Net clinical benefit of DOACs vs. usual anticoagulation treatment in venous thromboembolism and active cancer: systematic review and meta-analysis.

Patients with active cancer are at high risk of recurrent venous thromboembolism (VTE). Usual treatment includes low molecular weight heparin (LMWH), while vitamin K antagonists (VKAs) have also been used as substitutes for LMWH. Direct oral anticoagulants (DOACs) are considered a beneficial alternative to the usual treatment but are accompanied by an increased rate of bleeding compared to LMWH. We conducted a meta-analysis to evaluate the benefits and harms under a common denomination, namely the net clinical benefit (NCB), between DOACs and usual anticoagulation. The primary outcome was NCB-1, defined as non-fatal VTE, major non-fatal bleedings, and all-cause mortality). Co-primary outcomes were 1) NCB-2 (i.e., NCB-1 and clinically relevant non-major bleedings) and 2) NCB-3 (i.e., fatal or non-fatal VTE and major bleedings). A random-effects model was used to calculate outcome risk ratios and 95% confidence intervals (CI). Prospective Register of Systematic Reviews identification number CRD42021284238. We selected 8 studies (n = 4,4461 patients; mean follow-up, 6 months). The NCB-1 and -2 were not different between DOACs and usual anticoagulation, while the NCB-3 showed a reduction of 28% (95% CI, 10-42%), favoring DOACs. Recurrent VTE was reduced by 40% (95% CI, 25-53%) with DOACs than the usual treatment. Different bleeding outcomes and all-cause mortality were not different between treatments. All primary outcomes did not differ between DOACs and LMWH, while NCB-2 and NCB-3 were reduced with DOACs than VKAs. The NCB of DOACs was similar or more favorable to usual anticoagulation in patients with active cancer due to a substantial reduction of VTE and no bleeding excess.

Net clinical benefit of a reduced dose of DOACs in non-valvular atrial fibrillation: A meta-analysis of randomized trials.

BACKGROUND: In standard dosing, direct Oral Anticoagulants (DOACs) are used as an alternative to warfarin to prevent ischemic stroke and systemic embolism in non-valvular Atrial Fibrillation (AF). However, randomized comprehensive evidence considering the efficacy and safety of the low-dose DOACs in the same setting is still lacking. Toward this end, we conducted a meta-analysis of randomized trials to estimate the risk/benefit ratio, in terms of net clinical benefit, by comparing a reduced dose of DOACs and warfarin. METHODS: We searched three electronic databases, covering the period until end-February 2021. All-cause death, non-fatal stroke/systemic embolism, and major bleeding events, with or without the inclusion of myocardial infarction, were used to define two different net clinical benefit outcomes. In addition, we evaluated different component outcomes of net clinical benefit as secondary outcomes. Finally, risk ratios and 95% Confidence Intervals (CI) of each outcome were calculated (random-effects model). RESULTS: In the four randomized trials included (n = 29,779 patients), the net clinical benefit - with or without the inclusion of myocardial infarction - of low-dose DOACs, compared to warfarin, was a 12% (95% CI, 7%-16%) or a 10% (95% CI, 5%-13%) reduction of events, respectively. Compared to warfarin, the reduced dose of DOACs decreased death outcomes, major bleeding events, and hemorrhagic stroke, whereas all thrombotic outcomes were not different among the groups. CONCLUSIONS: DOACs at low dosing present a more favorable net clinical benefit profile compared to warfarin.

Renal outcomes associated with glucose-lowering agents: Systematic review and meta-analysis of randomized outcome trials.

Although the clinical questions of the recent glucose-lowering trials are principally oriented towards preventing macrovascular events, an updated review regarding renal outcome prevention is lacking. We assessed the impact of different antihyperglycemic classes on kidney damage progression. A systematic review and meta-analysis was performed by searching PubMed, Cochrane Collaboration Library, Medline, and previous overviews through June 2021 (any language) for earlier and contemporary glucose-lowering trials, including patients with, but not limited to, type 2 diabetes mellitus vs. placebo or less intense treatment. Incidences of kidney function worsening and macroalbuminuria development was extracted, and risk ratios and 95% confidence intervals (CI) under the random-effects model were calculated. The association between outcome reductions and glycohemoglobin (HBA1c) reductions was investigated through the meta-regression analyses. Among 27 eligible trials (n = 198,532 patients) an averaged HBA1c reduction of 0.6 ± 0.3% was followed by a reduction of 17% (95% CI, 8-25%) in worsening of kidney function, and of 25% (95% CI, 19-32%) in macroalbuminuria. Analog of human glucagon-like peptide 1 (GLP1)-agonists, and sodium-glucose cotransporter (SGLT2)-inhibitors, considered separately, compared with placebo, were associated with a significant reduction of both renal outcomes, at variance with dipeptidyl peptidase 4 (DPP4)-inhibitors, where no outcome change was observed. Logarithmic risk ratios of macroalbuminuria were related to HBA1c reductions, in contrast to the worsening of kidney function related to systolic blood pressure reduction. Worsening of kidney function and macroalbuminuria development were reduced following glucose-lowering. GLP1 agonists and SGLPT2 inhibitors were associated with protection against both outcomes, while DPP4 inhibitors do not provide renal protection.

Common surgical masks and unattended blood pressure changes in treated hypertensive patients.

Although the effect of face masks on preventing airborne transmission of SARS-CoV-2 is well studied, no study has evaluated their effect on blood pressure (BP). Therefore, we investigated the effect of surgical masks on BP in 265 treated hypertensive patients. Following the routine mask-on office BP measurement, patients were left alone and randomized to automated office BP measurement, with measurements taken after first wearing a mask for 10 min, then without wearing the mask for 10 min, and vice versa. Among the participants, 115 were women (43.4%), the mean age was 62 ± 12 years, and the mean office BP was 134 ± 15/81 ± 12 mmHg. There was no significant difference between mask-on unattended systolic BP (133 ± 15 mmHg) and mask-off unattended systolic BP (132 ± 15 mmHg) (P = 0.13) or between mask-on unattended diastolic BP (77 ± 13 mmHg) and mask-off unattended diastolic BP (76 ± 13 mmHg) (P = 0.32). Surgical masks had no effect on BP in treated hypertensive patients.

The mini-resectoscope: a new instrument for office hysteroscopic surgery.

BACKGROUND: Outpatient hysteroscopy has become well-established for the investigation abnormal uterine bleeding. Although "See and Treat" clinics have been widely introduced, the types of procedures offered are limited, and many patients with intrauterine pathology continue to be admitted as in-patients for hysteroscopic surgery. We wanted to investigate the feasibility and acceptability of surgery for small intrauterine lesions without the need for general anesthesia by using a miniature resectoscope. METHODS: This was a prospective observational study on 30 women with abnormal uterine bleeding associated with endometrial polyps or small (<3 cm) type 0 or 1 submucous fibroids. Hysteroscopic polypectomy (n=26) or myomectomy (n=4) was carried out using a 16 Fr gauge mini-resectoscope. RESULTS: Ten procedures were carried out in the outpatient clinic and 20 in the operating theatre. Sixteen procedures were done without any anaesthesia and 14 after intra-cervical local anesthetic injections. The polyps and fibroids ranged in size from 1 to 5 cm, and all procedures took less than 15 minutes from the time the vagina was instrumented to the end of surgery. All procedures were completed successfully and were well tolerated with little discomfort. There were no complications. CONCLUSIONS: The mini-resectoscope appears to be an efficient and acceptable instrument for hysteroscopic surgery and can be used without general anesthesia for minor procedure such as polypectomy and the resection of small submucous fibroids.

Do patients want to see recordings of their surgery?

OBJECTIVE: In an effort to improve patients' understanding and perception of their surgery and communication between doctors and patients we have evaluated the use of a mobile digital video recorder in the case of women undergoing gynaecological surgery. STUDY DESIGN: Patients scheduled for endoscopic or open surgery were asked if they would allow their surgery be recorded on a dedicated computer system. Those who agreed were offered the opportunity to have real-time edited highlights of their surgery recorded simultaneously on a miniature digital video recorder. They were shown the edited recording before discharge from hospital, and their reaction was assessed using a structured questionnaire. RESULTS: 51/54 (94.4%) women agreed to their surgery being recorded on the computer system, and 37/54 (68.5%) asked to see the edited highlights. The median duration of the computer and portable recordings for the 37 patients was 90 min (range 2-280) and 3.3 min (range 1-13.6) respectively. Thirty-four (91.9%) reported that the edited recording gave them a better understanding of their medical condition and surgery. Thirty (81.1%) would have liked a copy of the recording. CONCLUSIONS: Portable video recorders are a convenient tool for recording surgical procedures. In our experience, about two-third of patients are interested in reviewing their surgery and find it provides useful information and a perceived better understanding of their condition. As these recording devices are small and fit into a pocket, their use could easily become a routine part of post-operative ward rounds. For the surgeon, such recordings have an educational value and provide the basis for a library of surgery as well as being useful when planning future management or for referral purposes.

A new technique for temporary ovarian suspension: temporarily displacing the ovaries anterior to the uterus facilitates pelvic side wall access in the laparoscopic treatment of endometriosis.

The adnexa frequently hinder access to the pelvic side wall during laparoscopic surgery for endometriosis. An innovative tactic can facilitate dissection.