Annual case volume on mortality after coronary artery bypass grafting: a dose-response meta-analysis.

OBJECTIVES: This study evaluated the effect of both hospital and surgeon annual case volumes on patient mortality following coronary artery bypass grafting (CABG). METHODS: PubMed and Embase databases were searched for clinical studies on CABG. The outcome was mortality, including operative mortality, in-hospital mortality and 30-day mortality. RESULTS: Twenty-five studies involving 3 492 101 participants and 143 951 deaths were included for hospital volume, and 4 studies involving 108 356 participants and 2811 deaths were included for surgeon volume. The pooled estimate revealed that both hospital and surgeon annual case volumes were inversely associated with mortality in patients after CABG [odds ratio (OR) for hospital: 0.62, 95% confidence interval (CI) 0.56-0.69; P < 0.001; OR for surgeon: 0.51, 95% CI 0.31- 0.83; P < 0.001] with high heterogeneity (hospital: I2 = 90.6%, Pheterogeneity < 0.001; surgeon: I2 = 86.8%, Pheterogeneity < 0.001). The relationship remained consistent and robust in most subgroup and sensitivity analyses. Our meta-regression analysis of time suggested that the strength of the negative associations between volume and mortality for both hospitals and surgeons remained unattenuated over time even though the CABG mortality gradually decreased over time. The dose-response analysis suggested a non-linear relationship between both hospital and surgeon annual case volumes and mortality (both Pnon-linearity = 0.001). CONCLUSIONS: Both higher hospital and surgeon annual case volumes are associated with lower mortality in patients undergoing CABG, and the negative associations remain unattenuated over time. CLINICAL REGISTRATION NUMBER: The study was registered at PROSPERO as CRD42017067912.

Sole and combined vitamin C supplementation can prevent postoperative atrial fibrillation after cardiac surgery: A systematic review and meta-analysis of randomized controlled trials.

We undertook a systematic review and meta-analysis to evaluate the effect of vitamin C supplementation (vitamin C solely or as adjunct to other therapy) on prevention of postoperative atrial fibrillation (POAF) in patients after cardiac surgery. PubMed, Embase, Web of Science, and Cochrane Library were systematically searched to identify randomized controlled trials assessing the effect of vitamin C supplementation in adult patients undergoing cardiac surgery, and the meta-analysis was performed with a random-effects model. Thirteen trials involving 1956 patients were included. Pooling estimate showed a significantly reduced incidence of POAF (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.54 to 0.87, P = 0.002) both in vitamin C alone (RR: 0.75, 95% CI: 0.63 to 0.90, P = 0.002) and as an adjunct to other therapy (RR: 0.32, 95% CI: 0.20 to 0.53, P < 0.001). The results remain stable and robust in subgroup and sensitivity analyses, and trial sequential analysis also confirmed that the evidence was sufficient and conclusive. Additionally, vitamin C could significantly decrease intensive care unit length of stay (weighted mean difference: -0.24 days, 95% CI: -0.45 to -0.03, P = 0.023), hospital length of stay (weighted mean difference: -0.95 days, 95% CI: -1.64 to -0.26, P = 0.007), and risk of adverse events (RR: 0.45, 95% CI: 0.21 to 0.96, P = 0.039). Use of vitamin C alone and as adjunct to other therapy can prevent POAF in patients undergoing cardiac surgery and should be recommended for patients receiving cardiac surgery for prevention of POAF.

Zinc as an adjunct to antibiotics for the treatment of severe pneumonia in children <5 years: a meta-analysis of randomised-controlled trials.

The effect of Zn, as an adjunct to antibiotics, on the treatment of severe pneumonia in young children is still under debate; therefore, we performed a meta-analysis to evaluate the therapeutic role of Zn for severe pneumonia in children younger than 5 years. PubMed, Cochrane library and Embase databases were systematically searched from inception until October 2015 for randomised-controlled trials (RCT) that assessed the effect of Zn as an adjunct to antibiotics for severe pneumonia. Random-effects model was used for calculating the pooled estimates, and intention-to-treat principle was also applied. Nine RCT involving 2926 children were included. Overall, the pooled results showed that adjunct treatment with Zn failed to reduce the time to recovery from severe pneumonia (hazard ratios (HR)=1·04; 95% CI 0·90, 1·19; I(2)=39%; P=0·58), hospital length of stay (HR=1·04; 95% CI 0·83, 1·33; I(2)=57%; P=0·74), treatment failure (relative risk (RR)=0·95; 95% CI 0·79, 1·14; I(2)=20%; P=0·58) or change of antibiotics (RR=1·07; 95% CI 0·79, 1·45; I(2)=44%; P=0·67). In addition, continuous outcomes were consistent while meta-analysed with standard mean difference, and all outcomes remained stable in intention-to-treat analysis. No significant differences were observed in the two groups between death rate, adverse events or recovery times of severe pneumonia indicators. Our results suggested that adjunct treatment with Zn failed to benefit young children in the treatment of severe pneumonia. Considering the clinical heterogeneity, baseline characteristics of children, definition of severe pneumonia and Zn supplement way should be taken into consideration in future research. This study was registered at PRESPERO as CRD42015019798.

Pulmonary interstitial cholesterol crystals associated with diffuse lung cysts in adult: a case report and literature review.

BACKGROUND: Cholesterol pneumonitis or endogenous lipoid pneumonia (ELP) result from the accumulation of endogenous cholesterol esters in the lungs, leading to a fibroblastic interstitial inflammatory process, and may be complicated by a secondary bacterial or fungal infection. Striking features were cholesterol clefts in the alveolar and interstitial spaces and alveolar wall-thickening with lymphocytic infiltrations, which was called pulmonary interstitial and intra-alveolar cholesterol granulomas (PICG). CASE PRESENTATION: We report a case of pneumothorax with diffuse lung cysts and pulmonary interstitial cholesterol in a 26-year-old woman. Our case is unique because development of PICG or ELP has been observed in children, but rarely in adult. Most cases could be linked to exogenous sources like inhalation of lipid material or gastroesophageal reflex (GER). In our case, no signs of GER could be discovered. Diffuse lung cysts coexisting with pulmonary interstitial cholesterol crystals are never reported. Additionally, no multinucleated giant cells or granuloma are found pathologically, which make the diagnosis of PICG or lipoid pneumonia difficult. CONCLUSIONS: Pulmonary interstitial cholesterol crystals may develop gradually and evenly distributed throughout the entire lung and resulted in severe distortion of the native structure of the lung.

Remote Ischemic Preconditioning Fails to Benefit Pediatric Patients Undergoing Congenital Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials.

Remote ischemic preconditioning (RIPC) has been proven to reduce the ischemia-reperfusion injury. However, its effect on children receiving congenital cardiac surgery (CCS) was inconsistent. We therefore performed the current meta-analysis of randomized controlled trials (RCTs) to comprehensively evaluate the effect of RIPC in pediatric patients undergoing CCS.PubMed, Embase, and Cochrane library were searched to identify RCTs assessing the effect of RIPC in pediatric patients undergoing CCS. The outcomes included the duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay, postoperative cardiac troponin (cTnI) level, hospital length of stay (HLOS), postoperative inotropic score, and mortality. Subgroup and sensitivity analysis were also performed as predesigned. The meta-analysis was performed with random-effects model despite of heterogeneity. Sensitivity and subgroup analysis were predesigned to identify the robustness of the pooled estimate.Nine RCTs with 697 pediatric patients were included in the meta-analysis. Overall, RIPC failed to alter clinical outcomes of duration of MV (standard mean difference [SMD] -0.03, 95% confidence interval [CI] -0.23-0.17), ICU length of stay (SMD -0.22, 95% CI -0.47-0.04), or HLOS (SMD -0.14, 95% CI -0.55-0.26). Additionally, RIPC could not reduce postoperative cTnI (at 4-6 hours: SMD -0.25, 95% CI -0.73-0.23; P = 0.311; at 20-24 hours: SMD 0.09, 95% CI -0.51-0.68; P = 0.778) or postoperative inotropic score (at 4-6 hours: SMD -0.19, 95% CI -0.51-0.14; P = 0.264; at 24 hours: SMD -0.15, 95% CI -0.49-0.18; P = 0.365).RIPC may have no beneficial effects in children undergoing CCS. However, this finding should be interpreted with caution because of heterogeneity and large-scale RCTs are still needed.

Risk of major adverse cardiovascular events in patients with metabolic syndrome after revascularization: A meta-analysis of eighteen cohorts with 18,457 patients.

OBJECTIVE: To provide a comprehensive evaluation of the association between metabolic syndrome (MetS) and major adverse cardiovascular events (MACE) and to clarify the effect of revascularization methods among them in patients with coronary artery disease (CAD) undergoing successful revascularization. METHODS: PubMed and Embase databases were searched. Cohort studies evaluating the association between MetS and risk of MACE and providing the hazard ratio (HR) with 95% confidence interval (CI) or sufficient data to calculate HR and its 95%CI among patients after revascularization were included. The pooled estimates were performed by using a random-effects model despite heterogeneity. Subgroup and sensitivity analyses were also conducted adherence to guidelines. RESULTS: Eighteen trials with 18457 patients were included. Overall, MetS was associated with significant increased risks of MACE (HR 1.47, 95%CI 1.26-1.72, I(2)=46.4%, PH=0.016, P<0.001) and all-cause mortality (HR 1.58, 95%CI 1.29-1.92, I(2)=45.6%, PH=0.075, P<0.001) in CAD patients received revascularization. The results remained stable and robust in our subgroup analysis. However, no significant increased risk of MACE or all-cause mortality was found in patients undergoing coronary artery bypass graft (CABG) or drug-eluting stent (DES) in the sensitivity analysis. CONCLUSION: MetS was associated with increased risks of MACE and all-cause mortality in patients after revascularization, but not in patients receiving CABG or DES. Therefore, prevention and treatment of MetS are extremely necessary in patients undergoing revascularization. Moreover, CABG and DES should be recommended for CAD patients with MetS and future researches are still warranted.

Compression Therapy in the Prevention of Postthrombotic Syndrome: A Systematic Review and Meta-Analysis.

Although compression therapy has been widely used after deep vein thrombosis (DVT), its efficacy in prevention of postthrombotic syndrome (PTS) remains disputable. We aimed to update the meta-analysis to comprehensively evaluate the effect of compression therapy on the prevention of PTS in adult patients after DVT.PubMed, Embase, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) evaluating the preventive effect of compression therapy on PTS in adult patients after DVT were included. The primary outcome was the incidence of PTS. All meta-analyses were performed using random-effects models regardless of the heterogeneity. Subgroup and sensitivity analysis were also performed to examine the robustness of the pooled effects according to our predesigned plan. Potential publication bias was assessed.Eight RCTs with 1598 patients were included. Overall, compression therapy could significantly reduce the incidence of PTS (estimate 0.68, 95% confidence interval [CI] 0.52-0.90; P = 0.007). However, it was only associated with a reduction in the incidence of mild/moderate PTS (relative risk [RR] 0.66, 95% CI 0.46-0.93; P = 0.019) but not in the incidence of severe PTS (RR 0.64, 95% CI 0.27-1.50; P = 0.31). Additionally, compression therapy failed to reduce the incidence of recurrent venous thromboembolism (RR 0.91, 95% CI 0.65-1.27; P = 0.58), the incidence of ulceration (RR 0.74, 95% CI 0.36-1.53; P = 0.42), or mortality (RR 0.99, 95% CI 0.72-1.37; P = 0.96). No publication bias was observed.Current evidence still supports compression therapy to be a clinical practice for prophylaxis of PTS in adult patients after DVT. However, our findings should be cautiously interpreted because of heterogeneity and hence more large-scale and well-designed RCTs are still warranted.

Methods of reconstruction after esophagectomy on long-term health-related quality of life: a prospective, randomized study of 5-year follow-up.

The health-related quality of life (HRQL) is generally accepted as an important parameter for patients undergoing oncologic surgery. We conducted this prospective, randomized study to compare the effect of narrow gastric tube (NGT) reconstruction and whole-stomach (WS) reconstruction on the long-term HRQL in patients after esophagectomy. One hundred and four patients undergoing esophagectomy were enrolled in our study from 2007 to 2008, with 52 in NGT group and 52 in WS group. A questionnaire with reference to the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OES18 was used to assess the HRQL at 3 weeks, 6 months, 1, 2, 3, 4, and 5 years after esophagectomy. Data collection and follow-up were performed regularly. No significant difference was found between NGT group and WS group in the patients' baseline characteristics. Patients in NGT group had decreased risk of postoperative reflux esophagitis by comparison with those in WS group. The 5-year cumulative survival rate was 42 % (NGT) and 27 % (WS), respectively. Compared with WS group, a significant increased survival rate (P = 0.027) was found in NGT group. Additionally, patients had lower dysphagia scores (better) in NGT group than those in WS group at 5 years after esophagectomy (P < 0.05). However, the scores of the other scales did not show statistical difference at 5-year follow-up. NGT is a better option for the reconstruction after esophagectomy because of decreased risk of postoperative complication, increased survival rate, and better HRQL, and NGT should be preferred to be recommended for patients undergoing esophagectomy.

Erythropoietin administration for prevention of cardiac surgery-associated acute kidney injury: a meta-analysis of randomized controlled trials.

The effect of erythropoietin (EPO) on the prevention of cardiac surgery-associated acute kidney injury (CSA-AKI) is controversial. Therefore, we undertook the meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and safety of EPO on the prevention of CSA-AKI in adult patients and to explore whether risk factors for AKI could explain the inconsistent effects. PubMed and EMbase databases were searched to identify eligible RCTs. The meta-analysis was performed with fixed- or random-effects models according to the heterogeneity, and the subgroup analysis stratified by risk factors for AKI was carried out. Five RCTs involving 423 patients were included. Overall, EPO administration was not associated with a reduced incidence of CSA-AKI [relative risk (RR): 0.64, 95% confidence interval (CI): 0.35-1.16], with a moderate heterogeneity (I(2) = 67.4%, heterogeneity P = 0.02). Subgroup analysis showed that, in patients without high risk factors for AKI, EPO administration could significantly reduce the incidence of CSA-AKI (RR: 0.38, 95% CI: 0.24-0.61), intensive care unit length of stay [standardized mean difference (SMD): -0.54, 95% CI: -1.05 to -0.04] and hospital length of stay (SMD: -0.48, 95% CI: -0.94 to -0.02). The test of heterogeneity was not significant in the two subgroups. EPO administration could significantly reduce the incidence of CSA-AKI, but not in patients with high risk factors for AKI. Substantial heterogeneity across trials could be attributed to high risk factors for AKI. However, our findings should be interpreted cautiously because of the limited studies included, and high-quality RCTs are warranted.

Sodium bicarbonate in the prevention of cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis.

INTRODUCTION: Sodium bicarbonate (SBIC) was reported to be a promising approach to prevent cardiac surgery-associated acute kidney injury (CSA-AKI). However, the results remain controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of SBIC on the prevention of CSA-AKI in adult patients undergoing cardiac surgery. METHODS: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of SBIC versus placebo on the prevention of CSA-AKI in adult patients undergoing cardiac surgery were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome was the incidence of CSA-AKI. Meta-analysis was performed using random-effects models. RESULTS: Five RCTs involving 1079 patients were included in the meta-analysis. Overall, compared with placebo, SBIC was not associated with a reduced risk of CSA-AKI (relative risk [RR] 0.99; 95% confidence interval [CI] 0.78 to 1.24; P = 0.911). SBIC failed to alter the clinical outcomes of hospital length of stay (weighted mean difference [WMD] 0.23 days; 95%CI -0.88 to 1.33 days; P = 0.688), renal replacement therapy (RR 0.94; 95%CI 0.49 to 1.82; P = 0.861), hospital mortality (RR 1.37; 95%CI 0.46 to 4.13; P = 0.572), postoperative atrial fibrillation (RR 1.02; 95%CI 0.65 to 1.61; P = 0.915). However, SBIC was associated with significant increased risks in longer duration of ventilation (WMD 0.64 hours; 95%CI 0.16 to 1.11 hours; P = 0.008), longer ICU length of stay (WMD 2.06 days; 95%CI 0.54 to 3.58 days; P = 0.008), and increased incidence of alkalemia (RR 2.21; 95%CI 1.42 to 3.42; P <0.001). CONCLUSIONS: SBIC could not reduce the incidence of CSA-AKI. Contrarily, SBIC prolongs the duration of ventilation and ICU length of stay, and increases the risk of alkalemia. Thus, SBIC should not be recommended for the prevention of CSA-AKI and perioperative SBIC infusion should be administrated with caution.

Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Ultrasound guidance has emerged as an adjunct for central vein catheterization in both adults and children. However, the use of ultrasound guidance for radial arterial catheterization has not been well established. We conducted a systematic review and meta-analysis to evaluate the efficacy of ultrasound guidance for radial artery catheterization. METHODS: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) comparing ultrasound guidance with other techniques (palpation or Doppler) in adult or pediatric patients requiring radial artery catheterization were included. The primary outcome was first-attempt success. RESULTS: Seven RCTs enrolling 546 patients met the inclusion criteria, and all the selected trials were considered as at high risk of bias. Ultrasound-guided radial artery catheterization was associated with an increased first-attempt success (relative risk (RR) 1.55, 95% confidence interval (CI) 1.02 to 2.35). There was significant heterogeneity among the studies (I2 = 74%). Ultrasound-guided radial artery catheterization in small children and infants also provided an increased chance for first-attempt success (RR 1.94, 95% CI 1.31 to 2.88). Ultrasound guidance further significantly reduced mean attempts to success (weighted mean difference (WMD) -1.13, 95% CI -1.58 to -0.69), mean time to success (WMD -72.97 seconds, 95% CI -134.41 to -11.52), and incidence of the complication of hematoma (RR 0.17, 95% CI 0.07 to 0.41). CONCLUSIONS: Ultrasound guidance is an effective and safe technique for radial artery catheterization, even in small children and infants. However, the results should be interpreted cautiously due to the heterogeneity among the studies.

Nonsteroidal anti-inflammatory drugs versus corticosteroid for treatment of shoulder pain: a systematic review and meta-analysis.

OBJECTIVE: To compare the treatment efficacy between corticosteroid injection and nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with shoulder pain. DATA SOURCES: PubMed and EMBASE databases were searched from inception to January 2014. Reference lists of the retrieved studies were additionally scrutinized. STUDY SELECTION: Randomized controlled trials (RCTs) comparing corticosteroid injection with NSAIDs for treatment of shoulder pain were included. The primary outcome was remission, and the secondary outcomes were pain relief and improvement of range of active abduction. Study selection was conducted by 2 researchers independently. Any disagreements were solved by discussion and confirmed by the third reviewer. DATA EXTRACTION: Two reviewers independently conducted data extraction and the quality assessment. Data regarding patients, intervention, control, and outcomes were extracted from the included trials. DATA SYNTHESIS: Six high-quality RCTs of 267 patients meeting the inclusion criteria were included. For an outcome of remission, NSAIDs were less effective than corticosteroid in 4 or 6 weeks (relative risk, .64; 95% confidence interval, .45-.92). NSAIDs did not significantly differ with corticosteroid in pain relief and improvement of range of active abduction. CONCLUSIONS: Current meta-analysis suggests that NSAIDs are less effective than corticosteroid in achieving remission in patients with shoulder pain at 4 or 6 weeks after treatment. Considering the limited number of studies and small size of each trial, the results should be interpreted with caution, and more high-quality RCTs are encouraged.

Risk of acute lung injury/acute respiratory distress syndrome in critically ill adult patients with pre-existing diabetes: a meta-analysis.

BACKGROUND: The impact of pre-existing diabetes on the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in critically ill patients remains unclear. We performed a meta-analysis of cohort studies to evaluate the risk of ALI/ARDS in critically ill patients with and without pre-existing diabetes. MATERIALS AND METHODS: We searched PubMed and Embase from the inception to September 2013 for cohort studies assessing the effect of pre-existing diabetes on ALI/ARDS occurrence. Pooled odds ratio (OR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models when appropriate. RESULTS: Seven cohort studies with a total of 12,794 participants and 2,937 cases of pre-existing diabetes, and 2,457 cases of ALI/ARDS were included in the meta-analysis. A fixed-effects model meta-analysis showed that pre-existing diabetes was associated with a reduced risk of ALI/ARDS (OR 0.66; 95% CI, 0.55-0.80; p<0.001), with low heterogeneity among the studies (I(2)=18.9%; p=0.286). However, the asymmetric funnel plot and Egger's test (p=0.007) suggested publication bias may exist. CONCLUSIONS: Our meta-analysis suggests that pre-existing diabetes was associated with a decreased risk of ALI/ARDS in critically ill adult patients. However, the result should be interpreted with caution because of the potential bias and confounding in the included studies.

Efficacy and safety of ondansetron in preventing postanesthesia shivering: a meta-analysis of randomized controlled trials.

BACKGROUND: Shivering is a very common complication in the postanesthesia period. Increasing studies have reported ondansetron may be effective in prevention of postanesthesia shivering (PAS). However, the results remained controversial; hence we conducted a meta-analysis of randomized controlled trials to evaluate the efficacy and safety of ondansetron on the prevention of postanesthesia shivering. METHODS: PubMed and Embase databases were searched to identify the eligible randomized controlled trials assessing the effect of ondansetron on the prevention of PAS. Results were expressed as risk ratios (RRs) with accompanying 95% confidence intervals (CIs). The meta-analysis was performed with fixed-effect model or random-effect model according to the heterogeneity. RESULTS: Six trials including 533 subjects were included. Compared with placebo, ondansetron was associated with a significant reduction of PAS (RR 0.43, 95% CI, 0.27-0.70), without an increased risk of bradycardia (RR 0.37, 95% CI, 0.12-1.15). Compared with meperidine, no difference was observed in the incidence of PAS (RR 0.68, 95% CI, 0.39-1.19) and bradycardia (RR 2.0, 95% CI, 0.38-10.64). CONCLUSIONS: Ondansetron has a preventive effect on PAS without a paralleled side effect of bradycardia.

Risk of childhood overweight or obesity associated with excessive weight gain during pregnancy: a meta-analysis.

PURPOSE: Several investigations have shown that the risk of childhood overweight and obesity may be associated with excessive gestational weight gain (GWG), but the study samples were limited and results were mixed; hence we conducted this meta-analysis to assess the explicit association between them and present evidence. METHODS: We searched PubMed, EMbase, Ovid, Web of knowledge and Cochrane library for relevant studies. Bibliographies from retrieved articles were also manually searched. Cohort studies that presented results by OR or RR with 95 % CI for the association of maternal excessive GWG and child overweight/obesity were included. The pooled estimates were calculated by fixed-effect model or random-effect model according to the heterogeneity. RESULTS: Twelve cohort studies were identified, and the combined OR of excessive GWG and childhood overweight/obesity was 1.33 (95 % CI 1.18-1.50) with evidence of heterogeneity (P = 0.000, I (2) = 71.1 %). Adjustment of maternal BMI, investigation area, age of children, research type, and omission of any single study had little effect on the pooled estimate. After eliminating the effect of publication bias by trim and fill analyses, the result still remained statistically significant (OR 1.21, 95 % CI 1.05-1.40). CONCLUSIONS: This meta-analysis suggests that the risk of childhood overweight/obesity is significantly associated with excessive gestational weight gain.