BackgroundRegional citrate or heparin is often prescribed as an anticoagulant for continuous renal replacement therapy (CRRT). However, their efficacy and safety remain controversial. Therefore, we performed this meta-analysis to compare these two agents and to determine whether the currently available evidence is sufficient and conclusive by using trial sequential analysis (TSA).MethodsWe searched for relevant studies in PubMed, Embase, the Cochrane Library databases and the China National Knowledge Infrastructure (CNKI) Database from database inception until September 2015. We selected randomized controlled trials comparing regional citrate with heparin in adult patients with acute kidney injury (AKI) who were prescribed CRRT.ResultsFourteen trials (n = 1134) met the inclusion criteria. Pooled analyses showed that there was no difference in mortality between the regional citrate and heparin groups (relative risk (RR) 0.97, 95 % confidence interval (CI) 0.84, 1.13, P > 0.05), which was confirmed by TSA. Compared with heparin, regional citrate significantly prolonged the circuit life span in the continuous venovenous haemofiltration (CVVH) subgroup (mean difference (MD) 8.18, 95 % CI 3.86, 12.51, P < 0.01) and pre-dilution subgroup (MD 17.51, 95 % CI 9.85, 25.17, P < 0.01) but not in the continuous venovenous haemodiafiltration (CVVHDF) subgroup (MD 28.60, 95 % CI −3.52, 60.73, P > 0.05) or post-dilution subgroup (MD 13.06, 95 % CI −2.36, 28.48, P > 0.05). However, the results were not confirmed by TSA. A reduced risk of bleeding was found in the regional citrate compared with the systemic heparin group (RR 0.31, 95 % CI 0.19, 0.51, P < 0.01) and TSA provided conclusive evidence. Fewer episodes of heparin-induced thrombocytopoenia (HIT) (RR 0.41, 95 % CI 0.19, 0.87, P = 0.02) and a greater number of episodes of hypocalcaemia (RR 3.96, 95 % CI 1.50, 10.43, P < 0.01) were found in the regional citrate group. However, TSA did not provide conclusive evidence.ConclusionIn adult patients with AKI, there is no difference in mortality between the regional citrate and heparin treated groups. However, regional citrate is more efficacious in prolonging circuit life span and reducing the risk of bleeding and should be recommended as the priority anticoagulant for critically ill patients who require CRRT.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1299-0) contains supplementary material, which is available to authorized users.

The optimal surgical strategy for treatment of patients with synchronous colorectal liver metastases (SCLRM) remains controversial. We conducted a systematic review and metaanalysis of all observational studies to define the safety and efficacy of simultaneous versus delayed resection of the colon and liver. A search for all major databases and relevant journals from inception to April 2012 without restriction on languages or regions was performed. Outcome measures were the primary parameters of postoperative survival, complication, and mortality, as well as other parameters of blood loss, operative time, and length of hospitalization. The test of heterogeneity was performed with the Q statistic. A total of 2,880 patients were included in the meta-analysis. Long-term oncological pooled estimates of overall survival (hazard ratio [HR]: 0.96; 95% confidence interval [CI]: 0.81-1.14; P 5 0.64; I 2 5 0) and recurrence-free survival (HR: 1.04; 95% CI: 0.76-1.43; P 5 0.79; I 2 5 53%) all showed similar outcomes for both simultaneous and delayed resections. A lower incidence of postoperative complication was attributed to the simultaneous group as opposed to that in the delayed group (modified relative ratio [RR] 5 0.77; 95% CI: 0.67-0.89; P 5 0.0002; I 2 5 10%), whereas in terms of mortality within the postoperative 60 days no statistical difference was detected (RR 5 1.12; 95% CI: 0.61-2.08; P 5 0.71; I 2 5 32%). Finally, selection criteria were recommended for SCRLM patients suitable for a simultaneous resection. Conclusion: Simultaneous resection is as efficient as a delayed procedure for long-term survival. There is evidence that in SCRLM patients simultaneous resection is an acceptable and safe option with carefully selected conditions. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion. (HEPATOLOGY 2013;57:2346-2357 C olorectal cancer (CRC) remains the second leading cause of cancer-related death in Western Europe and North America, and there are more than 940,000 new cases annually and nearly 500,000 deaths each year worldwide. [1][2][3] Up to 50% of patients with CRC might have liver metastases during the course of the disease, and 15% to 20% have synchronous colorectal liver metastases (SCRLM) at the time of diagnosis, whereas an additional 20% to 25% develop metachronous hepatic tumors. [4][5][6][7] The presence of liver metastases has an important influence on patient prognosis, and the median survival is 2.3 to 21.3 months for patients in whom the cancer is nonresected. 3,5,[8][9][10] Furthermore, liver resection has been accepted as the only treatment offering the chance for a cure and long-term survival, with 5-year survival rates of 25% to 60% and 10-year survival rates of 22% to 26% reported in the literature. [11][12][13][14][15][16][17][18][19] However, optimal timing of liver surgery for synchronous metastases remains controversial and continues to evolve. 20 Previously, most series reporting on the surgical management ...

These findings strongly support the link between diabetes and increased risk of cancer of biliary tract and its subsites: gallbladder cancer or extrahepatic cholangiocarcinoma, but not cancer of ampulla of Vater.

BackgroundPotential benefits of subglottic secretion suction for preventing ventilator-associated pneumonia (VAP) are not fully understood.MethodsWe searched Cochrane Central, PubMed, and EMBASE up to March 2016 to identify randomized controlled trials (RCTs) that compared subglottic secretion suction versus non-subglottic secretion suction in adults with mechanical ventilation. Meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. The primary outcome was incidence of VAP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the level of evidence.ResultsTwenty RCTs (N = 3544) were identified. Subglottic secretion suction was associated with reduction of VAP incidence in four high quality trials (relative risk (RR) 0.54, 95 % confidence interval (CI) 0.40–0.74; p < 0.00001) and in all trials (RR = 0.55, 95 % CI 0.48– 0.63; p < 0.00001). Sensitivity analyses did not show differences in the pooled results. Additionally, the results of the above-mentioned analyses were confirmed in TSA. GRADE level was high. Subglottic secretion suction significantly reduced incidence of early onset VAP, gram-positive or gram-negative bacteria causing VAP, and duration of mechanical ventilation. It delayed the time-to-onset of VAP. However, no significant differences in late onset VAP, intensive care unit (ICU) mortality, hospital mortality, or ICU length of stay were found.ConclusionsSubglottic secretion suction decreased VAP incidence and duration of mechanical ventilation and delayed VAP onset. However, subglottic secretion suction did not reduce mortality and length of ICU stay. Subglottic secretion suction is recommended for preventing VAP and for reducing ventilation length, especially in the population at high risk of early onset VAP.Trial registrationA protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42015015715); registered on 5 January 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1527-7) contains supplementary material, which is available to authorized users.

Many studies have reported that selenium (Se) has a close relationship with autoimmune thyroiditis (AIT). The therapeutic effect of Se supplementation in AIT treatment remains unclear. The objective of the present study was to determine the efficacy of Se supplementation for the treatment of AIT. A structured literature search was undertaken to identify all randomized controlled trials conducted in patients with AIT receiving Se supplementation or placebo. Nine studies enrolling a total of 787 patients were included. The results showed that Se supplementation with duration 6 months significantly dropped the TPOAb titers but did not decrease the TgAb titers. Patients assigned to Se supplementation for 12-month duration showed significantly lower TPOAb titers and TgAb titers. Patients after Se supplementation had a higher chance to improve the mood or well-being compared with controls. Se supplementation is associated with a significant decrease in TPOAb titers at 6 and 12 months; meanwhile, the TgAb titers can be dropped at 12 months. After Se supplementation treatment, patients had a higher chance to improve the mood without significant adverse events.

On April 25, 2016, the FDA approved cabozantinib (Cabometyx; Exelixis, Inc.) for the treatment of advanced renal cell carcinoma (RCC) in patients who have received prior antiangiogenic therapy. The approval was based on data from one randomized, open-label, multicenter study in which patients with RCC who had received prior antiangiogenic therapy were treated with either cabozantinib 60 mg orally once daily (n = 330) or everolimus 10 mg orally once daily (n = 328). The major efficacy outcome measure was progression-free survival (PFS) as assessed by a blinded independent radiology review committee in the first 375 randomized patients. A statistically significant improvement in PFS was seen, with a median PFS of 7.4 and 3.8 months in the cabozantinib and everolimus arms, respectively [hazard ratio (HR), 0.58; 95% confidence interval (CI), 0.45-0.74; P < 0.0001]. At a second interim analysis, a statistically significant improvement in overall survival (OS) in the intent-to-treat population was also demonstrated, with a median OS of 21.4 and 16.5 months in the cabozantinib and everolimus arms, respectively (HR, 0.66; 95% CI, 0.53-0.83; P = 0.0003). The most common (greater than or equal to 25%) adverse reactions included diarrhea, fatigue, nausea, decreased appetite, palmar-plantar erythrodysesthesia syndrome, hypertension, vomiting, weight loss, and constipation. Clin Cancer Res; 23(2); 330-5. ©2016 AACR.

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BackgroundA long-axis in-plane (LA-IP) approach and a short-axis out-of-plane (SA-OOP) approach are the two main approaches used in ultrasound (US)-guided vascular catheterization. However, the efficacy and safety of these approaches remain controversial. Therefore, we performed this meta-analysis to compare the two techniques in vascular catheterization.Materials and methodsRelevant studies were searched in PubMed, Embase, and the Cochrane Library databases from database inception until August 2017. Randomized controlled trials comparing a long-axis approach with a short-axis approach for US-guided vascular cannulation were selected. The RevMan software was used to analyze the results, and trial sequential analysis (TSA) was further applied to determine whether the currently available evidence was sufficient and conclusive.ResultsEleven studies met the inclusion criteria. Overall, 1,210 patients were included. The total success rate was similar between the SA-OOP and LA-IP approaches for US-guided vascular catheterization (risk ratio [RR], 1.01; 95% CI, 0.99–1.04; P=0.35; I2=48%). In the radial artery (RA; RR, 1.00; 95% CI, 0.96–1.05; P=0.88; I2=49%) and internal jugular vein (IJV; RR, 1.00; 95% CI, 0.98–1.02; P=0.99; I2=0%) subgroups, the total success rate was also similar and was confirmed by the TSA. For populations with subclavian vein (SCV) and axillary vein catheterization, the SA-OOP approach showed a benefit for first-attempt success rate. No significant differences in first-attempt success rate, cannulation times, or complications were found between the two approaches.ConclusionDespite a similar total success rate between the SA-OOP approach and the LA-IP approach when used for RA and IJV catheterization (as confirmed by TSA), further robust well-designed trials are warranted to evaluate other outcomes. There is insufficient evidence to definitively state that the SA-OOP approach was superior to the LA-IP approach when used for SCV and axillary vein catheterization. High-quality trials are needed to confirm or refute this finding.