Direct oral anticoagulants in skin surgery: a systematic review of their complications and recommendations for perioperative management

INTRODUCTION

Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants (DOACs), there is a deficit of knowledge regarding optimal perioperative management. This review aims to evaluate the evidence and risk surrounding management of DOACs in patients undergoing skin surgeries.

METHODS

Systematic review of EMBASE, Scopus, and PubMed, with inclusion of studies that detailed perioperative management of DOACs in those undergoing skin surgery. Primary outcome measures were perioperative hemorrhagic and thromboembolic complications.

RESULTS

Seven thousand seven hundred and forty-one abstracts were identified, with 13 articles meeting inclusion criteria. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of hemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery, with a pooled thromboembolic complication rate of 0.15%. Articles comparing continuation and cessation discovered no decreased risk of bleeding with DOAC cessation prior to surgery (P = 0.93). Seven of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those on DOAC therapy.

CONCLUSION

Optimal management of anticoagulants perioperatively is difficult because of conflicting information, complicated by advent of novel agents. Risk of hemorrhagic complications with both continuation and interruption of DOAC therapy was low. Perioperative DOAC management can be guided by procedural bleeding and patient clotting risk and can often be continued in minor dermatologic procedures.

Short-Term Cardiovascular Complications in Dermatology Patients Receiving JAK-STAT Inhibitors: A Meta-Analysis of Randomized Clinical Trials

Importance

Evolving evidence suggests that patients receiving Janus kinase-signal transducer and activator of transcription inhibitors (JAK-STATi) may be at higher risk of major adverse cardiovascular events (MACE) and venous thromboembolism (VTE). Most existing literature has focused on indications that may confer a higher MACE and VTE risk than that among patients with isolated dermatological indications.

Objective

To evaluate risk of MACE, VTE, serious adverse events (SAEs), and tolerability of systemic JAK-STATi compared with placebo, in those with a dermatologic indication.

Data Sources

A systematic review of the literature was carried out to June 2023, using databases Embase, MEDLINE, SCOPUS, Cochrane Library of Registered Trials, and registered Clinical Trials. The analysis was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis itself took place in June 2023.

Study Selection

Placebo-controlled randomized clinical trials that compared systemic JAK-STATi with placebo, and investigated the safety in patients with alopecia areata, psoriasis, vitiligo, atopic dermatitis, lichen planus or hidradenitis suppurativa.

Data Extraction and Synthesis

Study selection and data extraction by 2 authors working independently using a standardized template. Crude numbers for MACE, VTE, SAEs, and study discontinuation due to treatment emergent adverse events (TEAEs) were pooled and underwent meta-analysis.

Main Outcomes and Measures

Incidence of MACE, VTE, SAE, and study discontinuation due to TEAEs. Analysis of these values against person exposure years to determine the incidence rate (IR). Risk ratios (RRs) compared incidence rates among treatment and placebo comparator arms.

Results

Forty-five randomized clinical trials were eligible for inclusion, with 12 996 patients receiving active JAK-STATi therapy and 4925 allocated to placebo treatment. Meta-analysis found no significant increase in MACE (I2 = 0.00%; RR, 0.47; 95% CI, 0.28-0.80) or VTE (I2 = 0.00%; RR, 0.46; 95% CI, 0.26-0.80) between placebo and JAK-STATi comparator arms. There was also no significant difference in SAEs (I2 = 12.38%; RR, 0.92; 95% CI, 0.72-1.20) and discontinuations between JAK-STATi and placebo (I2 = 23.55%; RR, 0.94; 95% CI, 0.76-1.19).

Conclusions and Relevance

This meta-analysis did not identify a significant increase in the risk of MACE and VTE in dermatology patients receiving JAK-STATi for median duration of 16 weeks. The results of this review suggest there is insufficient evidence that JAK-STATi confer an increased risk of cardiovascular complications in dermatological patients, especially when used for short time frames.

A Systematic Review of Ophthalmology Education in Medical Schools: The Global Decline

TOPIC

This systematic review examines geographical and temporal trends in medical school ophthalmology education in relation to course and student outcomes.

CLINICAL RELEVANCE

There is increasing evidence suggesting a decline in ophthalmology teaching in medical schools, raising concern for the adequacy of eye knowledge across the rest of the medical profession.

METHODS

Systematic review of Embase and SCOPUS, with inclusion of studies containing data on medical school ophthalmological course length, and/or one or more outcome measures on student ophthalmology knowledge, skills, self-evaluation of knowledge or skills, or student course appraisal. The systematic review was registered prospectively on PROSPERO, ID CRD42022323865. Results were aggregated with outcome sub-group analysis and description in relation to geographical and temporal trends. Descriptive statistics including nonparametric correlations were utilised to analyse data and trends.

RESULTS

Systematic review yielded 4 596 publication titles, of which 52 were included in the analysis, with data from 19 countries. Average course length ranged from 12.5-208.7 hours, with significant continental disparity between mean course length. Africa reported the longest average course length at 103.3 hours, and North America reported the shortest at 36.4 hours. On average course lengths have been declining over the last two decades, from an average overall course length of 92.9 hours in the 2000s, to 52.9 hours in the 2020s. Mean student self-evaluation of skills was 51.3%, and student self-evaluation of knowledge was 55.4%. Objective mean assessment mark of skills was 57.5%, and of knowledge was 71.7%, compared to an average pass mark of 66.7%. On average 26.4% of students felt confident in their ophthalmology knowledge, and 34.5% in their skills.

CONCLUSIONS

The majority of the evidence describes declining length of courses devoted to ophthalmology in the last 20 years, significant student dissatisfaction with courses and content, and suboptimal knowledge and confidence.

Analysis of soybean sapogenins by high-performance liquid chromatography

A method for the analysis of soybean sapogenins is described. The method is based on the extraction of soybean saponins from a defatted sample. The triterpene glycosides are then hydrolysed with subsequent analysis of the liberated sapogenins by high-performance liquid chromatography using gradient elution and mass detection. By use of a sapogenin/carbohydrate ratio, an estimate of the total saponin content can be made.