Radiofrequency ablation versus percutaneous ethanol injection for hepatocellular carcinoma: a meta-analysis of randomized controlled trials.

BACKGROUND: Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) are treatment methods for patients with early-stage hepatocellular carcinoma (HCC) who are not suitable for surgery. Although some reports indicate that RFA is better than PEI, results from previous reviews and analyses are inconsistent. Therefore, this meta-analysis was performed to more thoroughly evaluate the effects of these treatments in patients with HCC. METHODS: A literature search was conducted using the Excerpta Medica dataBASE, PubMed, the Cochrane Library, the American Society of Clinical Oncology database, the China National Knowledge Infrastructure database, the Wanfang database, the Chinese Biomedical Literature Database, and the Chongqing VIP database without language limitations. The primary outcome evaluated was overall survival, and secondary outcomes included complete response and local recurrence. Comparisons were made between Asian and European studies. RESULTS: Total pooled and subgroup analyses of Asian studies that included selection biases revealed that RFA is superior to PEI with respect to overall survival (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.37 to 0.80; P < 0.01) and complete response (relative risk (RR), 1.10; 95% CI 1.03 to 1.18; P < 0.01). However, no significant difference was observed between RFA and PEI in the European studies. In Asian studies, RFA was associated with a lower local recurrence rate than PEI at 1 year (RR, 0.44; 95% CI 0.20 to 0.95; P < 0.05) and 3 years (RR, 0.35; 95% CI 0.22 to 0.55; P < 0.01). However, local recurrence was significantly lower after only 3 years in European studies (RR, 0.50; 95% CI 0.32 to 0.78; P < 0.05). CONCLUSIONS: RFA was only superior to PEI in Asian studies that included selection bias. Thus, there is insufficient evidence to support the idea that RFA is superior to PEI for patients with cirrhotic HCC. Additional large-scale, multicenter, randomized controlled trials that control for selection bias are needed to fully elucidate the optimal treatment method for HCC.

Critical appraisal of clinical practice guidelines for treating pancreatic cancer based on the global disease burden.

OBJECTIVES: To evaluate the quality of pancreatic cancer guidelines with evidence-based methods based on the global burden of disease and to explore its status, distribution, characteristics of theme, and the difference of recommended therapies among various qualities of guidelines, so as to provide a reference for clinical decision. METHODS: The PubMed, The Cochrane Library (Issue 11, 2013), Chinese Biomedical Database, China National Knowledge Infrastructure, and VIP databases, as well as the website of National Guidelines Clearinghouse, Guidelines International Network, and National Institute for Clinical Excellence were systematically reviewed through November 2013 for pancreatic cancer guidelines. The Appraisal of Guidelines for Research and Evaluation (AGREE II) were applied to assess the methodological quality of the guidelines. RESULTS: A total of 14 relevant guidelines (including 5 evidence-based ones) were identified, involving four continents (Asia, Europe, North America, and Oceania), seven counties, and four international organizations. There were only two domains, namely 'scope and purpose' and 'clarity of presentations', getting high average scores (more than 60%) among all 14 guidelines. The mean AGREE domain score in guidelines varies among different areas, and the quality of 5 evidence-based guidelines was superior to that established by consensus. According to AGREE II, 11 guidelines were weakly recommended, while 3 were not recommended due to poor methodological quality. Their subjects of 14 guidelines covered six treatment categories, including chemotherapy, surgery, radiotherapy, support therapy, radiotherapy, and interventional therapy. CONCLUSION: The overall methodological quality of pancreatic cancer guidelines is suboptimal among different countries or regions. The qualities of evidence-based guidelines are significantly superior to consensus. The chemotherapy, surgery, radiotherapy, and support therapy were the predominant choices by guidelines.

Helical tomotherapy for cancer treatment: a rapid health technology assessment.

OBJECTIVES: Helical tomotherapy (HT) can be applied to treat complex malignant cancer with high-precise radiotherapy, and it can reduce the damage to normal tissues and improve treatment effects. But the procurement of HT must be approved by relevant departments of administration affairs. This study, appointed by the National Health and Family Planning Commission of China and undertook by the National Health Development Research Center and the Chinese Evidence-Based Medicine Centre, was aimed to rapidly assess the effectiveness, safety, costs, and applicability of HT, so as to provide currently available best evidence for decision-makers of health policies. METHODS: We electronically searched databases including PubMed, EMbase, The Cochrane Library, CNKI, WanFang Data, VIP, CBM, and other professional websites. Two reviewer independently screened literature according to the inclusion and exclusion criteria, extracted data, assessed quality, and then performed descriptive analysis. RESULTS: (i) We finally included 150 studies, encompassing 5 HTAs, 18 CCTs, and 127 observational studies. (ii) The included HTAs were published during 2006-2009, providing fairly less evidence of low quality and the results of 145 primary studies showed that: HT had been used mainly in the treatments of 14 kinds of cancer, with low total toxicity and high survival rates. Although the quality of the included studies was poor, there was much evidence about prostate cancer, head and neck cancer, nasopharynx cancer, cervical cancer, lung cancer and liver cancer, with enough sample and fairly reliable results in HT efficacy and safety. And (iii) a total of 56 clinical trials were registered in Clinicaltrials.gov, most of which were registered by the occident. Among them, 9 were completed but the results had not been published yet. CONCLUSIONS: The evidence of this study showed that, HT is safe and effective in clinic. But the abovementioned conclusion needs to be verified by conducting more high-quality studies with long-term follow-up. The costs of HT in procurement, maintenance, and application are high; and the skills, training, and qualification of operators are required. We suggest that the procurement of HT should be reduced; it should be allocated rationally and effectively used after comprehensive assessment in China's cancer epidemiology characteristics, health resource allocation, disease burden, medical service level, etc.; and also high-quality studies with long-term follow-up should be financially supported on the basis of establishing projects, so as to provide local evidence and consistently guide and improve scientific decision-making.

Capsule endoscopy in diagnosis of small bowel diseases: a health technology assessment.

OBJECTIVES: Capsule endoscopy (CE) has been widely used in the diagnosis of small bowel disease (SBD) in the world. To bring CE into the national health insurance directory, and intensify its popularization in primary hospital, the government needs high-quality HTA evidence for decision makers. We were appointed by the National Health and Family Planning Commission of China to evaluate the effectiveness, safety, economy, and applicability of CE in the diagnosis of SBD, to provide the best currently available evidence for decision making. METHODS: We searched the Cochrane Library (Issue 8, 2013), PubMed, EMbase, INAHTA, VIP, CBM, CNKI and WanFang Data. All confirmed or suspected SBD patients with diagnosis by CE versus other alternative therapies were considered. Health technology assessments (HTAs), systematic reviews (SRs), meta-analyses, randomized controlled trials (RCTs), guidelines and economic studies were included. Two investigators selected studies, assessed the quality and extracted data independently, and a descriptive analysis was used. RESULTS: We included 4 HTAs, 11 SRs/meta-analyses, 2 RCTs, 5 guidelines, and 10 economic studies for assessment. The results showed that the disease detection rate of CE was higher than that of many other traditional technologies and that the main adverse event for CE was retention (0.7% to 3.0%). These results were consistent with those of the guidelines. Comprehensive results of economic studies showed the superiority of CE compared with other technologies. As the first choice, CE can decrease potential costs, especially when used in outpatients. CONCLUSIONS: (i) CE has advantages in diagnostic yield, safety, and cost in the diagnosis of SBD, but some limitations exist. It still needs more high-quality evidence on CE diagnosis accuracy. (ii) When the government approves the introduction of CE in a hospital, many factors must be considered, such as the local disease burden, clinical demand, ability to pay, and staff. At the same time, it is necessary to standardize training for operating physicians, to reduce economic losses caused by poor technical ability of the medical staff.

Physical activity during pregnancy and the risk of gestational diabetes mellitus: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVES: We performed a systematic review and meta-analysis to assess the effects of physical activity in preventing gestational diabetes mellitus (GDM). SEARCH STRATEGY: We searched the literature in six electronic databases and bibliographies of relevant articles. SELECTION CRITERIA: We included randomised controlled trials on pregnant women who did not have GDM and other complications previously and had increased physical activity as the only intervention. The risk of developing GDM was documented separately for the intervention and control groups. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data and assessed quality independently. Data from the included trials were combined using a fixed-effects model. The effect size was expressed as relative risk (RR) and 95% CI. MAIN RESULTS: Of the 1110 studies identified, six randomised controlled trials met the inclusion criteria. In three trials, the incidence of GDM was lower in the intervention group than in the control group, whereas two trials showed a higher incidence of GDM in the intervention group and the remaining trial found no GDM in either the intervention or control group. The meta-analysis resulted in a relative risk (RR) of GDM of 0.91 (95% CI 0.57 to 1.44), suggesting no significant difference in the risk of developing GDM between the intervention and the control groups. No indication of publication bias was found. CONCLUSIONS: Evidence was insufficient to suggest that physical activity during pregnancy might be effective to lower the risk of developing GDM.

High-intensity focused ultrasound for treatment of pancreatic cancer: a systematic review.

OBJECTIVE: To explore the efficacy and safety of high-intensity focused ultrasound combined with other physical therapies for the treatment of pancreatic cancer, so as to provide reference for clinical application. METHODS: The PubMed, EMbase, The Cochrane Library (Issue 11, 2013), CBM, CNKI, and WanFang databases were systematically searched up to November 2013. The randomized controlled trials and clinical controlled trials about the treatment of high-intensity focused ultrasound were included. According to the inclusion and exclusion criteria, two reviewers independently screened the studies, exacted the data, and assessed the quality. The meta-analysis was performed by using the RevMan 5.0 software. RESULTS: A total of 23 studies including 19 randomized controlled trials and four clinical controlled trials were included. Of which 14 studies reported the safety. The results of meta-analyses showed that: the survival rate at 6 months and 12 months, overall efficacy, and clinical benefit rate in high-intensity focused ultrasound plus radiation and chemotherapy group were significantly higher than those in groups treated with three-dimensional conformal radiation therapy (P < 0.05), gemcitabine (P < 0.05), gemcitabine plus cisplatin (P < 0.05), and gemcitabine plus 5-fluorouracil (P < 0.05). The adverse effect caused by high-intensity focused ultrasound plus other therapy was equal to those in the control group. The major high-intensity focused ultrasound-related adverse effect was skin damage and fever. CONCLUSION: The current evidence suggested that the efficacy of high-intensity focused ultrasound for pancreatic cancer was superior to other therapies. However, the poor quality of trails may reduce the reliability of outcome to some extent. The current evidence suggested that the efficacy of HIFU for pancreatic cancer was superior to other therapies, but with poor quality. Therefore, a standard and unified criterion for the diagnosis and outcome measures of pancreatic cancer is needed, and the quality of study design and implementation should be bettered, so as to improve the high quality of evidence for its clinical application.

Sinomenine induces apoptosis in RAW 264.7 cell-derived osteoclasts in vitro via caspase-3 activation.

AIM: Sinomenine (SIN) is an alkaloid found in the roots and stems of Sinomenium acutum, which has been used to treat rheumatic arthritis in China and Japan. In this study we investigated the effects of SIN on osteoclast survival in vitro and the mechanisms of the actions. METHODS: Mature osteoclasts were differentiated from murine monocyte/macrophage cell line RAW264.7 through incubation in the presence of receptor activator of NF-κB ligand (RANKL, 100 ng/mL) for 4 d. The cell viability was detected using the CCK-8 method. The survival and actin ring construction of the osteoclasts were scored using TRACP staining and phalloidin-FITC staining, respectively. The apoptosis of the osteoclasts was detected by DNA fragmentation and Hoechst 33258 staining, and the cell necrosis was indicated by LDH activity. The activation of caspase-3 in osteoclasts was measured using Western blotting and the caspase-3 activity colorimetric method. RESULTS: SIN (0.25-2 mmol/L) inhibited the viability of mature osteoclasts in dose-dependent and time-dependent manners, but did not affect that of RAW264.7 cells. Consistently, SIN dose-dependently suppressed the survival of mature osteoclasts. The formation of actin ring, a marker associated with actively resorbing osteoclasts, was also impaired by the alkaloid. SIN (0.5 mmol/L) induced the apoptosis of mature osteoclasts, which was significantly attenuated in the presence of the caspase-3 inhibitor Ac-DEVD-CHO. SIN increased the cleavage of caspase-3 in mature osteoclasts in dose-dependent and time-dependent manners. Furthermore, SIN dose-dependently enhanced caspase-3 activity, which was blocked in the presence of Ac-DEVD-CHO. CONCLUSION: Sinomenine inhibits osteoclast survival in vitro through caspase-3-mediated apoptosis, thus it is a potential agent for treating excessive bone resorption diseases.