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The interscalene block (ISB) is the standard regional anesthesia for shoulder arthroscopy. However, the superior trunk block (STB) is an alternative with a potentially safer profile. This meta-analysis aimed to compare the incidence and degree of hemidiaphragmatic paralysis and block efficacy of these techniques. We searched MEDLINE, EMBASE, Scopus, and Cochrane databases to identify randomized controlled trials (RCTs). The main outcome was total hemidiaphragmatic paralysis. We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence.Four RCTs and 359 patients were included. The STB group showed lower total hemidiaphragmatic paralysis (RR 0.07; 95% CI 0.04 to 0.14; p<0.0001). The incidence of subjective dyspnea (p = 0.002) and Horner's syndrome (p<0.001) was significantly lower with STB relative to ISB. There was no significant difference between groups in block duration (p = 0.67). There was a high certainty of evidence in the main outcome as per the GRADE framework. Our findings suggest that STB has a better safety profile than ISB, resulting in lower rates of hemidiaphragmatic paralysis and dyspnea while providing a similar block. Therefore, STB could be preferred to ISB, especially in patients susceptible to phrenic nerve paralysis complications.

Background Patients with active cancer and aortic stenosis may be under-referred for valve interventions due to concerns over a prohibitive risk. However, whether active cancer impacts outcomes after transcatheter aortic valve replacement (TAVR) remains unknown. Methods We searched PubMed, Embase, and Cochrane Library in December 2023 for studies comparing the post-TAVR outcomes of patients with versus without active cancer. We pooled odds ratios (OR) and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) applying a random-effects model. Statistical analyses were performed in R version 4.3.2. Results We included nine observational studies analyzing 133,906 patients, of whom 9,792 (7.3%) had active cancer. Compared with patients without cancer, patients with active cancer had higher short- (OR 1.33; 95% CI 1.15–1.55; p  < 0.001) and long-term mortality (OR 2.29; 95% CI 1.80–2.91; p  < 0.001) rates, not driven by cardiovascular mortality (OR 1.30; 95% CI 0.70–2.40; p  = 0.40), and higher major bleeding rates (OR 1.66; 95% CI 1.15–2.42; p  = 0.008). The higher mortality rate was sustained in an adjusted analysis (aHR 1.77; 95% CI 1.34–2.35; p  < 0.001). There was no significant difference in cardiac, renal, and cerebral complications at a follow-up ranging from 180 days to 10 years. Conclusion Patients with active cancer undergoing TAVR had higher non-cardiovascular mortality and bleeding rates, with comparable incidences of other complications. This highlights the need for a shared decision and appropriate patient selection considering cancer type, staging, bleeding risk, and optimal timing for intervention. Graphical Abstract

BackgroundStudies targeting amyloid-ß in patients with Alzheimer’s disease (AD) have conflicting results and early initiation of therapy may yield better outcomes.MethodsWe systematically searched PubMed, Embase, Cochrane Library, and Clinicaltrials.gov for randomized trials comparing monoclonal antibodies (mAbs) with placebo in MCI or mild dementia due to AD.ResultsNineteen studies comprising 15,275 patients were included. In patients with early AD, mAbs reduced the rate of decline, in both the Clinical Dementia Rating Scale, the sum of boxes (CDR-SB; MD −0.30; 95% CI −0.42,−0.19; p < 0.01), and the Alzheimer’s Disease Assessment Scale, cognitive subscore (ADAS-cog; SMD −0.80; 95% CI −10.25,−0.35; p < 0.01). The results were similar between clinical stages for CDR-SB (MCI, MD −0.19; 95% CI −0.35,−0.03; p = 0.02; mild dementia, MD −0.45; 95% CI −0.65,−0.25; p < 0.01; subgroup differences, p = 0.13), as well as for ADAS-Cog (MCI, SMD −0.83; 95% CI −1.49,−0.17; p = 0.01; mild dementia, SMD −0.69; 95% CI −1.32 to −0.05; p = 0.03; subgroup differences, p = 0.47). The risk of amyloid-related imaging abnormalities (ARIA) was significantly higher in patients taking mAbs, including ARIA-edema (RR 7.7; 95% CI 4.60 to 13.00; p < 0.01), ARIA-hemorrhage (RR 1.8; 95% CI 1.22 to 2.59; p < 0.01), and symptomatic or serious ARIA (RR 14.1; 95% CI 7.30 to 27.14; p < 0.01).ConclusionAnti-amyloid-ß mAbs attenuate cognitive and functional decline compared with placebo in early AD; whether the magnitude of this effect is clinically important remains uncertain, especially relative to the safety profile of these medications. Starting immunotherapy in patients with MCI was not significantly different than starting in the mild dementia stage.PROSPERO registryCRD42023430698

PurposePatients with atrial fibrillation (AF) and end-stage renal disease on chronic hemodialysis are at risk for thromboembolic and bleeding events. We aimed to perform a meta-analysis to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in this population.MethodsWe systematically searched PubMed, Excerpta Medica Database (EMBASE) and Cochrane Library for randomized controlled trials (RCTs) comparing DOACs with VKAs in patients with AF on chronic hemodialysis from inception to February 2023 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes were reported using risk ratios (RRs) with 95% confidence intervals (CIs). Statistical analyses were performed using R version 4.2.2.ResultsWe selected three RCTs including 341 patients, of whom 176 (51.6%) were randomized to DOACs. Follow-up ranged from 174 days to 3.38 years. There was no significant difference between groups in terms of cardiovascular mortality (RR 1.34; 95% CI 0.69–2.60; p = 0.39), all-cause mortality (RR 0.96; 95% CI 0.72–1.27; p = 0.77), ischemic/uncertain type of stroke or transient ischemic attack (RR 0.50; 95% CI 0.19–1.35; p = 0.17), or major or life-threatening bleeding (RR 0.70; 95% CI 0.39–1.25; p = 0.22).ConclusionIn this meta-analysis of three RCTs, no significant difference was observed between DOACs and VKAs in cardiovascular mortality, all-cause mortality, ischemic/uncertain type of stroke or transient ischemic attack, or major or life-threatening bleeding in patients with AF on chronic hemodialysis.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page) Application for ESRA Abstract Prizes: I don’t wish to apply for the ESRA PrizesBackground and AimsThe Superior Trunk Block (STB) is being considered as an alternative to Interscalene Block (ISB) for shoulder arthroscopy. This study aims to compare efficacy and safety between these techniques.MethodsPubMed, EMBASE, Scopus and Cochrane were searched for randomized controlled trials (RCTs) comparing the STB to the ISB for shoulder arthroscopies. Outcomes assessed included incidence and extent of hemidiaphragmatic paralysis, pain scores, opioid consumption, patient satisfaction, block duration, and block-related complications. RevMan 5.4 analyzed data. Risk of bias was appraised using the RoB-2 tool.ResultsWe analyzed 4 RCTs involving 359 patients, of whom 49.5% underwent STB. The results showed that STB resulted in less total hemidiaphragmatic paralysis (figure 2), less subjective dyspnea (figure 3) and lower incidence of Horner’s Syndrome (RR 0.06; 95% CI 0.01 to 0.32; p < 0.001; I2 = 0%, 3 RCTs, 221 patients). No statistically significant differences were found between the two groups for other outcomes, except for pain score at rest at 24h, which was favorable to STB (MD -0.75; 95% CI -1.35 to -0.15; p = 0.01). However, we should consider the clinical relevance of this difference. Our study represents the largest sample size available comparing these techniques, and our results indicate that probably there was enough statistical power for the majority of outcomes analyzed.Abstract OP039 Figure 1The STB demonstrated less total hemidiaphragmatic paralysis (1A), and an increased absence of hemidiaphragmatic paralysis (1B) than the ISBAbstract OP039 Figure 2There was a significantly better diaphragmatic excursion 30 minutes after the STB than the ISBAbstract OP039 Figure 3There was significantly less subjective dyspnea in the STB group when compared to the ISBConclusionsOur findings suggest that STB is safer than ISB, as it results in a lower incidence and extent of hemidiaphragmatic paralysis, while demonstrating similar block efficacy.