly symmetric and not suggestive of presence of publication bias. The current study demonstrated that chronic HCV infection is significantly associated with a 1.94-fold increased risk of developing lung cancer. However, further studies are still needed to investigate if this association is causative.

Bariatric surgery before, during, and after liver transplantation: asystematic review and meta-analysis.

Morbid obesity is considered a relative contraindication for liver transplantation (LTX) because of increased risk of complications. The aim of this study was to investigate the role of bariatric surgery before, during, and after LTX. A systematic review of MEDLINE, EMBASE, CENTRAL, and PubMed databases was performed for studies investigating bariatric surgery in patients before, during, or after LTX. Random-effects meta-analysis of proportions was used to calculate pooled effect estimates. One hundred eighty-seven patients underwent bariatric surgery before LTX (8 studies). After surgery, 82% (95% confidence interval, 62%-97%) of patients were successfully listed for LTX and 70% (95% confidence interval, 40%-93%) successfully received LTX. The 30-day mortality rate was 0%. The graft survival rate after 1 year was 70% (95% confidence interval, 30%-99%). Thirty-day minor and major complications rate was 4% and 1%, respectively. Thirty-two patients underwent bariatric surgery during LTX (2 studies). The 30-day mortality rate after surgery was 0% and 1-year graft survival was 100%. Sixty-four patients underwent bariatric surgery after LTX (9 studies). The 30-day mortality was 0%, but 5 deaths occurred beyond 30 days (7.8%). Bariatric surgery may be safe and feasible as a bridge to LTX for patients who would otherwise be ineligible and post-LTX patients for weight loss.

A meta-analysis of iron-based additives on enhancements of biogas yields during anaerobic digestion of organic wastes

The profitability of biogas industries largely depends on substrate biodegradability. Most of the substrates for sustainable energy recovery via anaerobic digestion like lignocellulosic materials contains complex polymeric substances and requires some enhancements to achieve optimum biodegradability. Previous studies have reported that the use of iron additives improved both degradability of such substrates and biogas yield, but iron-based enhancements have shown variability in the input and yield results. This evidence-based study used meta-analysis in determining the performances of iron-based additives on biogas yield. Previously published articles on the subject were systematically identified and compiled based on set inclusion criteria. The database was used to analyze the influence of iron-based additives on the enhancement of biogas yield during anaerobic digestion of organic wastes. The pooled effect estimates at 95% confidence interval was generated with the use of Random-effects model. The overall result of the meta-analysis performed showed that iron-based additives supplementation significantly enhanced biogas yield at Standard mean difference = 1.451, 95% CI: 1.280–1.622, p < 0.001. Restricted subgroup analysis indicated that all the moderators had a significant influence on biogas yield of iron-based treated anaerobic digestion processes at p < 0.001. Evidence of heterogeneity was observed, while meta-regression analysis indicated that most of the sources of heterogeneity were explained by the additive-types, substrate-types, dosage range and research location at p < 0.05. The result of this study showed the potential of iron-based additives supplementation to improve biogas yield during anaerobic digestion of organic wastes. The information from this study avails important suggestions on policy advancements and sustainable usage of iron-based enhanced anaerobic digestion processes in biogas industries.

The role of cardio-protective agents in cardio-preservation in breast cancer patients receiving Anthracyclines ± Trastuzumab: a Meta-analysis of clinical studies.

Breast cancer patients often receive cardiotoxic drugs such as anthracyclines (ANT) and Trastuzumab. Numerous trials have tested angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), and beta-blockers (BB) as monotherapy or in combination to reprogram cardiac function dynamics in these patients, but no clear conclusions have been reached thus far, due to evident heterogeneity in the design of clinical studies. This PRISMA-guided systematic review and meta-analysis assessed a pooled effect estimate of the potential benefit/harm of ACEi/ARB/BB in breast cancer patients treated with ANT ± Trastuzumab. The protocol was registered on the PROSPERO database. Electronic databases (PubMed, Cochrane Central, Scopus, Web of Science) were searched from inception until February 2019. Twenty-two prospective studies comprising of 2,302 participants were included in the meta-analysis. The 16 studies testing the protective effects of ACEi/ARB/BB after immediate completion of chemotherapy showed a significant lower difference in the mean change of left ventricular ejection fraction (LVEF) in patiens receiving cardio-protective drugs as compared to controls, with a standardized mean difference [SMD = -2.36 (95% CI: -3.23 to -1.49), p < 0.00001] favoring the protective role of these drugs. LVEF was evaluated after 6 months after completion of chemotherapy in 3 studies, where ACEi/ARB/BB persistently showed cardio-protective effects as compared to controls [SMD = -6.54 (95% CI: -10.74 to -2.34), p = 0.002]. After 1 year from completion of chemotherapy, ACEi/ARB/BB preserved beneficial effects on LVEF vs control [SMD = -5.37 (95% CI: -9.31 to -1.43), p = 0.008]. The effect of ACEi/ARB/BB on end-systolic volume (ESV) and end-diastolic volume (EDV) were evaluated immediately after chemotherapy completion and after 1 year. No significant protective effect was apparent. On the other hand, end-diastolic diameter (EDD) was significantly spared in the ACEi/ARB/BB group vs control after chemotherapy completion [SMD = -1.11 (95% CI: -1.88 to -0.35), p = 0.004]. Heart failure as a clinical endpoint was assessed in 11 trials. The incidence of heart failure was significantly lower in the ACEi/ARB/BB group as compared to control [Odds ratio = 0.12 (95% CI: 0.03 to 0.45), p = 0.002]. ACEi/ARB/BB may act as cardioprotective agents in breast cancer patients who undergo ANT ± Trastuzumab. More studies are required to better assess the magnitude of the cardiotoxicity hazards of ANT ± Trastuzumab, with more precise assessment of the effect of ACEi/ARB/BB on cardio-protection.

Statin use is associated with a lower risk of diffuse large B-cell lymphoma: A systematic review and meta-analysis.

e13585 Background: Statin use is associated with decreased risk of several types of cancer such as hepatocellular carcinoma, colorectal cancer and hematologic malignancy, although the data on diffuse large B-cell lymphoma (DLBCL) is still inconclusive. The current systematic review and meta-analysis was conducted to summarize all available data on this association. Methods: A systematic review was performed using EMBASE and MEDLINE database from inception to October 2019 with search strategy that included terms for “statin” and “DLBCL”. Eligible studies could be either cohort or case-control studies that reported the association between statin use and risk of DLBCL. Eligible cohort studies must include patients with history of statin use and comparators with no history of statin use, then follow them for incident DLBCL and report the relative risk, hazard risk ratio, or standardized incidence ratio and associated 95% confidence intervals (CI) comparing the incidence of DLBCL between the two groups. Eligible case-control studies must include cases with DLBCL and controls without DLBCL, then search for prior statin use and report the odds ratio and associated 95% CI for this association. Point estimates along with standard errors were extracted and combined together for the calculation of the pooled effect estimate using the random effect, generic inverse variance method. Results: A total of 1,139 articles were identified using the search strategy. Six studies satisfied the inclusion criteria and were included into the meta-analysis. Statin use was associated with a significantly reduced risk of DLBCL with the pooled relative risk of 0.70 (95% CI, 0.56 – 0.88; I2 = 70%). Funnel plot was fairly symmetric and was not suggestive of presence of publication bias. Conclusions: This systematic review and meta-analysis found that patients with history of statin use had a significantly lower risk of DLBCL compared to individuals without history of statin use.

Association of chronic hepatitis C virus infection with an increased risk of lung cancer: A systematic review and meta-analysis.

e13562 Background: Chronic hepatitis C virus (HCV) infection is associated with increased risk of multiple types of extrahepatic cancer, such as lymphomas, thyroid cancer and renal cancer. However, whether HCV infection also increases the risk of lung cancer is still inconclusive. This systematic review and meta-analysis was performed in order to determine the relationship between chronic HCV infection and lung cancer. Methods: A systematic review was performed using EMBASE and MEDLINE databases from inception to November 2019 with search strategy that represents “hepatitis C virus” and “cancer”. Eligible studies must be cohort studies which include patients with chronic HCV infection and comparators without HCV infection, then follow them for incident lung cancer. Relative risk, incidence rate ratio (IRR), standardized incidence ratio, or hazard risk ratio of this association along with associated 95% confidence interval (CI) from each study were extracted and combined for the calculation of the pooled effect estimate using the random effect, generic inverse variance. Results: 20,459 articles were discovered using the aforementioned search strategy. After two rounds of review, eight studies fulfilled the inclusion criteria and were included into the meta-analysis. Chronic HCV infection was significantly associated with increased risk of lung cancer with the pooled relative risk of 1.94 (95% CI, 1.56 – 2.42; I2 = 87%). Funnel plot was fairly symmetric and not suggestive of presence of publication bias. Conclusions: Chronic HCV infection is significantly associated with a 1.94-fold increased risk in the development of lung cancer compared to no infection.

Lifestyle behaviors predict adolescents bullying victimization in low and middle-income countries

BackgroundIn this study we aimed to provide a global perspective of the association between different lifestyle behaviors and bullying in school adolescents and to ascertain whether or not the Human Development Index moderated those associations. MethodsData from the Global school-based Student Health Survey were analyzed in 273 121 from 82 countries. Logistic regression was applied to determine country-specific bullying victimization probability from meeting the recommended guidelines for physical activity, excessive sitting time, physical education attendance and active transport. Meta-analysis was then undertaken to ascertain pooled global effect estimates of the relationship between these behaviors and bullying victimization. Linear regression was used to study the relationship between odds of bullying from meeting the lifestyle guidelines and the Human Development Index. ResultsOur estimates indicate that excessive sitting time [1.38 (1.34,1.41)], attendance to physical education [0.87 (0.85,0.89)], and active transport [0.94 (0.91,0.97)] but not overall physical activity [1.01 (0.99,1.04)] were associated with bullying in the study sample. LimitationsThe present study is limited by its cross-sectional nature. Also, only two countries were surveyed from the European region ConclusionsActive commuting and attendance to physical education play a protective role for bullying, while physical activity does not.

Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials

This study aimed to evaluate whether ultrasound-guided techniques are superior compared to traditional palpation techniques in patients undergoing radial artery catheterization (RAC). Electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched to identify randomized controlled trials (RCTs). The relative risks (RRs) or weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to calculate the pooled effect estimates using the random effects model for categories and continuous data, respectively. A total of 19 RCTs comprising a total of 3220 individuals were selected for final analysis. The pooled RR suggested that ultrasound-guided techniques were associated with higher incidence of first attempt success than traditional palpation techniques (RR, 1.39; 95% CI, 1.21-1.59; P < 0.001). Moreover, we noted that ultrasound-guided techniques were associated with fewer mean attempts to success (WMD, -0.80 s; 95% CI, -1.35 to -0.25; P = 0.004) and a shorter mean time to success (WMD, -41.18 s; 95% CI, -75.43 to -6.93; P = 0.018) than traditional palpation techniques. Furthermore, individuals using ultrasound-guided techniques had a reduced risk of hematoma (RR, 0.40; 95% CI, 0.22-0.72; P = 0.003). This study indicated that ultrasound-guided techniques were superior compared to traditional palpation techniques for RAC in terms of efficacy and complications.

Prazosin for treatment of post-traumatic stress disorder: a systematic review and meta-analysis.

Prazosin has been an accepted treatment for patients with post-traumatic stress disorder (PTSD) who experience sleep disturbances, including nightmares. Results of a recent large randomized control trial did not find benefit of prazosin vs placebo in improving such outcomes. A meta-analysis that includes this most recent trial was conducted to examine the pooled effect of prazosin vs placebo on sleep disturbances and overall PTSD symptoms in patients with PTSD. A systematic review of the published literature on trials comparing prazosin vs placebo for improvement of overall PTSD scores, nightmares, and sleep quality was conducted. Hedges' g standardized mean differences (SMD) between prazosin and placebo were calculated for each outcome across studies. Six randomized placebo-controlled studies representing 429 patients were included in the analysis, including two studies with a crossover design. Results showed prazosin significantly improved overall PTSD scores (SMD=-0.31; 95% confidence intervals [CI]: -0.62, -0.01), nightmares (SMD=-0.75; 95% CI: -1.24, -0.27), and sleep quality (SMD=-0.57; 95% CI: -1.02, -0.13). In the largest trial, prazosin showed a reduction in clinical outcome measures similar to past studies, but a relatively large placebo effect size, particularly for nightmares, contributed to no treatment differences. Despite the results of a recent, large randomized study, pooled effect estimates show that prazosin has a statistically significant benefit on PTSD symptoms and sleep disturbances. Limitations that should be considered include heterogeneity of study design and study populations as well as the small number of studies conducted and included in this meta-analysis.

Pulmonary function sequelae after respiratory syncytial virus lower respiratory tract infection in children: A systematic review.

Respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) during early childhood may be associated with subsequent pulmonary sequelae, including recurrent wheezing and asthma. We undertook a systematic review to investigate the pulmonary function sequelae following RSV LRTI in the first 3 years of life. The systematic review protocol was registered on PROSPERO (CRD42018087168). PubMed, Scopus, Cochrane Library, and World Health Organization Global Index Medicus, as well as ClinicalTrials.gov and Cochrane Central Register of Controlled Trials, were searched up until 15 June 2019 for published and unpublished interventional and observational studies with the end-point outcome of pulmonary function testing (PFT) after a proven RSV LRTI in the first 3 years of life. Two independent reviewers screened all the titles, abstracts and full texts. Data were extracted using a standardized data extraction form. Corresponding authors were contacted for additional information if required. All studies were assessed for risk of bias using the Newcastle-Ottawa quality assessment scale. The final analysis included 31 studies. Thirteen studies using spirometry reported no association between RSV LRTI and pulmonary function sequelae. The remaining 16 reported abnormal spirometry; 12 obstructive airways disease, three restrictive lung disease, and one mixed lung disease. The heterogeneity in PFT techniques, different ages at testing, and methods used for reporting outcomes made direct comparisons or pooled effect estimates impossible. Children with confirmed RSV LRTI during the first 3 years of life often have abnormal PFTs, favoring obstructive airways disease. The evidence, however, is not overwhelming with conflicting results between studies.

Evaluation of the role of sex as a prognostic factor in critically ill adults with sepsis: systematic review protocol.

IntroductionSepsis is a leading cause of mortality in critically ill patients. Recently, it has been recognised that sex may contribute to a differential risk for developing sepsis and it remains uncertain if the prognosis of sepsis varies between the sexes. The aim of this systematic review is to summarise the available evidence to assess the role of sex as a prognostic factor in patients with sepsis managed in the intensive care unit (ICU).Methods and analysisThis is a systematic review protocol of prognostic studies of sex in patients with sepsis managed in the ICU. The primary outcomes include all-cause hospital mortality and all-cause hospital mortality during the first 28 days. The secondary outcomes include all-cause hospital mortality during the first 7 days and all-cause mortality at 1 year. We will conduct a search strategy based on the population (sepsis), the prognostic factor (sex), the outcome of interest (mortality) and prognostic study methods. We will search in the following databases up to December 2019: MEDLINE Ovid (from 1976), Embase Elsevier (from 1974), Web of Science and two trial registries. We will impose no language restrictions. Two authors will independently screen titles, abstracts and full-text articles for eligibility of studies, and subsequently extract data. Two authors will independently assess the risk of bias of each study using the Quality in Prognostic Studies (QUIPS) tool. If possible, we will carry out a meta-analysis to provide a pooled prognostic effect estimate for each outcome. We will use the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of evidence.Ethics and disseminationEthical approval will not be required. Findings from this review will be reported in a peer-reviewed scientific journal. Additionally, the results will be disseminated at conferences and in the mass media.PROSPERO registration numberCRD42019145054.

Frailty as apredictor of all-cause mortality and readmission in older patients with acute coronary syndrome : Asystematic review and meta-analysis.

Evidence from longitudinal studies linking frailty and outcome after acute coronary syndrome (ACS) is mixed. This systematic review and meta-analysis aimed to examine whether frailty is apredictor of all-cause mortality and hospital readmission in older patients with ACS. A systematic search was carried out in PubMed, EMBASE and Web of Science databases for studies evaluating the association between frailty and outcomes in older patients with ACS. Ameta-analysis was performed to determine the pooled effect estimate for the association between frailty and mortality and hospital readmission, respectively. Atotal of 1459 articles were retrieved based on our search strategy. Fifteen studies involving 10,245 patients were included in the meta-analysis. The pooled prevalence of frailty was 32% (95% confidence interval [CI]: 25-39%), and the pooled prevalence of pre-frailty was 33% (95% CI: 26-40%) in elderly patients with ACS. Pooled analyses showed that frailty was associated with significantly higher risk of all-cause mortality and readmission (hazard ratios [HRs] = 2.43 and 2.32, respectively). Pre-frailty was also associated with significantly higher risk of all-cause mortality and readmission, respectively (HRs = 1.55 and 1.34, respectively). Both frailty and pre-frailty are risk factors for all-cause mortality and readmission in older patients with ACS. Therefore, frailty assessment should be given sufficient attention in the management of older patients with ACS to help improve survival and reduce readmission rate.

Risk factors for loss to follow-up from antiretroviral therapy programmes in low-income and middle-income countries.

Loss to follow-up (LTFU) rates from antiretroviral treatment (ART) programmes in low- and middle-income countries (LMIC) are high, leading to poor treatment outcomes and onward transmission of HIV. Knowledge of risk factors is required to address LTFU. In this systematic review, risk factors for LTFU are identified and meta-analyses performed. PubMed, Embase, Psycinfo and Cochrane were searched for studies that report on potential risk factors for LTFU in adults who initiated ART in LMICs. Meta-analysis was performed for risk factors evaluated by at least five studies. Pooled effect estimates and their 95% confidence intervals (95% CI) were calculated using random effect models with inverse variance weights. Risk of bias was assessed and sensitivity analyses performed. Eighty studies were included describing a total of 1 605 320 patients of which 87.4% from sub-Saharan Africa. The following determinants were significantly associated with an increased risk of LTFU in meta-analysis: male sex, older age, being single, unemployment, lower educational status, advanced WHO stage, low weight, worse functional status, poor adherence, nondisclosure, not receiving cotrimoxazole prophylactic therapy when indicated, receiving care at secondary level and more recent year of initiation. No association was seen for CD4 cell count, tuberculosis at baseline, regimen, and geographical setting. There are several sociodemographic, clinical, patient behaviour, treatment-related and system level risk factors for LTFU from ART programs. Knowledge of risk factors should be used to better target retention interventions and develop tools to identify high-risk patients.

Antibiotic Prophylaxis for Transarterial Chemoembolization of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Purpose: Owing to persistent controversy regarding the use of routine antibiotic prophylaxis in patients undergoing transarterial chemoembolization (TCAE) and the availability of several new studies published on the subject, we conducted an up-to-date meta-analysis to provide the best current evidence. The aim of the article is to assess whether antibiotic prophylaxis is effective in reducing the incidence of infectious complications after TCAE. Materials and methods: PubMed, Google scholar, Cochrane Central Register of Controlled Trials, CNKI and Wan-Fang database were searched through October 2018 for randomized or non-randomized controlled trials for comparing the use of prophylactic antibiotics in TACE with placebo or no antibiotics were included in the review. Pooled effect estimates were calculated using fixed-effects and random-effects models. Results: Eight studies with a total number of 1672 of procedures were included in the meta-analysis. We found no evidence of publication bias or heterogeneity among the studies. Antibiotic prophylaxis did not reduce the incidence of infectious complications (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.62 to 1.24, p=0.464) and the rate of patients developing fever (RR 1.04, 95% CI 0.91 to 1.19, p=0.595). When the analyses were stratified into subgroups, there was no evidence that study design substantially influenced the estimate of effects. Furthermore, the sensitivity analysis confirmed the stability of our results. Conclusion: Although current evidence demonstrates that the routine use of antibiotic prophylaxis for TACE may not be necessary, more evidence from advanced multi-center studies is needed to provide instruction for the use of prophylactic antibiotics.

Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses

BackgroundWe previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital. MethodsWe used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity). Findings16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems. InterpretationAmong low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births. FundingPartial funding: Association of Ontario Midwives open peer reviewed grant.

Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence

IntroductionAcetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk...

Diabetes mortality burden attributable to short-term effect of PM10 in China.

Ambient air pollution may be associated with diabetes mellitus. However, evidence from developing countries is limited although the concentrations of air pollution are disproportionably higher in these countries. We collected daily data on diabetes mortality, air pollution, and weather conditions from 16 Chinese provincial cities during 2007-2013. A quasi-Poisson regression combined with a distributed lag model was used to quantify the city-specific mortality risk of PM10 (particulate matter with aerodynamic diameter < 10μm). Then, a random-effect meta-analysis was conducted to pool effect estimates from 16 cities. We also calculated the attributable fraction and attributable number of diabetes mortality due to PM10. Effects of PM10 were found to be acute and limited to 3days. Harvesting effect of PM10 was found during lag 4-10days on diabetes mortality. An increase of 0.17% (95%CI: 0.01-0.34), 0.48% (95%CI: 0.22-0.73), and 0.53% (95%CI: 0.27-0.80) in diabetes mortality was associated with per 10μg/m3 increase in PM10 at lag 0, 0-4 and 0-10days, respectively. Totally, 5.76% (95%CI: 2.59-8.00%) and 5878 (95%CI: 2639-8163) deaths due to diabetes could be attributable to PM10. If the concentration of PM10 attained the Chinese government and WHO targets, the reduction in number of PM2.5-attributed diabetes deaths was 2016 and 5528, respectively. Higher effect estimates of PM10 were observed among females and those aged 0-64years old at lag 0day, while greater cumulative effects of PM10 were among males, the elderly aged 75 or over, and the illiterate at lag 0-10days. However, the between-group differences were not statistically significant. It is one of the few studies on examining the attributable burden of diabetes mortality caused by particulate matter. Our findings indicated that effective efforts on controlling air pollution could reduce a prominent number of air pollution-related diabetes deaths.

Male and Female Physician Suicidality

Population-based findings on physician suicide are of great relevance because this is an important and understudied topic. To evaluate male and female physician suicide risks compared with the general population from 1980 to date and test whether there is a reduction of SMR in cohorts after 1980 compared with before 1980 via a meta-analysis, modeling studies, and a systematic review emphasizing physician suicide risk factors. This study uses studies retrieved from PubMed, Scielo, PsycINFO, and Lilacs for human studies published by October 3, 2019, using the search term "(((suicide) OR (self-harm) OR (suicidality)) AND ((physicians) OR (doctors)))." Databases were also searched from countries listed in articles selected for review. Data were also extracted from an existing article by other authors to facilitate comparisons of the pre-1980 suicide rate with the post-1980 changes. Original articles assessing male and/or female physician suicide were included; for the meta-analysis, only cohorts from 1980 to the present were included. The preregistered systematic review and meta-analysis followed Cochrane, PRISMA, and MOOSE guidelines. Data were extracted into standardized tables per a prespecified structured checklist, and quality scores were added. Heterogeneity was tested via Q test, I2, and τ2. For pooled effect estimates, we used random-effects models. The Begg and Egger tests, sensitivity analyses, and meta-regression were performed. Proportional mortality ratios were presented when SMR data could not be extracted. Suicide SMRs for male and female physicians from 1980 to the present and changes over time (before and after 1980). Of 7877 search results, 32 articles were included in the systematic review and 9 articles and data sets in the meta-analysis. Meta-analysis showed a significantly higher suicide SMR in female physicians compared with women in general (1.46 [95% CI, 1.02-1.91]) and a significantly lower suicide SMR in male physicians compared with men in general (0.67 [95% CI, 0.55-0.79]). Male and female physician SMRs significantly decreased after 1980 vs before 1980 (male physicians: SMR, -0.84 [95% CI, -1.26 to -0.42]; P < .001; female physicians: SMR, -1.96 [95% CI, -3.09 to -0.84]; P = .002). No evidence of publication bias was found. In this study, suicide SMR was found to be high in female physicians and low in male physicians since 1980 but also to have decreased over time in both groups. Physician suicides are multifactorial, and further research into these factors is critical.