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近年來衛生福利部倡議明智選擇(Choosing Wisely)，各醫療院所亦開始思索如何投入此運動。明智選擇是為了壓制低效益醫療對病人安全的傷害及醫療成本的損耗，在2012年由美國內科醫學會基金會開始倡議的新觀念，之後國際間相繼響應成為一項全球性的運動。活動透過各學會提出其領域最常見的5到10項過度診斷或過度治療的項目，彙整後形成一個建議清單，讓醫療人員及民眾得知哪些處置為低效益醫療，以便揚棄或減少使用。要正確執行明智選擇可透過限制、減量、和溝通三種方法來達成。醫病共享決策(Shared Decision Making, SDM)很多時候是協助溝通來達成明智選擇的手段之一。本文除了闡述了明智選擇的內涵、源起及執行方式，也說明了它和SDM的差異，希望對讀者認識及實踐明智選擇有所幫助。 As the Ministry of Health and Welfare campaigns for the idea of “Choosing Wisely,” hospitals in Taiwan have been working to see how they could contribute to this campaign. An initiative proposed by the American Board of Internal Medicine (ABIM) Foundation in 2012, Choosing Wisely serves to reduce the harm of low-value care to patient safety and the cost due to such care. This initiative later became a global movement with the support it gained from countries worldwide. In an event held by ABIM, they asked the participating associations to list 5 to 10 most common types of overdiagnosis or overtreatment in their fields. Based on items they provided, a list was then compiled to inform health-care professionals and the public of the low-value care practices for them to decide whether to stop or reduce such practices. The implementation of Choosing Wisely can be achieved through the actions of “Limit, Lean, or Listen”. Shared decision making is one of strategies to achieve Choosing Wisely through “Listening”. This article discussed the meaning, history, and implementation of Choosing Wisely and how it differs from shared decision making, with the aim of improving readers’ understanding and practice of Choosing Wisely. &nbsp

Whey protein (WP) can increase insulin secretion, produce an incretin effect, delay gastric emptying, and regulate appetite, resulting in improved glycemic control. We hypothesized that WP supplementation is associated with postprandial glycemia regulation in persons with type 2 diabetes mellitus (T2DM) and conducted a quantitative meta-analysis of randomized controlled trials (RCTs) to test this hypothesis. We searched PubMed, Embase, Cochrane Library, Scopus databases, and the ClinicalTrials.gov registry for relevant RCTs published before March 2022. We assessed the pooled effects using a random-effects model on glucose and insulin levels at 60 and 120 minutes, total glucagon-like peptide-1 (tGLP-1) at 30 and 60 minutes, and the incremental area under the curve (iAUC) of glucose, insulin, tGLP-1, and glucose-dependent insulinotropic polypeptide. Five RCTs involving 134 persons were included. Postprandial glycemia was significantly lower at 60 minutes (weighted mean difference: -2.67 mmol/L; 95% confidence interval, -3.62 to -1.72 mmol/L) and 120 minutes (-1.59 mmol/L; -2.91 to -0.28 mmol/L) in WP group than in placebo group. The iAUC of insulin was significantly higher in WP group (24.66 nmol/L × min, 1.65-47.66 nmol/L × min) than in placebo group. Although other results favored the WP group, differences between the groups were not statistically significant. The present study showed that premeal WP supplementation is beneficial for postprandial glycemia in persons with mild or well-controlled T2DM without substantial adverse effects. However, the level of certainty of current evidence is not high enough. Further larger and well-designed clinical trials are warranted for evaluating optimal dose and long-term effects of WP supplementation.

Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids. The necessity of preoperative enema preparation (PEP) in hemorrhoidal surgery is inconclusive. This study aims to evaluate the benefit and safety of PEP in hemorrhoidal surgery.This comparative study analyzed data from electronic medical record database and outpatient questionnaire archive. Data of patients who underwent hemorrhoidal surgery from March 2020 to February 2021 were obtained. Patients were allocated to either the PEP or non-PEP group. Primary outcome measurements were postoperative pain and oral analgesic use. Secondary outcomes were the number of days until first defecation, length of hospital stay, time to return to work, incidence of urinary retention, delayed bleeding, and local infection.Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups, respectively, who underwent hemorrhoidal surgery were analyzed. Most patients underwent stapled hemorrhoidopexy, with 106 (81.54%) in PEP group and 113 (80.71%) in non-PEP group. The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups.Our findings revealed that performing PEP before hemorrhoidal surgery produced no benefit when compared with not performing PEP. Typically, the procedure of PEP is inconvenient and discomforting for patients. Therefore, we suggest that it can be omitted in hemorrhoidal surgery.

BACKGROUND Omentectomy is conventionally performed in the procedure of gastrectomy for gastric cancer. However, the clinical value and importance of omentectomy remain unclear. This meta-analysis investigated the benefits and safety of gastrectomy with or without omentectomy for patients with gastric cancer. METHODS A literature search was conducted in PubMed, Embase, and the Cochrane Library for studies comparing complete omentectomy with omentum preservation or partial omentectomy. Primary outcomes were overall survival, relapse-free survival, and incidences of recurrence and complications, whereas secondary outcomes were the total length of operation and the amount of blood loss. RESULTS Nine studies involving 3,561 patients were included. Our meta-analysis revealed no significant differences between omentectomy and omentum preservation in terms of the 5-year overall survival (risk ratio [RR] = 0.95, 95% confidence interval [CI] = 0.89-1.01), 5-year relapse free survival (RR: 0.96, 95% CI: 0.89-1.03), incidence of recurrence in the peritoneum or other visceral organs (RR: 1.13, 95% CI: 0.80-1.60 and RR: 1.06, 95% CI: 0.78-1.45, respectively), and incidence of complications (RR: 1.15, 95% CI: 0.89-1.50). Moreover, omentum preservation significantly reduced the total length of operation (mean difference [MD] 25.70, 95% CI: 3.23-48.17) and the amount of blood loss (MD: 56.29, 95% CI: 14.02-98.56). CONCLUSION Omentectomy may not be necessary and can be omitted during gastrectomy for gastric cancer.

Background: Patients with breast cancer usually encounter difficulties in making treatment decisions. Shared decision making (SDM) is a way to minimize decisional conflicts of patients, and patients’ decision aids (PDAs) have been developed to support the implementation of SDM. However, the effect of PDAs in Asia is inconclusive. Therefore, we developed a randomized controlled trial to evaluate the effect of SDM assisted by PDAs on decisional conflict among patients with breast cancer in Taiwan. Methods: This is a two-group, outcome assessor-blind, randomized, controlled trial. A total of 151 patients diagnosed with breast cancer were assigned to the PDAs group or the classic group. Demographic and clinical variables were analyzed to identify the variables influencing the treatment choice. The patients’ decision-making difficulties were evaluated using the 4-item SURE scale during the pre-operative hospitalization, and the decisional conflicts were assessed by the 5-item Decision Regret scale and Hospital Anxiety and Depression Scale (HADS) at one month postoperatively.Results: The choice of breast conservation therapy and mastectomy was not significantly different between the PDA and classic groups. Compared with the classic group, patients in PDA group had more depression after making decision (P = 0.029). No significant difference was noted in terms of the total scores in the SURE scale and Decision Regret scale between the groups.Conclusions: Our study revealed that PDA did not assist breast cancer patients in decision making. Clinicians should focus on SDM based on evidence-based medicine with care, and help patients taking their individual preference into consideration. Citation Format: Ka-Wai Tam, Shi-Qian Lin. Influence of shared decision making with decision aids on decisional conflict and regret in breast cancer surgery: A randomized controlled trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-15-05.

The preservation of fertility in women of childbearing age with breast cancer is challenging because the time for ovarian stimulation is restricted and only a limited number of oocytes can be retrieved before gonadotoxic therapies. The aim of this meta-analysis was to evaluate the fertility preservation outcomes after ovarian stimulation with various protocols in women with breast cancer. PubMed, Embase and the Cochrane Library were searched. Twenty-two studies comparing the outcomes of women with breast cancer receiving random-start ovarian stimulation or conventional protocol; single or double ovarian stimulation cycles; and coadministration of aromatase inhibitors or tamoxifen were included. Random-start ovarian stimulation resulted in a comparable number of retrieved oocytes to the conventional protocol. Two ovarian stimulation cycles had significantly higher numbers of total retrieved oocytes than one cycle (mean difference 7.91, 95% confidence interval [CI] 3.42 to 12.40). Coadministration of letrozole and tamoxifen showed similar results for retrieved oocytes to those without. A significantly lower peak serum oestradiol concentration was observed in letrozole-based groups than in letrozole-free groups (mean difference -1.22; 95% CI -1.42 to -1.02). In conclusion, this study indicated that implementing random-start protocols to shorten the duration of waiting for ovarian stimulation, applying two ovarian stimulation cycles, and coadministration of letrozole can lead to more desirable outcomes.

Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT.The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed.The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT.Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.

Background Whether peritoneal lavage is beneficial for the postoperative outcomes of appendectomy is debatable. This study is a meta-analysis of randomized controlled trials (RCTs) that aimed to determine whether peritoneal lavage leads to improved appendectomy outcomes. Methods PubMed, Embase, and Cochrane Library databases were searched for articles published before September 2020. The meta-analysis calculated the pooled effect size by using a random effects model. The primary outcome was the incidence of intra-abdominal abscess. Secondary outcomes were the incidence of surgical-site infection, hospital stay duration, operation time, and readmission incidence. Results Eight RCTs involving 1487 patients were reviewed. The lavage group had a nonsignificantly lower incidence of intra-abdominal abscess (risk ratio [RR]: 0.81; 95% confidence interval [CI]: 0.55–1.18) and surgical-site infection (RR: 0.73; 95% CI: 0.31–1.72) than did the nonirrigation group. Furthermore, the lavage group showed a nonsignificantly shorter hospital stay duration and lower readmission incidence than did the nonirrigation group. However, the lavage group required significantly more operation time than did the nonirrigation group (mean difference: 7.59 min; 95% CI: 4.67–10.50). Conclusion Our study revealed that performing peritoneal lavage has no advantage over suction or drainage only in appendectomy. Moreover, peritoneal lavage significantly increased operation time. Consequently, for improving efficiency and reducing operation time, we suggest skipping peritoneal irrigation during appendectomy. However, the available evidence is of variable quality; therefore, high-quality prospective RCTs are required in the future.

Competency-based public communication skills are not systematically taught in most medical curricula, reflecting a gap between medical knowledge and holistic patient care as trainees transition into clinicians. We sought to investigate the efficacy of technology, entertainment, and design (TED) talks in postgraduate year (PGY) training programs.The authors organized an official internal TEDx event in which six PGY trainees volunteered as speakers. Two experienced physicians and two administrators also participated as speakers to provide trainees a didactic shadow learning experience. The remaining PGY trainees, along with clerks, physicians, nurses, pharmacists, and administrators, attended the conference. Before the event, speakers undertook individual training sessions and learned the principles of the presentation structure and storytelling mode. At the end of the event, a survey evaluating overall satisfaction in communication skills and professionalism was administered to all of the attendees.Survey participants totaled 104, with a response rate of 97.2%. TEDx talks improved trainees' levels of patient care, communication, and professionalism. Speakers reported the high level of satisfaction with the event (mean 4.96 on a 5-point Likert scale; standard deviation 0.20). Participants agreed that the shadowing experience was useful and that the event encouraged them to pursue interests outside the medical field.This study highlights that TED is successful in terms of participant satisfaction and training in communication and professionalism. Engaging and training PGY trainees through TED-style events could bridge the gap between acquired knowledge and professional competencies. The authors recommend the implementation of TED-style events in medical training programs.

INTRODUCTION Early feeding was previously considered to increase the risk of postprocedural bleeding. However, many trials have demonstrated the benefits of early feeding after therapeutic endoscopic procedures. We conducted a meta-analysis of randomized controlled trials to evaluate the safety and outcomes between early feeding and delayed feeding after therapeutic endoscopic procedures. METHODS Medline (PubMed), Embase, Google Scholar, the Cochrane Library, and clinicaltrials.gov were searched to identify randomized controlled trials that met our inclusion criteria. The pooled data for the mortality rate, postprocedural bleeding rate, and length of hospital stay were analyzed. RESULTS A total of seven trials consisting of 717 patients were reviewed. These seven trials examined various therapeutic endoscopic procedures. Three trials included patients undergoing endoscopic hemostasis for upper gastrointestinal bleeding, two included patients undergoing esophageal variceal ligation, and two included patients with gastric neoplasm treated with endoscopic submucosal dissection. Although no significant differences were observed in the postprocedural bleeding rate or the mortality rate between patients who received early feeding and those who received delayed feeding, early feeding resulted in shorter hospital stays (weighted mean difference -1.04, 95% confidence interval -1.45 to 0.63). CONCLUSION Early feeding appears to be a safe management method for patients undergoing therapeutic endoscopic procedures. Therefore, we recommend early feeding for these patients.

Background Ampullary carcinoma patients require radical resection for optimal survival; however, the outcomes are often unsatisfactory. The utility of adjuvant therapy among such patients is unclear, probably owing to its potential side effects. Therefore, this study investigated the benefits and safety of adjuvant therapy in resected ampullary carcinoma. Methods Cochrane, Embase, Medline, and PubMed databases were systematically searched for eligible studies, and those comparing adjuvant therapy and surgical treatment alone were included. Hazard ratios for survival outcomes and the number of adverse events for safety endpoints were extracted and subjected to pooled analyses through a random-effects model. Results In total, 27 studies involving 3,538 patients were included. Adjuvant therapy was significantly associated with decreased mortality risk (hazard ratio, 0.58; 95% confidence interval 0.40–0.84), especially for chemoradiotherapy (hazard ratio, 0.42; 95% confidence interval 0.28–0.62). Furthermore, adjuvant therapy was significantly associated with increased overall survival among high-risk patients (hazard ratio, 0.63; 95% confidence interval 0.48–0.82) or those with the pancreaticobiliary subtype (hazard ratio, 0.53; 95% confidence interval 0.32–0.85). By contrast, adjuvant therapy was not associated with improved overall survival among low-risk patients (hazard ratio, 0.93; 95% confidence interval 0.52–1.68) or those with the intestinal subtype (hazard ratio, 1.06; 95% confidence interval 0.57–1.95). Regarding the safety of adjuvant therapy, no intervention-related mortality occurred, and severe adverse events were within the acceptable range (risk difference, 0.04; 95% confidence interval 0.01–0.08). Conclusion The present results suggest that adjuvant therapy is safe and extends survival in high-risk patients or those with the pancreaticobiliary subtype of ampullary carcinoma.

Objective Uterine fibroids are one of the most common gynaecological tumours in premenopausal women. The conventional surgical treatments are myomectomy and hysterectomy, but high-intensity focused ultrasound (HIFU) is a new noninvasive treatment creating no surgical wound. The aim of this study was to evaluate the effectiveness and safety of HIFU treatment compared with conventional surgery for patients with uterine fibroids. Data sources PubMed, Embase, and the Cochrane Library were searched for studies published before January 2021. Methods of study selection Studies comparing the outcome of HIFU and conventional surgery-myomectomy and hysterectomy-for patients with uterine fibroids were included. We conducted meta-analyses by using a random effects model. Uterine fibroid symptom score and the quality of life score were analysed using the weighted mean difference (MD). The recovery time and frequency of major adverse events were also evaluated. Tabulation, integration, and results Ten studies were included. HIFU relieved uterine fibroid symptom significantly when compared to conventional surgery at 6 (MD: -1.61, 95% confidence interval [CI]: -2.88 to -0.33) and 12 (MD: -2.44, 95% CI: -3.68 to -1.20) months after treatment. Similarly, HIFU group improve the quality of life score significantly at 6 (MD: 2.14, 95% CI: 0.86 to 3.42) and 12 (MD: 2.34, 95% CI: 0.82 to 3.86) months after treatment when compared with surgery group. Conclusion HIFU could be an effective and safe treatment option for patients with uterine fibroids. However, one of its side effects, skin burns, requires further research and discussion. Additional studies involving more randomized controlled trials are warranted.

Objectives Although postpartum rooming-in is encouraged by the World Health Organization, independent separated nursery care is still widely adopted in Eastern countries. Our aim is to evaluate the effect of shared decision making (SDM) assisted by patient decision aids on subjective decisional conflict and regret among women who are required to make choices regarding postpartum infant care. Methods A total of 196 pregnant women who came for routine checkups 1 month before delivery were randomly assigned to the SDM group or the classic group. Before the mothers were discharged after delivery, their decision-making difficulties were evaluated. The primary outcome was the decisional conflict, which was assessed using the SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) scale. The secondary outcome was the decisional regret, which was measured using the Decision Regret scale. Results Compared with the classic group, SDM group had surer feelings about the choice (P＜.001), felt more confident about knowing the benefits and risks of each option (P＜.001), had a clearer understanding of the benefits and risks (P＜.001), and felt sufficiently supported with enough advice to make a suitable choice (P＜.001). No significant difference was noted in the Decision Regret scores between groups. The choice of 24-hour rooming-in, 12-hour rooming-in, and separated nursery care was not significantly different between groups. Conclusions SDM reduced the decisional conflict and uncertainty of the mothers. Available choices of postpartum mother–infant care should be provided to mothers through SDM that includes individual values, health goals, and clear knowledge and transparency.

BACKGROUND: The benefits of branched-chain amino acid (BCAA) administration after hepatic intervention in patients with liver diseases remains unclear. We conducted a systematic review and meta-analysis to evaluate the effects of BCAA on patients undergoing hepatectomy, trans-arterial embolization, radiofrequency ablation. METHODS: Relevant randomized controlled trials (RCTs) were obtained from PubMed, EMBASE, and Cochrane Library databases. A meta-analysis was performed to calculate the pooled effect size by using random-effects models. The primary outcomes were survival, hospital stay, nutrition status, and biochemistry profile. The secondary outcomes were the complication rate of liver treatment and adverse effect of BCAA supplementation. RESULTS: In total, 11 RCTs involving 750 patients were included. Our meta-analysis showed no significant difference in the rates of tumorrecurrence and overall survival between the BCAA and control groups. However, the pooled estimate showed that BCAA supplementation in patients undergoing hepatic intervention significantly increased serum albumin (mean difference [MD]: 0.11 g/dL, 95% confidence interval [CI]: 0.02–0.20) at 6 months and cholinesterase level (MD: 50.00 U/L, 95% CI: 21.08–78.92) at 12 months, increased body weight (MD: 3.29 kg, 95% CI: 1.07–5.50) at 12 months, and reduced ascites incidence (risk ratio: 0.39, 95% CI: 0.21–0.71) compared with the control group. Additionally, BCAA administration shortened the hospital stay length (MD: −2.36 days, 95% CI: −4.78 to 0.07) compared with the control group. CONCLUSION: BCAA supplementation significantly reduced postintervention complication and hospitalization duration and increased body weight. Thus, BCAA supplementation may benefit patients undergoing liver intervention.

Context: Athletes must maintain their peak state of strength. Previous studies have investigated the effect of low-level laser therapy (LLLT) on muscular performance. A previous systematic review and meta-analysis has investigated this issue in healthy participants but not in physically active athletes. Objective: To investigate whether LLLT can improve muscular performance and soreness recovery in athletes. Data Sources: PubMed, EMBASE, and Cochrane Library. Study Selection: Published randomized controlled trials and crossover studies till December 2020. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 3. Data Extraction: Assessment of study quality was rated using the risk of bias assessment method for randomized trials (Cochrane Handbook for Systematic Reviews of Interventions). Results: A total of 24 studies were included. LLLT application before exercise significantly improved lower-limb muscle strength in 24-hour, 48-hour, 96-hour, and 8-week follow-up groups. Furthermore, decreased soreness index, serum creatine kinase concentrations, interleukin-6, and thiobarbituric acid reactive substance concentrations and a trend toward the improvement of contract repetition number and VO2 kinetic outcomes were observed. Conclusion: Although a definite therapeutic effect of LLLT is yet to be established, the current evidence supports that LLLT use improves muscular performance in physically active athletes. Additional trials with large sample sizes and robust design should be conducted before strong recommendations are made.

Obstructive sleep apnea (OSA) is frequently accompanied by hypertension, resulting in cardiovascular comorbidities. Continuous positive airway pressure is a standard therapy for OSA but has poor adherence. Inspiratory muscle training (IMT) may reduce airway collapsibility and sympathetic output, which may decrease OSA severity and blood pressure. In this meta-analysis of randomized controlled trials (RCTs), we evaluated the efficacy of IMT in patients with OSA.We searched PubMed, EMBASE, Cochrane Library, Web of Science, and ClinicalTrials.gov databases for relevant RCTs published before November 2022.Seven RCTs with a total of 160 patients with OSA were included. Compared with the control group, the IMT group exhibited significantly lower systolic and diastolic blood pressure (mean difference [MD]: - 10.77 and - 4.58 mmHg, respectively), plasma catecholamine levels (MD: - 128.64 pg/mL), Pittsburgh Sleep Quality Index (MD: - 3.06), and Epworth Sleepiness Scale score (MD: - 4.37). No significant between-group differences were observed in the apnea-hypopnea index, forced vital capacity (FVC), ratio of forced expiratory volume in 1 s to FVC, or adverse effects. The data indicate comprehensive evidence regarding the efficacy of IMT for OSA. However, the level of certainty (LOC) remains low.IMT improved blood pressure- and sleep-related outcomes without causing adverse effects and may thus be a reasonable option for lowering blood pressure in patients with OSA. However, additional studies with larger sample sizes and rigorous study designs are warranted to increase the LOC.

Quetiapine is a common off-label antipsychotic drug for treating insomnia. Its effects in different disease conditions and dosages remain unclear. We conducted a systematic review and meta-analysis in clinical trials examining the efficacy of low-dose quetiapine in sleep. We obtained 21 clinical trials. Mean difference (MD), standard mean difference (SMD), and odds ratio (OR) were used to estimate the effect sizes using a random-effects model. The pooled results showed that quetiapine improved sleep quality compared with placebo (SMD: -0.57 [95%CI: -0.75, -0.4]). The SMD of sleep quality was correlated with age (coefficient: -0.0174) and sex (coefficient: -0.012). The significant effects were observed in the general anxiety disorder (SMD: -0.59 [95%CI: -0.92, -0.27]), major depressive disorder (SMD: -0.47 [95%CI: -0.66, -0.28]), and healthy (SMD: -1.33, [95%CI [-2.12, -0.54]) subgroups, at the dosage of 50 mg (SMD: -0.36 [95%CI: -0.36, -0.11]), 150 mg (SMD: -0.4 [95%CI: -0.52, -0.29]), and 300 mg (SMD: -0.17 [95%CI: -0.31,-0.04]). Quetiapine increased total sleep time compared with placebo (MD: 47.91 [95%CI: 28.06, 67.76]) but not when compared with other psychiatric drugs (MD: -4.19 [95%CI: -19.43, 11.05]). Adverse events (AEs) and discontinuation due to AEs were common among the quetiapine users. Quetiapine is effective as a sleep-helping drug. Precaution is suggested when interpreting the results on the elderly due to the high heterogeneity caused by incorporating patients over 66 years in the meta-analyses. We recommend an initial dosage of 50-150 mg/day with priority consideration for the elderly with GAD or MDD while monitoring its potential AEs.

Phyllodes tumor is rare but has a high recurrence rate. Treatment modalities and clinicopathological prognostic factors for recurrence remain unclear. The synthesis of real-world data can enable the integration of sufficient evidence on optimal treatment for this population.We searched PubMed, Embase, and Cochrane Library databases for studies focusing on the management of phyllodes tumor including the surgical margin, different clinicopathological prognostic factors, and postoperative adjuvant radiotherapy versus no radiotherapy.Fifty-two studies were retrieved. The pooled estimated recurrence rates of benign, borderline, and malignant tumors were 7.1%, 16.7%, and 25.1%, respectively. Surgical margins of 1 mm (odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.27-0.61) and 1 cm (OR: 0.45, 95% CI: 0.15-0.85) resulted in significantly higher recurrence rates. Postoperative adjuvant radiotherapy significantly reduced the recurrence rate of malignant tumors relative to no radiotherapy (P = 0.034) but did not significantly reduce the recurrence rates of overall and borderline tumors. Regarding clinicopathological features, moderate or severe stromal atypia and hypercellularity, stromal overgrowth, mitotic number of 5, tumor necrosis, tumor border, and margin status were determined as independent prognostic factors for recurrence, except a tumor size of 5 cm.The ideal surgical margin for phyllodes tumor incision should be at least 1 cm in width. Adjuvant radiotherapy reduced the recurrence of malignant tumor. By identifying patients with poor clinicopathological risk factors, surgeons may reduce the recurrence rate of phyllodes tumor.

Androgen deprivation therapy (ADT) can cause several adverse effects, including cancer-related fatigue (CRF). CRF has multiple manifestations, with no definitive treatment to date. Among management, exercise has been a field with high complexity and uncertainty. In other words, it has much potential to be explored. To evaluate whether exercise reduces cancer-related fatigue (CRF) in patients receiving androgen deprivation therapy (ADT).Randomized controlled trials were included and searches were performed from PubMed, Embase, and Cochrane Library databases. We extracted and pooled the CRF, quality of life (QoL), muscle strength, and adverse event severity. The study is registered with PROSPERO (number: CRD 42020203165). Eightteen RCTs were included. The CRF in the exercise group (SMD: -0.18, 95% CI: -0.31 to -0.05) was significantly lower than in the usual care group. The CRF subgroup analysis showed a significant reduction in the immediate exercise group (SMD: -0.37, 95% CI: -0.61 to -0.13), and the combined exercise group (aerobic plus resistance)(SMD: -0.18, 95% CI: -0.36 to -0.01). QoL improvement was also known in the exercise group (SMD: 0.16, 95% CI: 0.01 to 0.32). Leg press and chess press increase ability in the exercise group (SMD: 0.5, 95% CI: 0.42 to 1.05; SMD: 0.42, 95% CI: 0.17 to 0.67, respectively). The enhanced ability of leg press and chess press can also help patients deal with the feeling of CRF.Exercises improve CRF, QoL, and muscle strength in patients receiving ADT. We suggest immediate combined exercise intervention as supportive therapy to relieve cancer-related fatigue and enhance QoL.

BACKGROUND: Patients with amyotrophic lateral sclerosis (ALS) develop respiratory failure and progressive muscle weakness. The effects of pulmonary rehabilitation on the lung function of patients with ALS are unclear. OBJECTIVE: Through this meta-analysis of randomized controlled trials (RCTs), we evaluated the effects of pulmonary rehabilitation, such as type of treatment, on patients with ALS and compared the effectiveness of this treatment. METHODS: PubMed, EMBASE, Web of Science, and Cochrane databases were searched until December 2020. The methodological quality of each study was assessed using the updated Cochrane Risk of Bias tool (RoB 2.0). Data were analyzed using Review Manager version 5.4 (Cochrane Collaboration, Oxford, England), and the meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. RESULTS: Of 2168 articles, 10 trials were reviewed; among these trials, two focused on respiratory training and eight on physical exercise, three of which involved a combination of aerobic and resistance training. Our meta-analysis demonstrated no difference in the ALSFRS-R score and % FVC among patients with ALS. CONCLUSIONS: Respiratory training or physical exercise did not significantly affect the ALSFRS-R score and % FVC of patients with ALS. At 12 months after intervention, the ALSFRS-R score in the physical exercise group was higher than that in the usual care group. Further clinical trials are warranted to develop approaches for improving the lung function of patients with ALS.

Background: Concurrent use of valproate and carbapenem antibiotics may decrease serum valproate concentration (SVC). This study evaluated the effects of carbapenem–valproate drug interactions. Rese...

Safety in creating a preperitoneal space is crucial in laparoscopic totally extraperitoneal (TEP) hernia repairs. In this systematic review and meta-analysis, we compared the outcomes of balloon dissection and telescopic dissection in patients with inguinal or femoral hernias who underwent TEP hernia repair.We searched PubMed, Embase, Web of Science, and Cochrane databases for randomized controlled trials (RCTs) and prospective and retrospective studies published from inception to July 2022. Meta-analysis was performed using a random-effects model. The treatment outcome was measured using operation time, incidence of intraoperative hemorrhage, peritoneal laceration, conversion to other approaches, surgical site infection (SSI), hematoma, seroma formation, hernia recurrence, and postoperative pain.Five RCTs, one prospective study, and two retrospective studies (in total, 936 patients) were included. No significant between-group differences were noted in operation time, SSI, hematoma, seroma, recurrence rate, and postoperative pain on days 1 and 7. The conversion rate was significantly lower in the balloon group than in the telescopic group (odds ratio, 0.34; 95% confidence interval, 0.15-0.81).Both balloon dissection and telescopic dissection are viable techniques for creating preperitoneal space in laparoscopic TEP hernia repair and have similar operation time, complication rate, and postoperative pain. Nevertheless, the conversion rate was lower in patients undergoing balloon dissection than in those undergoing telescopic dissection.

Patients with breast cancer encounter difficulties in making surgical treatment decisions. Shared decision-making (SDM) with patient decision aids (PDAs) can minimize patients' decisional conflicts. However, the effect of PDAs in Asia remains inconclusive. This study investigated the effect of SDM assisted by PDAs on the decisional conflict of patients with breast cancer.In this two-group, outcome assessor-blind, randomized controlled trial, 151 patients diagnosed as having breast cancer were assigned to the PDA (SDM with PDA) group or the standard (SDM without PDA) group. Demographic and clinical variables were analyzed to identify variables affecting the treatment choice. The patients' decision-making difficulties were evaluated using the four-item SURE scale during preoperative hospitalization, and decisional conflicts were examined using the five-item Decision Regret scale and Hospital Anxiety and Depression Scale (HADS) 1 month after surgery.The choice of breast conservation therapy and mastectomy did not significantly differ between the PDA and standard groups. The PDA group had a higher level of depression after making decisions (P = 0.029) than did the standard group. No significant difference in the total scores of the SURE scale and Decision Regret scale were noted between the groups.PDAs did not assist the patients with breast cancer in making breast surgery-related decisions. Clinicians should focus on SDM grounded in evidence-based medicine with care and help patients consider their individual preferences.ClinicalTrial.gov, NCT03105076; April 7, 2017 ( http://www.gov ).

Objective: Currently, pharmaceutical treatment options for autism spectrum disorder are limited. Brain glutaminergic dysregulation is observed in autism spectrum disorder. N-acetylcysteine, which can be converted to glutathione and subsequently release glutamate into the extracellular space, and thus reduce glutamatergic neurotransmission at synapses, is considered a potential drug for autism spectrum disorder treatment. Here, we analyzed the treatment effects of N-acetylcysteine on autism spectrum disorder in randomized controlled trials. Study design: Updated systematic review and meta-analysis. Data sources: By systematically searching the PubMed, Embase and Cochrane Library, we obtained five randomized controlled trials. Study selection: Meta-analyses were performed to examine the improvement in autistic behaviors as measured by the Aberrant Behavior Checklist, Social Responsiveness Scale and Repetitive Behavior Scale–Revised, using mean difference with a 95% confidence interval and a random-effects model. Data Synthesis: After 8–12 weeks of N-acetylcysteine supplementation, the pooled result of four trials revealed an improvement in Aberrant Behavior Checklist total score (mean difference = 1.31, 95% confidence interval = [0.42, 2.20]). When one trial was excluded, the sensitivity test result was stronger (mean difference = 1.88, 95% confidence interval = [0.92, 2.83]). The pooled results of three trials revealed significant improvements in hyperactivity (mean difference = 4.80, 95% confidence interval = [1.20, 8.40]) and irritability (mean difference = 4.07, 95% confidence interval = [1.13, 7.04]). Regarding Social Responsiveness Scale, the pooled result of two trials showed significant improvement in social awareness after 8–12 weeks of N-acetylcysteine supplementation (mean difference = 1.34, 95% confidence interval = [0.09, 2.59]). No differences were observed in the pooled results of two trials using Repetitive Behavior Scale, either in the total or the subscales. Conclusion: We concluded that N-acetylcysteine is safe and tolerable, reduces hyperactivity and irritability and enhances social awareness in children with autism spectrum disorder. However, further evidence should be sought before a general recommendation.

PURPOSE: Two types of intraocular lenses (IOLs), namely ultraviolet-filtering IOL (UVF-IOL) and blue-light-filtering IOL (BF-IOL), are used to replace the aging lens in cataract patients. This provides a clinical scenario to investigate the BF and UVF effects on circadian rhythm. We revisited this topic and conducted an updated meta-analysis investigating the effects of UVF-IOL and BF-IOL on sleep quality. METHODS: A literature search was conducted using the PubMed, Embase, and Cochrane Library databases, and finally, four randomized controlled trials, one nonrandomized controlled study, and two cohort studies were included in this meta-analysis. RESULTS: The fixed-effect model revealed a significantly larger sleep quality improvement in the UVF-IOL group than in the BF-IOL group (standard mean difference [SMD] = 0.10, 95% confidence interval [CI]: 0.00–0.21) at 3–8 weeks but not 7–12 months after IOL implantation (SMD = 0.03, 95% CI: −0.08 to 0.13). The random effects model revealed no difference between groups at 3–8 weeks (SMD = 0.16, 95% CI: −0.07 to 0.39) and 7–12 months (SMD = 0.03, 95% CI: −0.08 to 0.13) after IOL implantation. CONCLUSIONS: Our study found some weak evidence supporting that UVF-IOL implantation demonstrated a greater improvement in subjective sleep quality than the BF-IOL implantation only in a shorter period but not in a longer period. More trials should be conducted before further recommendations. Nevertheless, our study provides some insights into the effects of short wavelength electromagnetic radiation on the circadian rhythm. PROSPERO registration number: CRD42019128832.