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OBJECTIVE To conduct a meta-analysis of the literature on training programs that aimed to improve nurses' pressure injury management skills. METHODS Literature searches were conducted using Ovid-MEDLINE, Cochrane Library, CINAHL, and Korean databases. The search terms used were: (nurse* AND ((pressure OR decubitus) AND (ulcer* OR injur*)) OR bed sore OR bedsore OR decubitus) AND (program* OR training)). Random-effects models were used to calculate the standardized mean difference and odds ratios, with 95% confidence intervals (CIs) to analyze the effects. MAIN RESULTS Initial searches yielded 1,067 studies. Of these, 23 met the selection criteria. Nurses' knowledge (standard mean difference, 1.23; 95% CI, 0.50-1.96; P < .001), visual discrimination ability (standard mean difference, 1.13; 95% CI, 0.88-1.38; P < .001), and clinical judgment (odds ratio, 1.52; 95% CI, 1.46-1.57; P < .001) improved after the programs. CONCLUSIONS Pressure injury training programs can improve nurses' competency. The results from this study indicate that such programs may help improve nurses' knowledge, visual discrimination ability, and clinical judgment and can be considered continuing education programs. However, large-scale studies are needed to confirm this conclusion.

Background Children with complex chronic multisystemic diseases frequently require care from multiple pediatric subspecialists. The aerodigestive program is a multidisciplinary program that diagnoses and treats pediatric patients with complex multi-systematic problems affecting airway, breathing, feeding, swallowing, or growth. The aim of this study is to present the protocol of the aerodigestive program of a children’s hospital. Methods and design This study is a prospective study to evaluate and compare the overall improvement of patients’ objective and subjective conditions before and after the AeroDigestive Team (ADT) program. Among children from 1 month to 18 years of age, patients with complex problems of the airway, breathing, feeding, swallowing, or growth meeting at least two parameters of the inclusion criteria were enrolled. The overall process included referral based on the inclusion criteria, enrollment of ADT program with informed consents, interview and questionnaire for assessing patients’ medical condition, prescheduling appointment, multi-specialists’ evaluation, monthly team meetings, wrap-up discussion with the patients and family, therapeutic intervention, and follow-up at 6 months with the assessment of outcome measures. The outcome was evaluated objectively and subjectively. The objective outcome measure was divided into surgical or medical intervention, assessment of changes in medical condition, and follow-up study. Both caregiver interviews and questionnaires using a scoring system were used as subjective outcome measures before and after the ADT program. Children were scheduled to be followed-up at 6 months after the interventions or ADT meeting. Discussion The aerodigestive program is expected to provide comprehensive and multidisciplinary management of children with complex airway and digestive tract disorders.

Objectives: The present meta-analysis sought to assess further evidence for the efficacy of steroids in vestibular neuritis (VN). Methods: The PubMed, EMBASE and Cochrane Library databases were searched through August 30, 2019. The main outcome measures were 1) complete caloric recovery, 2) improvement of canal paresis (CP) in caloric testing, and 3) dizziness handicap inventory. The follow-up times were divided into short, mid, and long-term. The main outcome measures were 1) complete caloric recovery, 2) improvement of canal paresis (CP) in caloric testing, and 3) dizziness handicap inventory. Results: Among 276 records identified, 5 studies (n = 253) were included in the analysis. The therapeutic effect of steroid on VN was confirmed (Hedges’g = 0.172, 95% CI 0.048 to 0.295, p = .006). This effect was statistically significant on long-term follow-up (Hedges’g = 0.496, 95% CI 0.285 to 0.708, p < .0001). The therapeutic effect of steroids on VN was better than that of non-steroid treatment (Hedges’g = 0.299, 95% CI 0.107 to 0.490, p = .002). However, this effect was obscured by combination of other treatments. The therapeutic effect of steroids on VN was statistically significant regarding complete caloric recovery and improvement in CP (Hedges’g = 0.364, 95% CI 0.181 to 0.547, p < 0.0001; Hedges’g = 0.592, 95% CI 0.315 to 0.5869, p < .0001) Conclusions: The results suggest that corticosteroids are effective at VN recovery, especially in long-term follow-up. More data are required before recommendations can be made regarding management in patients on corticosteroids.

Introduction. Matrix metalloproteinase (MMP) is an emerging disease marker in rheumatic diseases. This is a meta-analysis aimed at systematically reviewing association between serum MMP-3 levels and systematic lupus erythematosus (SLE) activity, which sought to raise interest in MMP-3 as a putative biomarker. Methods. We conducted a meta-analysis of serum MMP-3 levels in patients with SLE and controls. We performed a PubMed search, EMBASE search, and forward search of the retrieved articles published until Oct. 1, 2018. In addition to this, we included data from a case-control study on a national pediatric SLE cohort, in which serum MMP-3 levels were measured in 11 SLE patients and 9 controls (unpublished). Subgroup analyses based on gender and disease activity were performed. Results. A total of 662 cases and 771 controls including 651 patients and 762 controls from 11 publications were studied. We observed significantly higher MMP-3 levels in SLE patients compared to healthy controls (P<0.001, Hedges’ g: 2.104, 95% CI 1.426-2.782). In subgroup analyses, we found a significant elevation of MMP-3 in the patients with nephritis compared to those without (P=0.006, Hedges’ g: 0.611, 95% CI 0.611-1.704). This finding was consistent between patients with persistent proteinuria and those without (P=0.023, Hedges’ g: 1.535, 95% CI 0.207-2.862). Meta-analysis showed no association between MMP-3 levels and gender or anti-double strand DNA antibody titer. Conclusions. Our meta-analysis demonstrated significantly higher MMP-3 levels in SLE patients than in controls and in patients with renal involvement than in those without.

Objectives: Child abuse is a global problem, and various programs are under way to prevent it. The purpose of this study was to examine the effectiveness of specific programs through a systematic review of meta-analyzes of the effects of various child abuse programs. Methods: We searched the Ovid-Medline, EMBASE, and Cochrane library and so on up to October 2017 using search terms such as (child AND (maltreatment or abuse)) AND (prevent* AND(program* and educat*)) AND (meta-analysis or systemic review) in English. Results: The Child Abuse Prevention Program reported on the reduction of child abuse, parenting knowledge and attitudes, parenting behaviors, and interactions with children. We also analyzed the effects of child sexual abuse knowledge and preventive behavior through education. All results reported low or moderate positive effects. Conclusions: The results of this study suggest that prevention of child abuse is effective for both parents and children. However, consistent and systematic child abuse prevention education will be needed to confirm this conclusion.

Multiple studies have suggested that ω-3 fatty acid intake may have a protective effect on cancer risk; however, its true association with cancer risk remains controversial. We performed an umbrella review of meta-analyses to summarize and evaluate the evidence for the association between ω-3 fatty acid intake and cancer outcomes. We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to December 1, 2018. We included meta-analyses of observational studies that examined associations between intake of fish or ω-3 fatty acid and cancer risk (gastrointestinal, liver, breast, gynecologic, prostate, brain, lung, and skin) and determined the level of evidence of associations. In addition, we appraised the quality of the evidence of significant meta-analyses by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. We initially screened 598 articles, and 15 articles, including 57 meta-analyses, were eligible. Among 57 meta-analyses, 15 reported statistically significant results. We found that 12 meta-analyses showed weak evidence of an association between ω-3 fatty acid intake and risk of the following types of cancer: liver cancer (n = 4 of 6), breast cancer (n = 3 of 14), prostate cancer (n = 3 of 11), and brain tumor (n = 2 of 2). In the other 3 meta-analyses, studies of endometrial cancer and skin cancer, there were no assessable data for determining the evidence levels. No meta-analysis showed convincing, highly suggestive, or suggestive evidence of an association. In the sensitivity analysis of meta-analyses by study design, we found weak associations between ω-3 fatty acid intake and breast cancer risk in cohort studies, but no statistically significant association in case-control studies. However, the opposite results were found in case of brain tumor risk. Although ω-3 fatty acids have been studied in several meta-analyses with regard to a wide range of cancer outcomes, only weak associations were identified in some cancer types, with several limitations. Considering the nonsignificant or weak evidence level, clinicians and researchers should cautiously interpret reported associations between ω-3 fatty acid consumption and cancer risks. Copyright © 2020 The Author(s) on behalf of the American Society for Nutrition.

Purpose: This study aimed to evaluate the effects of an empowerment program on maternal stress, anxiety, depression and parenting confidence. Methods: A total of 44 mothers of preterm infants were assigned into an experimental or a control group (n=22 each). The experimental group received the usual nursing care and 7 sessions of an empowerment program. The control group only received the usual care. The program was implemented from June to December, 2016 in the neonatal intensive care unit of K university-affiliated hospital in Daegu, Korea. The outcome variables measured were parental stress (PSS: NICU), anxiety (STAI), depression (CES-D) and parenting confidence. Data were analyzed using t-test or repeated measures ANOVA. Results: Scores for both parental stress (t=3.07 p=.004) and depression (F=3.76, p=.26) were significantly lower in the experimental group than in the control group. However, there were no significant differences in anxiety between the groups (F=0.79, p=.505). Parenting confidence scores (F=9.05, p=.001) were significantly higher in the experimental group than in the control group. Conclusion: A maternal empowerment program can be an effective means of reducing parental stress and depression as well as enhancing parenting confidence, for mothers of preterm infants.

One of the typical symptoms of a psychological crisis is depression, an increasing concern in the elderly population. Although omega-3-polyunsaturated fatty acids (PUFAs) are reported to be promising nutrients for treating depression, currently, there are no systematic reviews or meta-analyses of randomized control trials that provide critical evidence regarding the potential benefits of omega-3 fatty acids in elderly patients with depression. This analysis was conducted to provide evidence for the clinical application of omega-3 fatty acids in the treatment of depressive symptoms of elderly subjects older than 65 years. Seven databases were searched from their inception date until September 2016. Following this search, 6 studies were selected, which included 4605 patients (mean age, 76.97 years; male-female ratio=3752:853; mean dose of omega 3 intake, 1.3 g/d). These results were divided into 2 categories: well-being mental health group and depressive group. In the well-being mental health group, the Hedges g was 0.12 (95% confidence interval, -0.05 to 0.29), which indicated no significant effect of n-3 PUFA supplementation on depressed mood compared with placebo. In the depressive group, the pooled Hedges g was -0.94 (95% CI, -1.37 to -0.50]) for the random-effects model, which indicated a large effect of n-3 PUFA supplementation on those with depressed mood compared with placebo. Although this review shows that omega-3 fatty acids are effective in the treatment of elderly depressed patients, the benefits of omega-3 fatty acid supplementation were significant only in the elderly patients with mild to moderate depression.

Background/Aims: Transient elastography (TE) has been proposed as a promising noninvasive alternative to hepatic venous pressure gradient (HVPG) for detecting portal hypertension (PH). However, previous studies have yielded conflicting results. We gathered evidence from literature on the clinical usefulness of TE versus HVPG for assessing PH. Methods: We conducted a systematic review by searching databases for relevant literature evaluating the clinical usefulness of non-invasive TE for assessing PH in patients with cirrhosis. A literature search in Ovid Medline, EMBASE and the Cochrane Library was performed for all studies published prior to December 30, 2015. Results: Eight studies (1,356 patients) met our inclusion criteria. For the detection of PH (HVPG ≥6 mmHg), the summary sensitivity and specificity were 0.88 (95% confidence interval [CI] 0.86-0.90) and 0.74 (95% CI 0.67-0.81), respectively. Regarding clinically significant PH (HVPG ≥10 mmHg), the summary sensitivity and specificity were 0.85 (95% CI 0.63-0.97) and 0.71 (95% CI 0.50-0.93), respectively. The overall correlation estimate of TE and HVPG was large (0.75, 95% CI: 0.65; 0.82, P

Relative adrenal insufficiency (RAI) is frequently observed in patients with cirrhosis. We sought to identify evidence in the literature regarding the impact of RAI on clinical outcomes in cirrhotic patients. We conducted a systematic review (SR) and meta-analysis (MA) using the Ovid-MEDLINE, EMBASE, and Cochrane Library databases to identify relevant studies in the literature. Of the 182 studies identified, 16 were eligible according to our inclusion criteria. The prevalence of RAI was 49.4% (744/1507), and cirrhotic patients with acute critical illnesses such as sepsis were more likely to have RAI compared to those without critical illnesses (P

Rationale: Patients with Down syndrome (DS) have a higher incidence of nonneurogenic neurogenic bladder (NNB) than do normal subjects. Renal failure may occur frequently in NNB patients. Although most of the cases of NNB patients with DS reported to date have been acute renal injuries, we report a patient with DS who was diagnosed late with urinary tract obstruction due to NNB that finally proceeded to end-stage renal disease (ESRD). This case of terminal renal failure is the first such reported case in the world. Patient concerns: A 35-year-old female patient had visited another hospital for 1 month for abdominal discomfort, nausea, constipation, and palpable mass. Cystic mass in the pelvic cavity, increased BUN, and Cr findings were observed. Residual urine was 1.8 L. She had a history of DS. Diagnoses: Based on computed tomography and urodynamic study, ESRD due to NNB was diagnosed. Interventions: An emergency hemodialysis was performed and a catheter was inserted into the bladder. Transfusion and amlodipine were administered according to the patient's condition. There was no improvement in renal function seen, and so arteriovenous fistula surgery and regular hemodialysis were performed. Outcomes: The patient was discharged from the hospital with a bladder catheter. She was visited on a regular basis for catheter replacement and hemodialysis. Lessons: Patients with DS have lower intelligence than normal people and often do not recognize or complain about inconveniences, even in the presence of urinary symptom. NNB has good prognosis when treated early, but there is a risk of ESRD if the diagnosis and treatment are delayed, as was the case here. Considering that the prevalence of NNB and other urinary tract diseases is high in patients with DS, clinicians need to take careful histories and observe deeply, even if the patient does not mention certain issues.

Background: Technology-mediated interventions help overcome barriers to program delivery and spread metabolic syndrome prevention programs on a large scale. A meta-analysis was performed to evaluate the impact of these technology-mediated interventions on metabolic syndrome prevention. Methods: In this meta-analysis, from 30 January 2018, three databases were searched to evaluate interventions using techniques to propagate diet and exercise lifestyle programs for adult patients with metabolic syndrome or metabolic risk. Results: Search results found 535 citations. Of these, 18 studies met the inclusion criteria analyzed in this article. The median duration of intervention was 4 months and the follow-up period ranged from 1.5 to 30 months. The standardized mean difference (SMD) between the two groups was waist circumference −0.35 (95% CI −0.54, −0.15), triglyceride −0.14 (95% CI −0.26, −0.03), fasting blood glucose −0.31 (95% CI −0.42, −0.19), body weight −1.34 (95% CI −2.04, −0.64), and body mass index −1.36 (95% CI −2.21, −0.51). There was no publication bias in this study. Conclusion: Technology-mediated intervention improved clinically important metabolic syndrome related indicators such as excess body fat around the waist, fasting glucose, and body mass index. These interventions will play an important role in the dissemination of metabolic syndrome prevention programs.

Objectives Despite the evidence supporting the use of vitamin D supplements for managing atopic dermatitis (AD), no meta-analysis providing definite conclusions in this field has been reported. The purpose of the present study was to conduct a systematic review and meta-analysis of all controlled studies of vitamin D for treating AD to elucidate the efficacy of vitamin D for alleviating the symptoms of AD. Methods Literature searches were conducted using Ovid-MEDLINE, EMBASE, Web of Science, Cochrane Library, and Korean and Chinese databases. Search terms used were “vitamin D”, “atopic dermatitis”, “randomized”, “controlled trial”, and “clinical trial”. Random effects models were used to calculate the mean difference, with 95% confidence intervals to analyze the effects of vitamin D supplementation for severity of AD. Results Initial searches yielded 266 citations. Of these original results, nine met specific selection criteria. Four of the randomized controlled trials compared the efficacy of vitamin D with a placebo on severity of AD and were included in the meta-analysis. The vitamin D supplementation interventions showed a higher mean difference in severity of AD symptoms (mean difference = −5.81, 95% CI: −9.03 to −2.59, P = 0.0004, I2 = 50%). Conclusions Vitamin D has a potentially significant role for improving the symptoms of AD. The results from this study suggest that vitamin D supplementation may help ameliorate the severity of AD, and can be considered as a safe and tolerable therapy. However, larger-scale studies over a longer duration of treatment are needed to confirm this conclusion.

The renin–angiotensin system (RAS) has an important role in hepatic fibrosis and portal hypertension. RAS inhibitors are already accepted in clinical fields for antihypertensive management, but their effects on hepatic fibrosis are controversial. The aim of this study was to systematically review the effects of RAS inhibitors on hepatic fibrosis based on histological assessment. We performed a systematic review and meta-analysis (MA) of the literature using the Ovid-MEDLINE, EMBASE, and Cochrane Library databases (up to January 2015) to identify clinical studies evaluating the effects of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers on hepatic fibrosis or cirrhosis patients based on histological assessment. Of the 455 studies identified, we analyzed 7, including a total of 1066 patients, which met our selection criteria. According to the MA, patients treated with RAS inhibitors had significantly lower fibrosis scores (SMD −0.68, 95 % CI −1.03, −0.34, I 2 = 0 %, p

Background: Objectives were to provide an overview and understand the strength of evidence and extent of potential biases and validity of claimed associations between body mass index (BMI) and risk of developing cancer.Methods: We carried out an umbrella review and comprehensively re-analyzed the data of dose-response meta-analyses on associations between BMI and risk of 20 specific cancers (bladder, brain, breast, colonic, rectal, endometrial, gallbladder, gastric, leukemia, liver, lung, melanoma, multiple myeloma, non-Hodgkins lymphoma, esophagus, ovarian, pancreatic, prostate, renal, thyroid) by adding big data or missed individual studies. Convincing evidence for an association was defined as a strong statistical significance in fixed-effects and random-effects meta-analyses at P Results: Convincing evidence for an association with BMI was detectable for six cancers (leukemia, multiple myeloma, pancreatic, endometrial, rectal, and renal cell carcinoma). Suggestive evidence was detectable for malignant melanoma, non-Hodgkins lymphoma, and esophageal adenocarcinoma. Weak evidence was detectable for brain and central nervous system tumors, breast, colon, gall bladder, lung, liver, ovarian, and thyroid cancer. No evidence was detectable for bladder, gastric, and prostate cancer.Conclusions: The association of increased BMI and cancer is heterogeneous across cancer types. Leukemia, multiple myeloma, pancreatic, endometrial, rectal, and renal cell carcinoma are convincingly associated with an increased BMI by dose-response meta-analyses.

This study was a systematic review and meta-analysis comparing the effects of aquatic exercise and land-based exercise in the treatment of knee osteoarthritis. 7 studies (n=449) met selection and exclusion criteria out of 287 potential studies obtained from the literature search via Ovid-Medline, Cochrane Library CENTRAL, CINAHL,RISS and KISS. The overall risk of bias of selected studies using SIGN (Scottish Intercollegiate Guidelines Network)checklist for randomized controlled trials (RCT) was regarded as low. As a result of meta analysis, Standardized Mean Difference (SMD) for pain was -0.26(95% CI -0.49, -0.03, p=0.03, I²=14%), which implies that aquatic exercise groups had significant less pain than land-based exercise groups. On the other hand, there was no significant difference between aquatic exercise groups and land based exercise groups for flexion Range of Motion (ROM) (-0.12,95% CI -0.51, 0.27, p=0.53, I²=0%), extension ROM (-0.04, 95% CI -0.55, 0.48, p=0.89, I²=43%), physical function(-0.12, 95% CI -0.44, 0.19, p=0.44, I²=0%), Quality of Life (QOL) (-0.15, 95% CI -0.54, 0.24, p=0.46, I²=0%). Thisstudy has some limitations due to few RCTs comparing aquatic exercise groups and land-based exercise groups inthe treatment of knee osteoarthritis. Therefore, further RCTs should be conducted along with long-term outcomes.

Background & Aims The need for further histological subclassification of cirrhosis has been increasingly recognized because of the heterogeneity of severity within cirrhosis. We sought to identify evidence in the literature regarding the histological subclassification of cirrhosis using the Laennec stage. Methods We conducted a systematic review and meta-analysis by searching databases, including MEDLINE, EMBASE and the COCHRANE library, for relevant studies. Results Of 208 studies identified, 16 were eligible according to the inclusion criteria. With higher grades of the Laennec stage, clinical stages of cirrhosis and Child–Pugh scores/Model for end-stage liver disease scores increased (P

Aim This study aimed to examine the effect of tepid massage in febrile children comparing with other fever management. Methods Experimental studies published in English were included; quasi-experimental research studies were also included in consideration of rare experimental studies in Korean. The search strategy sought to identify published research reports in the English language and covered all major databases up to 2016. The methodological quality of each study was assessed by 2 independent reviewers using a Scottish Intercollegiate Guidelines Network's Methodology Checklist. Means and standard deviations were used for continuous variables, and standardized mean difference was used for variables of different scales. Heterogeneity was assessed using the I2 statistics after visual reviewing with forest plots. Results This study reviewed mainly the effect of tepid massage on temperature compared with the use of antipyretics, along with other adverse effects in relation with fever management. The results revealed no significant effect of tepid massage on temperature in febrile children. In addition, incidence rates of adverse effects including chills, goose pimples, and discomfort were higher in tepid massage groups. Conclusion This meta-analysis showed the need for re-verification of commonly used practice including the use of tepid massage and proper body temperature measurement.

Background Sarcopenia is a common syndrome in chronic diseases such as liver cirrhosis. The association between sarcopenia and outcomes, such as complications and survival has recently been described in various patient groups. However, study results remain inconclusive. Therefore, the aim of this study was to systematically review the impact of sarcopenia on outcome in patients with cirrhosis. Methods and findings We conducted a systematic review (SR) and meta-analysis (MA) on the impact of sarcopenia on outcome in liver cirrhosis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Of the 312 studies identified, 20 were eligible according to our inclusion criteria. Most of the studies used CT to diagnose sarcopenia. Two studies used bioelectrical impedance analysis (BIA), 10 studies used skeletal muscle index (SMI) and 8 studies used total psoas muscle area (TPA). Seven studies included Asian participants and the remaining 13 studies included Western participants. The prevalence rate of sarcopenia among participants was mean 48.1%, and appeared more among men with a rate of 61.6% whereas the rate was 36% for women. With respect to clinical outcomes, patients with sarcopenia had poorer survival rates and an increased risk of complications such as infection compared to those without sarcopenia. According to the analysis of race subgroup, Asians had a HR 2.45 (95% confidence interval (CI) = 1.44–4.16, P = 0.001) of mortality whereas Westerners had a HR 1.45 (95% CI = 1.002–2.09, P

Bone-anchored hearing aids (BAHAs) have been known to partially restore some of the functions lost in subjects with single-sided deafness (SSD). Our aims in this systemic review were to analyze the present capabilities of BAHAs in the context of SSD, and to evaluate the efficacy of BAHAs in improving speech recognition in noisy conditions, sound localization, and subjective outcomes.A systematic search was undertaken until August 2015 by two independent reviewers, with disagreements resolved by consensus. Among 286 references, we analyzed 14 studies that used both subjective and objective indicators to assess the capabilities of a total of 296 patients in the unaided and aided situations.Although there was "no benefit" of BAHA implantation for sound localization, BAHAs certainly improved subjects' speech discrimination in noisy circumstances. In the six studies that dealt with sound localization, no significant difference was found after the implantation. Twelve studies showed the benefits of BAHAs for speech discrimination in noise. Regarding subjective outcomes of using the prosthesis in patients with SSD (abbreviated profile of hearing aid benefit [APHAB] and the Glasgow hearing aid benefit profile [GHABP], etc.), we noticed an improvement in the quality of life.This systematic review has indicated that BAHAs may successfully rehabilitate patients with SSD by alleviating the hearing handicap to a certain degree, which could improve patients' quality of life. This report has presented additional evidence of effective auditory rehabilitation for SSD and will be helpful to clinicians counseling patients regarding treatment options for SSD.

Background/Aims We compared the cirrhosis-prediction accuracy of an ultrasonographic scoring system (USSS) combining six representative sonographic indices with that of liver stiffness measurement (LSM) by transient elastography, and prospectively investigated the correlation between the USSS score and LSM in predicting cirrhosis. Methods Two hundred and thirty patients with chronic liver diseases (187 men, 43 women; age, 50.4±9.5 y, mean±SD) were enrolled in this prospective study. The USSS produces a combined score for nodularity of the liver surface and edge, parenchyma echogenicity, presence of right-lobe atrophy, spleen size, splenic vein diameter, and abnormality of the hepatic vein waveform. The correlations of the USSS score and LSM with that of a pathological liver biopsy (METAVIR scoring system: F0-F4) were evaluated. Results The mean USSS score and LSM were 7.2 and 38.0 kPa, respectively, in patients with histologically overt cirrhosis (F4, P=0.017) and 4.3 and 22.1 kPa in patients with fibrotic change without overt cirrhosis (F0-F3) (P=0.025). The areas under the receiver operating characteristic (ROC) curves of the USSS score and LSM for F4 patients were 0.849 and 0.729, respectively. On the basis of ROC curves, criteria of USSS ≥6: LSM ≥17.4 had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 89.2%:77.6%, 69.4%:61.4%, 86.5%:83.7%, 74.6%:51.9% and 0.83:0.73, respectively, in predicting F4. Conclusions The results indicate that this USSS has comparable efficacy to LSM in the diagnosis of cirrhosis.

Background/Aims: We identified reports in the literature regarding the diagnostic accuracy of hepatic vein arrival time (HVAT) measured by contrast-enhanced ultrasonography (CEUS) to assess hepatic fibrosis in cirrhosis. Methods: The Ovid MEDLINE, Embase, and Cochrane databases were searched for all studies published up to 23 July 2015 that evaluated liver status using CEUS and liver biopsy (LB). The QUADAS-II (quality assessment of diagnostic accuracy studies-II) was applied to assess the internal validity of the diagnostic studies. Selected studies were subjected to a meta-analysis with MetaDisc 1.4 and RevMan 5.3. Results: A total of 12 studies including 844 patients with chronic liver disease met our inclusion criteria. The overall summary sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the HVAT measured by CEUS for the detection of cirrhosis compared to LB were 0.83 (95% confidence interval [CI], 0.77 to 0.89), 0.75 (95% CI, 0.69 to 0.79), 3.45 (95% CI, 1.60 to 7.43), and 0.28 (95% CI, 0.10 to 0.74), respectively. The summary diagnostic odds ratio (random effects model) was 15.23 (95% CI, 3.07 to 75.47), the summary receiver operator characteristics area under the curve was 0.74 (standard error [SE]=0.14), and the index Q was 0.69 (SE=0.11). Conclusions: Based on a systematic review, the measurement of HVAT by CEUS exhibited an increased accuracy and correlation for the detection of cirrhosis. (Gut Liver 2017;11:93-101)

Based on their ability to differentiate into multiple cell types including hepatocytes, the transplantation of mesenchymal stem cells (MSCs) has been suggested as an effective therapy for chronic liver diseases. The aim of this study was to evaluate the safety, efficacy and therapeutic effects of MSCs in patients with chronic liver disease through a literature-based examination. We performed a systematic review (SR) and meta-analysis (MA) of the literature using the Ovid-MEDLINE, EMBASE and Cochrane Library databases (up to November 2014) to identify clinical studies in which patients with liver diseases were treated with MSC therapy. Of the 568 studies identified by the initial literature search, we analyzed 14 studies and 448 patients based on our selection criteria. None of the studies reported the occurrence of statistically significant adverse events, side effects or complications. The majority of the analyzed studies showed improvements in liver function, ascites and encephalopathy. In particular, an MA showed that MSC therapy improved the total bilirubin level, the serum albumin level and the Model for End-stage Liver Disease (MELD) score after MSC treatment. Based on these results, MSC transplantation is considered to be safe for the treatment of chronic liver disease. However, although MSCs are potential therapeutic agents that may improve liver function, in order to obtain meaningful insights into their clinical efficacy, further robust clinical studies must be conducted to evaluate the clinical outcomes, such as histological improvement, increased survival and reduced liver-related complications, in patients with chronic liver disease.

A systematic review (SR) provides the best and most objective analysis of the existing evidence in a particular field. SRs and derived conclusions are essential for evidence-based strategies in medicine and evidence-based guidelines in clinical practice. The popularity of SRs has also increased markedly in the field of hepatology. However, although SRs are considered to provide a higher level of evidence with greater confidence than original articles, there have been no reports on the quality of SRs and meta-analyses (MAs) in the field of hepatology. Therefore, we performed a quality assessment of 225 SRs and MAs that were recently published in the field of hepatology (January 2011 to September 2014) using A MeaSurement Tool to Assess systematic Reviews (AMSTAR). Using AMSTAR, we revealed both a shortage of assessments of the scientific quality of individual studies and a publication bias in many SRs and MAs. This review addresses the concern that SRs and MAs need to be conducted in a stricter and more objective manner to minimize bias and random errors. Thus, SRs and MAs should be supported by a multi-disciplinary approach that includes clinical experts, methodologists, and statisticians.

Objective Studies have presented conflicting results regarding the accuracy of ultrasonography (US) for diagnosing portal hypertension (PH). We sought to identify evidence in the literature regarding the accuracy of US for assessing PH in patients with liver cirrhosis. Materials and methods We conducted a systematic review by searching databases, including MEDLINE, EMBASE, and the Cochrane Library, for relevant studies. Results A total of 14 studies met our inclusion criteria. The US indices were obtained in the portal vein (n = 9), hepatic artery (n = 6), hepatic vein (HV) (n = 4) and other vessels. Using hepatic venous pressure gradient (HVPG) as the reference, the sensitivity (Se) and specificity (Sp) of the portal venous indices were 69-88% and 67-75%, respectively. The correlation coefficients between HVPG and the portal venous indices were approximately 0.296-0.8. No studies assess the Se and Sp of the hepatic arterial indices. The correlation between HVPG and the hepatic arterial indices ranged from 0.01 to 0.83. The Se and Sp of the hepatic venous indices were 75.9-77.8% and 81.8-100%, respectively. In particular, the Se and Sp of HV arrival time for clinically significant PH were 92.7% and 86.7%, respectively. A statistically significant correlation between HVPG and the hepatic venous indices was observed (0.545-0.649). Conclusion Some US indices, such as HV, exhibited an increased accuracy for diagnosing PH. These indices may be useful in clinical practice for the detection of significant PH.

Tetrahydrobiopterin (BH4) is an essential cofactor in NO synthesis by endothelial nitric oxide synthase (eNOS) enzymes. It has been previously suggested that reduced intrahepatic BH4 results in a decrease in intrahepatic NO and contributes to increased hepatic vascular resistance and portal pressure in animal models of cirrhosis. The main aim of the present study was to evaluate the relationship between BH4 and portal hypertension (PHT). One hundred ninety-three consecutive patients with chronic liver disease were included in the study. Liver biopsy, measurement of BH4 and hepatic venous pressure gradient (HVPG) were performed. Hepatic fibrosis was classified using the Laennec fibrosis scoring system. BH4 levels were determined in homogenized liver tissues of patients using a high performance liquid chromatography (HPLC) system. Statistical analysis was performed to evaluate the relationship between BH4 and HVPG, grade of hepatic fibrosis, clinical stage of cirrhosis, Child-Pugh class. A positive relationship between HVPG and hepatic fibrosis grade, clinical stage of cirrhosis and Child-Pugh class was observed. However, the BH4 level showed no significant correlation with HVPG or clinical features of cirrhosis. BH4 concentration in liver tissue has little relation to the severity of portal hypertension in patients with chronic liver disease. Graphical Abstract

한국보건의료연구원, 울산대학교 의과대학 서울아산병원 외과 (1) , 인하대학교 의과대학 외과 (2) , 동국대학교 일산병원 가정의학과, 경북대 약학대학 Gaeun Kim, Sunyoung Jang, Youn-Baik Choi, Yoonseok Hur, Sang Woo Oh, Jin-Won Kwon Sunhee Lee National Evidence-based Healthcare Collaborating Agency; Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center; Department of Surgery, School of Medicine, Inha University; Department of Family medicine, Dongguk University Ilsan Hospital ; and College of Pharmacy, Kyungpook National University

·Young-Sun Lee, PhD·In-Hee Cho, MD·Myung-Min Choi, PhD·Myoung-Ho Hyun, PhD Offices of Research Planning and Health Services Research, National Evidence-based Healthcare Collaborating Agency, Department of Psychiatry, Seoul National University College of Medicine, Office of Planning & Evaluation, Korea Youth Counseling & Welfare Institute, Seoul, Department of Psychiatry, Inje University College of Medicine, Busan, Division of Mental Health Policy, Ministry of Health & Welfare, Department of Psychiatry, Sungkyunkwan University School of Medicine, Seoul, Department of Psychiatry, Jeju National University School of Medicine, Jeju, Department of Psychiatry, The Catholic University of Korea School of Medicine, Seoul, Goyang Community Mental Health Center, Goyang, Department of Psychiatry, Kangwon National University School of Medicine, Chuncheon, Office of Students and Parents Research, Korean Educational Development Institute, Department of Preventive Medicine, The Catholic University of Korea School of Medicine, Students Health Management Division, Ministry of Education, Science and Technology, Central Church of Korea Evangelical Holiness Church, Seoul, Department of Nursing, Inje University, Busan, Office of Counseling & Welfare, Korea Youth Counseling & Welfare Institute, Department of Psychology, Ewha Womans University, Seoul, Department of Psychiatry, Gil Hospital, Gachon University, Incheon, Department of Social Welfare, Baekseok University, Cheonan, Department of