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

Defining the expected 30-day mortality for patients undergoing palliative radiotherapy : A meta-analysis

Background: The expected 30-day mortality rate for patients treated with palliative radiation is not established. The primary objective of this study is to define the proportion of patients with advanced cancer who die within 30-days of palliative radiotherapy (PR). Additionally, we explored the short term survival of patient subgroups undergoing PR treatment. Methods: We searched MEDLINE, CINAHL, Embase and Cochrane Database of Systematic Reviews from January 1st 1980 to June 26, 2020. We included PUBMED's related search and reference lists to further identify articles. A meta-analysis of these research studies and reviews was performed. Published and unpublished English language randomized controlled trials, observational or prospective studies, and systematic reviews that reported 30-day mortality for patients with advanced cancer who received PR were eligible. Data extraction was done by two independent authors and included study quality indicators. To improve distribution and variance, all proportions were transformed using logit transformation. A random-effects model was used to pool data, using Der Simonian and Laird method of estimation where possible and appropriate. Results: The data from 42 studies contributing 88,516 patients with advanced cancer who received PR were evaluated. The summary proportion of mortality in patients with advanced cancer within 30 days of receiving PR was 16% (95% CI = 14% to 18%). We found substantial heterogeneity in our data (I2 = 98.76%, p < 0.001), hence we applied subgroup analysis to identify potential moderating factors. We found a higher 30-day mortality rate after PR in the following groups: multiple treatment sites (QM(1) = 9.54, p = 0.002), hepatobiliary primary (QM(1) = 24.20, p < 0.001), inpatient status (QM(1) = 92.27, p < 0.001), Eastern Cooperative Oncology Group performance status (ECOG) 3–4 (QM(1) = 8.70, p = 0.003), United States (U.S.) patients (QM(1) = 28.70, p < 0.001) among others. Conclusions: We found that 16% of patients with advanced cancer receiving PR die within 30 days of treatment. Our finding can be used as a benchmark to establish a global quality metric for radiation oncology practice audits.</p

Vertebral body tethering for idiopathic scoliosis: a systematic review and meta-analysis

Purpose: Vertebral body tethering (VBT) is a recent procedure to correct and reduce spinal curves in skeletally immature patients with adolescent idiopathic scoliosis (AIS). The purpose of this systematic review and meta-analysis is to determine the expected curve reduction and potential complications for adolescent patients after VBT. Methods: PubMed, Embase, Google Scholar and Cochrane databases were searched until February 2022. Records were screened against pre-defined inclusion and exclusion criteria. Data sources were prospective and retrospective studies. Demographics, mean differences in Cobb angle, surgical details and complication rates were recorded. Meta-analysis was conducted using a random-effects model. Results: This systematic review includes 19 studies, and the meta-analysis includes 16 of these. VBT displayed a statistically significant reduction in Cobb angle from pre-operative to final (minimum 2 years) measurements. The initial mean Cobb angle was 47.8° (CI 95% 42.9–52.7°) and decreased to 22.2° (CI 95% 19.9–24.5°). The mean difference is − 25.8° (CI 95% − 28.9–22.7) (p < 0.01). The overall complication rate was 23% (CI 95% 14.4–31.6%), the most common complication was tether breakage 21.9% (CI 95% 10.6–33.1%). The spinal fusion rate was 7.2% (CI 95% 2.3–12.1%). Conclusion: VBT results in a significant reduction of AIS at 2 years of follow-up. Overall complication rate was relatively high although the consequences of the complications are unknown. Further research is required to explore the reasons behind the complication rate and determine the optimal timing for the procedure. VBT remains a promising new procedure that is effective at reducing scoliotic curves and preventing spinal fusion in the majority of patients. Level of evidence: Systematic review of Therapeutic Studies with evidence level II–IV.</p