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1.  N-acetylcysteine supplementation for the prevention of atrial fibrillation after cardiac surgery: a meta-analysis of eight randomized controlled trials 
Background
Atrial fibrillation is the most common type of arrhythmia after cardiac surgery. An increasing body of evidence demonstrates that oxidative stress plays a pivotal role in the pathophysiology of atrial fibrillation. N-acetylcysteine (NAC) is a free radical scavenger, and may attenuate this pathophysiologic response and reduce the incidence of postoperative AF (POAF). However, it is unclear whether NAC could effectively prevent POAF. Therefore, this meta-analysis aims to assess the efficacy of NAC supplementation on the prevention of POAF.
Methods
Medline and Embase were systematically reviewed for studies published up to November 2011, in which NAC was compared with controls for adult patients undergoing cardiac surgery. Outcome measures comprised the incidence of POAF and hospital length of stay (LOS). The meta-analysis was performed with the fixed-effect model or random-effect model according to the heterogeneity.
Results
Eight randomized trials incorporating 578 patients provided the best evidence and were included in this meta-analysis. NAC supplementation significantly reduced the incidence of POAF (OR 0.62, 95% CI 0.41 to 0.93; P = 0.021) compared with controls, but had no effect on LOS (WMD -0.07, 95% CI -0.42 to 0.28; P = 0.703).
Conclusions
The prophylactic NAC supplementation may effectively reduce the incidence of POAF. However, the overall quality of current studies is poor and further research should focus on adequately powered randomized controlled trials with POAF incidence as a primary outcome measure.
doi:10.1186/1471-2261-12-10
PMCID: PMC3331849  PMID: 22364379
2.  Moxifloxacin in acute exacerbations of chronic bronchitis and COPD 
Journal of Thoracic Disease  2014;6(7):E160.
doi:10.3978/j.issn.2072-1439.2014.07.08
PMCID: PMC4120165  PMID: 25093104
3.  The effect of goal-directed therapy on mortality in patients with sepsis - earlier is better: a meta-analysis of randomized controlled trials 
Critical Care  2014;18(5):570.
Introduction
The Surviving Sepsis Campaign guidelines recommend goal-directed therapy (GDT) for the early resuscitation of patients with sepsis. However, the findings of the ProCESS (Protocolized Care for Early Septic Shock) trial showed no benefit from GDT for reducing mortality rates in early septic shock. We performed a meta-analysis to integrate these findings with existing literature on this topic and evaluate the effect of GDT on mortality due to sepsis.
Methods
We searched the PubMed, Embase and CENTRAL (Cochrane Central Register of Controlled Trials) databases and reference lists of extracted articles. Randomized controlled trials comparing GDT with standard therapy or usual care in patients with sepsis were included. The prespecified primary outcome was overall mortality.
Results
In total, 13 trials involving 2,525 adult patients were included. GDT significantly reduced overall mortality in the random-effects model (relative risk (RR), 0.83; 95% confidence interval (CI), 0.71 to 0.96; P =0.01; I2 = 56%). Predefined subgroup analysis according to the timing of GDT for resuscitation suggested that a mortality benefit was seen only in the subgroup of early GDT within the first 6 hours (seven trials; RR, 0.77; 95% CI, 0.67 to 0.89; P =0.0004; I2 = 40%), but not in the subgroup with late or unclear timing of GDT (six trials; RR, 0.92; 95% CI, 0.69 to 1.24; P =0.59; I2 = 56%). GDT was significantly associated with the use of dobutamine (five trials; RR, 2.71; 95% CI, 1.20 to 6.10; P =0.02).
Conclusions
The results of the present meta-analysis suggest that GDT significantly reduces overall mortality in patients with sepsis, especially when initiated early. However, owing to the variable quality of the studies, strong and definitive recommendations cannot be made.
Electronic supplementary material
The online version of this article (doi:10.1186/s13054-014-0570-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13054-014-0570-5
PMCID: PMC4232636  PMID: 25327977
5.  Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials 
Critical Care  2014;18(3):R93.
Introduction
Ultrasound guidance has emerged as an adjunct for central vein catheterization in both adults and children. However, the use of ultrasound guidance for radial arterial catheterization has not been well established. We conducted a systematic review and meta-analysis to evaluate the efficacy of ultrasound guidance for radial artery catheterization.
Methods
PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched. Randomized controlled trials (RCTs) comparing ultrasound guidance with other techniques (palpation or Doppler) in adult or pediatric patients requiring radial artery catheterization were included. The primary outcome was first-attempt success.
Results
Seven RCTs enrolling 546 patients met the inclusion criteria, and all the selected trials were considered as at high risk of bias. Ultrasound-guided radial artery catheterization was associated with an increased first-attempt success (relative risk (RR) 1.55, 95% confidence interval (CI) 1.02 to 2.35). There was significant heterogeneity among the studies (I2 = 74%). Ultrasound-guided radial artery catheterization in small children and infants also provided an increased chance for first-attempt success (RR 1.94, 95% CI 1.31 to 2.88). Ultrasound guidance further significantly reduced mean attempts to success (weighted mean difference (WMD) −1.13, 95% CI −1.58 to −0.69), mean time to success (WMD −72.97 seconds, 95% CI −134.41 to −11.52), and incidence of the complication of hematoma (RR 0.17, 95% CI 0.07 to 0.41).
Conclusions
Ultrasound guidance is an effective and safe technique for radial artery catheterization, even in small children and infants. However, the results should be interpreted cautiously due to the heterogeneity among the studies.
doi:10.1186/cc13862
PMCID: PMC4056628  PMID: 24887241
6.  Procalcitonin-guided therapy in severe sepsis and septic shock 
Critical Care  2014;18(3):427.
doi:10.1186/cc13856
PMCID: PMC4057232  PMID: 25033407
7.  Risk of Acute Lung Injury/Acute Respiratory Distress Syndrome in Critically Ill Adult Patients with Pre-Existing Diabetes: A Meta-Analysis 
PLoS ONE  2014;9(2):e90426.
Background
The impact of pre-existing diabetes on the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in critically ill patients remains unclear. We performed a meta-analysis of cohort studies to evaluate the risk of ALI/ARDS in critically ill patients with and without pre-existing diabetes.
Materials and Methods
We searched PubMed and Embase from the inception to September 2013 for cohort studies assessing the effect of pre-existing diabetes on ALI/ARDS occurrence. Pooled odds ratio (OR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models when appropriate.
Results
Seven cohort studies with a total of 12,794 participants and 2,937 cases of pre-existing diabetes, and 2,457 cases of ALI/ARDS were included in the meta-analysis. A fixed-effects model meta-analysis showed that pre-existing diabetes was associated with a reduced risk of ALI/ARDS (OR 0.66; 95% CI, 0.55–0.80; p<0.001), with low heterogeneity among the studies (I2 = 18.9%; p = 0.286). However, the asymmetric funnel plot and Egger's test (p = 0.007) suggested publication bias may exist.
Conclusions
Our meta-analysis suggests that pre-existing diabetes was associated with a decreased risk of ALI/ARDS in critically ill adult patients. However, the result should be interpreted with caution because of the potential bias and confounding in the included studies.
doi:10.1371/journal.pone.0090426
PMCID: PMC3937384  PMID: 24587357
9.  Tooth Loss and Risk of Head and Neck Cancer: A Meta-Analysis 
PLoS ONE  2013;8(8):e71122.
Background
Observational studies suggest an association between tooth loss and risk of head and neck cancer. However, whether tooth loss is an independent risk factor for head and neck cancer still remains controversial. The aim of this study is to assess the association between tooth loss and head and neck cancer risk.
Methods
Eligible studies were searched in PubMed and Embase databases from their inception to March 2013. A random-effects model or fixed-effects model was used to calculate the overall combined risk estimates.
Results
Eight case-control studies and one cross-sectional study involving 5,204 patients and 5,518 controls were included in the meta-analysis. The overall combined odds ratio for tooth loss and head and neck cancer was 2.00 (95% confidence interval, 1.28–3.14). Similar results yielded both in the moderate and severe tooth loss group. Sensitivity analysis based on various exclusion criteria maintained this significance with respect to head and neck cancer individually. Little evidence of publication bias was observed.
Conclusion
This meta-analysis suggests that tooth loss is associated with increased risk of head and neck cancer. This increase is probably independent of conventional head and neck cancer risk factors.
doi:10.1371/journal.pone.0071122
PMCID: PMC3747175  PMID: 23990929
10.  Efficacy of Tai Chi on Pain, Stiffness and Function in Patients with Osteoarthritis: A Meta-Analysis 
PLoS ONE  2013;8(4):e61672.
Background
Whether Tai Chi benefits patients with osteoarthritis remains controversial. We performed a meta-analysis to assess the effectiveness of Tai Chi exercise for pain, stiffness, and physical function in patients with osteoarthritis.
Methods
A computerized search of PubMed and Embase (up to Sept 2012) was performed to identify relevant studies. The outcome measures were pain, stiffness, and physical function. Two investigators identified eligible studies and extracted data independently. The quality of the included studies was assessed by the Jadad score. Standard mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and pooled using a random effects model. The change in outcomes from baseline was compared to the minimum clinically important difference.
Results
A total of seven randomized controlled trials involving 348 patients with osteoarthritis met the inclusion criteria. The mean Jadad score was 3.6. The pooled SMD was −0.45 (95% CI −0.70–−0.20, P = 0.0005) for pain, −0.31 (95% CI −0.60–−0.02, P = 0.04) for stiffness, and −0.61 (95% CI −0.85–−0.37, P<0.00001) for physical function. A change of 32.2–36.4% in the outcomes was greater than the minimum clinically important difference.
Conclusions
Twelve-week Tai Chi is beneficial for improving arthritic symptoms and physical function in patients with osteoarthritis and should be included in rehabilitation programs. However, the evidence may be limited by potential biases; thus, larger scale randomized controlled trials are needed to confirm the current findings and investigate the long-term effects of Tai Chi.
doi:10.1371/journal.pone.0061672
PMCID: PMC3631149  PMID: 23620778
11.  Antioxidant supplementation for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of randomized controlled trials 
Nutrition Journal  2013;12:23.
Background
Acute pancreatitis remains the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). The pathogenesis of post-ERCP acute pancreatitis may be mediated by oxygen-derived free radicals, which could be ameliorated by antioxidants. Antioxidant supplementation may potentially prevent post-ERCP pancreatitis. We performed a meta-analysis of randomized controlled trials to evaluate the effect of prophylactic antioxidant supplementation compared with control on the prevention of post-ERCP pancreatitis.
Methods
PubMed and Embase databases were searched to identify relevant trials. A standardized Excel file was used to extract data by two independent authors. Results were expressed as risk ratio (RR) with accompanying 95% confidence interval (CI). The meta-analysis was performed with the fixed-effects model or random-effects model according to heterogeneity.
Results
Eleven studies involving 3,010 patients met our inclusion criteria. Antioxidant supplementation did not significantly decrease the incidence of post-ERCP pancreatitis (RR, 0.92; 95% CI, 0.65-1.32; P = 0.665). There was also no statistical difference in the severity grades between the antioxidant group and control group.
Conclusions
Based on current evidence, antioxidant supplementation shows no beneficial effect on the incidence and the severity of post-ERCP pancreatitis; thus, there is currently a lack of evidence to support using antioxidants for the prevention of post-ERCP pancreatitis.
doi:10.1186/1475-2891-12-23
PMCID: PMC3575286  PMID: 23398675
Antioxidant; Endoscopic retrograde cholangiopancreatography; Pancreatitis
12.  Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials 
Critical Care  2012;16(5):R190.
Introduction
Ventilator-associated pneumonia (VAP) remains a common hazardous complication in mechanically ventilated patients and is associated with increased morbidity and mortality. We undertook a systematic review and meta-analysis of randomized controlled trials to assess the effect of toothbrushing as a component of oral care on the prevention of VAP in adult critically ill patients.
Methods
A systematic literature search of PubMed and Embase (up to April 2012) was conducted. Eligible studies were randomized controlled trials of mechanically ventilated adult patients receiving oral care with toothbrushing. Relative risks (RRs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated and heterogeneity was assessed with the I2 test.
Results
Four studies with a total of 828 patients met the inclusion criteria. Toothbrushing did not significantly reduce the incidence of VAP (RR, 0.77; 95% CI, 0.50 to 1.21) and intensive care unit mortality (RR, 0.88; 95% CI, 0.70 to 1.10). Toothbrushing was not associated with a statistically significant reduction in duration of mechanical ventilation (WMD, -0.88 days; 95% CI, -2.58 to 0.82), length of intensive care unit stay (WMD, -1.48 days; 95% CI, -3.40 to 0.45), antibiotic-free day (WMD, -0.52 days; 95% CI, -2.82 to 1.79), or mechanical ventilation-free day (WMD, -0.43 days; 95% CI, -1.23 to 0.36).
Conclusions
Oral care with toothbrushing versus without toothbrushing does not significantly reduce the incidence of VAP and alter other important clinical outcomes in mechanically ventilated patients. However, the results should be interpreted cautiously since relevant evidence is still limited, although accumulating. Further large-scale, well-designed randomized controlled trials are urgently needed.
doi:10.1186/cc11675
PMCID: PMC3682292  PMID: 23062250
13.  Meta-analysis of randomized controlled trials on the efficacy of thoracic epidural anesthesia in preventing atrial fibrillation after coronary artery bypass grafting 
Background
Postoperative atrial fibrillation (POAF) is one of the most common complications in patients undergoing coronary artery bypass grafting (CABG). The goal of this meta-analysis was to evaluate the efficacy of thoracic epidural anesthesia (TEA) in preventing POAF in adult patients undergoing CABG.
Methods
MEDLINE and EMBASE were searched to identify randomized controlled trails in adult patients undergoing CABG who were randomly assigned to receive general anesthesia plus thoracic epidural anesthesia (GA + TEA) or general anesthesia only (GA). Two authors independently extracted data using a standardized Excel file. The primary outcome measure was the incidence of POAF. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals.
Results
Five studies involving 540 patients met our inclusion criteria. No significant difference in the incidence of POAF was observed between the two groups (risk ratio, 0.61; 95% confidence interval, 0.33 to 1.12; P = 0.11), with significant heterogeneity among the studies (I2 = 73%, P = 0.005). Sensitivity analyses by primary endpoint, methodological quality and surgical technique yielded similar results.
Conclusions
The limited evidence suggests that TEA shows no beneficial efficacy in preventing POAF in adult patients undergoing CABG. However, the results of this meta-analysis should be interpreted with caution due to significant heterogeneity of the studies included. Thus, the potential infuence of TEA on the incidence of atrial fibrillation following CABG warrants further investigation.
doi:10.1186/1471-2261-12-67
PMCID: PMC3489521  PMID: 22900930
Thoracic epidural anesthesia; Postoperative atrial fibrillation; Meta-analysis
14.  Intravenous magnesium prevents atrial fibrillation after coronary artery bypass grafting: a meta-analysis of 7 double-blind, placebo-controlled, randomized clinical trials 
Trials  2012;13:41.
Background
Postoperative atrial fibrillation (POAF) is the most common complication after coronary artery bypass grafting (CABG). The preventive effect of magnesium on POAF is not well known. This meta-analysis was undertaken to assess the efficacy of intravenous magnesium on the prevention of POAF after CABG.
Methods
Eligible studies were identified from electronic databases (Medline, Embase, and the Cochrane Library). The primary outcome measure was the incidence of POAF. The meta-analysis was performed with the fixed-effect model or random-effect model according to heterogeneity.
Results
Seven double-blind, placebo-controlled, randomized clinical trials met the inclusion criteria including 1,028 participants. The pooled results showed that intravenous magnesium reduced the incidence of POAF by 36% (RR 0.64; 95% confidence interval (CI) 0.50-0.83; P = 0.001; with no heterogeneity between trials (heterogeneity P = 0.8, I2 = 0%)).
Conclusions
This meta-analysis indicates that intravenous magnesium significantly reduces the incidence of POAF after CABG. This finding encourages the use of intravenous magnesium as an alternative to prevent POAF after CABG. But more high quality randomized clinical trials are still need to confirm the safety.
doi:10.1186/1745-6215-13-41
PMCID: PMC3359243  PMID: 22520937

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