Rhubarb-based Chinese herbal formulae for hepatic encephalopa-thy:a systematic review and Meta-analysis

OBJECTIVE: To evaluate the effectiveness and safety of rhubarb-based Chinese herbal formulae(RCHF), which are widely used to treat hepatic encephalopathy(HE) in China.METHODS: Nine online databases were searched from inception to November 22, 2016. Eligible studies were randomized controlled trials of Traditional Chinese Medicine(TCM) treatment for adult patients(≥ 18 years old) with HE. Outcomes such as mortality rate, clinical response rate, blood ammonia level, and alanine aminotransferase were evaluated between TCM group and control group.RESULTS: Thirty studies involving 2661 HE patients were analyzed. Most studies used RCHF treatment.Compared with conventional treatment as usual,lactulose, and vinegar, RCHF were associated with significant improvement in clinical response rate[risk ratio(RR) = 1.33, 95% confidence interval(CI) =1.25, 1.43, I2= 0%; RR = 1.26, 95% CI = 1.14, 1.38, I2=22%; and RR = 1.19, 95% CI = 1.06, 1.33, I2= 0%, respectively] and significant reductions in levels of blood ammonia and alanine aminotransferase. Only minor RCHF-associated adverse events, such as abdominal pain(0.3%), anal tenesmus(0.3%), and diarrhea(2.3%), were reported, and there were no significant differences in these events between the treatment group and the three types of control group.CONCLUSION: The findings suggest that RCHF may be an alternative treatment option for HE patients. More rigorous multicenter studies with larger samples and longer observational periods are needed to confirm these findings.

Endoscopic pancreatic duct stenting for pain palliation in selected pancreatic cancer patients:a systematic review and meta-analysis

Background Abdominal pain is a debilitating symptom affecting-80%of pancreatic cancer(PC)patients.Pancreatic duct(PD)decompression has been reported to alleviate this pain,although this practice has not been widely adopted.We aimed to evaluate the role,efficacy,and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.Methods A systematic review until 7 October 2020 was performed.Two independent reviewers selected studies,extracted data,and assessed the methodological quality.Results We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain,in whom PD decompression was attempted,and was successful in 167 patients(mean age 62.5 years,58.7%males).The use of plastic stents was reported in 159 patients(95.2%).All included studies reported partial or complete improvement in pain levels after PD stenting,with an improvement rate of 93%(95%confidence interval,79%-100%).The mean duration of pain improvement was 94616 days.Endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events(AEs)were postsphincterotomy bleeding(1.8%),post-ERCP pancreatitis(0.6%),and hemosuccus pancreaticus(0.6%).AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression.In the 167 patients with technical success,the stent-migration and stent-occlusion rates were 3.6%and 3.0%,respectively.No AE-related mortality was reported.The methodological quality assessment showed the majority of the studies having low or unclear quality.Conclusion In this exploratory analysis,endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain.However,a randomized–controlled trial is needed to delineate the role of this invasive practice.

Systematic review of mixed cryoglobulinemia associated with hepatitis E virus infection:association or causation?

Background and aim:Mixed cryoglobulinemia(MC)has been associated with several viral infections,and chronic hepatitis C is recognized as a major cause.MC associated with hepatitis E virus(HEV)has been described and little is known about this rare association.The aim of this study is to perform a systematic review of MC associated with HEV,and examine the presence of a causal relationship.Methods:An experienced librarian conducted a search of databases from each database’s inception to 12 December 2016 based on a priori criteria.The risk of bias was assessed,and Hill’s criteria were applied to determine causality.Results:Five publications met inclusion criteria,with a total of 15 cases.Three studies had low,one low to moderate and one moderate risk of bias.Median age was 43 years,and all patients came from Western Europe.Two patients were immunocompetent,while 13 were immunosuppressed,post solid organ transplant and had chronic hepatitis E.Renal involvement was observed in seven patients,mild to moderately severe cryoglobulinemic disease in one patient and severe cryoglobulinemic disease in three patients.One patient improved spontaneously,and another was treated with immunosuppressant reduction leading to viral clearance.Ten patients treated with peg-interferon or ribavirin for 3 months achieved loss of cryoglobulinemia and end-of-treatment response,but sustained virologic response was reported and achieved in two.Immunosuppressant achieved loss of cryoglobulinemia in three patients.One case of chronic renal failure,three cases of end-stage renal disease and one death were observed.Five of the nine Hill’s criteria were fulfilled.Conclusion:MC has been described with HEV infection.A causal relationship between HEV infection and cryoglobulinemia is highly probable.