Cochrane Db Syst Rev
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Cochrane Db Syst Rev · Oct 2021
ReviewProphylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer.
This is an updated version of a Cochrane Review last published in 2013. Long-term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram-positive bacteria. Antimicrobial prevention strategies aimed at these micro-organisms could potentially decrease the majority of CVC-related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram-positive infections in people with cancer who have long-term CVCs. ⋯ We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram-positive catheter-related infection events and total number of CVCs and CVC days. We pooled the data using a random-effects model for meta-analyses. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long-term CVC. One study did not observe any CVC-related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram-positive CVC-related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate-certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin-only solution for flushing or locking the long-term CVC after use. One study did not observe any CRS events and was not include this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long-term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram-positive CVC-related infections compared to a heparin-only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC-days; 5 studies, 443 participants; moderate-certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. AUTHORS' CONCLUSIONS: Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long-term CVCs to prevent gram-positive CVC-related infections. Flushing or locking long-term CVCs with an antibiotic solution likely reduces gram-positive CVC-related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high-risk people or if the baseline CVC-related infection rates are high. Further research is needed to identify high-risk groups most likely to benefit from these antibiotic flush/lock solutions.
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Cochrane Db Syst Rev · Oct 2021
Review Meta AnalysisInterventions for preventing weight gain after smoking cessation.
Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting. ⋯ Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.
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Cochrane Db Syst Rev · Oct 2021
Review Meta AnalysisComputed tomography for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease.
Hepatocellular carcinoma occurs mostly in people with chronic liver disease and ranks sixth in terms of global incidence of cancer, and fourth in terms of cancer deaths. In clinical practice, computed tomography (CT) is used as a second-line diagnostic imaging modality to confirm the presence of focal liver lesions suspected as hepatocellular carcinoma on prior diagnostic test such as abdominal ultrasound or alpha-foetoprotein, or both, either in surveillance programmes or in clinical settings. According to current guidelines, a single contrast-enhanced imaging study CT or magnetic resonance imaging (MRI) showing typical hallmarks of hepatocellular carcinoma in people with cirrhosis is valid to diagnose hepatocellular carcinoma. However, a significant number of hepatocellular carcinomas do not show typical hallmarks on imaging modalities, and hepatocellular carcinoma is, therefore, missed. There is no clear evidence of the benefit of surveillance programmes in terms of overall survival: the conflicting results can be a consequence of inaccurate detection, ineffective treatment, or both. Assessing the diagnostic accuracy of CT may clarify whether the absence of benefit could be related to underdiagnosis. Furthermore, an assessment of the accuracy of CT in people with chronic liver disease, who are not included in surveillance programmes is needed for either ruling out or diagnosing hepatocellular carcinoma. ⋯ In the clinical pathway for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease, CT has roles as a confirmatory test for hepatocellular carcinoma lesions, and for staging assessment. We found that using CT in detecting hepatocellular carcinoma of any size and stage, 22.5% of people with hepatocellular carcinoma would be missed, and 8.7% of people without hepatocellular carcinoma would be unnecessarily treated. For resectable hepatocellular carcinoma, we found that 28.6% of people with resectable hepatocellular carcinoma would improperly not be resected, while 8% of people without hepatocellular carcinoma would undergo inappropriate surgery. The uncertainty resulting from the high risk of bias in the included studies and concerns regarding their applicability limit our ability to confidently draw conclusions based on our results.
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Cochrane Db Syst Rev · Oct 2021
ReviewEffect of testing for cancer on cancer- or venous thromboembolism (VTE)-related mortality and morbidity in people with unprovoked VTE.
Venous thromboembolism (VTE) is a collective term for two conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). A proportion of people with VTE have no underlying or immediately predisposing risk factors and the VTE is referred to as unprovoked. Unprovoked VTE can often be the first clinical manifestation of an underlying malignancy. This has raised the question of whether people with an unprovoked VTE should be investigated for an underlying cancer. Treatment for VTE is different in cancer and non-cancer patients and a correct diagnosis would ensure that people received the optimal treatment for VTE to prevent recurrence and further morbidity. Furthermore, an appropriate cancer diagnosis at an earlier stage could avoid the risk of cancer progression and lead to improvements in cancer-related mortality and morbidity. This is the third update of the review first published in 2015. ⋯ Specific testing for cancer in people with unprovoked VTE may lead to earlier diagnosis of cancer at an earlier stage of the disease. However, there is currently insufficient evidence to draw definitive conclusions concerning the effectiveness of testing for undiagnosed cancer in people with a first episode of unprovoked VTE (DVT or PE) in reducing cancer- or VTE-related morbidity and mortality. The results could be consistent with either benefit or no benefit. Further good-quality large-scale randomised controlled trials are required before firm conclusions can be made.
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Cochrane Db Syst Rev · Sep 2021
ReviewCHIVA method for the treatment of chronic venous insufficiency.
Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (in French 'cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire' (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is the second update of the review first published in 2013. ⋯ There may be little or no difference in the recurrence of varicose veins when comparing CHIVA to stripping (low-certainty evidence), but CHIVA may slightly reduce nerve injury and hematoma in the lower limb (low-certainty evidence). Very limited evidence means we are uncertain of any differences in recurrence when comparing CHIVA with compression (very low-certainty evidence). CHIVA may make little or no difference to recurrence compared to RFA (low-certainty evidence), but may result in more bruising (low-certainty evidence). CHIVA may make little or no difference to recurrence and side effects compared to endovenous laser therapy (low-certainty evidence). However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed, and the results were imprecise due to the low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.