A Randomized Controlled Trial on Optimal Sampling Sequence in Radial Guide Sheath Endobronchial Ultrasound Lung Biopsy

Background: An optimal sampling sequence in radial guide sheath endobronchial ultrasound lung biopsy (R-EBUS) is unclear. This prospective single-center pilot randomized controlled trial aimed to determine if the initial method and sequence of sampling affect the diagnostic accuracy of the procedure. Methods: Consecutive patients undergoing R-EBUS for lesions >15 mm with a bronchus sign were randomly assigned (1:1:1) to biopsy first (group A), brushings first (group B) or combination (group C). The primary outcome was a positive diagnosis from any sampling method. Results: Fifty-four patients were randomized. The overall diagnostic yield of the procedure was 77.8% (95% confidence interval: 66%-89%), with no difference between groups. A higher rate of positive cytology from brushings was seen if the biopsies were performed before brushings (77.8% in group A vs. 44.4% in group B, P=0.03). The rate of positive cytology from washings was higher if the washings were obtained just after the brushings (61.1% in group A vs. 11.1% in group B, P=0.02). There was no difference in the rate of positive biopsy histology in the groups (P=0.27). All 3 sampling modalities were more likely to be positive in group A (50.0% vs. 11.1% in group B and 22.2% in group C, P=0.04). Complications rate was low and not significantly different between groups. Conclusion: The overall rate of a positive R-EBUS procedure was not affected by the initial sampling method or sequence. However, all 3 sampling modalities were more likely to be positive if biopsies were performed first, followed by brushings and washings

Direct oral anticoagulants for cancer associated venous thromboembolisms: a systematic review and network meta-analysis : DOACs for VTE in Cancer

Several recent randomized controlled trials (RCTs) have investigated the use of direct oral anticoagulants (DOACs) in the treatment of malignancy associated venous thromboembolisms (VTE).This meta-analysis combines all RCT data to determine the risks of recurrent VTE and bleeding with DOACs in patients with malignancy associated VTE compared to low molecular weight heparin (LMWH).The study followed PRISMA guidelines. MEDLINE, EMBASE, CENTRAL were systematically searched from inception to 1st of April 2020. References of reviews and relevant conference proceedings were hand-searched. Two authors independently evaluated study eligibility, extracted data, and assessed risk-of-bias. Direct and indirect meta-analyses were performed.In four RCTs with low risk-of-bias (2907 patients), high certainty evidence suggested that DOACs had a 37% reduction in risk of recurrent VTE compared to LMWH (direct pooled risk ratio (RR) 0.63, 95%CI 0.44-0.91; I = 28%). No significant difference was observed in the risk of major bleeding with DOACs compared to LMWH (RR 1.31, 95%CI 0.83-2.07; I = 22%; moderate certainty evidence), including in patients in gastrointestinal and genitourinary malignancy. An increased risk of combined major or CRNMB was seen with DOACs (RR 1.52, 95%CI 1.09-2.12; I = 51%; low certainty evidence). Apixaban had the highest probability of being ranked most effective and least bleeding risk amongst the DOACs.DOACs are effective in treating malignancy associated VTE, however caution is required in patients with high risk of bleeding. Apixaban had lower risk of bleeding compared to other DOACs in this population. This article is protected by copyright. All rights reserved