ObjectiveTo provide an overview of the evidence on prevalence and outcomes of incidental imaging findings. DeSiGNUmbrella review of systematic reviews. Data SOurceSSearches of MEDLINE, EMBASE up to August 2017; screening of references in included papers. eliGibility criteria Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities ("incidentalomas"). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient's symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses. reSultS 20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extracolonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 metaanalyses with I 2 >50%).cONcluSiONS There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions.

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Summary Background Calcineurin‐inhibitor immunosuppressants (tacrolimus and ciclosporin) have been associated with an exposure‐related increase in tumour recurrence following liver transplantation for hepatocellular carcinoma (HCC). Conversely, mechanistic target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) have been suggested to reduce recurrence rates and improve survival in this patient group. Aim To clarify the potential benefit of mTOR‐inhibitors in HCC transplant patients by comparing recurrence and survival outcomes with calcineurin‐inhibitor‐based immunosuppression. Methods A systematic review and meta‐analysis was performed. The inclusion criteria were observational or interventional studies reporting the effect of early‐initiated (<6 months post‐transplant) mTOR‐inhibitor‐based immunosuppression on survival or tumour recurrence in patients transplanted with HCC, compared to a control of calcineurin‐inhibitor‐based therapy. Results Meta‐analysis demonstrated that compared with calcineurin‐inhibitor controls, recurrence‐free‐survival was significantly increased with mTOR‐inhibitor‐based therapy at 1‐year (Risk‐Ratio (RR): 1.09, 95% CI: 1.01‐1.18) and 3‐years (RR: 1.1, 95% CI: 1.01‐1.21) post‐transplant, with a nonsignificant increase at 5‐years (RR: 1.15, 95% CI: 0.99‐1.35). Overall survival was improved at 1‐year (RR: 1.07, 95% CI: 1.02‐1.12), 3‐years (RR: 1.1, 95% CI: 1.02‐1.19), and 5‐years (RR: 1.18, 95% CI: 1.08‐1.29). Recurrence‐rate was lower in the mTOR‐inhibitor arm (RR: 0.67, 95% CI: 0.56‐0.82), with no significant increase in acute rejection (RR: 1.1, 95% CI: 0.94‐1.28). Conclusions mTOR‐inhibitor‐based immunosuppression may be a preferable option in patients transplanted with HCC. It improves recurrence‐free‐survival over at least three years and reduces the recurrence rate compared with standard calcineurin‐inhibitor‐based therapy, with no significant increase in the rate of acute rejection. Future research should clarify the effect in higher vs lower risk cohorts.

IMPORTANCE Atrial fibrillation (AF) affects more than 6 million people in the United States; however, much AF remains undiagnosed. Given that more than 265 million people in the United States own smartphones (>80% of the population), smartphone applications have been proposed for detecting AF, but the accuracy of these applications remains unclear. OBJECTIVE To determine the accuracy of smartphone camera applications that diagnose AF. DATA SOURCES AND STUDY SELECTION MEDLINE and Embase were searched until January 2019 for studies that assessed the accuracy of any smartphone applications that use the smartphone's camera to measure the amplitude and frequency of the user's fingertip pulse to diagnose AF. DATA EXTRACTION AND SYNTHESIS Bivariate random-effects meta-analyses were constructed to synthesize data. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) of Diagnostic Test Accuracy Studies reporting guideline. MAIN OUTCOMES AND MEASURES Sensitivity and specificity were measured with bivariate random-effects meta-analysis. To simulate the use of these applications as a screening tool, the positive predictive value (PPV) and negative predictive value (NPV) for different population groups (ie, age Ն65 years and age Ն65 years with hypertension) were modeled. Lastly, the association of methodological limitations with outcomes were analyzed with sensitivity analyses and metaregressions. RESULTS A total of 10 primary diagnostic accuracy studies, with 3852 participants and 4 applications, were included. The oldest studies were published in 2016 (2 studies [20.0%]), while most studies (4 [40.0%]) were published in 2018. The applications analyzed the pulsewave signal for a mean (range) of 2 (1-5) minutes. The meta-analyzed sensitivity and specificity for all applications combined were 94.2% (95% CI, 92.2%-95.7%) and 95.8% (95% CI, 92.4%-97.7%), respectively. The PPV for smartphone camera applications detecting AF in an asymptomatic population aged 65 years and older was between 19.3% (95% CI, 19.2%-19.4%) and 37.5% (95% CI, 37.4%-37.6%), and the NPV was between 99.8% (95% CI, 99.83%-99.84%) and 99.9% (95% CI, 99.94%-99.95%). The PPV and NPV increased for individuals aged 65 years and older with hypertension (PPV, 20.5% [95% CI, 20.4%-20.6%] to 39.2% [95% CI, 39.1%-39.3%]; NPV, 99.8% [95% CI, 99.8%-99.8%] to 99.9% [95% CI, 99.9%-99.9%]). There were methodological limitations in a number of studies that did not appear to be associated with diagnostic performance, but this could not be definitively excluded given the sparsity of the data. CONCLUSIONS AND RELEVANCE In this study, all smartphone camera applications had relatively high sensitivity and specificity. The modeled NPV was high for all analyses, but the PPV was modest, (continued) Key Points Question What is the overall accuracy of smartphone camera applications that diagnose and screen for atrial fibrillation (AF)? Findings In this meta-analysis of 10 primary diagnostic accuracy studies with 3852 participants, all app...

Background and Aim Owing to wide‐spread use, low‐dose aspirin (LDA) produces a substantial amount of peptic ulcer disease. Current guidelines are ambivalent about the need for Helicobacter pylori eradication to protect against LDA ulcers. This study aimed to determine, through meta‐analysis, if (and by how much) infection alters the baseline risk of peptic ulcers during LDA therapy. Methods Literature screening was performed in MEDLINE and EMBASE from inception to May 2018. Original studies reporting prevalence or incidence of uncomplicated ulcers in LDA users were included. Ulcer endpoints needed to be specified separately, according to H. pylori infection status. Meta‐analysis was performed in MIX 2.0 Pro. Results Ten cross‐sectional studies and seven randomized controlled trials were included (n = 5964). The pooled odds ratios with 95% confidence intervals (CI) for the risk of LDA ulcers in H. pylori‐positive versus H. pylori‐negative individuals were 1.68 (95%CI 1.40–2.02) and 1.65 (95%CI 1.29–2.08) under fixed‐effects and random‐effects models, respectively. Heterogeneity among studies was minimal (I2 = 26.9%). After adjusting for the protective effects of antisecretory drugs, the odds ratios increased to 1.94 (95%CI 1.54–2.46). Conclusion This analysis suggests that H. pylori increases the risk of LDA ulcers by almost 70% in a population where some were taking proton pump inhibitors and/or other acid suppressants. Without antisecretory drugs, the risk almost doubles. Clinically, these findings may support the use of a test‐and‐treat approach to H. pylori in LDA users, particularly those already at higher risk of developing peptic ulcers.