渡部 純

Purpose Spinal nerve injections have traditionally been performed under fluoroscopic (FL) and computed tomography (CT) guidance. Recently, ultrasound (US)-guided procedures have provided an alternative guidance approach that does not expose the patient and operator to radiation. The aim of this study was to compare the efficacy and safety of US-guided spinal nerve injections compared with FL- or CT-guided spinal nerve injections. Methods MEDLINE, Cochrane Library, EMBASE, international clinical trials registry platform (ICTRP) and ClinicalTrials.gov database searches for inclusion until February 2023 were independently performed by two authors using predefined criteria. Randomized controlled trials (RCTs) were included. Primary outcomes were change in pain score (numeric rating scale or visual analogue scale) and major adverse events. Secondary outcomes were procedure time, change in functional disability score and minor adverse events. Meta-analysis was performed using random-effect model. We evaluated the certainty of evidence based on the Grading of Recommendations, Assessment and Development (GRADE) approach. Results Eight RCTs involving 962 patients were included. There might be little to no difference in the mean score of the pain change between the US-guided methods and the FL- or CT-guided injections (standard mean difference -0.06; 95% confidence interval [CI] −0.26 to 0.15). US guidance probably reduced major adverse events (0.7% [3/433] and 6.5% [28/433], respectively), reduced procedure time (mean difference −4.19 min; 95% CI −5.09 to −3.30), and probably reduced minor adverse events (2.1% [9/433] and 4.2% [18/433], respectively) compared with FL or CT guidance. There was probably little to no difference in the change in functional disability score with either method. Conclusion US-guided spinal nerve injections remained effective and reduced adverse events compared with conventional FL- or CT-guided spinal nerve injections. Further RCTs are required to verify our results. Study registration Open Science Forum (Available from: https://osf.io/vt92w/).

Background: The prognostic importance of osteopenia in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatectomy is unclear. The aim of this study was to evaluate the impact of osteopenia on survival in patients with ICC. Methods: A total of 71 patients who underwent hepatectomy at Jichi Medical University between July 2008 and June 2022 were included in this study. Non-contrast computed tomography scan images at the eleventh thoracic vertebra were used to assess bone mineral density. The cutoff value was calculated using a threshold value of 160 Hounsfield units. Overall survival curves were made using the Kaplan–Meier method and the log-rank test was used to evaluate survival. The hazard ratio (HR) and 95% confidence interval (CI) for overall survival were calculated using Cox’s proportional hazard model. Results: In multivariable analysis, osteopenia (HR 3.66, 95%CI 1.16–14.1, p = 0.0258) and the platelet–lymphocyte ratio (HR 6.26, 95%CI 2.27–15.9, p = 0.0008) were significant independent factors associated with overall survival. There were no significant independent prognostic factors for recurrence-free survival. Conclusions: Preoperative osteopenia is significantly associated with postoperative survival in patients with ICC undergoing hepatectomy.

Oxidative stress is known to be associated with the pathophysiology of chronic kidney disease (CKD). Paraoxonase 1 (PON1) is an antioxidant enzyme that has been proposed as a biomarker for CKD. While several studies have reported an association between serum PON1 activity and CKD, consensus based on systematically analyzed data remains necessary. We set out to conduct a meta-analysis of literature on PON1 in CKD. Electronic databases, such as MEDLINE, Embase and CENTRAL, were searched for available studies on PON1 activity in patients with CKD (without dialysis) as published before December 2022. A random-effects meta-analysis was performed. In total, 24 studies (22 studies on paraoxonase and 11 on arylesterase activity) were eligibly identified. Patients with CKD showed a lower activity of paraoxonase (standard mean difference [SMD], −1.72; 95% confidence interval [CI], −2.15 to −1.29) and arylesterase (SMD, −2.60; 95%CI, −3.96 to −1.24) than healthy controls. In the subgroup analyses, paraoxonase activity was lower in chronic kidney failure (CKF), an advanced stage of CKD, than in non-CKF. In summary, PON1 activity is low in patients with CKD, suggesting that the antioxidant defense by PON1 is impaired in CKD. The decrease in enzyme activity is pronounced in advanced CKD showing some variability depending on the substrate employed to measure PON1 activity. Further studies are warranted.

Background: For people who are malnourished and unable to consume food by mouth, nasoenteral feeding tubes are commonly used for the administration of liquid food and drugs. Postpyloric placement is when the tip of the feeding tube is placed beyond the pylorus, in the small intestine. Endoscopic-guided placement of postpyloric feeding tubes is the most common approach. Usually, an endoscopist and two or more medical professionals perform this procedure using a guidewire technique. The position of the tube is then confirmed with fluoroscopy or radiography, which requires moving people undergoing the procedure to the radiology department. Alternatively, electromagnetic-guided placement of postpyloric nasoenteral feeding tubes can be performed by a single trained nurse, at the bedside and with less equipment than endoscopic-guided placement. Hence, electromagnetic-guided placement may represent a promising alternative to endoscopic-guided placement, especially in settings where endoscopy and radiographic facilities are unavailable or difficult to access. Objectives: To assess the efficacy and safety of electromagnetic-guided placement of postpyloric nasoenteral feeding tubes compared to endoscopic-guided placement. Search methods: We searched the Cochrane Library, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and OpenGrey until February 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. We contacted the study authors for missing data. Selection criteria: We included randomised trials comparing electromagnetic-guided placement with endoscopic-guided placement of nasoenteral feeding tubes. We excluded prospective cohort studies, retrospective cohort studies, (nested) case-control studies, cross-sectional studies, and case series or case reports. Data collection and analysis: Two review authors independently assessed the methodological quality of potentially eligible trials and extracted data from the included trials. The primary outcomes were technical success in insertion and aspiration pneumonitis. The secondary outcomes were the time for postpyloric placement of nasoenteral feeding tubes, direct healthcare costs, and adverse events. We performed a random-effects meta-analysis. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs) with 95% CIs for continuous outcomes. We evaluated the certainty of evidence based on the GRADE approach. Main results: We identified four randomised controlled trials with 541 participants which met our inclusion criteria. All trials had methodological limitations, and lack of blinding of participants and investigators was a major source of bias. We had 'some concerns' for the overall risk of bias in all trials. Electromagnetic-guided postpyloric placement of nasoenteral feeding tubes may result in little to no difference in technical success in insertion compared to endoscopic-guided placement (RR 1.09, 95% CI 0.88 to 1.35; I2 = 81%; low-certainty evidence). Electromagnetic-guided placement may result in a difference in the proportion of participants with aspiration pneumonitis compared to endoscopic-guided placement, but these results are unclear (RR 0.24, 95% CI 0.03 to 2.18; I2 = 0%; low-certainty evidence). Electromagnetic-guided placement may result in little to no difference in the time for postpyloric placement of nasoenteral feeding tubes compared to endoscopic-guided placement (MD 4.06 minutes, 95% CI -0.47 to 8.59; I2 = 97%; low-certainty evidence). Electromagnetic-guided placement likely reduces direct healthcare costs compared to endoscopic-guided placement (MD -127.69 US dollars, 95% CI -135.71 to -119.67; moderate-certainty evidence). Electromagnetic-guided placement likely results in little to no difference in adverse events compared with endoscopic-guided placement (RR 0.78, 95% CI 0.41 to 1.49; moderate-certainty evidence). Authors' conclusions: We found low-certainty evidence that electromagnetic-guided placement at the bedside results in little to no difference in technical success in insertion and aspiration pneumonitis, compared to endoscopic-guided placement. The heterogeneity of the healthcare professionals who performed the procedures and the small sample sizes limited our confidence in the evidence. Future research should be based on large studies with well-defined endpoints to potentially elucidate the differences between these two procedures.

BACKGROUND: There is no consensus on the relationship between visceral fat mass and long-term postoperative prognosis in patients with upper gastrointestinal (GI) cancer. OBJECTIVE: : The purpose of this study was to investigate the association of preoperative visceral fat mass with postoperative complications and overall survival (OS) in patients with upper GI cancer. METHODS: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE (Dialog), the World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov and identified observational studies published from inception through July 20, 2022. We conducted a systematic review and random-effects meta-analysis of studies including patients who were surgically treated for upper GI cancer and whose visceral fat mass was assessed on the basis of body composition. We independently assessed the risk of bias and quality of evidence using Quality In Prognosis Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. The primary outcome was OS. Hazard ratios and 95% confidence intervals (CIs) for OS were pooled. RESULTS: Ninety-one studies (N=20583) were included. All studies used computed tomography (CT) to assess the body composition of patients. Twenty-four studies reported the relationship between high visceral fat and postoperative outcomes, and their results were synthesized. Compared with low visceral adipose tissue, high visceral adipose tissue assessed by CT may improve OS (hazard ratio: 0.69; 95%CI: 0.55, 0.87; I2 = 65%; n=3407). The risk of bias for OS in each study was moderate or high. The certainty of evidence for OS was very low because of inconsistency in the forest plot, the moderate or high risk of bias and publication bias. CONCLUSIONS: High visceral fat may be associated with improved OS after radical resection in patients with upper GI cancer. Further studies are needed to confirm these findings and mitigate the risk.

The Surgical Patient Safety System (SURPASS) has been proven to improve patient outcomes. However, few studies have evaluated the details of litigation and its prevention in terms of systemic and diagnostic errors as potentially preventable problems. The present study explored factors associated with accepted claims (surgeon-loss). We retrospectively searched the national Japanese malpractice claims database between 1961 and 2017. Using multivariable logistic regression models, we assessed the association between medical malpractice variables (systemic and diagnostic errors, facility size, time, place, and clinical outcomes) and litigation outcomes (acceptance). We evaluated whether or not the factors associated with litigation could have been prevented with the SURPASS checklist. We identified 339 malpractice claims made against general surgeons. There were 159 (56.3%) accepted claims, and the median compensation paid was 164,381 USD. In multivariable analyses, system (odds ratio, 27.2 95% confidence interval 13.8-53.5) and diagnostic errors (odds ratio 5.3, 95% confidence interval 2.7-10.5) had a significant statistical association with accepted claims. The SURPASS checklist may have prevented 7% and 10% of the accepted claims and systemic errors, respectively. It is unclear what proportion of accepted claims indicated that general surgeon loses should be prevented from performing surgery if the SURPASS checklist were used. In conclusion, systemic and diagnostic errors were associated with accepted claims. Surgical teams should adhere to the SURPASS checklist to enhance patient safety and reduce surgeon risk.

Background and Objectives: Adequate initial fixation of the uncemented acetabular component in total hip arthroplasty is necessary to achieve long-term survival. Although screw fixation contributes to improved cup stability, there is currently no consensus on the use of this method. This study aimed to assess the existing randomized controlled trials (RCTs) on the efficacy and safety of cup fixation in total hip arthroplasty without screws. Materials and Methods: We searched the EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs published before February 2022. Primary outcomes were reoperation, cup migration, and Harris Hip Score. Secondary outcomes were the presence of a radiolucent line in the acetabular region, translation and rotation movement, and polyethylene wear. We conducted meta-analyses using the random-effects models. The revised Cochrane risk-of-bias tool was used to assess the risk of bias for outcomes of interest; the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to summarize the body of evidence. Results: We included six reports from four studies. Total hip arthroplasty without screw fixation to the acetabular cup had little to no effect on reoperation (pooled relative risk, 0.98; 95% confidence interval, 0.14–6.68; I2 = 0%), cup migration (pooled relative risk, 1.72; 95% confidence interval, 0.29–10.33; I2 = 1%), Harris Hip Score (mean difference, 1.19; 95% confidence interval, −1.31–3.70; I2 = 0%), radiolucent line (pooled relative risk, 5.91; 95% confidence interval, 0.32–109.35), translation and rotation of all axes, and polyethylene wear (mean difference, 0.01; 95% confidence interval, −0.01–0.04; I2 = 0%), with very low certainty of evidence on all measures. Conclusions: The efficacy of acetabular cups without screw fixation in total hip arthroplasty remains uncertain, suggesting the need for prudent clinical application. Further large-scale, well-designed studies with low risk of bias are required.

We read the article by Gulacti et al. [1] with great interest, and we appreciate the authors' efforts to determine the analgesic efficacy of transcutaneous electrical nerve stimulation (TENS) for renal colic. However, we would like to point out two concerns. First, the absence of analgesic therapy for the control group in this study may be ethically questionable due to the high degree of patient pain [2]. The efficacy of pharmacotherapy such as NSAIDs, acetaminophen, and opioids as analgesic methods for renal colic is well established [3,4]. We suggest that the participants be randomly assigned into either a control group receiving analgesic pharmacotherapy and sham TENS, an intervention group receiving TENS only, and another intervention group receiving TENS combined with analgesic pharmacotherapy. Second, we would like to caution the readers about interpreting the results becausewe do not knowif themean difference in the Visual Analog Scale (VAS) scores shown in this study is clinically significant. Although there is no established minimally important difference in analgesic therapy for renal colic, we believe it is useful to be aware of minimally important difference and report results [5]. For example, it might be informative to indicate the percentage of patients whose VAS score improved with TENS, referring to the degree of improvement in the VAS scorewith pharmacotherapy for renal colic in previous studies. Some past studies have shown the percentage of patients whose VAS score improved by 50% or more after 30 min [3,4]. However, we suggest that this should be shown in addition to the results of this study to avoid misclassification by dividing the patients into two groups.

In 2018, the Global Leadership Initiative on Malnutrition consortium published global consensus diagnostic criteria for malnutrition and highlighted the association between malnutrition and poor postoperative outcomes in patients with gastrointestinal cancer. The aforementioned criteria consist of phenotypic and etiologic criteria to diagnose malnutrition in individuals who undergo conventional screening to determine the at-risk population. Recent studies have reported the usefulness of prediction of postoperative outcomes using body mass index, weight loss, and reduced muscle mass as phenotypic criteria. Reduced muscle mass is an essential diagnostic criterion for sarcopenia, which is associated with poor outcomes in patients with cancer. The Global Leadership Initiative on Malnutrition criteria define reduced muscle mass as undernutrition. Malnutrition diagnosed based on the Global Leadership Initiative on Malnutrition criteria is an important risk factor for postoperative complications and also an independent poor prognostic factor for long-term outcomes; greater severity of malnutrition is associated with poorer outcomes. The current Global Leadership Initiative on Malnutrition criteria for malnutrition accurately predict outcomes, including postoperative complications and long-term prognosis; however, a revision may be warranted to ensure consistency with the diagnostic criteria for sarcopenia. Patients diagnosed with malnutrition based on the Global Leadership Initiative on Malnutrition criteria should be targeted for nutritional intervention. Further accumulation of evidence is necessary to conclusively establish the role of nutritional interventions in patients with malnutrition to improve postoperative complications and long-term outcomes.

BACKGROUND/PURPOSE: Metal stents (MS) are recommended for preoperative biliary drainage (PBD) in patients with periampullary cancer, but whether MS are superior in terms of re-intervention and direct cost is debatable. This study aimed to compare the effects of MS and PS on the outcomes of patients with periampullary cancer. METHODS: For this random-effects meta-analysis, electronic databases were screened for randomized controlled trials (RCTs) published until January 2022. Subgroup analyses were performed basis on the center type and presence of NAC. RESULTS: In this meta-analysis, seven RCTs (440 participants) were included. MS reduced re-interventions (risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.25-0.72) and direct costs (mean difference = -474 USD, 95% CI = -656 to -292). PBD-related complications (RR = 0.74, 95% CI = 0.32-1.71) and postoperative complications (RR = 0.73, 95% CI = 0.45-1.17) did not differ between MS and PS. Compared PS, MS reduced postoperative complications in high-volume centers (RR = 0.64, 95% CI = 0.49-0.84) and PBD-related complications in patients receiving NAC (RR = 0.29, 95% CI = 0.08-1.08). CONCLUSIONS: Metal stents likely reduces re-interventions and direct costs. Further studies are needed to confirm the effects of MS on the outcomes.

<title>Abstract</title><sec> <title>Purpose</title> Osteopenia typically presents low bone mineral density (BMD) and has recently been reported as a prognostic factor in various cancers. However, the prognostic value of osteopenia in digestive tract cancers remains to be defined. We aimed to review the prognostic value of preoperative osteopenia in patients with digestive cancers. </sec><sec> <title>Methods</title> Cohort studies evaluating the prognostic value of preoperative osteopenia in digestive cancers (colorectal, esophageal, hepatic, bile duct, and pancreatic cancer) were searched using electronic databases and trial registries. The exposure was defined as low BMD estimated by computed tomography at 11^th thoracic vertebra, while comparator was normal BMD. The primary outcomes were overall survival and recurrence-free survival for osteopenia. Random effect meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence. </sec><sec> <title>Results</title> A total of 11 studies (2230 patients) were included. Osteopenia was an independent risk factor for overall survival (hazard ratio [HR] = 2.02, 95% CI = 1.47 to 2.78; <italic>I</italic>² = 74%), along with sarcopenia. Osteopenia also predicted poor recurrence-free survival (HR = 1.96, 95% CI = 1.36 to 2.81; <italic>I</italic>² = 85%). In subgroup analyses, osteopenia predicted prognosis in colorectal, esophageal, hepatic, and bile duct cancers, but not in pancreatic cancer. The certainty of the evidence was low due to inconsistency and publication bias. </sec><sec> <title>Conclusion</title> Osteopenia may be independently associated with poor prognosis in patients with digestive tract cancer. Further studies are needed to establish the relevance of osteopenia in the operative prognosis of these patients. </sec>

<sec><title>Introduction</title>This systematic review investigated the efficacy of a meal sequence, the carbohydrate-later meal pattern (CL), on type 2 diabetes mellitus (T2DM). </sec><sec><title>Research design and methods</title>We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov until April 2020 to perform meta‐analyses using random-effects models. Primary outcomes were hemoglobin A1c (HbA1c) and quality of life. Secondary outcomes were plasma concentrations of glucose, insulin and incretin 120 min after a meal, and any adverse outcomes. The revised Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluation approach were used to assess the quality of individual studies and the body of evidence, respectively. The present study was registered in the UMIN Clinical Trials Registry. </sec><sec><title>Results</title>We included 230 participants in eight trials, including both trials that examined long-term changes (more than 2 months and less than 2 years) and short-term changes (in 2-hour postprandial values). CL resulted in a slight to no difference in HbA1c (mean difference (MD), −0.21% in the intervention group; 95% CI −0.44% to+0.03%), plasma glucose (MD,+4.94 mg/dL; 95% CI −8.34 mg/dL to +18.22 mg/dL), plasma insulin (MD, −3.63 μIU/mL; 95% CI −11.88 μIU/mL to +4.61 μIU/mL), plasma GLP-1 (MD, +0.43 pmol/L; 95% CI −0.69 pmol/L to +1.56 pmol/L), and plasma GIP (MD, −2.02 pmol/L; 95% CI −12.34 pmol/L to +8.31 pmol/L). All of these outcomes were of low-certainty evidence or very low-certainty evidence. None of the trials evaluated quality of life or adverse events. </sec><sec><title>Conclusions</title>There was no evidence for the potential efficacy of recommending CL beyond standard dietary advice on T2DM. </sec><sec><title>Trial registration number</title>UMIN000039979. </sec>

Background Sarcopenia, as assessed by body composition, can affect morbidity and survival in several gastrointestinal cancer. However, the impact of sarcopenia, referring to both quantity and quality of skeletal muscle, in biliary tract cancer (BTC) is debatable. We aimed to investigate the impact of sarcopenia on morbidity and mortality in patients with BTC. Methods Electronic databases and trial registries were searched through July 2021 to perform random-effects meta-analyses. Study selection, data abstraction and quality assessment were independently performed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results Twenty-nine studies (4443 patients) were included; 28 used computed tomography and one used dual-energy X-ray absorptiometry to assess body composition. Eighteen studies reported the impact of pre-operative sarcopenia on postoperative outcomes; namely, sarcopenia increased postoperative complications (risk ratio = 1.23, 95% confidence interval [CI] = 1.07 to 1.41; I2 = 2%), and decreased recurrence-free survival (hazard ratio [HR] = 2.20, 95% CI = 1.75 to 2.75; I2 = 0%) in multivariable analyses. Low muscle quantity (HR = 2.26, 95% CI = 1.75 to 2.92; I2 = 66%) and quality (HR = 1.75, 95% CI = 1.33 to 2.29; I2 = 50%) decreased overall survival in multivariable analyses. The certainty of the evidence was low because of heterogeneity and imprecision. Conclusions In sarcopenia, low muscle quantity and quality by body composition conferred an independent risk of morbidity and mortality in patients with BTC. Further studies are needed to confirm these findings and mitigate risk.

Background/purpose: Previous systematic reviews have shown that radical antegrade modular pancreatosplenectomy (RAMPS) had favorable outcomes including prognosis. However, recent large studies have shown opposite results, thus necessitating clarification of RAMPS efficacy. We aimed to update existing evidence on the clinical outcomes of RAMPS for left-sided pancreatic cancer by comparing them to those of the conventional approach. Methods: Electronic databases and registries were searched until August 2021 to perform random-effect meta-analysis. Methodological quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The protocol was registered at protocols.io (dx.doi.org/10.17504/protocols.io.bxhfpj3n). Results: Thirteen cohort studies (1641 patients) and four ongoing randomized controlled trials (RCTs) were identified. RAMPS increased disease-free survival (HR 0.62, 95% CI = 0.42-0.91), but it had little effect on overall survival (hazard ratio [HR] 0.92, 95% confidence interval [CI] = 0.79-1.09) and recurrence-free survival (HR 0.72, 95% CI = 0.37-1.38) with low certainty of evidence. Conclusion: The meta-analysis of recent studies suggests that RAMPS may have little effect on clinical outcomes. These findings highlight the necessity of further studies, including RCTs to determine the efficacy and subsequent indication of RAMPS in clinical cases.

Postoperative pain is the main reason for delayed recovery after herniorrhaphy. Preoperative glucocorticoid administration may improve postoperative recovery. The present study assessed the efficacy of preoperative glucocorticoids in facilitating recovery after herniorrhaphy. Randomized controlled trials (RCTs) conducted up to January 2021 were searched in electronic databases and trial registries. Meta-analyses were performed using random effects models. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence. Seven RCTs (744 patients) were included in the meta-analysis. Preoperative glucocorticoid administration reduced patients’ pain on postoperative day 0 (standard mean diference [SMD]=− 0.73, 95% confidence interval [CI] − 1.45 to − 0.01; I2=94%). However, there was no marked diference in rescue analgesic use (risk ratio [RR]=− 0.06, 95% CI − 0.28 to − 0.16; I2=0%) or vomiting (RR=0.78, 95% CI 0.50–1.20; I2=30%) between preoperative glucocorticoid administration and control. The certainty of evidence was moderate because of inconsistencies or imprecision. No serious adverse effects were observed. Preoperative glucocorticoid administration reduced pain in patients following herniorrhaphy without increasing the occurrence of adverse events. Further studies will be required to confirm the efficacy of preoperative glucocorticoids.

Acoustic radiation force impulse (ARFI) elastography has been used to diagnose acute pancreatitis (AP). The present study aimed to assess the effectiveness of ARFI elastography in the diagnosis of AP. Studies examining the efficacy of ARFI elastography in AP were selected by searching MEDLINE, EMBASE, CENTRAL, ICTRP, and ClinicalTrial.gov. until September 2021. Meta-analyses were performed using random effects models. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of the evidence. Eight case-control studies (994 patients) were included in the meta-analysis. The ARFI-Virtual Touch Quantification value (or ARFI shear wave propagation velocity) of the AP patient group was 0.83 m/s higher (95% confidence interval [CI]: 0.36-1.3) than that in the control group (95% CI: 1.0-1.28). The sensitivity and specificity of ARFI elastography for diagnosing AP were 98.3% (95% CI: 92.6-96.6%) and 95.5% (95% CI: 87.5-98.5%), respectively. The results showed that physicians could use ARFI elastography to accurately diagnose patients with AP. Additional well-designed studies are necessary to validate the efficacy of ARFI elastography in patients with AP.

Background: Previous systematic reviews have not clarified the effect of postoperative coffee consumption on the incidence of postoperative ileus (POI) and the length of hospital stay (LOS). We aimed to assess its effect on these postoperative outcomes. Methods: Studies evaluating postoperative coffee consumption were searched using electronic databases until September 2021 to perform random-effect meta-analysis. The quality of evidence was assessed using the Cochrane risk-of-bias tool. Caffeinated and decaffeinated coffee were also compared. Results: Thirteen trials (1246 patients) and nine ongoing trials were included. Of the 13 trials, 6 were on colorectal surgery, 5 on caesarean section, and 2 on gynecological surgery. Coffee reduced the time to first defecation (mean difference (MD) −10.1 min; 95% confidence interval (CI) = −14.5 to −5.6), POI (risk ratio 0.42; 95% CI = 0.26 to 0.69); and LOS (MD −1.5; 95% CI = −2.7 to −0.3). This trend was similar in colorectal and gynecological surgeries. Coffee had no adverse effects. There was no difference in POI or LOS between caffeinated and decaffeinated coffee (p > 0.05). The certainty of evidence was low to moderate. Conclusion: This review showed that postoperative coffee consumption, regardless of caffeine content, likely reduces POI and LOS after colorectal and gynecological surgery.

Background: The prediction of at-home deaths has become an important topic in rural areas of Japan with an advanced aging society. However, there are no well-established predictors to explain how these factors influence intention. This study aims to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan. Methods: This is a nationwide cross-sectional survey. A self-administered questionnaire was sent to 493 rural clinics in Japan. The main outcome was the realization of at-home deaths for cancer patients. Results: Among the 264 clinics (54%) that responded to the survey, there were 194 clinics with the realization of at-home death. The use of a clinical pathway (adjusted odds ratio 4.19; 95% confidence interval 1.57–11.19) and the provision of organized palliative care (adjusted odds ratio 19.16; 95% confidence interval 7.56–48.52) were associated with the prediction of at-home death, irrespective of island geography or the number of doctors and nurses. Conclusions: Having a clinical pathway and systematizing palliative care could be important to determine the possibility of at-home deaths for cancer patients in rural clinics in Japan.

INTRODUCTION: There is no consensus regarding the range of immobilization in the conservative treatment of distal radius fractures (DRFs). Therefore, this systematic review and meta-analysis aimed to compare the clinical outcome of patients with DRFs treated conservatively with below- or above-elbow immobilization. MATERIALS AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, two independent reviewers searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform in April 2020; a subsequent update search was conducted in April 2021. We identified all randomised controlled trials comparing two immobilization methods in DRFs. The primary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) or QuickDASH questionnaire scores in the short- and long-term (≤ and >six weeks, respectively) follow-up as well as the treatment failure rate. The secondary outcome measures were radiographic outcome, patient-rated wrist evaluation (PRWE) score, pain score and adverse events. Risk of bias was evaluated using the Cochrane Risk of Bias tool version 2. We used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of evidence. RESULTS: The initial search revealed 1,775 records, and ten studies with 909 participants in total were included. There was no significant difference in DASH score in the short-term follow-up (4.99 lower, 95% confidence interval (CI): 10.45 lower to 0.46 higher; very low certainty) and treatment failure (risk ratio: 0.91, 95% CI: 0.59 to 1.40; low certainty). A clinically irrelevant but significant mean difference (0.83 lower, 95%CI: 1.64 lower to 0.03 lower; low certainty) was found in the DASH score in favour of below-elbow immobilization in the long-term follow-up. The overall risk of bias in DASH scores was high based on the measurement bias. Furthermore, there was no significant difference in secondary outcome measures. CONCLUSION: This meta-analysis did not demonstrate clinically meaningful difference between below- and above-elbow immobilization in terms of DASH score both in the short- and long-term follow-ups. However, overall certainty of evidence was considered very low, based on the very serious risk of bias, inconsistency and imprecision. Hence, there is a need for further higher quality research. TRIAL REGISTRATION NUMBER: UMIN000040134 (4/14/2020).

Oxidative stress is a driving factor in the pathophysiology of chronic obstructive pulmonary disease (COPD). While paraoxonase 1 (PON1) is an antioxidant enzyme and a potential biomarker of this disease, data regarding the status of PON-1 in COPD are inconclusive. In this regard, to shed light on this issue, we performed a meta-analysis of data on PON1 activity in COPD. Electronic databases (MEDLINE, Embase and CENTRAL) were searched for available studies on PON1 activity in patients with stable COPD published before October 2021. A meta-analysis was performed using random-effects models. Twelve studies (12 studies on paraoxonase and three on arylesterase) were identified. Patients with COPD had lower levels of paraoxonase activity (standard mean difference [SMD] −0.77, 95% confidence interval [CI] −1.35 to −0.18) and arylesterase activity (SMD −1.15, 95% CI −1.95 to −0.36) in comparison to healthy controls. In subgroup analyses, paraoxonase activity was lower in patients of studies as consisted of mainly non-severe COPD (SMD −1.42, 95% CI −2.04 to −0.79) and, by contrast, slightly higher in patients of studies including severe COPD (SMD 0.33, 95% CI 0.02 to 0.64) in comparison to healthy controls. Arylesterase activity showed a similar trend. Overall, PON1 activity was lower in patients with COPD, suggesting that PON1-related antioxidant defense is impaired in COPD. Future studies are warranted.

Punch incision is an alternative to elliptical excision for treating epidermal inclusion cysts, but its efficacy has not been systematically reviewed. This study assessed the efficacy and safety of punch incision versus elliptical excision for epidermal inclusion cysts. Randomized controlled trials published through January 2021 that evaluated the performance of punch incision versus elliptical excision on epidermal inclusion cysts were identified through electronic databases and clinical registries. Version 2 of the Cochrane risk-of-bias tool for randomized trials tool was used. Review Manager software was used for the meta-analysis. Two trials (100 participants) were identified. The primary outcomes were recurrence rate (risk ratio, 2.40; 95% confidence interval [CI], 0.37–15.60 [favoring elliptical excision]), mean operative time (mean difference [MD], −5.28; 95% CI, −12.72 to 2.16 [favoring punch incision]), and mean postoperative wound length (MD, −11.67; 95% CI, −20.59 to −2.76 [favoring punch incision]). The evidence was low to moderate due to the small sample size and its considerable heterogeneity. The use of punch incision shortened the mean postoperative wound length and had comparable safety to that of elliptical excision.

Abstract For colonoscopy, bowel preparation, especially that using polyethylene glycol (PEG) or senna, is performed among children with gastrointestinal disorders; however, it is not fully grounded in evidence. This study reviewed via meta-analyses the approaches to bowel preparation for colonoscopy in children. Electronic databases and trial registries were searched until April 2021. Quality assessment was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation method. In total, three randomized controlled trials (318 patients) were identified. PEG was observed as a preferred protocol of bowel preparation compared with senna (risk ratio [RR] 1.35, 95% confidence interval [CI] 1.05-1.74; I2 = 15%). It was less painful than senna (RR 0.62, 95% CI 0.44-0.87; I2 = 0%). No serious adverse events were noted. Overall, the certainty of the evidence was low to moderate. PEG might be a preferred preparation agent for colonoscopy in children. Given the limited data, more studies are recommended.

Recently, underwater endoscopic mucosal resection (UEMR) without submucosal injection was introduced as a new replacement for conventional EMR (CEMR) and was reported to be useful for resecting large colonic polyps. Here, we aimed to assess the efficacy and safety of these two methods by a systematic review and meta-analysis. We comprehensively searched multiple databases until July 2021 to identify randomized controlled trials (RCTs) comparing UEMR with CEMR. The primary outcomes were the proportion of R0 resection and mean procedure time, and the secondary outcomes were the proportion of en bloc resection and all adverse events. Three reviewers independently searched for articles, extracted data, and assessed the risk of bias. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. This study was registered in www.protocols.io (Protocol Integer ID: 40849). We included six RCTs (1,374 polyps). We judged that a meta-analysis was not available, and the data were summarized narratively for the proportion of R0 resection. Regarding procedure time, UEMR likely resulted in a large reduction (mean difference = -64.3 seconds; 95% confidence interval (CI) = -122.5 to -6.0 seconds; I2 = 86%; moderate certainty of evidence). UEMR likely resulted in a large increase in en bloc resection (odds ratio = 1.85; 95% CI = 1.15 to 2.98; I2 = 60%; moderate certainty of evidence). Percentages of adverse events were 0-17% with CEMR and 0-16% with UEMR. In summary, UEMR might have higher efficacy than CEMR in the endoscopic resection of nonpedunculated colorectal polyps, with likely a large reduction in procedure time.