Histological Outcomes of Pharmacological Interventions in Eosinophilic Esophagitis for Adults and Children: A Network Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Multiple pharmacological interventions have been studied for managing eosinophilic esophagitis (EoE). We performed a comprehensive systematic review and network meta-analysis of all available randomized controlled trials (RCT) to assess the efficacy and safety of these interventions in EoE in adults and children. METHODS: We performed a comprehensive review of Embase, PubMed, MEDLINE OVID, Cochrane CENTRAL, and Web of Science through May 10, 2023. We performed frequentist approach network meta-analysis using random effects model. We calculated the odds ratio (OR) with 95% CI for dichotomous outcomes. RESULTS: Our search yielded 25 RCTs with 25 discrete interventions and 2067 patients. Compared with placebo, the following interventions improved histology (using study definitions) in decreasing order on ranking: orodispersible budesonide (ODB) low dose, ODB high dose, oral viscous budesonide (OVB) high dose, fluticasone tablet 1.5 mg twice daily, fluticasone 3 mg twice daily, esomeprazole, dupilumab every 2 weeks, dupilumab weekly, OVB medium dose, fluticasone 3 mg daily, cendakimab 180 mg, prednisone, swallowed fluticasone, fluticasone tablet 1.5 mg daily, OVB low dose, reslizumab 3 mg/kg, reslizumab 1 mg/kg, and reslizumab 2 mg/kg. CONCLUSIONS: Network meta-analysis demonstrates histological efficacy of multiple medications for EoE. Because of the heterogeneity and large effect size, we recommend more trials comparing pharmacotherapeutic interventions with each other and placebo. An important limitation of this study is absence of clinical efficacy data due to insufficient data. Other limitations include heterogeneity of operator, population, and outcome analysis.

Correlation of Autoimmune Pancreatitis and Malignancy: Systematic Review and Meta-Analysis.

BACKGROUND: There is conflicting evidence regarding autoimmune pancreatitis (AIP) association with pancreatic and non-pancreatic cancers. Literature lacks data on overall prevalence of malignancies in autoimmune pancreatitis. AIM: Given the lack of definite evidence, we aimed to pool and summarize data from available literature regarding prevalence of different malignancies in AIP. METHODS: We conducted a systematic search of MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science through February 16, 2021, to include observational studies assessing the incidence of cancer in AIP. We used the DerSimonian-Laird method with random effects for meta-analysis. Pooled prevalence, 95% confidence interval (CI), and I2 statistic are reported. RESULTS: A total of 17 studies with 2746 patients were included assessing the prevalence of cancer in AIP. The overall prevalence of cancer in AIP was 9.6% [95% confidence interval (CI), 5.7-13.5%]. The cancers with the highest prevalence in AIP population were gastric and colorectal cancer, with prevalence of 1.3% (95% CI, 0.5-2.1%) and 1.2% (95% CI, 0.6-1.8%), respectively. CONCLUSION: We demonstrate the prevalence of different cancers in AIP. Inflammatory surge in AIP and subsequent carcinogenesis is one explanation for this association. Moreover, AIP can be a paraneoplastic syndrome manifestation of malignancies.

Predictors of mortality in 217 COVID-19 patients in Northwest Ohio, United States: A retrospective study.

The coronavirus disease 2019 (COVID-19) pandemic continues to cause significant morbidity and mortality worldwide. This study aims to identify specific lab markers, complications, and treatments that may be associated with increased mortality in COVID-19 patients. This study is retrospective in nature; it included 217 COVID-19 positive patients who were admitted to a ProMedica Health System hospital in Northwest Ohio, United States, between March 25 and June 16, 2020. We collected various laboratory values, complications, and treatment courses. T test and χ2 analyses were used to predict mortality. COVID-19 test was confirmed via polymerase chain reaction. Of 217 patients included in the study, the mean age of the population was 63.13 (SD, 17.8), of which 194 (89.4%, mean age 61.7 years) survived while 23 (10.6%, mean age 74.6 years) died. Among them, 53% were females and 47% male. Laboratory values that were associated with mortality were low hemoglobin (p = .0046), elevated INR (p = .0005), low platelets (p = .0246) and elevated procalcitonin (p = .0472). Marginally significant laboratory values included elevated troponin (p = .0661), and elevated creatinine (p = .0741). Treatment with either antibiotic, antifungals, antivirals, blood transfusion, steroids, and intubation were all statistically significant for mortality. COVID-19 related complications with either ARDS, myocarditis, elevated INR, septic shock, or age greater than 63 were significant predictors of mortality. Low hemoglobin, elevated INR, Low platelet, elevated procalcitonin, treated with either antibiotic, antifungal, antiviral, blood transfusion, steroids, and intubation are associated with high mortality related to COVID-19 infection. Healthcare professionals must be aware of these predictors.

Efficacy of tocilizumab in COVID-19: A systematic review and meta-analysis.

The efficacy of tocilizumab (TOC), monoclonal antibody against interleukin-6 (IL-6) receptor, in patients with coronavirus disease-2019 (COVID-19) patients has led to conflicting results. We performed a systematic review and meta-analysis to compare the efficacy of addition of TOC to standard of care (SOC) versus SOC in patients with COVID-19. We performed a comprehensive literature search of PubMed, Embase, Web of Science, WHO COVID, LitCOVID, and Cochrane databases. Pooled outcomes (overall mortality, need for mechanical ventilation, intensive care unit admission, and secondary infections) were compared using DerSimonian-Laird/Random-effects approach. Risk difference (RD), confidence interval (CI), and p values were generated. A total of 23 studies with 6279 patients (1897 in TOC and 4382 in SOC group, respectively) were included. The overall mortality was lower in TOC group compared to SOC group (RD: -0.06; CI: -0.12 to -0.01; p = .03). Subgroup analysis including studies with only severe cases revealed lower mortality (RD: -0.12; CI: -0.18 to -0.06; p < .01) and need for mechanical ventilation (RD: -0.11; CI: -0.19 to -0.02; p = .01) in TOC group compared to SOC group. The addition of TOC to SOC has the potential to reduce mortality and need for mechanical ventilation in patients with severe COVID-19. Randomized controlled trials are needed to validate this.

Do Water-aided Techniques Improve Serrated Polyp Detection Rate During Colonoscopy?: A Systematic Review With Meta-Analysis.

BACKGROUND AND STUDY AIMS: The utility of water-aided techniques (WT): water exchange (WE) and water immersion (WI) have been studied extensively in the literature for improving colonoscopy outcome metrics such as adenoma detection rate. Serrated polyps owing to their location and appearance have a high miss rate. The authors performed a systematic review and meta-analysis of studies comparing WT with the standard gas-assisted (GA) method to determine if there was any impact on serrated polyp detection rate (SPDR) and sessile serrated polyp detection rate. METHODS: The following databases were queried for this systematic review: Medline, EMBASE, Cochrane Library, CINAHL, and Web of Sciences. The authors only included randomized controlled trials (RCTs). The primary outcome was SPDR and secondary outcomes were sessile serrated polyp detection rate and cecal intubation rate. Risk ratios (RRs) were calculated for each outcome. A P-value <0.05 was considered to be statistically significant. RESULTS: A total of 4 RCTs (5 arms) with 5306 patients (2571 in the GA group and 2735 in the WT group) were included. The SPDR was significantly increased for the WT group compared with GA (6.1% vs. 3.8%; RR, 1.63; 95% confidence interval, 1.24-2.13; P<0.001; I2=22.7%). A subgroup analysis for WE technique also demonstrated improved SPDR compared with the GA method (4.9% vs. 3.2%; RR, 1.57; 95% confidence interval, 1.15-2.14; P=0.004; I2=6.1%). CONCLUSIONS: WT, particularly, the WE method results in improved SPDR. This technique should be encouraged in a clinical setting to detect these polyps to prevent interval colorectal cancer.

Use of 2 Observers Increases Adenoma Detection Rate During Colonoscopy: Systematic Review and Meta-analysis.

Current efforts are directed toward improving quality metrics such as adenoma/polyp detection rates during colonoscopy to decrease the incidence of colorectal cancer.1 Previous studies have reported variable detection rates for adenomas/polyps during colonoscopy for active participation/observation by nurses, trainees, and/or technician (dual observer [DO] group) with an endoscopist.2,3 We performed a systematic review and meta-analysis to evaluate the detection rate of adenomas/polyps during colonoscopy via DO versus single observers (ie, endoscopist alone).

Rectal indomethacin with topical epinephrine versus indomethacin alone for preventing Post-ERCP pancreatitis - A systematic review and meta-analysis.

BACKGROUND: Recent studies have compared the utility of rectal indomethacin with topical epinephrine (IE) sprayed on duodenal papilla and rectal indomethacin alone (IS) to prevent post-ERCP pancreatitis (PEP) with conflicting results. We performed a systematic review and meta-analysis to evaluate the benefit of using the combination prophylaxis as oppose to rectal indomethacin alone. METHODS: The following database were searched for our systematic review: PubMed∖Medline, Embase, Cochrane, and Web of Science. We included both randomized controlled trials (RCTs) and cohort studies. Primary outcome was incidence of PEP and secondary outcomes were adverse events and mortality. RESULTS: A total of 3 studies (all RCTs) with 2244 patients (1132 in IS and 1112 in IE group) were included. The IE group did not demonstrate any significant benefit over IS group in preventing PEP (RR: 1.15, 95% CI 0.62-2.2), mortality (RR: 0.85, 95% CI 0.22-3.24) or overall adverse events (RR: 1.3, 95% CI 0.93-1.7). CONCLUSION: The combination of rectal indomethacin and topical epinephrine failed to demonstrate any benefit over indomethacin alone in preventing PEP, decreasing mortality and overall adverse events.

The impact of deep convolutional neural network-based artificial intelligence on colonoscopy outcomes: A systematic review with meta-analysis.

BACKGROUND AND AIM: The utility of artificial intelligence (AI) in colonoscopy has gained popularity in current times. Recent trials have evaluated the efficacy of deep convolutional neural network (DCNN)-based AI system in colonoscopy for improving adenoma detection rate (ADR) and polyp detection rate (PDR). We performed a systematic review and meta-analysis of the available studies to assess the impact of DCNN-based AI-assisted colonoscopy in improving the ADR and PDR. METHODS: We queried the following database for this study: PubMed, Embase, Cochrane Library, Web of Sciences, and Computers and Applied Sciences. We only included randomized controlled trials that compared AI colonoscopy to standard colonoscopy (SC). Our outcomes included ADR and PDR. Risk ratios (RR) with 95% confidence interval (CI) were calculated using random effects model and DerSimonian-Laird approach for each outcome. RESULTS: A total of three studies with 2815 patients (1415 in SC group and 1400 in AI group) were included. AI colonoscopy resulted in significantly improved ADR (32.9% vs 20.8%, RR: 1.58, 95% CI 1.39-1.80, P = < 0.001) and PDR (43.0% vs 27.8%, RR: 1.55, 95% CI 1.39-1.72, P = < 0.001) compared with SC. CONCLUSION: Given the results and limitations, the utility of AI colonoscopy holds promise and should be evaluated in more randomized controlled trials across different population, especially in patients solely undergoing colonoscopy for screening purpose as improved ADR will ultimately help in reducing incident colorectal cancer.

Improving serrated adenoma detection rate in the colon by electronic chromoendoscopy and distal attachment: systematic review and meta-analysis.

BACKGROUND AND AIMS: The evidence for modification of conventional colonoscopy using either "distal attachments" (DAs; endocap, endocuff, and endoring) or "electronic chromoendoscopy" (EC; narrow-band imaging [NBI], iScan, blue-light imaging, autofluorescence imaging, and linked-color imaging) to improve the detection of serrated adenomas during colonoscopy has shown conflicting results. METHODS: A comprehensive literature search was performed using Medline, Google Scholar, Embase, and Cochrane Library based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) comparing any DA or EC with high-definition white-light colonoscopy for detection of serrated adenomas (sessile serrated adenoma/polyp and traditional serrated adenoma) were included. The primary outcome was serrated adenoma detection rate (SADR) defined as the number of patients with at least 1 serrated adenoma of total patients in that group. The secondary outcome was the number of serrated adenomas per subject. Pooled rates were reported using risk ratio (RR) with 95% confidence interval. RESULTS: Seventeen studies with 13,631 patients (56% men; age range, 50-66 years) met the inclusion criteria. The use of DAs (RR, 1.21; P = .45) and EC (RR, 1.29; P = .09) during colonoscopy did not show a significant improvement in SADR. The SADR using EC was 6.9% (4 studies) and that with NBI alone was 3.7% (3 studies). CONCLUSIONS: The results indicate that, except for NBI, the use of DAs or EC during colonoscopy does not improve detection of serrated adenomas in the colon. More RCTs evaluating NBI are needed to explore the effect.

Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis.

(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.

The United States Medical Licensing Exam Step 2 Clinical Skills Examination: Potential Alternatives During and After the COVID-19 Pandemic.

We feel that the current COVID-19 crisis has created great uncertainty and anxiety among medical students. With medical school classes initially being conducted on the web and the approaching season of "the Match" (a uniform system by which residency candidates and residency programs in the United States simultaneously "match" with the aid of a computer algorithm to fill first-year and second-year postgraduate training positions accredited by the Accreditation Council for Graduate Medical Education), the situation did not seem to be improving. The National Resident Matching Program made an official announcement on May 26, 2020, that candidates would not be required to take or pass the United States Medical Licensing Examination Step 2 Clinical Skills (CS) examination to participate in the Match. On January 26, 2021, formal discontinuation of Step 2 CS was announced; for this reason, we have provided our perspective of possible alternative solutions to the Step 2 CS examination. A successful alternative model can be implemented in future residency match seasons as well.

Epidemiological and Clinical Characteristics of 217 COVID-19 Patients in Northwest Ohio, United States.

Background There is limited data on the clinical characteristics and predictors of mortality of coronavirus disease-2019 (COVID-19) in North West Ohio. We performed a retrospective review of patients hospitalized with COVID-19 in the ProMedica Health System in Northwest Ohio from March 25 to June 16, 2020. The study aims to identify epidemiological, clinical characteristics, and predictors of Mortality of COVID-19 patients in Northwest Ohio. Methods This study was conducted on 217 COVID-19 patients admitted to ProMedica Health System Hospitals in Northwest Ohio from March 25 to June 16, 2020. We collected data, including clinical signs, symptoms, and outcomes of the COVID-19 patients. We compared clinical signs and symptoms along with comorbidities of survivors and non-survivors. Results Of the 217 patients included in the study, the mean age of the population was 63.13 (SD 17.8), of which 194 (89.4%, mean age 61.7 years) survived while 23 (10.6%, mean age 74.6 years) died. Among them, 53% were females and 47% male. Common presenting symptoms were chest pain (91.71%), shortness of breath (79.7%), cough (71%), and fever (64%). Mortality was associated with age greater than 63 (p-value 0.0052) and hypertension (p-value: 0.0058) with marginal significance with gender (p-value: 0.0642), chest pain (p-value: 0.0944), and history of cancer (p-value: 0.0944). Conclusions Advanced age and hypertension (HTN) are independent predictors for increased mortality. History of cancer and chest pain are associated with increased mortality with marginal significance. Awareness among physicians about predictors of mortality is essential in dealing with COVID-19 patients. It is essential to educate the public about preventative strategies such as wearing masks to decrease mortality and morbidity from this pandemic.