Lawrence Mj Best

Medical Therapies for Uterine Fibroids – A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials

Background Uterine fibroids are common, often symptomatic and a third of women need repeated time off work. Consequently 25% to 50% of women with fibroids receive surgical treatment, namely myomectomy or hysterectomy. Hysterectomy is the definitive treatment as fibroids are hormone dependent and frequently recurrent. Medical treatment aims to control symptoms in order to replace or delay surgery. This may improve the outcome of surgery and prevent recurrence. Purpose To determine whether any medical treatment can be recommended in the treatment of women with fibroids about to undergo surgery and in those for whom surgery is not planned based on currently available evidence. Study Selection Two authors independently identified randomised controlled trials (RCT) of all pharmacological treatments aimed at the treatment of fibroids from a list of references obtained by formal search of MEDLINE, EMBASE, Cochrane library, Science Citation Index, and ClinicalTrials.gov until December 2013. Data Extraction Two authors independently extracted data from identified studies. Data Synthesis A Bayesian network meta-analysis was performed following the National Institute for Health and Care Excellence—Decision Support Unit guidelines. Odds ratios, rate ratios, or mean differences with 95% credible intervals (CrI) were calculated. Results and Limitations A total of 75 RCT met the inclusion criteria, 47 of which were included in the network meta-analysis. The overall quality of evidence was very low. The network meta-analysis showed differing results for different outcomes. Conclusions There is currently insufficient evidence to recommend any medical treatment in the management of fibroids. Certain treatments have future promise however further, well designed RCTs are needed.

Microwave Ablation of Pulmonary Metastases Associated with Perioperative Takotsubo Cardiomyopathy

From: Lawrence Best, BSc Beatrice Seddon, PhD, MRCP, FRCR Simon Woldman, MD, FRCP (Glas), FRCP, FESC Alexander Lyon, PhD, MRCP Rowland Illing, DM, MRCS, FRCR University College London Medical School (L.B.) Department of Specialist Imaging (R.I.) Podium Level 2 University College Hospital London NW1 2BU, UK University College London Hospitals NHS Foundation Trust (B.S., S.W.) NIHR Cardiovascular Biomedical Research Unit (A.L.) Royal Brompton Hospital London, United Kingdom

Closed‐system drug‐transfer devices in addition to safe handling of hazardous drugs versus safe handling alone for reducing healthcare staff exposure to infusional hazardous drugs

and obtaining full texts for references considered relevant based on the full text. Besides, these studies (which do not mention CSTD in the title or abstract) are likely to show no evidence of benefit of CSTD (the probable reason for not mentioning about CSTD in the title or abstract); therefore, the systematic review authors’ conclusions are unlikely to change. The intra-cluster correlation coefficient was not reported in any of the studies. Therefore, the systematic review authors used the intra-cluster correlation coefficient of 0.10 decided a priori based on studies about implementation research. The results were robust in a sensitivity analysis of using 0.05 for intra-cluster correlation coefficient (i.e. half the correlation noted in similar studies) for most analyses; therefore, the systematic review authors’ conclusions are unlikely to change if the studies had reported the intra-cluster correlation. However, the systematic review authors recommend the study authors to report intra-cluster correlation in future to enable accurate estimation of the results. This is the first systematic review on the topic. The systematic review authors disagree with the study authors who concluded that routine CSTD use is beneficial 26, 60-63, 65-68, . Ignoring the design effect by not adjusting the effect estimates for intra-cluster correlation can lead to an underestimation of random errors; therefore, this could lead to erroneous conclusions. Ignoring the design effect by the study authors, the risk of bias in the studies, and the excessive importance given to unvalidated surrogate outcomes by the study authors are the major differences in the conclusions between this systematic review and the primary research studies. The systematic review authors also disagreed with any guidelines or recommendations that CSTD should be used routinely whenever possible 27, . The possible reasons for our disagreement with those guidelines or recommendations that CSTD should be used routinely are the same as the reasons why we disagree with the study authors who concluded that routine CSTD use is beneficial.

Reply to: 'Re: "Microwave ablation of pulmonary metastases associated with perioperative Takotsubo cardiomyopathy"'.

For these reasons, preservation of left arm access was prioritized. Right BCV/SVC thrombolysis alone may have relieved her symptoms, but would have sacrificed left-sided access in the future, especially because we planned to perform salvage on the right side with a covered stent. Recanalization of the left BCV with stent placement through the interstices of the existing 10-mm right BCV/SVC stent would limit the sizes of the right and left BCV stents to 7 mm. The small caliber of the stents and the high likelihood of central venous catheters traversing the stents in the future would limit patency.