Search

Background and Aim: The quality of clinical practice guidelines (CPGs) for the management of antithrombotic agents in patients undergoing gastrointestinal (GI) endoscopy has not been systematically appraised. The goal of this study was to evaluate the methodological quality of CPGs for the management of antithrombotic agents in periendoscopic period published within last 6 years. Methods: A systematic search of PubMed and Embase databases was performed to identify eligible CPGs published between January 1, 2016, and April 14, 2022, addressing the management of antithrombotic agents in the periendoscopic period. The quality of the CPG was independently assessed by six reviewers using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Domain scores were considered of sufficient quality when > 60% and of good quality when > 80%. Results: The search yielded 343 citations, of which seven CPGs published by the gastroenterology associations in Asia (n = 3), Europe (n = 2), and North America (n = 2) were included for the critical appraisal. The overall median score for the AGREE II domains was 93% (interquartile range [IQR] 11%) for scope and purpose, 79% (IQR 61%) for stakeholder involvement, 79% (IQR 36%) for rigor of development, 100% (IQR 14%) for clarity of presentation, 32% (IQR 36%) for applicability, 93% (IQR 29%) for editorial independence, and 86% (IQR 29%) for overall assessment. Conclusions: The findings show that the overall methodological quality of the CPGs for the management of antithrombotic agents in the periendoscopic period varies across the domains. There is significant scope for improvement in the methodological rigor and applicability of CPGs. [ABSTRACT FROM AUTHOR]

Objectives: The policies regarding resident physician work hours are constantly being evaluated and changed. However, the results of randomised control trials (RCTs) are mixed. This systematic review of RCTs aims to synthesise the evidence associated with resident duty hour restrictions and its impact on resident‐ and patient‐based outcomes. Methods: A comprehensive search of the Cochrane Library, EMBASE and PubMed was conducted from inception until 31 July 2020. Any RCT evaluating the impact of longer resident physician work hours compared to shorter resident physician work hours on resident‐ and patient‐based outcomes was eligible for inclusion. Two reviewers extracted data independently. The primary outcome was the impact of resident duty hour restrictions on emotional exhaustion, depersonalisation and personal accomplishment, as defined by the Maslach Burnout Inventory. The secondary patient‐related outcomes were patient hospital length of stay, serious medical errors and preventable adverse events. Data were pooled using a random‐effects model. Results: Of the 873 references, nine RCTs met the inclusion criteria. A shorter shift length compared with longer shift length was associated with significantly less emotional exhaustion (standardised mean difference [SMD] = −0.11, 95% CI = −0.21, −0.00) and less dissatisfaction with overall well‐being (OR = 0.61, 95% CI 0.38, 0.99) but not with hospital length of stay (SMD = −0.01, 95% CI = −0.05, 0.02, p = 0.45) and serious medical errors per 1000 patient hours (OR = 1.07, 95% CI = 0.52, 2.21; p = 0.86). Conclusions: Shorter resident duty hours is possibly associated with improvement in resident‐based outcomes, specifically, emotional exhaustion, dissatisfaction with overall well‐being, sleep duration and sleepiness. These findings may inform the policy change in support of reduced shift hours resulting in overall well‐being for the residents with possible reduction in burnout without adverse impact on patient‐based outcomes. In this systematic review and meta‐analysis, the authors report that shorter resident duty hours are associated with better resident outcomes. [ABSTRACT FROM AUTHOR]

The management of newly diagnosed primary central nervous system lymphoma (PCNSL) includes administration of high‐dose methotrexate based regimens followed by consolidation therapy to minimize the risk of relapse. However, the best consolidation strategy (autologous hematopoietic cell transplant [auto‐HCT] vs. whole‐brain radiotherapy [WBRT]) is controversial. Hence, we performed a systematic review and meta‐analysis of all randomized controlled trials that compared auto‐HCT versus WBRT consolidation for patients with PCNSL after first‐line treatment.The primary outcome was overall survival (OS), while the secondary outcomes included progression‐free survival (PFS), response rates (overall response rate [ORR] and complete remission [CR]), relapse rate, treatment‐related mortality (TRM), and neuropsychological adverse events. We performed a pooled analysis of the single‐arm studies that incorporated auto‐HCT or WBRT consolidation and evaluated neurocognitive outcomes. Only two studies met the inclusion criteria (n = 240). There was no significant difference in OS (HR = 1.50; 95% CI = 0.95–2.36), PFS (HR = 0.99; 95% CI = 0.44–2.22), ORR (RR = 1.48; 95% CI = 0.90–2.44), CR rate (RR = 1.21; 95% CI = 0.90–1.63), relapse rate (RR = 0.46; 95% CI = 0.05–4.28), and TRM (RR = 5.67; 95% CI = 1.01–31.91). The neuropsychological tests to assess neurocognitive domains were different and inconsistently reported in the two studies and therefore we were unable to perform a meta‐analysis but provide a descriptive assessment. Both the studies showed a significant decline in the attention/executive function (based on the trail making test A and trail making test B) in those receiving WBRT compared to auto‐HCT. We found 9 single‐arm phase II studies that reported data on outcomes associated with either auto‐HCT (5 studies) or WBRT (4 studies) consolidation. Of these, two studies (n = 43) reported data on neurocognitive decline following auto‐HCT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 6% (95% CI, 0%–17%) for those receiving auto‐HCT and there was no heterogeneity between studies (I2 = 0%). Three studies (n = 122) reported data on neurocognitive decline following WBRT consolidation. Pooled proportion of patients with neurocognitive decline in these studies was 43% (95% CI, 11%–78%) for those receiving WBRT and there was high heterogeneity between studies (I2 = 94%). There was significant heterogeneity between subgroups (p = 0.035). The outcomes were not significantly different in patients with PCNSL receiving auto‐HCT or WBRT consolidation therapies, however, there is a higher degree of neurocognitive decline associated with WBRT compared to auto‐HCT consolidation. The decision to choose a consolidation strategy needs to be individualized based on age, frailty, and co‐morbidities. [ABSTRACT FROM AUTHOR]

Introduction: Lenalidomide maintenance, commonly prescribed in the postautologous transplantation (AHCT) setting for multiple myeloma (MM), is associated with development of secondary primary malignancies (SPM). Proteasome inhibitor maintenance (PIM) has also been evaluated in MM. We conduct a systematic review/meta‐analysis to assess the efficacy of PIM in MM. Methods: Performing a comprehensive search of the medical literature using PubMed/Medline and EMBASE on September 11, 2019, we extracted data on clinical outcomes related to benefits (OS, PFS, and depth of hematologic response [DOHR]) and harms (SPM and adverse events). 2144 references were identified; three studies were eligible for inclusion. Results: A total of 1760 patients were included in the analysis; 507 patients received bortezomib and 395 received ixazomib maintenance. Control arms were either placebo (n = 261) or thalidomide (n = 358). PIM did not improve OS (HR 0.88, 95% CI 0.73‐1.05, P =.15) but improved PFS (HR 0.77, 95% CI 0.69‐0.86, P ≤.00001) and DOHR (HR 0.88, 95% CI 0.79‐0.98, P =.02) compared with control. There were no significant differences between PIM and control regarding SPM (p = NS) and ≥grade 3 peripheral neuropathy (PN) (p = NS). Conclusions: PIM following AHCT in MM improves PFS and DOHR without an increase in development of SPM or severe PN compared with placebo/thalidomide. [ABSTRACT FROM AUTHOR]

Background: The outcomes for patients with diffuse large B-cell lymphoma (DLBCL) with adverse clinical prognostic factors such as a high age-adjusted International Prognostic Index (aaIPI) are not optimal. In the current study, the authors performed a systematic review and meta-analysis to assess the totality of evidence pertaining to the efficacy of autologous hematopoietic stem cell transplantation (auto-HCT) consolidation for patients with DLBCL in first remission.Methods: The authors searched the Cochrane and MEDLINE/PubMed databases through December 1, 2018, for studies comparing conventional chemotherapy with rituximab (R-chemo) versus R-chemo and auto-HCT. Two authors independently reviewed all references for study inclusion and extracted data related to benefits (overall survival, progression-free survival, and response rates) and harms (treatment-related mortality and adverse events).Results: Four studies (1173 patients) met the inclusion criteria and were included in the current analysis. The median duration of follow-up ranged from 42 to 76 months. There was no difference noted with regard to the overall survival (hazard ratio, 1.01; 95% CI, 0.74-1.37), progression-free survival (hazard ratio, 0.77; 95% CI, 0.58-1.04), or response rates (risk ratio, 0.98; 95% CI, 0.92-1.04) between patients who received R-chemo and auto-HCT and those who received R-chemo alone. The risk of mortality and therapy failure was not found to be different when the analysis was limited to high aaIPI between the 2 groups. Although there was no difference noted with regard to the risk of treatment-related mortality, there was a significantly higher incidence of CTCAE grade 3 or 4 adverse events in patients who received R-chemo and auto-HCT compared with patients treated with R-chemo alone.Conclusions: The findings from what to the authors' knowledge is the first meta-analysis performed in the rituximab era demonstrated no beneficial effect of upfront auto-HCT consolidation in patients with aggressive B-cell non-Hodgkin lymphoma, including high-risk clinical groups (high aaIPI). [ABSTRACT FROM AUTHOR]

Evidence regarding the efficacy of gemtuzumab ozogamicin ( GO) addition to standard induction chemotherapy in newly diagnosed acute myeloid leukaemia ( AML) is conflicting. This systematic review aimed to identify and summarize all evidence regarding the benefits and harms of adding GO to conventional chemotherapy for induction treatment of AML. A comprehensive literature search of two databases ( PUBMED and Cochrane) from inception up to November 22, 2012, and 4 years of proceedings from four major haematology/oncology conferences was undertaken. Endpoints included benefits (complete remission, relapse-free, event-free, and overall survival), and harms (early mortality and incidence of hepatic veno-occlusive disease/sinusoidal obstructive syndrome). Seven trials (3942 patients) met all inclusion criteria. Addition of GO showed improved relapse-free [ Hazard Ratio ( HR) = 0·84 (95% confidence interval ( CI) 0·71-0·99)] and event-free survival [ HR = 0·59 (95% CI 0·48-0·74)] but not overall survival [ HR = 0·95 (95% CI 0·83-1·08)]. Addition of GO resulted in higher rate of early mortality [ Risk Ratio = 1·60 (95% CI 1·07-2·39)]. Improved overall survival was observed in studies using a lower cumulative GO dose (<6 mg/m2) [ HR = 0·89 (95% CI 0·81-0·99)]. Addition of GO to conventional chemotherapy as induction therapy may improve relapse-free and event-free survival, but does not impact overall survival and significantly increases early mortality in AML. [ABSTRACT FROM AUTHOR]