Pooled Risk Difference Research Articles

The efficacy of ciprofol versus propofol on anesthesia in patients undergoing endoscopy: a systematic review and meta-analysis of randomized controlled trials.

Ciprofol is a new intravenous anesthetic with a similar chemical structure to propofol. We aimed to compare the incidence of adverse actions like injection pain and time indexes of ciprofol versus propofol on anesthesia in patients undergoing endoscopy. We also compared anesthetists' satisfaction during the procedure. Two independent researchers (Liu and Zeng) searched the Cochrane Library, Embase databases, and PubMed for controlled clinical trials. This meta-analysis of randomized controlled trials (RCTs) was performed with the Review Manager, Stata and the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes. Ten trials, including 1545 patients, were examined in the current meta-analysis. During anesthesia in patients undergoing endoscopy, the incidence of injection pain was significantly reduced in the research group. Compared with propofol, the pooled risk difference (RD) with the use of ciprofol for injection pain for all the procedures was - 0.34 (95% confidence interval [CI], -0.48 to 0.19), and RR for hypotension was 0.73(95% CI:0.58 to 0.92). GRADE showed this meta-analysis has moderate or low confidence. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment for lower incidence of hypotension. In painless endoscopy, compared with propofol, ciprofol exhibited non-inferiority anesthesia/sedation in patients, and had a good safety profile with a lower incidence of pain on injection and may reduce the chance of hypotension. Trial sequential analysis suggested the need for more cases, and GRADE highlighted moderate certainty, emphasizing the necessity for further targeted RCTs. PROSPERO, CRD42023433627.

Effectiveness and implementation of decentralized, community- and primary care-based strategies in promoting hepatitis B testing uptake: a systematic review and meta-analysis

Expanding chronic hepatitis B (CHB) testing through effective implementation strategies in primary- and community-care setting is crucial for elimination. Our study aimed to determine the effectiveness of all available strategies in the literature and evaluate their specifications and implementation outcomes, thereby informing future programming and policymaking. We conducted a systematic review and meta-analysis (PROSPERO CRD42023455781), searching Scopus, Embase, PubMed, and CINAHL databases up to June 05, 2024, for randomized controlled trials investigating primary- and community-care-based implementation strategies to promote CHB testing. Studies were screened against a priori eligibility criteria, and their data were extracted using a standardized protocol if included. ROB-2 was used to assess the risk of bias. Implementation strategies' components were characterized using the Behavior Change Wheel (BCW) framework. Random-effect models were applied to pool the effectiveness estimate by strategy. Mixed-effect meta-regression was employed to investigate if effectiveness varied by the number of strategy's BCW components. 7146 unique records were identified. 25 studies were eligible for the review, contributing 130,598 participants. 19 studies were included in the meta-analysis. No studies were conducted in low-and-middle-income countries. Implementation outcomes were reported in only ten studies (40%). Community-based strategies included lay health workers-led education (Pooled Risk Difference=27.9% [95% Confidence Interval=3.4-52.4], I2=99.3%) or crowdsourced education on social media (3.1% [-2.2 to 8.4], 0.0%). Primary care-based strategies consisted of electronic alert system (8.4% [3.7-13.1], 95.0%) and healthcare providers-led education (HCPs, 62.5% [53.1-71.9], 27.5%). The number of BCW-framework-driven strategy components showed a significant dose-response relationship with effectiveness. HCPs-led education stands out, and more enriched multicomponent strategies had better effectiveness. Future implementation strategies should consider critical contextual factors and policies to achieve a sustainable impact towards hepatitis B elimination targets. Tran Dolch Post-Doctoral Fellowship in Hepatology, Johns Hopkins University School of Medicine, Baltimore MD, USA.

Tenecteplase versus alteplase for acute ischaemic stroke: a meta-analysis of phase III randomised trials

BackgroundTenecteplase (TNK) was found non-inferior to alteplase in recent clinical trials. We aimed to elucidate the efficacy and safety of TNK versus alteplase for acute ischaemic stroke (AIS).MethodsSystematic literature search...

Negative Pressure Wound Therapy versus Conventional Dressing in Lower Limb Fractures: Systematic Review and Meta-analysis.

Gustilo 3 lower limb fractures represent a significant challenge because of high complication risk. Two management strategies are commonly used for wound coverage until final closure: negative pressure wound therapy (NPWT) and conventional wound dressing (CWD), also described as standard wound coverage without subatmospheric pressure. Understanding their relative effectiveness is essential to improve patient outcomes. The aim of this systematic review and meta-analysis was to compare the efficacy of NPWT and CWD in Gustilo 3 lower limb fracture management, with a focus on overall rates, superficial infection, and deep infection rates. A systematic review of medical research databases was conducted in accordance with PRISMA guidelines. Studies comparing NPWT with CWD for Gustilo 3 fractures were included. Data extraction and quality assessment were performed. Treatment with CWD was associated with significantly higher rates of overall infection [pooled risk ratio (RR): 0.33; 95% confidence interval (CI): 0.14-0.51] and pooled risk difference (RD: 0.27; 95% CI: 0.15-0.38), superficial infection (pooled RR: 0.35; 95% CI: 0.04-0.66), and deep infection (pooled RR: 0.20; 95% CI: 0.02-0.38) compared with NPWT treatment. Overall infection rate remained significantly higher in the CWD group after analyzing only open tibia fractures (pooled RR: 0.35; 95% CI: 0.21-0.48). Nonunion rate was significant higher in the CWD group (pooled RR: 0.30; 95% CI: 0.00-0.59). Flap failure rate was similar in both groups (pooled RR: 0.09; 95% CI: -0.05 to 0.23). NPWT appears to be a reasonable option for wound management in Gustilo 3 lower limb fractures in terms of infection rates.

Periviable Premature Rupture of Membranes-Maternal and Neonatal Risks: A Systematic Review and Meta-analysis.

Periviable premature rupture of membranes (PROM) counseling should describe maternal and neonatal outcomes associated with both immediate delivery and expectant management. Unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared with immediate delivery of periviable PROM. We performed a search on PubMed, MEDLINE, Web of Science, PROSPERO, Cochrane library, and ClinicalTrials.gov utilizing a combination of key terms. Published clinical trials and observational cohorts were included if published after 2000. Publications were selected if they included maternal and/or neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences (RDs) were calculated for each outcome using a random-effects model. Publication bias was assessed using funnel plots and Harbord test. A total of 2,550 studies were screened. After removal of duplicates and filtering by abstract, 44 manuscripts were reviewed. A total of five publications met inclusion for analysis: four retrospective and one prospective. Overall, 364 (68.0%) women underwent expectant management and 171 (32.0%) underwent immediate delivery. Maternal sepsis was significantly more frequent in the expectant group (RD, 4%; 95% confidence interval, 2-7%) as was chorioamnionitis (RD: 30%; p < 0.01) and any laparotomy (RD: 28%; p < 0.01). Neonatal survival in the expectant group was 39% compared with 0% in the immediate group (p < 0.01). Women who undergo expectant management following periviable rupture of membranes experience significantly increased risks of sepsis, chorioamnionitis, and laparotomy. Overall, 39% of neonates survive to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis. · Expectant management associated with 4% increased risk of sepsis.. · Expectant management associated with 30% increased risk of chorioamnionitis.. · A total of 39% of neonates survived to discharge with expectant management..

Outcomes of ablative therapy and radical treatment for prostate cancer: a systematic review and meta-analysis.

To compare biochemical recurrence, sexual potency and urinary continence outcomes of ablative therapy and radical treatment (radical prostatectomy or radiotherapy with androgen deprivation therapy). A systematic review and meta-analysis followed the PRISMA guidelines were performed. We searched MEDLINE/PubMed. Biochemical recurrence at three and five years; incontinence rate (patients who used one pad or more) and erectile dysfunction rate at 12 and 36 months (patients who did not have sufficient erection to achieve sexual intercourse) were evaluated. The Mantel-Haenszel method was applied to estimate the pooled risk difference (RD) in the individual studies for categorical variables. All results were presented as 95% confidence intervals (95%CI). Random effects models were used regardless of the level of heterogeneity (I²). (PROSPERO CRD42022296998). Eight studies comprising 2,677 men with prostate cancer were included. There was no difference in biochemical recurrence between ablative and radical treatments. We observed the same biochemical recurrence between ablative therapy and radical treatment within five years (19.3% vs. 16.8%, respectively; RD 0.07; 95%CI=-0.05, 0.19; I2=68.2%; P=0.08) and continence rate at 12 months (9.2% vs. 31.8%, respectively; RD -0.13; 95%CI, -0.27, 0.01; I2=89%; P=0.32). When focal treatment was analyzed alone, two studies with 582 patients found higher erectile function at 12 months in the ablative therapy group than in the radical treatment (88.9% vs. 30.8%, respectively; RD -0.45; 95%CI -0.84, -0.05; I2=93%; P=0.03). Biochemical recurrence and urinary continence outcomes of ablative therapy and radical treatment were similar. Ablative therapy appears to have a high rate of sexual potency.

Pulmonary Involvement in Recurrent Respiratory Papillomatosis: A Systematic Review.

Recurrent respiratory papillomatosis (RRP) is a non-malignant disease, characterized by the production of wart-like growths in the respiratory tract, affecting both young people and adults (juvenile-onset recurrent respiratory papillomatosis, JORRP, and adult-onset recurrent respiratory papillomatosis, AORRP, respectively). Infection caused by human papillomavirus (HPV) is known as the main factor involved in RRP development. Complications of RRP may rarely occur, including lung involvement and malignant transformation. The present systematic review aimed to evaluate the prevalence of severe complications, such as lung involvement and lung tumor in JORRP and AORRP patients, and assess the role of HPV genotypes in the progression of disease severity following the guideline for reporting systematic reviews and meta-analysis (PRISMA Statement). A total of 378 studies were found on PubMed and Scopus using the following MESH terms: "recurrent respiratory papillomatosis and lung tumor" and "pulmonary tumor and recurrent respiratory papillomatosis". Basing on inclusion and exclusion criteria, a total of 11 studies were included in the systematic review. We found a pooled prevalence of 8% (95% CI: 4-14%; I2: 87.5%) for lung involvement in RRP patients. In addition, we found a pooled risk difference of 5% in lung involvement between JORRP and AORRP (95% CI: -7-18%; I2: 85.6%, p-value: 0.41). Among patients with lung involvement, we observed a pooled prevalence of lung tumor of 4% (95% CI:1-7%; I2: 67.1%) and a pooled prevalence mortality for this group of 4% (95% CI:2-6%; I2: 0%). Overall, the positivity rate for HPV-6 and -11 in patients with RRP was 91%. Considering only cases with pulmonary involvement, the pooled prevalence for HPV-11 was 21% (95% CI: 5-45%; I2: 77.2%). Our results evidenced a low/middle risk of pulmonary involvement and lung tumor in JORRP and AORRP patients, with an increased risk for HPV-11-positive patients. Further studies should be performed to improve knowledge and adopt preventive measures to contrast the progression to severe diseases in RRP patients.

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials.

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery. PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool. Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG. Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Antithrombotic Prophylaxis with Rivaroxaban in Patients with Prehospital COVID-19: A Meta-analysis of Two Placebo-Controlled Trials.

We conducted a prespecified meta-analysis of two randomized, placebo-controlled trials of rivaroxaban 10 mg daily in prehospital patients with acute coronavirus disease 2019 (COVID-19). Individually, the trials had limited power to detect a treatment effect due to recruitment stopping ahead of plan. The statistical analysis plan for the meta-analysis was finalized before unblinding of PREVENT-HD, the larger of the two trials. Pooled risk ratios and pooled risk differences along with the two-sided 95% confidence intervals were calculated using random-effect models. Rivaroxaban did not reduce the occurrence of either the primary prespecified endpoint, a composite of symptomatic arterial and venous thromboembolism, myocardial infarction, ischemic stroke, acute limb ischemia, all-cause hospitalization, and all-cause mortality (risk difference: 0.0044; 95% confidence interval: -0.0263, 0.0175; p = 0.69 for pooled risk difference) or the secondary endpoint of all-cause hospitalization (p = 0.76). Although thrombotic events were infrequent, pooled analysis did reveal that rivaroxaban reduced arterial and venous thrombotic events (placebo 6 events, rivaroxaban 0 events; pooled risk difference: -0.0068; 95% confidence interval: -0.0132, -0.0006; p = 0.03). In the pooled studies, only one major bleeding event was observed in a rivaroxaban-allocated patient with no critical site or fatal bleeding events. Although this meta-analysis does not support antithrombotic prophylaxis with rivaroxaban in a broad prehospital population with acute COVID-19, the prevention of arterial and venous thrombotic events among rivaroxaban-allocated patients is consistent with the known thromboprophylactic effect of the drug in medically ill patients.

Clinical phenotypes and outcomes in children with multisystem inflammatory syndrome across SARS-CoV-2 variant eras: a multinational study from the 4CE consortium

Multisystem inflammatory syndrome in children (MIS-C) is a severe complication of SARS-CoV-2 infection. It remains unclear how MIS-C phenotypes vary across SARS-CoV-2 variants. We aimed to investigate clinical characteristics and outcomes of MIS-C across SARS-CoV-2 eras. We performed a multicentre observational retrospective study including seven paediatric hospitals in four countries (France, Spain, U.K., and U.S.). All consecutive confirmed patients with MIS-C hospitalised between February 1st, 2020, and May 31st, 2022, were included. Electronic Health Records (EHR) data were used to calculate pooled risk differences (RD) and effect sizes (ES) at site level, using Alpha as reference. Meta-analysis was used to pool data across sites. Of 598 patients with MIS-C (61% male, 39% female; mean age 9.7 years [SD 4.5]), 383 (64%) were admitted in the Alpha era, 111 (19%) in the Delta era, and 104 (17%) in the Omicron era. Compared with patients admitted in the Alpha era, those admitted in the Delta era were younger (ES-1.18 years [95% CI-2.05,-0.32]), had fewer respiratory symptoms (RD-0.15 [95% CI-0.33,-0.04]), less frequent non-cardiogenic shock or systemic inflammatory response syndrome (SIRS) (RD-0.35 [95% CI-0.64,-0.07]), lower lymphocyte count (ES-0.16×109/uL [95% CI-0.30,-0.01]), lower C-reactive protein (ES-28.5mg/L [95% CI-46.3,-10.7]), and lower troponin (ES-0.14ng/mL [95% CI-0.26,-0.03]). Patients admitted in the Omicron versus Alpha eras were younger (ES-1.6 years [95% CI-2.5,-0.8]), had less frequent SIRS (RD-0.18 [95% CI-0.30,-0.05]), lower lymphocyte count (ES-0.39×109/uL [95% CI-0.52,-0.25]), lower troponin (ES-0.16ng/mL [95% CI-0.30,-0.01]) and less frequently received anticoagulation therapy (RD-0.19 [95% CI-0.37,-0.04]). Length of hospitalization was shorter in the Delta versus Alpha eras (-1.3 days [95% CI-2.3,-0.4]). Our study suggested that MIS-C clinical phenotypes varied across SARS-CoV-2 eras, with patients in Delta and Omicron eras being younger and less sick. EHR data can be effectively leveraged to identify rare complications of pandemic diseases and their variation over time. None.

Prevention of Re-attempt Suicide Through Brief Contact Interventions: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Controlled Trials.

Brief contact intervention (BCI) is a low-cost intervention to prevent re-attempt suicide. This meta-analysis and meta-regression study aimed to evaluate the effect of BCI on re-attempt prevention following suicide attempts (SAs). We systematically searched using defined keywords in MEDLINE, Embase, and Scopus up to April, 2023. All randomized controlled trials (RCTs) were eligible for inclusion after quality assessment. Random-effects model and subgroup analysis were used to estimate pooled risk difference (RD) and risk ratio (RR) between BCI and re-attempt prevention with 95% confidence intervals (CIs). Meta-regression analysis was carried out to explore the potential sources of heterogeneity. The pooled estimates were (RD = 4%; 95% CI 2-6%); and (RR = 0.62; 95% CI 0.48-0.77). Subgroup analysis demonstrated that more than 12 months intervention (RR = 0.46; 95% CI 0.10-0.82) versus 12 months or less (RR = 0.67; 95% CI 0.54-0.80) increased the effectiveness of BCI on re-attempt suicide reduction. Meta-regression analysis explored that BCI time (more than 12months), BCI type, age, and female sex were the potential sources of the heterogeneity. The meta-analysis indicated that BCI could be a valuable strategy to prevent suicide re-attempts. BCI could be utilized within suicide prevention strategies as a surveillance component of mental health since BCI requires low-cost and low-educated healthcare providers.

Nebulized amphotericin B for preventing exacerbations in allergic bronchopulmonary aspergillosis: A systematic review and meta-analysis

BackgroundAllergic bronchopulmonary aspergillosis (ABPA) is complicated by exacerbations in more than one-third of the subjects. Whether nebulized amphotericin B (NAB) therapy prevents ABPA exacerbations remains unclear. ObjectivesThe primary objective of this systematic review and meta-analysis was to determine the frequency of subjects remaining exacerbation-free, one year after initiating NAB. The key secondary objectives were the time to first exacerbation and the safety of NAB therapy. MethodsWe searched the PubMed and Embase databases for studies evaluating ≥5 subjects of ABPA managed with NAB. We report the pooled proportion of ABPA subjects remaining exacerbation free after one year. For the randomized controlled trials (RCTs), we estimate the pooled risk difference (RD) of exacerbation-free status at one year with NAB versus the control arm. ResultsWe included five studies for our analysis; three were observational (n = 28) and two RCTs (n = 160). The pooled proportion (95% confidence interval [CI]) of subjects remaining exacerbation free with NAB at one year was 76% (62–88). The pooled RD (95% CI) of an exacerbation-free status at one year was 0.33 (−0.12 to 0.78) and was not significantly different between the NAB and control arms. The time to first exacerbation was longer with NAB than with the standard therapy. No serious adverse events were reported with NAB. ConclusionNAB does not improve exacerbation-free status at one year; however, weak evidence suggests it delays ABPA exacerbations. More research using different dosing regimens is required.

Obstetric and neonatal outcomes after natural versus artificial cycle frozen embryo transfer and the role of luteal phase support: a systematic review and meta-analysis.

The number of frozen embryo transfers (FET) has increased dramatically over the past decade. Based on current evidence, there is no difference in pregnancy rates when natural cycle FET (NC-FET) is compared to artificial cycle FET (AC-FET) in subfertile women. However, NC-FET seems to be associated with lower risk of adverse obstetric and neonatal outcomes compared with AC-FET cycles. Currently, there is no consensus about whether NC-FET needs to be combined with luteal phase support (LPS) or not. The question of how to prepare the endometrium for FET has now gained even more importance and taken the dimension of safety into account as it should not simply be reduced to the basic question of effectiveness. The objective of this project was to determine whether NC-FET, with or without LPS, decreases the risk of adverse obstetric and neonatal outcomes compared with AC-FET. A systematic review and meta-analysis was carried out. A literature search was performed using the following databases: CINAHL, EMBASE, and MEDLINE from inception to 10 October 2022. Observational studies, including cohort studies, and registries comparing obstetric and neonatal outcomes between singleton pregnancies after NC-FET and those after AC-FET were sought. Risk of bias was assessed using the ROBINS-I tool. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. We calculated pooled odds ratios (ORs), pooled risk differences (RDs), pooled adjusted ORs, and prevalence estimates with 95% CI using a random effect model, while heterogeneity was assessed by the I2. The conducted search identified 2436 studies, 890 duplicates were removed and 1546 studies were screened. Thirty studies (NC-FET n = 56 445; AC-FET n = 57 231) were included, 19 of which used LPS in NC-FET. Birthweight was lower following NC-FET versus AC-FET (mean difference 26.35 g; 95% CI 11.61-41.08, I2 = 63%). Furthermore NC-FET compared to AC-FET resulted in a lower risk of large for gestational age (OR 0.88, 95% 0.83-0.94, I2 = 54%), macrosomia (OR 0.81; 95% CI 0.71-0.93, I2 = 68%), low birthweight (OR 0.81, 95% CI 0.77-0.85, I2 = 41%), early pregnancy loss (OR 0.73; 95% CI 0.61-0.86, I2 = 70%), preterm birth (OR 0.80; 95% CI 0.75-0.85, I2 = 20%), very preterm birth (OR 0.66, 95% CI 0.53-0.84, I2 = 0%), hypertensive disorders of pregnancy (OR 0.60, 95% CI 0.50-0.65, I2 = 61%), pre-eclampsia (OR 0.50; 95% CI 0.42-0.60, I2 = 44%), placenta previa (OR 0.84, 95% CI 0.73-0.97, I2 = 0%), and postpartum hemorrhage (OR 0.43; 95% CI 0.38-0.48, I2 = 53%). Stratified analyses on LPS use in NC-FET suggested that, compared to AC-FET, NC-FET with LPS decreased preterm birth risk, while NC-FET without LPS did not (OR 0.75, 95% CI 0.70-0.81). LPS use did not modify the other outcomes. Heterogeneity varied from low to high, while quality of the evidence was very low to moderate. This study confirms that NC-FET decreases the risk of adverse obstetric and neonatal outcomes compared with AC-FET. We estimate that for each adverse outcome, use of NC-FET may prevent 4 to 22 cases per 1000 women. Consequently, NC-FET should be the preferred treatment in women with ovulatory cycles undergoing FET. Based on very low quality of evidence, the risk of preterm birth be decreased when LPS is used in NC-FET compared to AC-FET. However, because of many uncertainties-the major being the debate about efficacy of the use of LPS-future research is needed on efficacy and safety of LPS and no recommendation can be made about the use of LPS.

Periviable Premature Rupture of Membranes—Maternal and Neonatal Risks: A Meta-Analysis [ID: 1363862

INTRODUCTION: Periviable rupture of membranes counseling should describe maternal and neonatal outcomes associated with both immediate delivery or expectant management; unfortunately, most published data focuses on neonatal outcomes and maternal risk estimates vary widely. We performed a meta-analysis to describe outcomes associated with expectant management compared to immediate delivery of periviable PROM. METHODS: We performed a systematic review of the literature including published clinical trials and observational cohorts after the year 2000. Publications were selected if they included maternal and neonatal outcomes for both expectant management and immediate delivery. Gestational age range was limited from 14 to 25 weeks. The primary outcome was maternal sepsis. Secondary outcomes included chorioamnionitis, hemorrhage, laparotomy, and neonatal survival. Pooled risk differences were calculated for each outcome using a random effects model. Publication bias was assessed using funnel plots and Harbord test. RESULTS: A total of 2,550 studies were initially screened, and 44 manuscripts were reviewed. Of these, 5 publications met inclusion for analysis: 4 retrospective and 1 prospective. Overall, 61.1% of women chose expectant management. Expectant management was associated with a 4% increased risk of maternal sepsis, 30% increased risk of chorioamnionitis, and 28% increased risk of any laparotomy. Neonatal survival with expectant management was 34% compared to 0% with immediate delivery. CONCLUSION: Women who choose to undergo expectant management experience an increased risk of sepsis, chorioamnionitis, and laparotomy with only one-third of neonates surviving to discharge. Knowledge of these risks is critical to counseling patients with this diagnosis.

Endovascular thrombectomy with or without intravenous thrombolysis in large-vessel ischemic stroke: A non-inferiority meta-analysis of 6 randomised controlled trials

BackgroundIt is unclear whether thrombectomy alone is non-inferior to thrombectomy with intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion. PurposeTo perform a comprehensive, trial-level data, non-inferiority meta-analysis of randomised controlled trials comparing endovascular thrombectomy with and without intravenous thrombolysis in patients with ischemic stroke due to large-vessel occlusion of anterior circulation. MethodsThe prespecified primary efficacy outcome was functional independence, defined as a modified Rankin scale (mRS)score of 0 to 2 at 90 days. The two prespecified non-inferiority margins were risk differences of −10% and − 5%. The study was registered in PROSPERO (CRD42022361110) and conducted according to PRISMA guidelines. ResultsSix trials were included in this analysis (DIRECT-MT, DEVT, SKIP, MR CLEAN-NO IV, DIRECT-SAFE and SWIFT DIRECT) comprising a total of 2334 patients. Functional independence at 90 days was achieved by 570 (49·0%) of 1164 patients in the thrombectomy alone group and 595 (50·9%) of 1170 patients in the thrombectomy with thrombolysis group (pooled risk difference − 0·02, [95% CI -0·06–0·02]). Combined thrombectomy and thrombolysis were associated with significantly higher rates of successful reperfusion (pooled risk ratio 0·96 [95% CI, 0·93–0·99], p = 0·006) but at the expense of a significantly increased risk of overall - but not symptomatic - intracranial haemorrhage (pooled risk ratio 0·87 [95% CI, 0·77–0·98], p = 0·02). ConclusionsCompared with a combined treatment approach, thrombectomy alone was non-inferior at −10% non-inferiority margin, but not at a − 5% inferiority margin for functional independence. Current evidence cannot exclude clinically important differences between the two treatment approaches.

PD39-05 IMPACT OF MRI-TARGETING ON PATHOLOGIC UPGRADING AND DOWNGRADING AT PROSTATECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD39-05 IMPACT OF MRI-TARGETING ON PATHOLOGIC UPGRADING AND DOWNGRADING AT PROSTATECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS Ilon Weinstein, Xian Wu, Alexander Hill, Donald Brennan, Danly Omil-Lima, Spyridon Basourakos, Aaron Brant, Patrick Lewicki, Bashir Al Hussein Al Awamlh, Daniel Spratt, Leonardo Kayat Bittencourt, Doug Scherr, Nicholas Zaorsky, Himanshu Nagar, Jim Hu, Christopher Barbieri, Lee Ponsky, Andrew Vickers, and Jonathan Shoag Ilon WeinsteinIlon Weinstein More articles by this author , Xian WuXian Wu More articles by this author , Alexander HillAlexander Hill More articles by this author , Donald BrennanDonald Brennan More articles by this author , Danly Omil-LimaDanly Omil-Lima More articles by this author , Spyridon BasourakosSpyridon Basourakos More articles by this author , Aaron BrantAaron Brant More articles by this author , Patrick LewickiPatrick Lewicki More articles by this author , Bashir Al Hussein Al AwamlhBashir Al Hussein Al Awamlh More articles by this author , Daniel SprattDaniel Spratt More articles by this author , Leonardo Kayat BittencourtLeonardo Kayat Bittencourt More articles by this author , Doug ScherrDoug Scherr More articles by this author , Nicholas ZaorskyNicholas Zaorsky More articles by this author , Himanshu NagarHimanshu Nagar More articles by this author , Jim HuJim Hu More articles by this author , Christopher BarbieriChristopher Barbieri More articles by this author , Lee PonskyLee Ponsky More articles by this author , Andrew VickersAndrew Vickers More articles by this author , and Jonathan ShoagJonathan Shoag More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003342.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The evidence supporting multiparametric magnetic resonance imaging (mpMRI) targeting for biopsy is nearly exclusively based on biopsy pathologic outcomes. This is problematic, as targeting likely allows the preferential identification of small high-grade areas of questionable oncologic significance, raising the likelihood of overdiagnosis and overtreatment. We estimate the impact of MRI-targeted, systematic, and combined biopsies on radical prostatectomy (RP) grade group concordance. METHODS: PubMed MEDLINE and Cochrane Library were searched from July 2018 - January 2022. Studies that conducted systematic and MRI-targeted prostate biopsies and compared biopsy results with pathology after RP were included. We performed a meta-analysis to assess whether pathologic upgrading and downgrading was influenced by biopsy type and a net-benefit analysis using pooled risk-difference (RD) estimates. RESULTS: Both targeted and combined biopsies were less likely to result in upgrading (odds ratio [OR] vs. systematic of 0.70 (95% CI 0.63-0.77, p<0.001 and 0.50, 95% CI 0.45-0.55, p<0.001), respectively). Combined biopsy doubled the odds of downgrading (1.96, 95% CI, 1.68- 2.27, p<0.001) compared to systematic biopsies (15% vs. 9.0%). Net benefit of targeted and combined biopsies is 8 and 7 per 100 if harms of up- and downgrading are considered equal, but 7 and -1 per 100 if the harm of downgrading is considered twice that of upgrading. CONCLUSIONS: Combined MRI- and systematic biopsies are associated with less upgrading but more downgrading at RP. Our findings highlight a potential net-harm of performing combined MRI-targeted and systematic biopsies if pathologic downgrading is considered more detrimental than upgrading at prostatectomy. Strong heterogeneity suggests further research into factors that influence rates of up- and downgrading and should distinguish clinically relevant from irrelevant grade changes. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1046 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ilon Weinstein More articles by this author Xian Wu More articles by this author Alexander Hill More articles by this author Donald Brennan More articles by this author Danly Omil-Lima More articles by this author Spyridon Basourakos More articles by this author Aaron Brant More articles by this author Patrick Lewicki More articles by this author Bashir Al Hussein Al Awamlh More articles by this author Daniel Spratt More articles by this author Leonardo Kayat Bittencourt More articles by this author Doug Scherr More articles by this author Nicholas Zaorsky More articles by this author Himanshu Nagar More articles by this author Jim Hu More articles by this author Christopher Barbieri More articles by this author Lee Ponsky More articles by this author Andrew Vickers More articles by this author Jonathan Shoag More articles by this author Expand All Advertisement PDF downloadLoading ...

Influence of different methods for calculating gestational age at birth on prematurity and small for gestational age proportions: a systematic review with meta-analysis

BackgroundRecognizing premature newborns and small-for-gestational-age (SGA) is essential for providing care and supporting public policies. This systematic review aims to identify the influence of the last menstrual period (LMP) compared to ultrasonography (USG) before 24 weeks of gestation references on prematurity and SGA proportions at birth.MethodsSystematic review with meta-analysis followed the recommendations of the PRISMA Statement. PubMed, BVS, LILACS, Scopus-Elsevier, Embase-Elsevier, and Web-of-Science were searched (10–30-2022). The research question was: (P) newborns, (E) USG for estimating GA, (C) LMP for estimating GA, and (O) prematurity and SGA rates for both methods. Independent reviewers screened the articles and extracted the absolute number of preterm and SGA infants, reference standards, design, countries, and bias. Prematurity was birth before 37 weeks of gestation, and SGA was the birth weight below the p10 on the growth curve. The quality of the studies was assessed using the New-Castle-Ottawa Scale. The difference between proportions estimated the size effect in a meta-analysis of prevalence.ResultsAmong the 642 articles, 20 were included for data extraction and synthesis. The prematurity proportions ranged from 1.8 to 33.6% by USG and varied from 3.4 to 16.5% by the LMP. The pooled risk difference of prematurity proportions revealed an overestimation of the preterm birth of 2% in favor of LMP, with low certainty: 0.02 (95%CI: 0.01 to 0.03); I2 97%). Subgroup analysis of USG biometry (eight articles) showed homogeneity for a null risk difference between prematurity proportions when crown-rump length was the reference: 0.00 (95%CI: -0.001 to 0.000; I2: 0%); for biparietal diameter, risk difference was 0.00 (95%CI: -0.001 to 0.000; I2: 41%). Only one report showed the SGA proportions of 32% by the USG and 38% by the LMP.ConclusionsLMP-based GA, compared to a USG reference, has little or no effect on prematurity proportions considering the high heterogeneity among studies. Few data (one study) remained unclear the influence of such references on SGA proportions. Results reinforced the importance of qualified GA to mitigate the impact on perinatal statistics.Trial registrationRegistration number PROSPERO: CRD42020184646.

Benefits and harm of probiotics and synbiotics in adult critically ill patients. A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

Several systematic reviews and meta-analyses of randomized controlled trials concluded that probiotics administration in critically ill patients was safe and associated with reduced rates of ventilator-associated pneumonia and diarrhea. However, a recent large multicenter trial found probiotics administration, compared to placebo, was not efficacious and increased adverse events. An updated meta-analysis that controls for type-1 and -2 errors using trial sequential analysis, with a detailed account of adverse events associated with probiotic administration, is warranted to confirm the safety and efficacy of probiotic use in critically ill patients. RCTs that compared probiotics or synbiotics to usual care or placebo and reported clinical and diarrheal outcomes were searched in 4 electronic databases from inception to March 8, 2022 without language restriction. Four reviewers independently extracted data and assessed the study qualities using the Critical Care Nutrition (CCN) Methodological Quality Scoring System. Random-effect meta-analysis and trial sequential analysis (TSA) were used to synthesize the results. The primary outcome was ventilator-associated pneumonia (VAP). The main subgroup analysis compared the effects of higher versus lower quality studies (based on median CCN score). Seventy-five studies with 71 unique trials (n=8551) were included. In the overall analysis, probiotics significantly reduced VAP incidence (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.56-0.88; I2=65%; 16 studies). However, such benefits were demonstrated only in lower (RR 0.47, 95% CI 0.32, 0.69; I2=44%; 7 studies) but not higher quality studies (RR 0.89, 95% CI 0.73, 1.08; I2=43%; 9 studies), with significant test for subgroup differences (p=0.004). Additionally, TSA showed that the VAP benefits of probiotics in the overall and subgroup analyses were type-1 errors. In higher quality trials, TSA found that future trials are unlikely to demonstrate any benefits of probiotics on infectious complications and diarrhea. Probiotics had higher adverse events than control (pooled risk difference: 0.01, 95% CI 0.01, 0.02; I2=0%; 22 studies). High-quality RCTs did not support a beneficial effect of probiotics on clinical or diarrheal outcomes in critically ill patients. Given the lack of benefits and the increased incidence of adverse events, probiotics should not be routinely administered to critically ill patients. CRD42022302278.

Anticancer Therapy and Mortality of Adult Patients with Hematologic Malignancy and COVID-19: A Systematic Review and Meta-Analysis.

Coronavirus disease 2019 (COVID-19) might affect cancer treatment outcomes. This systematic review and meta-analysis identified the prognostic predictors of adult patients with hematologic malignancies and COVID-19, and evaluated the effect of anticancer therapy on mortality. We performed a literature search of electronic databases and identified additional studies from the bibliographies of the articles that were retrieved. Two investigators independently extracted data according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. We evaluated study quality using the Newcastle-Ottawa Scale and performed a meta-analyses in order to evaluate the effect of anticancer therapy on mortality among adult patients with hematologic malignancies and COVID-19. Heterogeneity was assessed with the I2 statistic. The meta-analysis included 12 studies. The overall mortality rate was 36.3%. The pooled risk difference (RD) in mortality between patients receiving and not receiving anticancer therapy was 0.14 (95% confidence interval [CI]: 0.02-0.26; I2 = 76%). The pooled RD in mortality associated with chemotherapy was 0.22 (95% CI: 0.05-0.39; I2 = 48%), and with immunosuppression was 0.20 (95% CI: 0.05-0.34; I2 = 67%). In the subgroup analyses, anticancer-therapy-associated mortality was higher in females (RD = 0.57; 95% CI: 0.29-0.85; I2 = 0%) than in males (RD = 0.28; 95% CI: 0.04-0.52; I2 = 0%). Among patients with hematologic malignancies and COVID-19, those receiving anticancer therapy had a higher mortality risk, regardless of sex. The mortality risk was higher in females than in males. These results indicate that caution should be exercised when administering anticancer therapy to patients with hematologic malignancies and COVID-19.

Current evidence on the effectiveness of Ready-to-Use Supplementary Foods in children with moderate acute malnutrition: a systematic review and meta-analysis.

Moderate acute malnutrition (MAM) is defined by a weight-for-height Z-score (WHZ) between -3 and -2 of the WHO reference or by a mid-upper arm circumference (MUAC) of ≥11⋅5 and <12⋅5 cm. This study aimed to synthesise the evidence for the effectiveness of Ready-to-Use Supplementary Food (RUSF) compared to other dietary interventions or no intervention on functioning at different levels of the International Classification of Functioning, Disability, and Health (ICF) among children with MAM between 2 and12 years old. Three databases (PubMed, Scopus, and Web of Science) were systematically searched (last update: 20 November 2022). Pooled estimates of effect were calculated using random-effects meta-analyses. The level of evidence was estimated with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. Seven studies were included. RUSF had a significant small-sized better effect (pooled mean: 0⋅38; 95 % CI = [0⋅10, 0⋅67], P = 0⋅01, I² = 97 %) on different anthropometric measurements compared to other dietary interventions among MAM children (n 6476). Comparing RUSF with corn-soy blend Plus Plus (CSB++) showed that RUSF had a small-sized but significantly better effect on the children's anthropometric measures compared to children who received CSB++ (pooled mean: 0⋅16; 95 % CI = [0⋅05, 0⋅27], P = 0⋅01; I2 = 35 %). MAM children treated with RUSF had a better recovery rate compared to those treated with CSB++ (pooled risk difference: 0⋅11; 95 % CI = [0⋅06, 0⋅11], P < 0⋅001; I2 = 0 %). The RUSF intervention seems promising in improving MAM children's nutritional outcomes and recovery rate compared to other dietary interventions.