Search

Risk models, informing optimal long-term medical management, seldom use natriuretic peptides (NP) in ascertaining the absolute risk of outcomes for HF patients. Individual studies evaluating the prognostic value of NPs in HF patients have reported varying effects, arriving at best estimates requires a systematic review. We systematically summarized the best evidence regarding the prognostic value of brain natriuretic peptide (BNP) and NT-proBNP in predicting mortality and hospitalizations in ambulatory heart failure (HF) patients. We searched bibliographic databases from 2005 to 2018 and included studies evaluating the association of BNP or NT-proBNP with mortality or hospitalization using multivariable Cox proportional hazard models. We pooled hazard ratios using random-effect models, explored heterogeneity using pre-specified subgroup analyses, and evaluated the certainty of evidence using the Grading of Recommendations and Development Evaluation framework. We identified 67 eligible studies reporting on 76,178 ambulatory HF patients with a median BNP of 407 pg/mL (261–574 pg/mL). Moderate to high-quality evidence showed that a 100-pg/mL increase in BNP was associated with a 14% increased hazard of mortality (HR 1.14, 95% CI 1.06–1.22); a 1-log-unit increase was associated with a 51% increased hazard of mortality (HR 1.51, 95% CI 1.41–1.61) and 48% increased hazard of mortality or hospitalization (HR 1.48, 95% CI 1.29–1.69). With moderate to high certainty, we observed a 14% independent relative increase in mortality, translating to a clinically meaningful increase in absolute risk even for low-risk patients. The observed associations may help in developing more accurate risk models that incorporate NPs and accurately prognosticate HF patients.

Previous primary studies have explored the association between blood pressure (BP) and mortality in ambulatory heart failure (HF) patients reporting varying and contrasting associations. The aim is to determine the pooled BP prognostic value and explore potential reasons for between-study inconsistency. We searched Medline, Cochrane, EMBASE and CINAHL from January 2005 to October 2018 for studies with ≥ 50 events (mortality and/or hospitalization) and included BP in a multivariable model in ambulatory HF patients. We pooled hazard ratios (random effects model) for systolic BP (SBP) or diastolic BP (DBP) effect on mortality and/or hospitalization risk. We used a priori defined sub-group analyses to explore heterogeneity and GRADE approach to assess the certainty of the evidence. Seventy-one eligible articles (239,467 screened) at low to moderate risk of bias included 235,752 participants. Higher SBP was associated with reduced all-cause mortality (HR 0.93, 95%CI 0.91–0.95, I2 = 87.13%, moderate certainty), all-cause hospitalization events (HR 0.91, 95%CI 0.88–0.93, I2 = 44.4%, high certainty) and their composite endpoint (HR 0.93 per 10 mmHg, 95%CI 0.91–0.94, I2 = 86.3%, high certainty). DBP did not demonstrate a statistically significant effect for all outcomes. The association strength was significantly weaker in studies following patients with either LVEF > 40%, higher average SBP (> 130 mmHg), increasing age and diabetes. All other a priori subgroup hypotheses did not explain between study differences. Higher ambulatory SBP is associated with reduced risk of all-cause mortality and hospitalization. Patients with lower BP and reduced LVEF are in a high-risk group of developing adverse events with moderate certainty of evidence.

Background Positron emission tomography (PET), alone or combined with computed tomography (CT), potentially enhances detection of occult metastatic colorectal cancer. Methods We compared the impact of PET/PET-CT with conventional imaging, versus conventional imaging alone, in patients with potentially resectable colorectal cancer liver metastases. MEDLINE, EMBASE, and CENTRAL were searched for studies investigating PET/PET-CT to determine resectability. Outcomes included overall (OS), disease-free survival (DFS), change in surgical management, and futile laparotomy. Evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A pre-specified protocol was registered in PROSPERO. Results Of 4034 articles, two randomized trials (n = 554), and 11 non-randomized studies (n = 2251) were included. PET/PET-CT did not improve OS (hazard ratio [HR] 0.94, 95% CI 0.69–1.26, moderate quality) or DFS (HR 1.01, 95% CI 0.82–1.26, moderate quality). In the two trials, PET/PET-CT changed surgical management in 8% of cases (95% CI 5–11%, high quality), and did not significantly reduce futile laparotomies (risk ratio 0.59, 95% CI 0.24–1.47, low quality). Among non-randomized studies, PET/PET-CT changed surgical management in 20% of cases (95% CI 17–22%, very low quality) and reduced futile laparotomies (odds ratio 0.51, 95% CI 0.32–0.81, very low quality). Conclusions Moderate-quality evidence suggests that preoperative PET/PET-CT does not improve OS or DFS in patients with colorectal cancer liver metastases. These results do not support routine use of PET/PET-CT in patients with potentially resectable disease. The main limitation of this study was the lack of randomized studies.

Background Resting heart rate is a risk factor of adverse heart failure outcomes; however, studies have shown controversial results. This meta-analysis evaluates the association of resting heart rate with mortality and hospitalization and identifies factors influencing its effect. Methods and Results We systematically searched electronic databases in February 2019 for studies published in 2005 or before that evaluated the resting heart rate as a primary predictor or covariate of multivariable models of mortality and/or hospitalization in adult ambulatory patients with heart failure. Random effects inverse variance meta-analyses were performed to calculate pooled hazard ratios. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess evidence quality. Sixty-two studies on 163,445 patients proved eligible. Median population heart rate was 74 bpm (interquartile range 72–76 bpm). A 10-bpm increase was significantly associated with increased risk of all-cause mortality (hazard ratio 1.10, 95% confidence interval 1.08–1.13, high quality). Overall, subgroup analyses related to patient characteristics showed no changes to the effect estimate; however, there was a strongly positive interaction with age showing increasing risk of all-cause mortality per 10 bpm increase in heart rate. Conclusions High-quality evidence demonstrates increasing resting heart rate is a significant predictor of all-cause mortality in ambulatory patients with heart failure on optimal medical therapy, with consistent effect across most patient factors and an increased risk trending with older age.

With a growing demand for endoscopic services, the role of anesthesiologists in endoscopy units must be reassessed. The aim of this study was to compare patient outcomes in non-anesthesiologist-administered propofol (NAAP) versus anesthesiologist-administered propofol (AAP) during routine endoscopy.We systematically searched MEDLINE, CINAHL, Embase, Web of Science, CENTRAL and the grey literature for studies comparing NAAP and AAP. Primary outcomes included endoscopy- and sedation-related complications. Secondary outcomes included measures of endoscopy quality and of patient and endoscopist satisfaction. We reported treatment effects using random-effects models.Of 602 articles identified, 5 met the inclusion criteria. Most studies included only patients with an American Society of Anesthesiologists (ASA) classification of I or II. Non-anesthesiologist-administered propofol did not result in increased rates of airway intervention (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.29 to 3.95; 3443 patients) or hypotension (OR 1.47, 95% CI 0.40 to 5.41; 17 978 patients) but did result in higher rates of bradycardia (OR 3.68, 95% CI 1.65 to 8.17; 17 978 patients). Nonanesthesiologists administered lower propofol dosages than anesthesiologists (mean difference -61.79, 95% CI -114.46 to -9.12; 3443 patients), and their patients more commonly experienced awareness with recall (OR 19.99, 95% CI 7.88 to 50.76; 2090 patients). However, NAAP neither compromised patient willingness to repeat the procedure (OR 0.42, 95% CI 0.10 to 1.83; 2367 patients) nor lengthened total procedure time (mean difference -0.08, 95% CI -3.51 to 3.34; 2367 patients).Endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The results of this meta-analysis are limited by a lack of available high-quality studies. Further, large-scale studies are needed for definitive conclusions.Étant donné que les services endoscopiques sont de plus en plus demandés, le rôle des anesthésiologistes dans les unités d'endoscopie doit être réévalué. Le but de cette étude était de comparer les résultats cliniques chez les patients selon que le propofol était administré par des non-anesthésiologistes (NAAP, pour non-anesthesiologist-administered propofol) ou par des anesthésiologistes (AAP, pour anesthesiologist-administered propofol).Nous avons procédé à une revue systématique des réseaux MEDLINE, CINAHL, Embase, Web of Science et CENTRAL et de la littérature grise pour recenser les études ayant comparé les méthodes NAAP et AAP. Les paramètres principaux incluaient les complications liées à l'endoscopie et à la sédation, et les paramètres secondaires incluaient les mesures de la qualité de l'endoscopie et la satisfaction des patients et des endoscopistes. Nous avons fait état des effets des traitements à l'aide de modèles à effets aléatoires.Sur les 602 articles recensés, 5 répondaient aux critères d'inclusion. La plupart des études incluaient uniquement des patients présentant une classe ASA (American Society of Anesthesiologists) I ou II. Le propofol administré par des non-anesthésiologistes n'a pas donné lieu à un taux accru d'interventions touchant les voies respiratoires (rapport des cotes [RC] 1,07, intervalle de confiance [IC] de 95 %, 0,29 à 3,95; 3443 patients) ou d'hypotension (RC 1,47, IC de 95 %, 0,40 à 5,41; 17 978 patients), mais a donné lieu à des taux plus élevés de bradycardie (RC 3,68, IC de 95 %, 1,65 à 8,17; 17 978 patients). Comparativement aux anesthésiologistes, les non-anesthésiologistes ont administré des doses de propofol plus faibles (différence moyenne -61,79, IC de 95 %, -114,46 à -9,12; 3443 patients) et leurs patients ont plus souvent gardé conscience, avec souvenirs post-intervention (RC 19,99, IC à 95 %, 7,88 à 50,76; 2090 patients). Toutefois, la méthode NAAP n'a ni compromis la volonté des patients à répéter l'intervention (RC 0,42, IC à 95 %, 0,10 à 1,83; 2367 patients) ni prolongé la durée totale de l'intervention (différence moyenne −0,08, IC à 95 %, −3,51 à 3,34; 2367 patients).Les endoscopistes peuvent administrer le propofol de manière sécuritaire sans compromettre la qualité de l'intervention chez les patients de classe ASA I ou II soumis à une endoscopie de routine. Les résultats de cette méta-analyse sont limités par l'absence d'études de grande qualité. En outre, des études de plus grande envergure sont requises pour arriver à des conclusions définitives.

591 Background: It has been proposed that PET with 18F-fluorodeoxyglucose alone or combined with CT improves detection of extra hepatic disease in the setting of colorectal cancer liver metastasis (CRLM). However, there remains conflicting evidence on the added benefit of PET/PET-CT prior to liver resection, and its effect on long-term survival. Thus, we set out to perform a systematic review of literature and meta-analysis. Methods: From 2000 to April 2017, MEDLINE, EMBASE, and CENTRAL were searched for studies (prospective and retrospective) investigating the preoperative use of PET/PET-CT in the management of patients with CRLM. We excluded studies in which neoadjuvant chemotherapy was given 2 weeks prior to PET/PET-CT. Screening, data abstraction, and quality assessment was performed in duplicate. Primary outcome was overall survival (OS). Secondary outcomes included disease-free survival (DFS), pre-operative change in surgical management, and open-close surgery. Random effect models were used to pool treatment effects. The protocol was published in PROSPERO. Results: Of 4034 articles reviewed, 37 met the inclusion criteria and were analyzed, and 8 compared PET/PET-CT to conventional imaging. All studies included PET (n=18), PET-CT (n=17), or both (n=2). OS for all patients was similar whether or not pre-operative staging included PET/PET-CT (HR 0.94, 95% CI 0.69-1.26). A similar effect was seen in the subgroup of patients who underwent surgery (HR 0.92, 95% CI 0.72-1.17). DFS in patients who underwent surgery was not different either (HR 0.93, 95% CI 0.81-1.08). PET/PET-CT reduced the odds of undergoing an open-close surgery (OR 0.52, 95% CI 0.35-0.76) and changed the surgical management of 23.4% patients (95% CI 19.33-27.47), however heterogeneity (I2=100%). Conclusions: Pre-operative PET/PET-CT may have a meaningful impact on surgical decision making in CRLM, however heterogeneity between studies is high, likely due to different study designs. It may also reduce the rate of open-close surgeries. The addition of PET/PET-CT to routine pre-operative imaging does not improve OS or DFS.