The Efficiency and Safety of Bivalirudin versus Heparin in The Anticoagulation Therapy in Extracorporeal Membrane Oxygenation: A Meta-Analysis

Abstract Background: Bivalirudin is a direct thrombin inhibitor (DTI), which can be the alternative of unfractionated heparin (UFH). The efficiency and safety of bivalirudin versus UFH in the anticoagulation therapy in Extracorporeal membrane oxygenation(ECMO) remains unclear. The purpose of the meta-analysis is to evaluate the efficiency and safety of bivalirudin versus UFH in the anticoagulation therapy in ECMO.Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed. A systematic literature search for original studies was performed in PubMed, EMBASE and The Cochrane Library to identify all relevant studies published prior to January 13,2021. Studies were reviewed according to eligibility and exclusion criteria. The meta-analysis was used to estimate the efficiency and safety of bivalirudin versus UFH in the anticoagulation therapy in extracorporeal membrane oxygenation. Results: 6 retrospective studies with 254 patients were eventually included for the quantitative analysis. The results showed that the incidence of major bleeding(I2=66%, P=0.16, OR=0.43, 95%CI:0.13-1.40), thrombosis(I2=0%, P=0.09<0.1, OR=0.56, 95%CI:0.29-1.09) and 30-day mortality(I2=0%, P=0.50, OR=0.90, 95%CI:0.42-1.53) was not statistically significant between the bivalirudin group and the UFH group.Conclusions:This study suggests that bivalirudin and UFH are associated with similar rates of major bleeding, thrombosis and 30-day mortality in adult and pediatric ECMO support, which is safe, practicable, dependable, and cost-effective in comparison with UFH. Bivalirudin is non-inferior to UFH in the anticoagulation therapy in ECMO.

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Low vs standardized dose anticoagulation regimens for extracorporeal membrane oxygenation: A meta-analysis

PLoS ONE ◽

10.1371/journal.pone.0249854 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0249854

Author(s):

Xiaochai Lv ◽

Manjun Deng ◽

Lei Wang ◽

Yi Dong ◽

Liangwan Chen ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Meta Analysis ◽

Pulmonary Hemorrhage ◽

Cochrane Library ◽

Heparin Group ◽

Future Studies ◽

Membrane Oxygenation ◽

Search Terms ◽

The Cochrane Library

Background To compare the safety and efficacy of low-dose anticoagulation (LA) with that of standardized dose anticoagulation (SA) for patients supported with extracorporeal membrane oxygenation (ECMO). Methods PubMed, MEDLINE, the Cochrane Library, and Web of Science were screened for original articles. Screening was performed using predefined search terms to identify cohort studies reporting the comparison of LA with SA in patients supported with ECMO from Nov 1990 to Jun 2020. The effect size was determined by the odds ratio (OR) with the 95% confidence interval (CI). Results An analysis of 7 studies including a total of 553 patients was performed. LA (Low-heparin group) was administered to 255 patients, whereas the other 298 patients received SA (Full-heparin group). The incidence of gastrointestinal tract hemorrhage (OR 0.36, 95% CI 0.20–0.64) and surgical site hemorrhage (OR 0.43, 95% CI 0.20–0.94) were significantly lower in patients who underwent LA compared with that in those who underwent SA. The rates of hospital mortality (OR 0.81, 95% CI 0.42–1.56), successfully weaning off of ECMO (OR 0.80, 95% CI 0.30–2.14), pulmonary embolism (OR 0.79, 95% CI 0.24–2.65), intracardiac thrombus (OR 0.34, 95% CI 0.09–1.30), intracranial hemorrhage (OR 0.62, 95% CI 0.22–1.74), and pulmonary hemorrhage (OR 0.77, 95% CI 0.30–1.93) were similar between the two groups. Conclusions This meta-analysis confirms that LA is a feasible and safe anticoagulation strategy in patients supported by ECMO. Future studies should focus on the long-term benefits of LA compared with SA.

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Direct Oral Anticoagulants for Treatment of Venous Thromboembolism Associated with Cancer: A Systematic Review and Meta-Analysis

Clinical Oncology and Research ◽

10.31487/j.cor.2020.06.14 ◽

2020 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Maryam Saleem ◽

Mohammed Osman ◽

Saira Farid ◽

Christopher M. Bianco ◽

...

Keyword(s):

Venous Thromboembolism ◽

Major Bleeding ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Primary Objective ◽

Cochrane Library ◽

Current Standard ◽

The Cochrane Library

There is uncertainty about the choice of anticoagulation therapy in patients with malignancy and venous thromboembolism (VTE). While low-molecular weight heparin (LMWH) remains the current standard, direct oral anticoagulants (DOACs) have emerged as an appealing alternative option. The primary objective of this analysis was to compare the efficacy and safety of DOACs versus LMWH in patients with malignancy and VTE. The secondary objective was to compare the safety and efficacy of the different DOACs. An online search of PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov from inception until April 2020 was conducted. Four RCTs encompassing 2,907 patients, (50.5% men and mean age of 65.7 ± 10.5) were selected. At a mean follow up of 12 months, moderate certainty evidence showed no differences between DOAC and LMWH in VTE recurrence (HR, 0.54 [CI 0.23 to 1.28], I2 = 56%, p=0.23), in major bleeding (HR, 1.38 [CI 0.45 to 4.22], I2 = 33%, p=0.21) or clinically relevant non-major bleeding (CRNMB) (HR, 1.77 [CI 0.49 to 6.40], I2 = 73.9%, p=0.087). There was no difference between the DOACs when compared to each other. In conclusion, DOACs are an acceptable alternative to LMWHs for the treatment of VTE in patients with malignancy.

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Efficacy of left ventricular unloading strategies during venoarterial extracorporeal membrane oxygenation in patients with cardiogenic shock: a protocol for a systematic review and Bayesian network meta-analysis

BMJ Open ◽

10.1136/bmjopen-2020-047046 ◽

2021 ◽

Vol 11 (10) ◽

pp. e047046

Author(s):

Pengbin Zhang ◽

Shilin Wei ◽

Kerong Zhai ◽

Jian Huang ◽

Xingdong Cheng ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Bayesian Network ◽

Meta Analysis ◽

Left Ventricular ◽

Cochrane Library ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Patient Consent ◽

Va Ecmo

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for patients with refractory cardiogenic shock. A common side effect of this technic is the resultant increase in left ventricular (LV) afterload which could potentially aggravate myocardial ischaemia, delay ventricular recovery and increase the risk of pulmonary congestion. Several LV unloading strategies have been proposed and implemented to mitigate these complications. However, it is still indistinct that which one is the best choice for clinical application. This Bayesian network meta-analysis (NMA) aims to compare the efficacy of different LV unloading strategies during VA-ECMO.Methods and analysisPubMed, Embase, the Cochrane Library and the International Clinical Trials Registry Platform will be explored from their inception to 31 December 2020. Random controlled trials and cohort studies that compared different LV unloading strategies during VA-ECMO will be included in this study. The primary outcome will be in-hospital mortality. The secondary outcomes will include neurological complications, haemolysis, bleeding, limb ischaemia, renal failure, gastrointestinal complications, sepsis, duration of mechanical ventilation, length of intensive care unit and hospital stays. Pairwise and NMA will respectively be conducted using Stata (V.16, StataCorp) and Aggregate Data Drug Information System (V.1.16.5), and the cumulative probability will be used to rank the included LV unloading strategies. The risk of bias will be conducted using the Cochrane Collaboration’s tool or Newcastle-Ottawa Quality Assessment Scale according to their study design. Subgroup analysis, sensitivity analysis and publication bias assessment will be performed. The Grading of Recommendations Assessment, Development and Evaluation will be conducted to explore the quality of evidence.Ethics and disseminationEither ethics approval or patient consent is not necessary, because this study will be based on literature. The results will be disseminated through peer-reviewed publications and conference presentations.PROSPERO registration numberCRD42020165093.

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The Effectiveness and Safety of Manual Acupuncture Therapy in Patients with Poststroke Cognitive Impairment: A Meta-analysis

Neural Plasticity ◽

10.1155/2020/8890521 ◽

2020 ◽

Vol 2020 ◽

pp. 1-15

Author(s):

Wei Liu ◽

Chang Rao ◽

Yuzheng Du ◽

Lili Zhang ◽

Jipeng Yang

Keyword(s):

Cognitive Impairment ◽

Cognitive Function ◽

Barthel Index ◽

Daily Life ◽

Meta Analysis ◽

Cochrane Library ◽

Activities Of Daily Life ◽

Rigorous Study ◽

Meta Analyses ◽

The Cochrane Library

Background. Poststroke cognitive impairment (PSCI) is a common cause of disability among patients with stroke. Meanwhile, acupuncture has increasingly been used to improve motor and cognitive function for stroke patients. The aim of the present study was to summarize and evaluate the evidence on the effectiveness of acupuncture in treating PSCI. Methods. Eight databases (PubMed, The Cochrane Library, CNKI, WanFang Data, VIP, CBM, Medline, Embase databases) were searched from January 2010 to January 2020. Meta-analyses were conducted for the eligible randomized controlled trials (RCTs). Assessments were performed using Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Barthel Index (BI), or modified Barthel Index (MBI). Results. A total of 657 relevant RCTs were identified, and 22 RCTs with 1856 patients were eventually included. Meta-analysis showed that acupuncture appeared to be effective for improving cognitive function as assessed by MMSE ( mean difference MD = 1.73 , 95% confidence interval (CI) (1.39, 2.06), P < 0.00001 ) and MoCA ( MD = 2.32 , 95% CI (1.92, 2.73), P < 0.00001 ). Furthermore, it also suggested that acupuncture could improve the activities of daily life (ADL) for PSCI patients as assessed by BI or MBI ( SMD = 0.97 , 95% CI (0.57, 1.38), P < 0.00001 ). Conclusions. Compared with nonacupuncture group, acupuncture group showed better effects in improving the scores of MMSE, MoCA, BI, and MBI. This meta-analysis provided positive evidence that acupuncture may be effective in improving cognitive function and activities of daily life for PSCI patients. Meanwhile, long retention time of acupuncture may improve cognitive function and activities of daily life, and twist technique may be an important factor that could influence cognitive function. However, further studies using large samples and a rigorous study design are needed to confirm the role of acupuncture in the treatment of PSCI.

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Influence ofDPYDGenetic Polymorphisms on 5-Fluorouracil Toxicities in Patients with Colorectal Cancer: A Meta-Analysis

Gastroenterology Research and Practice ◽

10.1155/2014/827989 ◽

2014 ◽

Vol 2014 ◽

pp. 1-11 ◽

Cited By ~ 9

Author(s):

Qiang Li ◽

Ying Liu ◽

Hong-Mei Zhang ◽

Yin-Peng Huang ◽

Tian-Yi Wang ◽

...

Keyword(s):

Colorectal Cancer ◽

Genetic Polymorphisms ◽

Web Of Science ◽

Meta Analysis ◽

Dihydropyrimidine Dehydrogenase ◽

Cochrane Library ◽

Inclusion Criteria ◽

Meta Analyses ◽

The Cochrane Library ◽

Stratified Analysis

Our meta-analysis aggregated existing results from relevant studies to comprehensively investigate the correlations between genetic polymorphisms in dihydropyrimidine dehydrogenase (DPYD) gene and 5-fluorouracil (5-FU) toxicities in patients with colorectal cancer (CRC). The MEDLINE (1966∼2013), the Cochrane Library Database (Issue 12, 2013), EMBASE (1980∼2013), CINAHL (1982∼2013), Web of Science (1945∼2013), and the Chinese Biomedical Database (CBM) (1982∼2013) were searched without language restrictions. Meta-analyses were conducted with the use of STATA software (Version 12.0, Stata Corporation, College Station, TX, USA). Seven clinical cohort studies with a total of 946 CRC patients met our inclusion criteria, and NOS scores of each of the included studies were ≥5. Our findings showed thatDPYDgenetic polymorphisms were significantly correlated with high incidences of 5-FU-related toxicity in CRC patients. SNP-stratified analysis indicated that there were remarkable connections of IVS14+1G>A, 464T>A, and 2194G>A polymorphisms with the incidence of marrow suppression in CRC patients receiving 5-FU chemotherapy. Furthermore, we found that IVS14+1G>A, 496A>G, and 2194G>A polymorphisms were correlated with the incidence of gastrointestinal reaction. Ethnicity-stratified analysis also revealed thatDPYDgenetic polymorphisms might contribute to the development of marrow suppression and gastrointestinal reaction among Asians, but not among Caucasians. The present meta-analysis suggests thatDPYDgenetic polymorphisms may be correlated with the incidence of 5-FU-related toxicity in CRC patients.

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Complications and mortality of venovenous extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure: a systematic review and meta-analysis

10.21203/rs.2.11328/v2 ◽

2019 ◽

Author(s):

Jing Xiong ◽

Li Zhang ◽

Lei Bao

Keyword(s):

Systematic Review ◽

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Meta Analysis ◽

Cochrane Library ◽

Membrane Oxygenation ◽

Venovenous Ecmo ◽

Complications And Mortality ◽

Overall Mortality

Abstract Background: Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. To systematically evaluate the complications and mortality of venovenous ECMO in the treatment of neonatal respiratory failure, we performed a systematic review and meta-analysis of all the related studies. Methods: PubMed, Embase, and Cochrane Library were searched. The retrieval period was from the establishment of the database to February 2019. Two investigators independently screened articles according to the inclusion and exclusion criteria. The quality of article was assessed by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by Stata 15.0 software. Results: Four observational studies were included, with a total of 347 newborns. The overall mortality at hospital charge was 12% (5% - 18%) with a heterogeneity of I2 = 73.8% (p = 0.01). Two studies reported mortality during ECMO and after decannulation, with 10% (0.8% -19.2%) and 6.1% (2.6% - 9.6%) respectively. The most common complications associated with venovenous ECMO were: pneumothorax (20.6%), hypertension (20.4%), cannula dysfunction (20.2%), seizure (14.9%), renal failure requiring hemofiltration (14.7%), infectious complications (10.3%), thrombi (7.4%), intracranial hemorrhage or infarction (6.6%), hemolysis (5.3%), cannula site bleeding (4.4%), gastrointestinal bleeding (3.7%), oxygenator failure (2.8%), other bleeding events (2.8%), brain death (1.9%), and myocardial stun (0.9%). Conclusion: The overall mortality at discharge of venovenous ECMO in the treatment of neonatal respiratory failure was 12%. Although complications are frequent, the survival rate during hospitalization is still high. Further larger samples and higher quality of randomized controlled trials (RCT) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.

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Complications and mortality of venovenous extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure: a systematic review and meta-analysis

10.21203/rs.2.11328/v3 ◽

2020 ◽

Author(s):

Jing Xiong ◽

Li Zhang ◽

Lei Bao

Keyword(s):

Systematic Review ◽

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Meta Analysis ◽

Cochrane Library ◽

Membrane Oxygenation ◽

Complications And Mortality ◽

Vv Ecmo ◽

Overall Mortality

Abstract Background: Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. To systematically evaluate the complications and mortality of venovenous ECMO (VV ECMO) in the treatment of neonatal respiratory failure, we performed a systematic review and meta-analysis of all the related studies. Methods: PubMed, Embase, and Cochrane Library were searched. The retrieval period was from the establishment of the database to February 2019. Two investigators independently screened articles according to the inclusion and exclusion criteria. The quality of article was assessed by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by Stata 15.0 software. Results: Four observational studies were included, with a total of 347 newborns. VV ECMO was used for neonates with refractory respiratory failure unresponsive to maximal medical therapy. Median ages of the newborns at cannulation were 43.2 hours, 23 hours, 19hours, and 71 hours in the included four studies, respectively. The overall mortality at hospital charge was 12% (5%-18%) with a heterogeneity of I 2 =73.8% (p=0.01). Two studies reported mortality during ECMO and after decannulation, with 10% (0.8%-19.2%) and 6.1% (2.6%-9.6%), respectively. The most common complications associated with VV ECMO were: pneumothorax (20.6%), hypertension (20.4%), cannula dysfunction (20.2%), seizure (14.9%), renal failure requiring hemofiltration (14.7%), infectious complications (10.3%), thrombi (7.4%), intracranial hemorrhage or infarction (6.6%), hemolysis (5.3%), cannula site bleeding (4.4%), gastrointestinal bleeding (3.7%), oxygenator failure (2.8%), other bleeding events (2.8%), brain death (1.9%), and myocardial stun (0.9%). Conclusion: The overall mortality at discharge of VV ECMO in the treatment of neonatal respiratory failure was 12%. Although complications are frequent, the survival rate during hospitalization is still high. Further larger samples, and higher quality of randomized controlled trials (RCTs) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.

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Complications and mortality of venovenous extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure: a systematic review and meta-analysis

10.21203/rs.2.11328/v1 ◽

2019 ◽

Author(s):

Jing Xiong ◽

Li Zhang ◽

Lei Bao

Keyword(s):

Respiratory Failure ◽

Extracorporeal Membrane Oxygenation ◽

Meta Analysis ◽

Cochrane Library ◽

Bleeding Events ◽

Membrane Oxygenation ◽

Venovenous Ecmo ◽

Complications And Mortality ◽

Overall Mortality

Abstract Background Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. To systematically evaluate the complications and mortality of venovenous ECMO in the treatment of neonatal respiratory failure. Methods PubMed, Embase, and Cochrane Library were searched. The retrieval period was from the establishment of the database to February 2019. Two investigators independently screened articles according to the inclusion and exclusion criteria. The quality of article was assessed by the Newcastle-Ottawa scale (NOS). The meta-analysis was performed by Stata 15.0 software. Results Four observational studies were included, with a total of 347 newborns. The overall mortality at hospital charge was 12% (5% - 18%) with a heterogeneity of I2 = 73.8% (p = 0.01). Two studies reported mortality during ECMO and after decannulation, with 10% (0.8% -19.2%) and 6.1% (2.6% - 9.6%) respectively. The most common complications associated with venovenous ECMO were: pneumothorax (20.6%), hypertension (20.4%), cannula dysfunction (20.2%), seizure (14.9%), renal failure requiring hemofiltration (14.7%), infectious complications (10.3%), thrombi (7.4%), intracranial hemorrhage or infarction (6.6%), hemolysis (5.3%), cannula site bleeding (4.4%), gastrointestinal bleeding (3.7%), oxygenator failure (2.8%), other bleeding events (2.8%), brain death (1.9%), and myocardial stun (0.9%). Conclusion The overall mortality at discharge of venovenous ECMO in the treatment of neonatal respiratory failure was 12%. Although complications are frequent, the survival rate during hospitalization is still high. Further larger samples, and higher quality of randomized controlled trials (RCT) are needed to clarify the efficacy and safety of this technique in the treatment of neonatal respiratory failure.

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Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm9041039 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1039 ◽

Cited By ~ 5

Author(s):

Mariusz Kowalewski ◽

Pietro Giorgio Malvindi ◽

Kamil Zieliński ◽

Gennaro Martucci ◽

Artur Słomka ◽

...

Keyword(s):

Systematic Review ◽

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mortality Risk ◽

Meta Analysis ◽

Left Ventricular ◽

Membrane Oxygenation ◽

Va Ecmo ◽

Critically Ill Adults ◽

Meta Analyses

During veno-arterial extracorporeal membrane oxygenation (VA-ECMO), the increase of left ventricular (LV) afterload can potentially increase the LV stress, exacerbate myocardial ischemia and delay recovery from cardiogenic shock (CS). Several strategies of LV unloading have been proposed. Systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement included adult patients from studies published between January 2000 and March 2019. The search was conducted through numerous databases. Overall, from 62 papers, 7581 patients were included, among whom 3337 (44.0%) received LV unloading concomitant to VA-ECMO. Overall, in-hospital mortality was 58.9% (4466/7581). A concomitant strategy of LV unloading as compared to ECMO alone was associated with 12% lower mortality risk (RR 0.88; 95% CI 0.82–0.93; p < 0.0001; I2 = 40%) and 35% higher probability of weaning from ECMO (RR 1.35; 95% CI 1.21–1.51; p < 0.00001; I2 = 38%). In an analysis stratified by setting, the highest mortality risk benefit was observed in case of acute myocardial infarction: RR 0.75; 95%CI 0.68–0.83; p < 0.0001; I2 = 0%. There were no apparent differences between two techniques in terms of complications. In heterogeneous populations of critically ill adults in CS and supported with VA-ECMO, the adjunct of LV unloading is associated with lower early mortality and higher rate of weaning.

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Effects of aerobic exercise on obese children with metabolic syndrome: a systematic review and meta-analysis

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2021-0295 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Youxiang Cao ◽

Lin Zhu ◽

Jingxin Liu

Keyword(s):

Blood Pressure ◽

Metabolic Syndrome ◽

Aerobic Exercise ◽

Meta Analysis ◽

Density Lipoprotein ◽

Exercise Group ◽

Cochrane Library ◽

Obese Children ◽

Meta Analyses ◽

The Cochrane Library

Abstract Objectives Metabolic syndrome (MetS) is systemic metabolic disease that results from insulin resistance or obesity. Numerous meta-analyses have investigated the effect of exercise on different populations, but none were aimed at the effect of aerobic exercise alone on obese children. This review systematically assessed and performed a meta-analysis on the effect of aerobic exercise on obese children with MetS. Content MEDLINE via PubMed, Embase, SPORTDiscus, and the Cochrane library were searched and screened from inception to 20 October 2020 for randomized controlled trials. The inclusion criteria were obese children who met the criteria for MetS and aged 5–19 years old in an aerobic exercise group. The meta-analysis included eight trials with a total of 197 participants. Aerobic exercise significantly improved the waist circumference (mean difference [MD]=−3.97; 95% confidence interval [CI]=−6.12 to −1.83; p<0.01), body mass index (standardized MD [SMD]=−0.5; 95% CI=−0.70 to −0.29; p<0.01), triglyceride (SMD=−24.6; 95% CI=−33.85 to −15.35; p<0.01), high-density lipoprotein cholesterol (SMD=2.36; 95% CI=0.44 to 4.27; p<0.01), and systolic blood pressure (SMD=−6.90; 95% CI=−10.46 to −3.35; p<0.01). Summary Based on the results of this meta-analysis, during the intervention period of the included studies, aerobic exercise alone mainly affected the lipoprotein, blood pressure, and body dimensions but cannot completely cure the MetS of obese children. Outlook The effects of different types of aerobic exercise on obese children with MetS and exercise dose to cure the MetS of obese children needs to be further studied.

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