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1.  Magnetic endoscopic imaging vs standard colonoscopy: Meta-analysis of randomized controlled trials 
AIM: To assess the theoretical advantages of magnetic endoscope imaging (MEI) over standard colonoscopies (SCs) and to compare their efficacies.
METHODS: Electronic databases, including PubMed, EMBASE, the Cochrane library and the Science Citation Index, were searched to retrieve relevant trials. In addition, abstracts from papers presented at professional meetings and the reference lists of retrieved articles were reviewed to identify additional studies. The meta-analyses were performed using RevMan 5.1. A random effect model with the Mantel-Haenszel method was used for pooling dichotomous and continuous data. A sensitivity analysis was performed by excluding the trials with a small number of patients and by excluding the trials performed by inexperienced providers.
RESULTS: Eight randomized controlled trials (RCTs), including 2967 patients, were included in the meta-analysis to compare cecal intubation rates and times, sedation dose, abdominal pain scores and the use of ancillary maneuvers between MEI and SC. The overall OR was 1.92 (95%CI: 1.13-3.27, eight RCTs), as indicated by the cecal intubation rate of MEI compared with SC, but MEI did not have any distinct advantage over SC for cecal intubation time (MD = -0.07, 95%CI: -0.16-0.02; three RCTs). MEI did not generally result in lower pain scores. Outcomes were also analyzed for the two subgroups based on the endoscopists’ experience level to evaluate cecal intubation rates. MEI presented better outcomes for non-experienced colonoscopists than experienced colonoscopists.
CONCLUSION: The real-time magnetic imaging system is of benefit in training and educating inexperienced endoscopists and improves the cecal intubation rate for experienced and inexperienced endoscopists.
PMCID: PMC3819558  PMID: 24222966
Colonoscope; Magnetic endoscope imaging; Magnetic; Standard colonoscope; Meta-analysis
2.  Effect of a proprietary intraluminal stiffening wire device on cecal intubation time and rate with used colonoscopes; a randomized, controlled trial 
BMC Research Notes  2013;6:48.
Colonoscopes are designed with balance between flexibility, required to negotiate angulations, and stiffness, required to counteract the propensity for looping in unfixed sections of the colon, which retards advancement of the instrument. Colonoscopy can be challenging with old instruments that have lost native stiffness and become less responsive to torquing.
A new intraluminal stiffening device has become available in two grades of stiffness. However, there is no published evidence of its effectiveness. This randomized, controlled trial was designed to determine the effectiveness of the stiffening wires in improving cecal intubation rate and time following routine application. A secondary analysis determines effectiveness of application only after intractable failure with the unaided colonoscope.
The colonoscope tested was an Olympus CF-100TL, approximately fifteen years old. Patients were randomly assigned to the unaided colonoscope or the standard or firm wire introduced routinely on entry into transverse colon. Each phase of colonoscopy was timed. Failure to advance the colonoscope for 5 minutes (despite usual manipulations to minimize looping) required switching to another intervention according to a prescribed methodology and the originally assigned intervention was recorded as failed.
The study was terminated after accrual of 112 participants (target sample size 480) because the colonoscope required repairs (no damage attributable to stiffening wires) which would have been uneconomical. There were no statistically significant differences between per-protocol cecal intubation rates (81.1, 71.1 and 70.3 percent respectively), a finding which persisted after multiple imputation for a virtual sample size of 480. Similarly, there were no statistically significant differences between per-protocol cecal intubation times (15, 16.2 and 13.9 minutes). However, a statistically significant improvement in cecal intubation rate (from 81.1% to 97.3%, P = 0.0313) was achieved when the wires were applied after intractable failure of the unaided colonoscope in the first intervention group.
Routine application of either stiffening wire does not improve caecal intubation rate nor time compared to the unaided colonoscope. However, application of the stiffening wires after intractable failure of the unaided colonoscope enabled a statistically significant improvement in cecal intubation rate.
Trial Registration Identifier: NCT01115010
PMCID: PMC3571927  PMID: 23379922
Used colonoscope; Old colonoscope; Colonoscope stiffness; Colonoscope stiffening device; Colonoscope stiffening wire
3.  Use of an electromagnetic colonoscope to assess maneuvers associated with cecal intubation 
BMC Gastroenterology  2009;9:24.
Safe and effective colonoscopy is aided by the use of endoscopic techniques and maneuvers (ETM) during the examination including patient repositioning, stiffening of the endoscope and abdominal pressure.
To better understand the use and value of ETM during colonoscopy by using a device that allows real-time imaging of the colonoscope insertion shaft.
The use of ETM during colonoscopy and their success was recorded. Experienced colonoscopists and endoscopy assistants used a commercially available electromagnetic (EM) transmitter and a special adult variable stiffness instrument with 12 embedded sensors to examine 46 patients. In 5 of these a special EM probe passed through the instrument channel of a standard pediatric variable stiffness colonoscope was used instead of the EM colonoscope.
Thirty-nine men and 7 women with a mean age of 64 years (range 33–90) were studied. The cecum was intubated in 93.5% (43/46). The mean time to reach the cecum was 10.6 minutes (range 3–25). ETM were used a total of 174 times in 41 of the patients to assist with cecal intubation. When ETM were required to reach the cecum, and the cecum was intubated, an average of 3.82 ETM/patient was used. While ETM were used most often when the tip of the colonoscope was in the left side of the colon (rectum 5.0%, sigmoid colon 20.7%, descending colon 5.0%, and splenic flexure 11.6%), when the instrument was in the transverse colon (14.8%), hepatic flexure (20.7%) and ascending colon (19.8%) the use of ETM was also required. When the colonoscope tip was in the transverse colon, hepatic flexure and ascending colon, ETM success rates were less (61.1%, 52.0%, and 41.7% respectively) compared to the left colon success rates (rectum 83.3%, sigmoid colon 84.0%, descending colon 100%, and splenic flexure 85.7%).
The EM colonoscope allows imaging of the insertion shaft without fluoroscopy and is a useful device for evaluating the efficacy of ETM. ETM are important tools of the colonoscopist and are used most often in the left colon where they are most effective.
PMCID: PMC2670842  PMID: 19358723
4.  Meta-analysis of the efficacy of pancreatoduodenectomy with extended lymphadenectomy in the treatment of pancreatic cancer 
The purpose of this meta-analysis is to compare the efficacy of pancreatoduodenectomy (PD) with extended lymphadenectomy (PD/ELND) versus standard PD in the treatment of pancreatic cancer, with the hope of providing evidence for clinical practice.
The retrieval of relevant literature published before September 2012 was carried out on PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) by computer. Information was extracted according to Cochrane systematic review methods, and analyzed using software Stata 11.0.
Five prospective randomized controlled trials (RCTs) were included in this meta-analysis of 555 cases (278 in the PD/ELND group and 277 in the standard PD group). The PD/ELND group showed a significantly lower 3-year survival rate (relative risk (RR) = 1.46, 95% confidence interval (CI) 1.03 to approximately 2.06, P = 0.034), prolonged operative time (weighted mean difference WMD = −1.03, 95% CI −1.96 to approximately −0.10, P = 0.029) and higher incidence of postoperative complications (RR = 0.56, 95% CI 0.42 to approximately 0.77, P = 0.000) by comparing with standard PD group. Besides, no significant difference was observed in the 1-year survival rate (RR = 0.87, 95% CI 0.60 to approximately 1.25, P = 0.69), 5-year survival rate (RR = 1.04, 95% CI 0.68 to approximately 1.58, P = 0.854), postoperative mortality (RR = 1.14, 95% CI 0.43 to approximately 3.00, P = 0.789), length of stay (WMD = −0.32, 95% CI −2.57 to approximately 1.94 , P = 0.784) and the amount of blood transfusions (WMD = −0.14, 95% CI −0.36 to approximately 0.08, P = 0.213).
PD/ELND does not have an advantage over standard PD in the survival rate for patients with pancreatic cancer, but does increase operative time and incidences of postoperative complications.
PMCID: PMC4029310  PMID: 24321394
Pancreatic cancer; Pancreatoduodenectomy with extended lymphadenectomy; Standard pancreatoduodenectomy; Meta-analysis
5.  Efficacy and tolerability of oxycodone in moderate-severe cancer-related pain: A meta-analysis of randomized controlled trials 
In order to evaluate the efficacy and tolerability of oxycodone in moderate-severe cancer-related pain, we conducted a systematic review of randomized controlled trials (RCTs). Publications addressing the efficacy and tolerability of oxycodone in moderate-severe cancer-related pain were selected from the Cochrane library, PubMed, Embase and CBM databases. Data were extracted from the studies by two independent reviewers. The meta-analysis was performed by RevMan 5.0.25 and STATA 9.2 software. From these data, odds ratios (ORs) or the standard mean difference (SMD) with 95% confidence intervals (CIs) were calculated. Finally, only seven RCTs were retrieved with a total of 613 cancer patients with moderate-severe pain. The meta-analysis results showed that oxycodone was statistically superior to other strong opioids based on pain intensity scores following intervention [weighted mean difference (WMD), 0.25; 95% CI, 0.05–0.45; P=0.01; WMD, −1.30; 95% CI, −1.55–1.05; P<0.001, respectively]. In addition, there were statistically significant differences between oxycodone and other strong opioids in cancer-related pain on the obvious effective rate and the overall effective rate (OR, 2.03; 95% CI, 1.40–2.95; P=0.0002; OR, 1.94; 95% CI, 1.09–3.44; P=0.02, respectively). Compared with other strong opioids, nausea and constipation occurred significantly less frequently with the use of oxycodone for cancer-related pain (OR=0.52, 95% CI=0.32–0.85, P=0.009; OR= 0.55, 95% CI= 0.35–0.87, P= 0.01; respectively). In conclusion, this meta-analysis confirms that the efficacy and tolerability of oxycodone are superior to those of other strong opioids, including morphine sulfate, codeine and tramadol, supporting its use as an opioid for cancer-related pain.
PMCID: PMC3439087  PMID: 22970030
oxycodone; cancer-related pain; randomized controlled trial; meta-analysis
6.  The safety and efficacy of daptomycin versus other antibiotics for skin and soft-tissue infections: a meta-analysis of randomised controlled trials 
BMJ Open  2014;4(6):e004744.
Daptomycin, a cyclic lipopeptide that exhibits rapid, concentration-dependent bactericidal activity in vitro against a broad spectrum of Gram-positive pathogens, has now, since 2003, been approved in more than 70 countries and regions to treat skin and soft-tissue infections (SSTIs). The purpose of this meta-analysis was to compare the safety and efficacy of daptomycin with other antibiotics, especially with vancomycin which has long been considered the standard therapy for complicated SSTIs.
Meta-analysis of randomised controlled trials (RCTs).
Data sources
We thoroughly searched PubMed, EMBASE, Cochrane Central to identify relevant RCTs. Six RCTs with a total of 1710 patients were included in this meta-analysis.
The results demonstrated that the efficacy of daptomycin was at par with or maybe better than other first-line antibiotics for treating SSTIs as shown by the OR for clinical success (OR=1.05, 95% CI 0.84 to 1.31, p=0.65, I2=0%); daptomycin versus vancomycin subgroup (OR=1.19, 95% CI 0.77 to 1.83, p=0.43, I2=0%); overall microbiological success (OR=1.05, 95% CI 0.61 to 1.79, p=0.86, I2=42%); microbiological success of daptomycin versus comparators for Staphylococcus aureus (SA, OR=1.05, 95% CI 0.61 to 2.60, p=0.53, I2=47%), for methicillin-resistant S. aureus (OR=0.90, 95% CI 0.77 to 1.06, p=0.20, I2=56%). However, daptomycin tended to have a similar treatment-related adverse events (AEs) incidence in comparison with other antibiotics (OR=1.06, 95% CI 0.71 to 1.59, p=0.76, I2=41%). The trend showed that daptomycin might cause less discontinuation due to AEs and death compared with other first-line antibiotics (OR=0.71, 95% CI 0.46 to 1.10, p=0.12, I2=11%). Significantly more patients in the daptomyicn group had creatine phosphokinase elevation than those in the control group; however, it could be reversed when the therapy ended (OR=1.95, 95% CI 1.04 to 3.65, p=0.04, I2=0).
This meta-analysis demonstrated that the safety and efficacy of daptomycin was not inferior to that of other first-line drugs, and daptomycin tended to exhibit superior efficacy when compared with vancomycin or with comparators for SA infections; nevertheless, more high-quality RCTs are needed to draw a more credible conclusion.
PMCID: PMC4078778  PMID: 24961714
7.  Minimally Invasive Midvastus versus Standard Parapatellar Approach in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials 
PLoS ONE  2014;9(5):e95311.
Minimally invasive midvastus approach (mini-midvastus) has been widely used in total knee arthroplasty (TKA). However, the clinical effects still remains controversial. This meta-analysis was based on randomized controlled trials (RCTs) aiming to quantitatively analyze the clinical efficacy of mini-midvastus versus standard parapatellar approach in TKA.
This meta-analysis was performed according to the PRISMA guidelines. A literature search for the eligible RCTs was carried out in the databases of PubMed, the Cochrane library, EMBASE and Web of Science. Two independent reviewers independently completed the study selection, data extraction, and the assessment of methodological quality. Meta-analysis was conducted by the RevMan 5.2 software.
A total of 18 RCTs (937 patients with 1093 TKAs) published from 2007 to 2013 were included. The meta-analysis suggested that the mini-midvastus approach significantly improved knee range of motion (ROM) and decreased visual analog score (VAS) at postoperative 1–2 weeks (p<0.05), and there were no statistical differences in terms of knee society score (KSS) (6 weeks to 1 year), VAS (6 weeks to 6 months), ROM (6 weeks to 6 months), lateral retinacular release, blood loss, straight leg raise, hospital stay and postoperative complications between the mini-midvastus and standard parapatellar approach (p>0.05). However, the operative time was significantly longer when performing the mini-midvastus group than the parapartellar approach (p<0.05).
This meta-analysis found that compared with the standard parapatellar approach, the mini-midvastus approach had early advantages in the VAS and ROM, but had the disadvantage in the operative time.
Level of Evidence
Therapeutic study Level I.
PMCID: PMC4028179  PMID: 24845859
8.  Surgical treatment for primary angle closure-glaucoma: a Meta analysis 
To evaluate the efficacy and safety of trabeculectomy, phacotrabeculectomy plus intraocular lens implantation(phacotrab+IOL group) and phacoemulsification with IOL(phaco+IOL) in primary angle-closure glaucoma(PACG).
It was a systematic review and meta-analysis, randomized controlled trials(RCT) and clinical controlled trials(CCT) were collected through electronic searches of the Cochrane Library, PubMed, EMbase, Wanfang Database online, Chinese journal Full-text Database, Chinese Scientific Journals Full-text Database (from the date of building the database to October 2010) We also checked the bibliographies of retrieved articles. All the related data that matched our standards were abstracted. The quality of included trials was evaluated according to the Dutch Cochrane Centre. RevMan 5.0 software was used for Meta-analysis.
A total of 5 RCT and 11 CCT involving 1495 eyes were included. The results of meta-analysis showed that phacotrab+IOL group was superior than trabeculectomy(trab group) (MD -3.93,95%CI [-7.31, -0.54]) which was also superior than phaco+IOL group(MD 0.52,95%CI [0.10, 0.95]) in decreasing Intraocular Pressure(IOP). Phacotrab group(MD -1.45,95%CI [-1.68, -1.22])and phaco group (MD-1.12,95%CI [-1.87, -0.37])are both deeper than trab group in the anterior chamber depth. In increasing the coefficient of outflow facility of aqueous humor(C values) there was no statistical difference in the three groups. And there was no statistical difference between phacotrab groups and phaco groups in visual acuity but phacotrab group was superior than phaco group (MD 1.07, 95%CI [0.73, 1.40])in the use of IOP-lowering drugs. There was no statistical difference among three groups.
Current evidence suggests that phacotrab+ IOL group was superior than trab group which was also superior than phaco+IOL group in decreasing IOP. Phacotrab group and phaco group are both deeper than trab group in the anterior chamber depth. Phacotrab group was superior than phaco group in the use of IOP-lowering drugs.
PMCID: PMC3340819  PMID: 22553649
trabeculectomy; phacoemulsification; phacotrabeculectomy; primary angle-closure glaucoma; meta-analysis
9.  The efficacy of dapagliflozin combined with hypoglycaemic drugs in treating type 2 diabetes mellitus: meta-analysis of randomised controlled trials 
BMJ Open  2014;4(4):e004619.
This meta-analysis aimed to evaluate whether dapagliflozin is synergistic with other antidiabetic drugs without body weight gain.
Randomised controlled trial (RCT) reports were retrieved from PubMed, Cochrane Library, EMBASE,, Google Scholar and Google. Eligible RCTs were selected according to the criteria (including types of participants, intervention, outcomes) and assessed by the Cochrane risk of bias tool and GRADEpro software for evidential quality. Meta-analysis on the eligible RCTs was performed with the random effects model. The RCTs of low-quality and interim stages were excluded for further sensitivity analysis. Meta-regression was conducted on the follow-up durations. Publication bias was evaluated with funnel plots and the Egger's regression test and adjusted using the trim-and-fill procedure. Heterogeneity was assessed with the I2 statistics.
Adult patients with type 2 diabetes mellitus (T2DM).
Dapagliflozin combined with conventional antidiabetic drugs.
Primary and secondary outcome measures
Glycaemic level (measured by glycosylated haemoglobin (HbA1c) and fasting plasma glucose (FPG)) and body weight.
12 RCTs were eligible for quantitative synthesis and meta-analysis. The overall effect size of HbA1c calculated from mean difference was −0.52% (Z=−13.56, p<0.001) with 95% CI (−0.60 to −0.45). The effect size of FPG was −1.13 mmol/L (Z=−11.12, p<0.001) with 95% CI (−1.33 to −0.93). The effect size of body weight was −2.10 kg (Z=−18.77, p<0.001) with 95% CI (−2.32 to −1.88). Exclusions of low quality and interim RCTs changed the overall mean differences respectively to −0.56%, −1.11 mmol/L, 2.23 kg and −0.50%, −1.08 mmol/L, −2.08 kg. The sensitivity analysis indicated good robustness of the meta-analysis on HbA1c, FPG and body weight.
The meta-analysis showed that dapagliflozin as an add-on drug to conventional antidiabetic drugs improved the glycaemic control in T2DM participants without significant body weight gain.
Trial registration number
PMCID: PMC3987716  PMID: 24710132
Dapagliflozin; type 2 diabetes mellitus; meta-analysis
10.  Single Incision versus Conventional Laparoscopic Cholecystectomy Outcomes: A Meta-Analysis of Randomized Controlled Trials 
PLoS ONE  2013;8(10):e76530.
Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.
Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).
25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.
SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.
PMCID: PMC3788730  PMID: 24098522
11.  A Randomized Controlled Trial of Comparison on Time and Rate of Cecal and Termianl Ileal Intubation according to Adult-Colonoscope Length: Intermediate versus Long 
For a complete colonoscopic examination, a high intubation rate and a short intubation time have been demanded to colonoscopists, if possible. The aim of the present study was to compare these examination parameters, intubation time and rate, according to the length of colonoscope. A total of 507 healthy Korean subjects were randomly assigned into two groups: intermediate length adult-colonoscope (n=254) and long length adult-colonoscope (n=253). There were significant differences in cecal intubation time and in terminal ileal intubation rate according to the length of the colonoscope. Time-to-cecal intubation was shorter for the intermediate-scope group than for the long-scope group (234.2 ± 115.0 sec vs 280.7 ± 135.0 sec, P < 0.001). However, the success rate of terminal ileal intubation was higher in the long-scope group than in the intermediate-scope group (95.3% vs 84.3%, P < 0.001). There were no significant differences in other colonoscopic parameters between the two groups. The intermediate length adult-colonoscope decreased the time to reach the cecum, whereas the long-scope showed a success rate of terminal ileal intubation. These findings suggest that it is reasonable to prepare and use these two types of colonoscope appropriate to the needs of the patient and examination, instead of employing only one type of colonoscope.
PMCID: PMC3890483  PMID: 24431912
Colonoscopy; Intubation Time; Intubation Rate; Colonoscope Length
12.  Retrospective analysis showing the water method increased adenoma detection rate — a hypothesis generating observation 
A water method developed to attenuate discomfort during colonoscopy enhanced cecal intubation in unsedated patients. Serendipitously a numerically increased adenoma detection rate (ADR) was noted.
To explore databases of sedated patients examined by the air and water methods to identify hypothesis-generating findings. Design: Retrospective analysis. Setting: VA endoscopy center. Patients: creening colonoscopy. Interventions: From 1/2000–6/2006 the air method was used - judicious air insufflation to permit visualization of the lumen to aid colonoscope insertion and water spray for washing mucosal surfaces. From 6/2006–11/2009 the water method was adopted - warm water infusion in lieu of air insufflation and suction removal of residual air to aid colonoscope insertion. During colonoscope withdrawal adequate air was insufflated to distend the colonic lumen for inspection, biopsy and polypectomy in a similar fashion in both periods. Main outcome measurements: ADR.
The air (n=683) vs. water (n=495) method comparisons revealed significant differences in overall ADR 26.8% (183 of 683) vs. 34.9% (173 of 495) and ADR of adenomas >9 mm, 7.2% vs. 13.7%, respectively (both P<0.05, Fisher's exact test). Limitations: Non-randomized data susceptible to bias by unmeasured parameters unrelated to the methods.
Confirmation of the serendipitous observation of an impact of the water method on ADR provides impetus to call for randomized controlled trials to test hypotheses related to the water method as an approach to improving adenoma detection. Because of recent concerns over missed lesions during colonoscopy, the provocative hypothesis-generating observations warrant presentation.
PMCID: PMC3109466  PMID: 21686105
colorectal cancer screening; optical colonoscopy; water method; adenoma detection
13.  Does hyoscine butylbromide really improve polyp detection during colonoscopy? A meta-analysis of randomized controlled trials 
AIM: To investigate the benefits of hyoscine butylbromide in polyp detection during colonoscopy by a meta-analysis of available randomized controlled trials (RCTs).
METHODS: Databases, including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index up to September 2013, were searched. The primary outcome was polyp detection rate, and the secondary outcome was adenoma detection rate. The meta-analysis was performed using the free software Review Manager. Differences observed between the treated and the control groups were expressed as odds ratio (OR) with a 95% confidence interval (CI). A fixed-effects model was used to pool data when statistical heterogeneity was absent. If statistical heterogeneity was present (P < 0.05), a random-effects model was used.
RESULTS: The initial search identified nine articles. After screening, five RCTs with a total of 1998 patients were included in this meta-analysis. Of the five studies, all described a comparison of baseline patient characteristics and showed that there was no statistically significant difference between the two groups. Among the 1998 patients, 1006 received hyoscine butylbromide and 992 were allocated to the control group, and the polyp detection rate was reported. There were no significant differences between the treated and the control group (OR = 1.09, 95%CI: 0.91-1.31, P = 0.33). Four RCTs included 1882 patients, of whom 948 received hyoscine butylbromide, and the adenoma detection rate was reported. There were no significant differences between the treated and the control group (OR = 1.13, 95%CI: 0.92-1.38, P = 0.24).
CONCLUSION: The use of hyoscine butylbromide did not significantly improve the polyp detection rate during colonoscopy.
PMCID: PMC4051948  PMID: 24944499
Hyoscine butylbromide; Polyp detection; Adenoma detection; Colonoscopy
14.  Probiotic supplementation decreases intestinal transit time: Meta-analysis of randomized controlled trials 
AIM: To determine the efficacy of probiotic supplementation on intestinal transit time (ITT) and to identify factors that influence these outcomes.
METHODS: A systematic review of randomized controlled trials (RCTs) of probiotic supplementation that measured ITT in adults was conducted by searching MEDLINE and EMBASE using relevant key word combinations. Main search limits included RCTs of probiotic supplementation in healthy or constipated adults that measured ITT. Study quality was assessed using the Jadad scale. A random effects meta-analysis was performed with standardized mean difference (SMD) of ITT between probiotic and control groups as the primary outcome. Meta-regression and subgroup analyses were conducted to examine the impact of moderator variables on ITT SMD.
RESULTS: A total of 11 clinical trials with 13 treatment effects representing 464 subjects were included in this analysis. Probiotic supplementation was associated with decreased ITT in relation to controls, with an SMD of 0.40 (95%CI: 0.20-0.59, P < 0.001). Constipation (r2 = 39%, P = 0.01), higher mean age (r2 = 27%, P = 0.03), and higher percentage of female subjects (r2 = 23%, P < 0.05) were predictive of decreased ITT with probiotics in meta-regression. Subgroup analyses demonstrated statistically greater reductions in ITT with probiotics in subjects with vs without constipation and in older vs younger subjects [both SMD: 0.59 (95%CI: 0.39-0.79) vs 0.17 (95%CI: -0.08-0.42), P = 0.01]. Medium to large treatment effects were identified with Bifidobacterium Lactis (B. lactis) HN019 (SMD: 0.72, 95%CI: 0.27-1.18, P < 0.01) and B. lactis DN-173 010 (SMD: 0.54, 95%CI: 0.15-0.94, P < 0.01) while other single strains and combination products yielded small treatment effects.
CONCLUSION: Overall, short-term probiotic supplementation decreases ITT with consistently greater treatment effects identified in constipated or older adults and with certain probiotic strains.
PMCID: PMC3732843  PMID: 23922468
Constipation; Gastrointestinal; Intestinal transit time; Meta-analysis; Probiotics
15.  Retrograde-viewing device improves adenoma detection rate in colonoscopies for surveillance and diagnostic workup 
AIM: To determine which patients might benefit most from retrograde viewing during colonoscopy through subset analysis of randomized, controlled trial data.
METHODS: The Third Eye® Retroscope® Randomized Clinical Evaluation (TERRACE) was a randomized, controlled, multicenter trial designed to evaluate the efficacy of a retrograde-viewing auxiliary imaging device that is used during colonoscopy to provide a second video image which allows viewing of areas on the proximal aspect of haustral folds and flexures that are difficult to see with the colonoscope’s forward view. We performed a post-hoc analysis of the TERRACE data to determine whether certain subsets of the patient population would gain more benefit than others from use of the device. Subjects were patients scheduled for colonoscopy for screening, surveillance or diagnostic workup, and each underwent same-day tandem examinations with standard colonoscopy (SC) and Third Eye colonoscopy (TEC), randomized to SC followed by TEC or vice versa.
RESULTS: Indication for colonoscopy was screening in 176/345 subjects (51.0%), surveillance after previous polypectomy in 87 (25.2%) and diagnostic workup in 82 (23.8%). In 4 subjects no indication was specified. Previously reported overall results had shown a net additional adenoma detection rate (ADR) with TEC of 23.2% compared to SC. Relative risk (RR) of missing adenomas with SC vs TEC as the initial procedure was 1.92 (P = 0.029). Post-hoc subset analysis shows additional ADRs for TEC compared to SC were 4.4% for screening, 35.7% for surveillance, 55.4% for diagnostic and 40.7% for surveillance and diagnostic combined. The RR of missing adenomas with SC vs TEC was 1.11 (P = 0.815) for screening, 3.15 (P = 0.014) for surveillance, 8.64 (P = 0.039) for diagnostic and 3.34 (P = 0.003) for surveillance and diagnostic combined. Although a multivariate Poisson regression suggested gender as a possibly significant factor, subset analysis showed that the difference between genders was not statistically significant. Age, bowel prep quality and withdrawal time did not significantly affect the RR of missing adenomas with SC vs TEC. Mean sizes of adenomas detected with TEC and SC were similar at 0.59 cm and 0.56 cm, respectively (P = NS).
CONCLUSION: TEC allows detection of significantly more adenomas compared to SC in patients undergoing surveillance or diagnostic workup, but not in screening patients ( Identifier: NCT01044732).
PMCID: PMC3396192  PMID: 22807609
Colonoscopy; Colorectal cancer; Adenomas; Miss rates; Retrograde-viewing
16.  Pre-emptive small dose of fentanyl suppresses fentanyl-induced cough: a meta-analysis of randomized controlled trials 
Fentanyl-induced cough (FIC) should be effectively prevented in patients requiring stable induction of general anesthesia. We reviewed available randomized-controlled trials (RCTs) that focused on the pre-emptive fentanyl to prevent FIC, and preformed this meta-analysis to clarify the efficacy and to recommend a specific application. The PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Chinese BioMedical Literature Database were searched for relevant RCTs without restriction on the year or language of the publications. All of the published RCTs that assessed the efficacy of pre-emptive fentanyl on preventing FIC were selected. A total of seven studies were identified for inclusion. Meta-analysis showed that a priming fentanyl dose of 0.5 μg/kg decreased the FIC incidence (RR = 0.29, 95% CI: 0.17-0.49) and severity (WMD = -0.46, 95% CI -0.70 - -0.23) of FIC; however, a priming fentanyl dose of 1.0 μg/kg (RR = 0.26, 95% CI 0.04-1.70; WMD = -0.60, 95% CI -1.33-0.14) or 1.5 μg/kg (RR = 0.94; 95% CI: 0.77-1.15; WMD = -0.08, 95% CI -0.33-0.17) had no effect on FIC. Our meta-analysis demonstrated that pre-emptive low dose of fentanyl could effectively prevent FIC, and the dose of 0.5 μg/kg was recommended.
PMCID: PMC4057830  PMID: 24955151
Pre-emptive fentanyl; fentanyl induced cough; anesthesia; meta-analysis
17.  High-dose vs low-dose proton pump inhibitors for upper gastrointestinal bleeding: A meta-analysis 
AIM: To evaluate the efficacy of high-dose proton pump inhibitors (PPIs) vs low-dose PPIs for patients with upper gastrointestinal bleeding.
METHODS: PubMed, Embase, the Cochrane Library, and Web of Science were searched to identify relevant randomized controlled trials (RCTs). Eligible trials were RCTs that compared high-dose PPI with low-dose PPI following endoscopic hemostasis. The primary endpoint was rebleeding; secondary endpoints were patient numbers that needed surgery, and mortality. The meta-analysis was performed with a fixed effects model or random effects model.
RESULTS: Nine eligible RCTs including 1342 patients were retrieved. The results showed that high-dose intravenous PPI was not superior to low-dose intravenous PPI in reducing rebleeding [odds ratio (OR) = 1.091, 95% confidential interval (CI): 0.777-1.532], need for surgery (OR = 1.522, 95% CI: 0.643-3.605) and mortality (OR = 1.022, 95% CI: 0.476-2.196). Subgroup analysis according to different region revealed no difference in rebleeding rate between Asian patients (OR = 0.831, 95% CI, 0.467-1.480) and European patients (OR = 1.263, 95% CI: 0.827-1.929).
CONCLUSION: Low-dose intravenous PPI can achieve the same efficacy as high-dose PPI following endoscopic hemostasis.
PMCID: PMC2877188  PMID: 20503458
Meta-analysis; High-dose; Low-dose; Proton pump inhibitors; Gastrointestinal bleeding
18.  Comparison of Treatment Effect Estimates for Pharmacological Randomized Controlled Trials Enrolling Older Adults Only and Those including Adults: A Meta-Epidemiological Study 
PLoS ONE  2013;8(5):e63677.
Older adults are underrepresented in clinical research. To assess therapeutic efficacy in older patients, some randomized controlled trials (RCTs) include older adults only.
To compare treatment effects between RCTs including older adults only (elderly RCTs) and RCTs including all adults (adult RCTs) by a meta-epidemiological approach.
All systematic reviews published in the Cochrane Library (Issue 4, 2011) were screened. Eligible studies were meta-analyses of binary outcomes of pharmacologic treatment including at least one elderly RCT and at least one adult RCT. For each meta-analysis, we compared summary odds ratios for elderly RCTs and adult RCTs by calculating a ratio of odds ratios (ROR). A summary ROR was estimated across all meta-analyses.
We selected 55 meta-analyses including 524 RCTs (17% elderly RCTs). The treatment effects differed beyond that expected by chance for 7 (13%) meta-analyses, showing more favourable treatment effects in elderly RCTs in 5 cases and in adult RCTs in 2 cases. The summary ROR was 0.91 (95% CI, 0.77–1.08, p = 0.28), with substantial heterogeneity (I2 = 51% and τ2 = 0.14). Sensitivity and subgroup analyses by type-of-age RCT (elderly RCTs vs RCTs excluding older adults and vs RCTs of mixed-age adults), type of outcome (mortality or other) and type of comparator (placebo or active drug) yielded similar results.
The efficacy of pharmacologic treatments did not significantly differ, on average, between RCTs including older adults only and RCTs of all adults. However, clinically important discrepancies may occur and should be considered when generalizing evidence from all adults to older adults.
PMCID: PMC3665786  PMID: 23723992
19.  Effect of Flexible Sigmoidoscopy-Based Screening on Incidence and Mortality of Colorectal Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials 
PLoS Medicine  2012;9(12):e1001352.
A systematic review and meta-analysis of randomized trials conducted by B. Joseph Elmunzer and colleagues reports that that flexible sigmoidoscopy-based screening reduces the incidence of colorectal cancer in average-risk patients, as compared to usual care or no screening.
Randomized controlled trials (RCTs) have yielded varying estimates of the benefit of flexible sigmoidoscopy (FS) screening for colorectal cancer (CRC). Our objective was to more precisely estimate the effect of FS-based screening on the incidence and mortality of CRC by performing a meta-analysis of published RCTs.
Methods and Findings
Medline and Embase databases were searched for eligible articles published between 1966 and 28 May 2012. After screening 3,319 citations and 29 potentially relevant articles, two reviewers identified five RCTs evaluating the effect of FS screening on the incidence and mortality of CRC. The reviewers independently extracted relevant data; discrepancies were resolved by consensus. The quality of included studies was assessed using criteria set out by the Evidence-Based Gastroenterology Steering Group. Random effects meta-analysis was performed.
The five RCTs meeting eligibility criteria were determined to be of high methodologic quality and enrolled 416,159 total subjects. Four European studies compared FS to no screening and one study from the United States compared FS to usual care. By intention to treat analysis, FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73–0.91, p<0.001, number needed to screen [NNS] to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59–0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (relative risk [RR] 0.72, 95% CI 0.65–0.80, p<0.001, NNS = 850). The efficacy estimate, the amount of benefit for those who actually adhered to the recommended treatment, suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001).
Limitations of this meta-analysis include heterogeneity in the design of the included trials, absence of studies from Africa, Asia, or South America, and lack of studies comparing FS with colonoscopy or stool-based testing.
This meta-analysis of randomized controlled trials demonstrates that FS-based screening significantly reduces the incidence and mortality of colorectal cancer in average-risk patients.
Please see later in the article for the Editors' Summary
Editor's Summary
Colorectal cancer (CRC) is the second leading cause of cancer-related death in the United States. Regular CRC screening has been shown to reduce the risk of dying from CRC by 16%, and CRC screening can identify early stage cancers in otherwise healthy people, which allows for early treatment and management of the disease. Screening for colorectal cancer is frequently performed using a flexible sigmoidoscopy (FS), which is a thin, flexible tube with a tiny camera and light on the end, allowing a doctor to look at the inside wall of the bowel and remove any small growths or polyps. Although screening may detect early cancers, the life-saving and health benefits of screening are uncertain because the polyp may not necessarily progress. This could lead to anxiety and unnecessary interventions and treatments amongst those screened. Randomized controlled trials (RCTs) are needed to determine all of the risks involved in cancer screenings, however the guidelines that recommend FS-based screening do not rely upon RCT data. Recently, the results of four large-scale RCTs evaluating FS screening for CRC have been published. The conflicting results with respect to the incidence and mortality of CRC in these studies have called into question the effectiveness of endoscopic screening.
Why Was This Study Done?
The results of RCTs measuring the risks and outcomes of CRC screening have shown varying estimates of the benefits of using FS screening. If better estimates of the risks and benefits of FS screening are developed, then the current CRC screening guidelines may be updated to reflect this new information. In this study, the authors show the results of a meta-analysis of published RCTs, which more precisely estimates the effects of FS-based screening on the incidence and mortality of colorectal cancer.
What Did the Researchers Do and Find?
The researchers used the Medline and Embase databases to find relevant studies from 1966 to May 28, 2012. After screening 3,319 citations and 29 potentially relevant articles, five RCTs of high methodologic quality and 416,159 total subjects evaluating the effect of FS screening on the incidence and mortality of CRC were identified. The data were extracted and random effects meta-analysis was performed. The meta-analysis revealed that FS-based screening was associated with an 18% relative risk reduction in the incidence of CRC (0.82, 95% CI 0.73–0.91, p<0.001, number needed to screen (NNS) to prevent one case of CRC = 361), a 33% reduction in the incidence of left-sided CRC (RR 0.67, 95% CI 0.59–0.76, p<0.001, NNS = 332), and a 28% reduction in the mortality of CRC (RR 0.72, 95% CI 0.65–0.80, p<0.001, NNS = 850). The amount of benefit for those who adhered to the recommended treatment suggested that FS screening reduced CRC incidence by 32% (p<0.001), and CRC-related mortality by 50% (p<0.001).
What Do These Findings Mean?
This meta-analysis of RCTs evaluating the effect of FS on CRC incidence and mortality demonstrates that a FS-based strategy for screening is very effective in reducing the incidence and mortality of CRC in patients. The current recommendations for endoscopic screening are based on observational studies, which may not accurately reflect the effect of FS-based screening on the incidence and mortality of CRC. Here, the authors performed a systematic review and meta-analysis of five recent RCTs to better estimate the true effect of FS-based screening on the incidence and mortality of CRC. Thus, the results of this meta-analysis may affect health policy, and directly impact patients and clinicians.
Additional Information
Please access these Web sites via the online version of this summary at
Cancer research UK provides comprehensive information about screening for colorectal cancers as does the UK National Screening Committee
PubMed Health has general information about colon cancer
The National Cancer Institute also has comprehensive resources on colorectal cancer and treatment
The Mayo Clinic provides an overview of all aspects of colon cancer
PMCID: PMC3514315  PMID: 23226108
20.  Effect of green tea supplementation on blood pressure among overweight and obese adults: a protocol for a systematic review 
BMJ Open  2014;4(4):e004971.
Emerging randomised controlled trials (RCTs) exploring the effect of green tea (GT) supplementation or GT extract (GTE) on blood pressure (BP) among overweight and obese adults yielded inconclusive results. We aim to conduct a systematic review to summarise the evidence of RCTs until now, to clarify the efficacy of GT supplementation or GTE in BP in overweight and obese populations.
Methods and analysis
The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and will be searched to retrieve potential RCTs. Unpublished studies will be identified by searching the abstract books or websites of the three major conference proceedings: the International Society of Hypertension, the Nutrition & Health Conference and the World Congress of Nutrition and Health. A random-effects meta-analysis will be performed to pool the mean difference for the change in BP from baseline (ie, postintervention BP minus baseline BP) between intervention groups and placebo groups of the included studies, presenting the pooled results with 95% CIs. Subgroups analyses will be conducted according to different doses of GT or GTE, trial duration, geographic regions, overweight versus obese participants, and participants with versus without change in body weight after intervention. Sensitivity analysis will be performed by excluding studies classified as having a high risk of bias, applying a fixed-effects model, using the postintervention BP for analyses and excluding trials with non-study cointerventions.
Ethics and dissemination
This systematic review will be published in a peer-reviewed journal. It will be disseminated electronically and in print. Summarising the RCT evidence to clarify the efficacy in BP among overweight and obese adults will aid in making the dietary recommendation of GT and improving the clinical management of hypertension.
Trial registration number
PROSPERO CRD42014007273.
PMCID: PMC3996813  PMID: 24742977
green tea; blood pressure; overweight; obese; systematic review protocol
21.  Does paracetamol (acetaminophen) reduce the pain of osteoarthritis?: a meta-analysis of randomised controlled trials 
Annals of the Rheumatic Diseases  2004;63(8):901-907.
Design: Systematic review and meta-analysis of randomised controlled trials (RCTs).
Data sources: Medline, Embase, Scientific Citation Index, CINAHL, Cochrane Library, and conference abstracts in the past 2 years from the British Society for Rheumatology, the European League Against Rheumatism, the American College of Rheumatology, and the Osteoarthritis Research Society International.
Subjects: 10 RCTs including 1712 patients with either symptomatic OA of the knee (6 trials) or hip/knee (3 trials) or multiple joints (1 trial).
Main outcome measures: (a) effect size (ES) for pain, stiffness, and functional scores from baseline to end point; (b) rate ratio (RR) and number needed to treat for clinical response rate and patient preference for treatment.
Results: Paracetamol was effective in relieving pain due to OA (ES = 0.21, 95% confidence interval (CI) 0.02 to 0.41). Non-steroidal anti-inflammatory drugs (NSAIDs) were better than paracetamol for pain relief (ES = 0.20, 95% CI 0.10 to 0.30). Clinical response rate was higher with NSAIDs than with paracetamol (RR = 1.24, 95% CI 1.08 to 1.41), and the number of patients who preferred NSAIDs was more than twice the number of those preferring paracetamol (RR = 2.46, 95% CI 1.51 to 4.12). NSAIDs were associated with more frequent gastrointestinal discomfort than paracetamol (RR = 1.35, 95% CI 1.05 to 1.75).
Conclusion: Paracetamol is an effective agent for pain relief due to OA. Although safer, it is less effective than NSAIDs. For safety reasons paracetamol should be the first line treatment, with NSAIDs reserved for those who do not respond.
PMCID: PMC1755098  PMID: 15020311
22.  Timing of Tracheostomy in Critically Ill Patients: A Meta-Analysis 
PLoS ONE  2014;9(3):e92981.
To compare important outcomes between early tracheostomy (ET) and late tracheostomy (LT) or prolonged intubation (PI) for critically ill patients receiving long-term ventilation during their treatment.
We performed computerized searches for relevant articles on PubMed, EMBASE, and the Cochrane register of controlled trials (up to July 2013). We contacted international experts and manufacturers. We included in the study randomized controlled trials (RCTs) that compared ET (performed within 10 days after initiation of laryngeal intubation) and LT (after 10 days of laryngeal intubation) or PI in critically ill adult patients admitted to intensive care units (ICUs). Two investigators evaluated the articles; divergent opinions were resolved by consensus.
A meta-analysis was evaluated from nine randomized clinical trials with 2,072 participants. Compared to LT/PI, ET did not significantly reduce short-term mortality [relative risks (RR) = 0.91; 95% confidence intervals (CIs) = 0.81–1.03; p = 0.14] or long-term mortality (RR = 0.90; 95% CI = 0.76–1.08; p = 0.27). Additionally, ET was not associated with a markedly reduced length of ICU stay [weighted mean difference (WMD) = −4.41 days; 95% CI = −13.44–4.63 days; p = 0.34], ventilator-associated pneumonia (VAP) (RR = 0.88; 95% CI = 0.71–1.10; p = 0.27) or duration of mechanical ventilation (MV) (WMD = − 2.91 days; 95% CI = −7.21–1.40 days; p = 0.19).
Among the patients requiring prolonged MV, ET showed no significant difference in clinical outcomes compared to that of the LT/PI group. But more rigorously designed and adequately powered RCTs are required to confirm it in future.
PMCID: PMC3965497  PMID: 24667875
23.  Korean Guideline for Colonoscopic Polypectomy 
Clinical Endoscopy  2012;45(1):11-24.
There is indirect evidence to suggest that 80% of colorectal cancers (CRC) develop from adenomatous polyps and that, on average, it takes 10 years for a small polyp to transform into invasive CRC. In multiple cohort studies, colonoscopic polypectomy has been shown to significantly reduce the expected incidence of CRC by 76% to 90%. Colonoscopic polypectomy is performed frequently in primary outpatient clinics and secondary and tertiary medical centers in Korea. However, there are no evidence-based, procedural guidelines for the appropriate performance of this procedure, including the technical aspects. For the guideline presented here, PubMed, Medline, and Cochrane Library literature searches were performed. When little or no data from well-designed prospective trials were available, an emphasis was placed on the results from large series and reports from recognized experts. Thus, these guidelines for colonoscopic polypectomy are based on a critical review of the available data as well as expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data become available. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions for any particular case involve a complex analysis of the patient's condition and the available courses of action.
PMCID: PMC3363129  PMID: 22741130
Colonoscopy; Polypectomy; Guideline
24.  Whole brain radiotherapy with radiosensitizer for brain metastases 
To study the efficacy of whole brain radiotherapy (WBRT) with radiosensitizer in comparison with WBRT alone for patients with brain metastases in terms of overall survival, disease progression, response to treatment and adverse effects of treatment.
A meta-analysis of randomized controlled trials (RCT) was performed in order to compare WBRT with radiosensitizer for brain metastases and WBRT alone. The MEDLINE, EMBASE, LILACS, and Cochrane Library databases, in addition to Trial registers, bibliographic databases, and recent issues of relevant journals were researched. Significant reports were reviewed by two reviewers independently.
A total of 8 RCTs, yielding 2317 patients were analyzed. Pooled results from this 8 RCTs of WBRT with radiosensitizer have not shown a meaningful improvement on overall survival compared to WBRT alone OR = 1.03 (95% CI0.84–1.25, p = 0.77). Also, there was no difference in local brain tumor response OR = 0.8(95% CI 0.5 – 1.03) and brain tumor progression (OR = 1.11, 95% CI 0.9 – 1.3) when the two arms were compared.
Our data show that WBRT with the following radiosentizers (ionidamine, metronidazole, misonodazole, motexafin gadolinium, BUdr, efaproxiral, thalidomide), have not improved significatively the overall survival, local control and tumor response compared to WBRT alone for brain metastases. However, 2 of them, motexafin- gadolinium and efaproxiral have been shown in recent publications (lung and breast) to have positive action in lung and breast carcinoma brain metastases in association with WBRT.
PMCID: PMC2648943  PMID: 19126230
25.  Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program – Endoscopy 
Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.
To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.
A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.
Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).
Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.
Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.
PMCID: PMC3027329  PMID: 21258663
Colonoscopy; Health care; Practice audit; Quality assurance; Quality indicators

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