Parenteral anticoagulation in ambulatory patients with cancer

Impact of early heparin therapy on outcomes in patients with solid malignancy associated sepsis: a marginal structural model causal analyse

Background: Previous studies documented that heparin can inhibit the invasion and metastasis of tumors, but its role on outcomes in patients with solid malignancy complicated sepsis remains unclear. Methods: A retrospective cohort study was conducted in critically ill patients with solid malignancy associated sepsis from the Medical Information Mart for Intensive Care (MIMIC)-IV database. The primary endpoint was intensive care unit (ICU) mortality, secondary outcomes were thrombosis and hospital mortality. Propensity score matching (PSM), marginal structural Cox model (MSCM), cox proportional hazards model, stratification analysis and E-value were used to account for baseline differences, time-varying confounding and unmeasured variables. Results: A total of 1,512 patients with solid malignancy complicated sepsis were enrolled, of which 683 in the heparin group with intensive care unit mortality, thrombosis rate and hospital mortality were 9.7%, 5.4%, 16.1%, and 829 in the non-heparin group with ICU mortality, thrombosis rate and hospital mortality were 14.6%, 12.5%, 22.6%. Similar results were observed on outcomes for patients with PSM (ICU mortality hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.92), thrombosis rate (HR 0.42, 95% confidence interval 0.26-0.68); hospital mortality HR 0.70, 95% CI 0.50-0.99). marginal structural Cox model further reinforced the efficacy of heparin in reducing ICU mortality (HR 0.48, 95% CI 0.34-0.68). Logistic regression and Cox regression model showed heparin use also markedly reduced thrombosis (HR 0.42; 95% CI 0.26-0.68; p < 0.001) and hospital mortality (HR 0.70; 95% CI 0.50-0.99; p = 0.043). Stratification analysis with the MSCM showed an effect only those with digestive system cancer (HR 0.33, 95% CI 0.16-0.69). Conclusion: Early heparin therapy improved outcomes in critically ill patients with solid malignancy complicated sepsis. These results are evident especially in those with digestive system cancer. A prospective randomized controlled study should be designed to further assess the relevant findings.

Clinical use of low-dose parenteral anticoagulation, incidence of major bleeding and mortality: a multi-centre cohort study using the French national health data system

PURPOSE

Low-dose parenteral anticoagulation has demonstrated its efficacy for venous thromboembolism prophylaxis in randomized trials. However, current practice is not widely documented. In ambulatory settings, we aimed to provide an overview of the clinical use of low-dose parenteral anticoagulation in France and to assess the incidence of major bleeding and death rates.

METHODS

A population-based prospective cohort study using the French national health data system (SNIIRAM) identified 142,815 adults living in five well-defined geographical areas who had a course of low-dose parenteral anticoagulants (a total of 150,389 courses) in the period 2013-2015. The main outcome measures were the types of low-dose parenteral anticoagulant, the duration and the clinical context. Adjusted incidence rate ratios (IRR) were derived from Poisson models.

RESULTS

Enoxaparin was the most frequently prescribed anticoagulant (58.9%) followed by tinzaparin (27.3%) and fondaparinux (10.9%). Patients receiving unfractionated heparin (N = 766, 0.53%) were older, more frequently had renal disease (48.75%) and had a higher modified HAS-B(L)ED score (≥ 3 in 61.6%) than patients receiving low-molecular weight heparin (LMWH). Surgical thrombo-prophylaxis was the most frequent indication (47.6%), followed by medical prophylaxis (29.9%). Course durations were in line with regulatory agency specifications. Only 43 (0.028%) major bleeding events and 478 (0.32%) deaths were observed. Adjusted IRRs for major bleeding or death were not significantly different for dalteparin/nadroparin, tinzaparin or fondaparinux compared to enoxaparin.

CONCLUSION

Very low incidence rates of major bleeding and all-cause mortality were observed. Our study confirms the safety of LMWHs and fondaparinux in thrombo-prophylaxis in ambulatory settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02886533.

New prophylaxis strategies to reduce the risk of thromboembolism in cancer

INTRODUCTION

: Patients with cancer are at risk of thrombotic events, mainly deep vein thrombosis and/or pulmonary embolism. The thrombosis risk is generally 4-6 times higher than in a healthy population and depends on factors related to patient characteristics, tumor factors, and treatment-related factors. The decision-making for prophylactic anticoagulation is individualized according to the relative risks and benefits. The VTE risk has been quantified using different assessment scores. In recent years, an effort has been made to establish "risk assessment models" specifically for patients undergoing chemotherapy.

AREAS COVERED

This article reviews current data and ongoing research on predictive factors involved in cancer-related thrombosis and it is highlighted the currently suggested strategies for prophylaxis. Several trials that compared the two treatment options, direct factor Xa inhibitor or LMWH, with placebo and not each other are discussed. In this article, was analyzed the safety and efficacy features that led several international organizations such as ASCO, NCCN, and others, to issue guidelines for the prophylaxis and treatment of patients at high risk of thrombosis by using LMWH, fondaparinux and DOACs.

EXPERT OPINION

ASCO, NCCN, and other international organizations recommend thromboprophylaxis in high risk patients. However, further investigation is needed to define better biomarkers for more accurate identification of cancer patients that will benefit from anticoagulant treatment.

Tailored PRISMA 2020 flow diagrams for living systematic reviews: a methodological survey and a proposal

Background: While the PRISMA flow diagram is widely used for reporting standard systematic reviews (SRs), it was not designed for capturing the results of continual searches for studies in living systematic reviews (LSRs). The objectives of this study are (1) to assess how published LSRs report on the flow of studies through the different phases of the review for the different updates; (2) to propose an approach to reporting on that flow. Methods: For objective 1, we identified all LSRs published up to April 2021. We abstracted information regarding their general characteristics and how they reported on search results. For objective 2, we based our proposal for tailored PRISMA approaches on the findings from objective 1, as well as on our experience with conducting Cochrane LSRs. Results: We identified 279 living publications relating to 76 LSRs. Of the 279 publications, 11% were protocols, 23% were base versions (i.e., the first version), 50% were partial updates (i.e., does not include all typical sections of an SR), and 16% were full updates (i.e., includes all typical sections of an SR). We identified six ways to reporting the study flow: base separately, each update separately (38%); numbers not reported (32%); latest update separately, all previous versions combined (20%); base separately, all updates combined (7%); latest update version only (3%); all versions combined (0%). We propose recording in detail the results of the searches to keep track of all identified records. For structuring the flow diagram, we propose using one of four approaches. Conclusion: We identified six ways for reporting the study flow through the different phases of the review for the different update versions. We propose to document in detail the study flow for the different search updates and select one of our four tailored PRISMA diagram approaches to present that study flow.

Tailored PRISMA 2020 flow diagrams for living systematic reviews: a methodological survey and a proposal

Background: While the PRISMA flow diagram is widely used for reporting standard systematic reviews (SRs), it was not designed for capturing the results of continual searches for studies in living systematic reviews (LSRs). The objectives of this study are (1) to assess how published LSRs report on the flow of studies through the different phases of the review for the different updates; (2) to propose an approach to reporting on that flow. Methods: For objective 1, we identified all LSRs published up to July 2020. We abstracted information regarding their general characteristics and how they reported on search results. For objective 2, we based our proposal for tailored PRISMA approaches on the findings from objective 1, as well as on our experience with conducting Cochrane LSRs. Results: We identified 108 living publications relating to 32 LSRs. Of the 108 publications, 7% were protocols, 24% were base versions (i.e., the first version), 62% were partial updates (i.e., does not include all typical sections of an SR), and 7% were full updates (i.e., includes all typical sections of an SR). We identified six ways to reporting the study flow: base separately, each update separately (38%); numbers not reported (32%); latest update separately, all previous versions combined (20%); base separately, all updates combined (7%); latest update version only (3%);  all versions combined (0%). We propose recording in detail the results of the searches to keep track of all identified records. For structuring the flow diagram, we propose using one of four approaches. Conclusion: We identified six ways for reporting the study flow through the different phases of the review for the different update versions. We propose to document in detail the study flow for the different search updates and select one of our four tailored PRISMA diagram approaches to present that study flow.

PRISMA flow diagrams for living systematic reviews: a methodological survey and a proposal

Background: While the PRISMA flow diagram is widely used for reporting standard systematic reviews (SRs), it was not designed for capturing the results of continual searches for studies in living systematic reviews (LSRs). The objectives of this study are (1) to assess how published LSRs report on the flow of studies through the different phases of the review for the different updates; (2) to propose an approach to reporting on that flow. Methods: For objective 1, we identified all LSRs published up to July 2020. We abstracted information regarding their general characteristics and how they reported on search results. For objective 2, we based our proposal for tailored PRISMA approaches on the findings from objective 1, as well as on our experience with conducting Cochrane LSRs. Results: We identified 108 living publications relating to 32 LSRs. Of the 108 publications, 7% were protocols, 24% were base versions (i.e., the first version), 62% were partial updates (i.e., does not include all typical sections of an SR), and 7% were full updates (i.e., includes all typical sections of an SR). We identified six ways to reporting the study flow: base separately, each update separately (38%); numbers not reported (32%); latest update separately, all previous versions combined (20%); base separately, all updates combined (7%); latest update version only (3%);  all versions combined (0%). We propose recording in detail the results of the searches to keep track of all identified records. For structuring the flow diagram, we propose using one of four approaches. Conclusion: We identified six ways for reporting the study flowthrough the different phases of the review for the different update versions. We propose to document in detail the study flow for the different search updates and select one of our four tailored PRISMA diagram approaches to present that study flow.

Association between Radiotherapy and Risk of Cancer Associated Venous Thromboembolism: A Sub-Analysis of the COMPASS-CAT Study

Simple Summary

Cancer patients are at an increased risk of developing venous thromboembolism (VTE) compared to non-cancer patients. VTE in cancer patients poses as a financial burden and influences quality of life and is correlated with increased morbidity and mortality. Several cancer-related and patient-related risk factors have been shown to be predictors of VTE in cancer patients. However, the effect of radiotherapy on development of thrombosis in cancer patients is not extensively explored. In this report, radiotherapy was significantly associated with increased risk for VTE. The risk of VTE was higher in women, patients >50 and those receiving chemo- or hormonal therapy.

Abstract

Background: The role and effect of radiotherapy in the development of VTE has not been extensively explored; Methods: This is a post-hoc analysis from the COMPASS-CAT trial. Patients with breast, lung, colon or ovarian cancer, with early, locally advanced or metastatic disease and receiving chemotherapy were included. Primary endpoint was documented symptomatic VTE; Results: A total of 1355 patients were enrolled between November 2013 and November 2015. Of those, 194 patients were excluded because of missing data or the use of anticoagulation. Of the evaluable patients, 361 patients received radiotherapy (33.6%) At a median follow up of 6 months, 9.1% (n = 33) of patients receiving radiotherapy developed a VTE event (excluding those with missing data on follow up). After applying the competing risk model, radiotherapy remained significantly associated with increased risk for VTE (HR 2.47, 95% CI: 1.47–4.12, p = 0.001). Stratification analysis for the cohort that received radiotherapy revealed an increased risk of VTE in women compared to men (10.8% vs. 2.7%; p = 0.03), in those older than 50 (12.2% vs. 3.7%; p = 0.011); for patients receiving anthracycline chemotherapy (14.4% vs. 2.9%; p < 0.001) and hormonal therapy (12.9% vs. 3.9%; p < 0.001); Conclusions: Analysis from the COMPASS-CAT revealed a significant correlation between radiotherapy and VTE in patients with cancer. Further studies are needed to better understand the potential cellular toxicity associated with radiotherapy.

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

BACKGROUND

Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer.

CONCLUSIONS

Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.

Methodology for the American Society of Hematology VTE guidelines: current best practice, innovations, and experiences

BACKGROUND

Methods for the development of clinical guidelines have advanced dramatically over the past 2 decades to strive for trustworthiness, transparency, user-friendliness, and rigor. The American Society of Hematology (ASH) guidelines on venous thromboembolism (VTE) have followed these advances, together with application of methodological innovations.

OBJECTIVE

In this article, we describe methods and methodological innovations as a model to inform future guideline enterprises by ASH and others to achieve guideline standards. Methodological innovations introduced in the development of the guidelines aim to address current challenges in guideline development.

METHODS

We followed ASH policy for guideline development, which is based on the Guideline International Network (GIN)-McMaster Guideline Development Checklist and current best practices. Central coordination, specialist working groups, and expert panels were established for the development of 10 VTE guidelines. Methodological guidance resources were developed to guide the process across guidelines panels. A methods advisory group guided the development and implementation of methodological innovations to address emerging challenges and needs.

RESULTS

The complete set of VTE guidelines will include >250 recommendations. Methodological innovations include the use of health-outcome descriptors, online voting with guideline development software, modeling of pathways for diagnostic questions, application of expert evidence, and a template manuscript for publication of ASH guidelines. These methods advance guideline development standards and have already informed other ASH guideline projects.

CONCLUSIONS

The development of the ASH VTE guidelines followed rigorous methods and introduced methodological innovations during guideline development, striving for the highest possible level of trustworthiness, transparency, user-friendliness, and rigor.

Justifying Total Costs of Extended Venothromboembolism Prophylaxis After Colorectal Cancer Surgery

BACKGROUND

Current guidelines recommend extended venothromboembolism (VTE) prophylaxis for most patients following colorectal cancer surgery, but provider uptake has been limited. The purpose of this study was to identify thresholds for when such extended prophylaxis (ePpx) may be value-appropriate.

METHODS

All colorectal cancer postoperative discharges were identified within a private payer administrative database (MarketScan® 2010-2014, IBM Truven Health Analytics). Outcomes of interest were VTE event rate, mortality, and overall costs of care. The data along with published literature were used as parameter estimations for a decision analysis model with probabilistic sensitivity analysis.

RESULTS

We identified 22,463 colorectal cancer surgical patients (4.0% with ePpx) that served as the parameter estimates for the decision model with a VTE event rate of 0.2%. Decision analysis demonstrated that prescribing ePpx was dominated by usual practice with the former having higher probability-adjusted incremental costs ($1078.68 per person) and lower probability-adjusted benefits (- 0.000098 quality adjusted life years). Broad sensitivity analysis found that probability of a VTE event, bleeding case fatality rate, and probability of an ePpx-associated bleeding event were the primary effectors of the model. VTE event rates of greater than 3.0% benefited from prescribing ePpx to all patients.

CONCLUSIONS

Very few patients are discharged on ePpx following colorectal cancer surgery despite its endorsement by national guidelines. A decision analysis model does not support the use of ePpx except in cases of markedly high VTE rates. Clinical guidance could be improved by further recognizing the role of risk stratification in the determination of high-risk patients requiring ePpx.

Prevention of venous thromboembolism in patients with cancer with direct oral anticoagulants: A systematic review and meta-analysis

BACKGROUND

Patients with cancer are of a high level risk of venous thromboembolism (VTE). Low molecular weight heparin (LMWH) is recommended as the normal treatment for cancer-associated venous thrombosis. Recently, some studies suggest that patients with cancer-associated venous thrombosis can get a good efficacy and safety profile from treating with direct oral anticoagulants (DOACs) compared with other anticoagulants. However, when it comes to the efficacy of DAOCs in preventing VTE in patient with cancer, the data are limited. Thus, we performed such a meta-analysis to determine the efficacy and safety of DOACs in preventing VTE in patient with cancer compared with LMWHs.

METHODS

Medline/PubMed and CENTRAL (The Cochrane Central Register of Controlled Trials) were systematically searched for relevant studies. For each trial, data on VTE, major bleeding, or bleeding were extracted by 2 reviewers independently. Pooled risk ratios (RRs) were calculated by using Review Manager 5.3 software and the significance was determined by the Z test.

RESULTS

A total of 6 studies with 7185 patients were included in our meta-analysis. DOACs (RR = 0.55, 95% confidence interval [95%CI]: 0.34-0.90, I = 31%) had a similar prevention effect of VTE to LMWH (RR = 0.59, 95% CI: 0.37-0.95, I = 59%). DOACs (RR = 1.52, 95% CI: 0.99-2.33, I = 0%) yielded a similar bleeding occurrence rate compared with LMWH (RR = 1.35, 95% CI: 1.07-1.70, I = 35%). DOACs (RR = 1.95, 95% CI: 0.88-4.30, I = 0%) showed a sight higher major bleeding occurrence rate than LMWH (RR = 1.38, 95% CI: 0.88-2.14, I = 0%).

CONCLUSION

DOACs show comparable efficacy to LMWH in cancer patients without VTE with a slightly higher major bleeding occurrence rate. DOACs are inclined to be an alternative thromboprophylaxis strategy in cancer patients as they have superiorities compared to traditional anticoagulation agents. Further studies are still demanded as exiting relevant researches are limited.

Feasibility and acceptability of living systematic reviews: results from a mixed-methods evaluation

BACKGROUND

Living systematic reviews (LSRs) offer an approach to keeping high-quality evidence synthesis continually up to date, so the most recent, relevant and reliable evidence can be used to inform policy and practice, resulting in improved quality of care and patient health outcomes. However, they require modifications to authoring and editorial processes and pose technical and publishing challenges. Several teams within Cochrane and the international Living Evidence Network have been piloting living systematic reviews.

METHODS

We conducted a mixed-methods evaluation with participants involved in six LSRs (three Cochrane and three non-Cochrane). Up to three semi-structured interviews were conducted with 27 participants involved with one or more of the pilot LSRs. Interviews explored participants' experiences contributing to the LSR, barriers and facilitators to their conduct and opportunities for future development. Pilot team members also completed monthly surveys capturing time for key tasks and the number of citations screened for each review.

RESULTS

Across the pilot LSRs, search frequency was monthly to three-monthly, with some using tools such as machine learning and Cochrane Crowd to screen searches. Varied approaches were used to communicate updates to readers. The number of citations screened varied widely between the reviews, from three to 300 citations per month. The amount of time spent per month by the author team on each review also varied from 5 min to 32 h. Participants were enthusiastic to be involved in the LSR pilot. They highlighted the importance of a motivated and well-organised team; the value of technology enablers to improve workflow efficiencies; the need to establish reliable and efficient processes to sustain living reviews; and the potential for saving time and effort in the long run. Participants highlighted challenges with the current publication processes, managing ongoing workload and the lack of resources to support LSRs in the long term.

CONCLUSIONS

Findings to date support feasibility and acceptability of LSR production. There are challenges that need to be addressed for living systematic reviews to be sustainable and have maximum value. The findings from this study will be used in discussions with the Cochrane community, key decision makers and people more broadly concerned with LSRs to identify and develop priorities for scale-up.

Cost-Benefit Limitations of Extended, Outpatient Venous Thromboembolism Prophylaxis Following Surgery for Crohn's Disease

BACKGROUND

Patients with Crohn's disease are at increased risk of postoperative venous thromboembolism. Historically, extended outpatient prophylaxis has not met conventional measures of societal cost-benefit advantage. However, extended prophylaxis for patients with Crohn's disease may be more cost-effective because of the patients' high thrombotic risk and long life expectancy.

OBJECTIVE

This study aimed to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery.

DESIGN

A decision tree model was used to assess the incremental cost-effectiveness and cost per case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery.

SETTING

The risk of a postdischarge thrombotic event, age at surgery, type of thrombotic event, prophylaxis risk reduction, bleeding complications, and mortality were estimated by using existing published sources.

PATIENTS

Studied were patients with Crohn's disease versus routine care.

INTERVENTION

We constructed a decision analysis to compare costs and outcomes in patients with Crohn's disease postoperatively with and without extended prophylaxis over a lifetime horizon.

MAIN OUTCOME MEASURES

Productivity costs ($) and benefits (quality-adjusted life-year) were used to reflect a societal perspective and were time discounted at 3%. Multivariable probabilistic sensitivity analysis accounted for uncertainty in probabilities, costs, and utility weights.

RESULTS

With the use of reference parameters, the individual expected societal total cost of care was $399.83 without and $1387.95 with prophylaxis. Preventing a single mortality with prophylaxis would cost $43.00 million (number needed to treat: 39,839 individuals). The incremental cost was $1.90 million per quality-adjusted life-year. Adjusting across a range of scenarios upheld these conclusions 88% of the time. With further sensitivity testing, subpopulations with postdischarge thrombosis rates greater than 4.9% favors postoperative extended-duration venous thromboembolism prophylaxis.

LIMITATIONS

Further investigation is needed to determine if specific high-risk individuals can be preemptively identified in the Crohn's surgical population for targeted prophylaxis.

CONCLUSION

Extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment. See Video Abstract at http://links.lww.com/DCR/A998. LIMITACIONES DE COSTO-BENEFICIO DE LA PROFILAXIS AMBULATORIA PROLONGADA DEL TROMBOEMBOLISMO VENOSO DESPUÉS DE CIRUGÍA EN CASOS DE ENFERMEDAD DE CROHN:: Los pacientes con enfermedad de Crohn tienen un mayor riesgo de tromboembolismo venoso postoperatorio. Históricamente, la profilaxis ambulatoria prolongada no ha cumplido con las medidas convencionales de ventajas en costo-beneficio para la sociedad. Sin embargo, la profilaxis prolongada en los pacientes con Crohn puede ser más rentable debido al alto riesgo trombótico y a una larga esperanza de vida en estos pacientes.Evaluar la rentabilidad de la profilaxis prolongada en pacientes postoperados de un Crohn.Se utilizó un modelo de árbol de decisión para evaluar el incremento de rentabilidad y el costo por cada caso evitado con la profilaxis prolongada de tromboembolismo venoso después de cirugía abdominal.Se calcularon utilizando fuentes publicadas el riesgo de evento trombótico posterior al alta, la edad del paciente al momento de la cirugía, el tipo de evento trombótico, la reducción del riesgo de profilaxis, las complicaciones hemorrágicas y la mortalidad.Se estudiaron los pacientes de atención rutinaria versus aquellos portadores de Crohn.Construimos un arbol de análisis decisional para comparar costos y resultados de pacientes portadores de Crohn, con y sin profilaxis prolongada en el postoperatorio en un horizonte de por vida.Los costos de productividad ($) y los beneficios (año de vida ajustado por calidad) se utilizaron para reflejar la perspectiva social y se descontaron en el tiempo de un 3%. El análisis de sensibilidad probabilística multivariable dió cuenta de la incertidumbre en las probabilidades, costos y peso de utilidades.Usando parámetros de referencia, el costo total social esperado de la atención individual fue de $ 399.83 sin y $ 1,387.95 con profilaxis. La prevención del deceso de un paciente con profilaxis costaría $ 43.00 millones (valor requerido para tratar: 39,839 individuos). El costo incrementado fue de $ 1.90 millones por año de vida ajustado por la calidad. El ajuste a través de una gama de escenarios confirmó estas conclusiones el 88% del tiempo. Con pruebas de sensibilidad adicionales, las subpoblaciones con tasas de trombosis posteriores al alta fueron superiores al 4,9% y favorecían la profilaxis prolongada del tromboembolismo venoso en el postoperatorio.Se necesita más investigación para determinar si se puede identificar de manera preventiva los individuos específicos de alto riesgo en la población quirúrgica de Crohn en casos de profilaxis dirigida.La profilaxis prolongada en pacientes postoperados de un Crohn no es rentable cuando la incidencia acumulada de trombosis posthospitalaria sigue siendo inferior al 4,9%. Estos hallazgos son impulsados por el bajo riesgo absoluto de trombosis en esta población y el costo considerable del tratamiento universal. Vea el resumen del video en http://links.lww.com/DCR/A998.

Animal models of chemotherapy-induced peripheral neuropathy: A machine-assisted systematic review and meta-analysis

We report a systematic review and meta-analysis of research using animal models of chemotherapy-induced peripheral neuropathy (CIPN). We systematically searched 5 online databases in September 2012 and updated the search in November 2015 using machine learning and text mining to reduce the screening for inclusion workload and improve accuracy. For each comparison, we calculated a standardised mean difference (SMD) effect size, and then combined effects in a random-effects meta-analysis. We assessed the impact of study design factors and reporting of measures to reduce risks of bias. We present power analyses for the most frequently reported behavioural tests; 337 publications were included. Most studies (84%) used male animals only. The most frequently reported outcome measure was evoked limb withdrawal in response to mechanical monofilaments. There was modest reporting of measures to reduce risks of bias. The number of animals required to obtain 80% power with a significance level of 0.05 varied substantially across behavioural tests. In this comprehensive summary of the use of animal models of CIPN, we have identified areas in which the value of preclinical CIPN studies might be increased. Using both sexes of animals in the modelling of CIPN, ensuring that outcome measures align with those most relevant in the clinic, and the animal's pain contextualised ethology will likely improve external validity. Measures to reduce risk of bias should be employed to increase the internal validity of studies. Different outcome measures have different statistical power, and this can refine our approaches in the modelling of CIPN.

Methods of conduct and reporting of living systematic reviews: a protocol for a living methodological survey

Background: The living systematic review (LSR) is an emerging approach for improved evidence synthesis that uses continual updating to include relevant new evidence as soon as it is published. The objectives of this study are to: 1) assess the methods of conduct and reporting of living systematic reviews using a living study approach; and 2) describe the life cycle of living systematic reviews, i.e., describe the changes over time to their methods and findings.

Methods: For objective 1, we will begin by conducting a cross-sectional survey and then update its findings every 6 months by including newly published LSRs. For objective 2, we will conduct a prospective longitudinal follow-up of the cohort of included LSRs. To identify LSRs, we will continually search the following electronic databases: Medline, EMBASE and the Cochrane library. We will also contact groups conducting LSRs to identify eligible studies that we might have missed. We will follow the standard systematic review methodology for study selection and data abstraction. For each LSR update, we will abstract information on the following: 1) general characteristics, 2) systematic review methodology, 3) living approach methodology, 4) results, and 5) editorial and publication processes. We will update the findings of both the surveys and the longitudinal follow-up of included LSRs every 6 months. In addition, we will identify articles addressing LSR methods to be included in an ‘LSR methods repository’.

Conclusion: The proposed living methodological survey will allow us to monitor how the methods of conduct, and reporting as well as the findings of LSRs change over time. Ultimately this should help with ensuring the quality and transparency of LSRs.

Methods of conduct and reporting of living systematic reviews: a protocol for a living methodological survey

Background: The living systematic review (LSR) is an emerging approach for improved evidence synthesis that uses continual updating to include relevant new evidence as soon as it is published. The objectives of this study are to: 1) assess the methods of conduct and reporting of living systematic reviews using a living study approach; and 2) describe the life cycle of living systematic reviews, i.e., describe the changes over time to their methods and findings. Methods: For objective 1, we will begin by conducting a cross-sectional survey and then update its findings every 6 months by including newly published LSRs. For objective 2, we will conduct a prospective longitudinal follow-up of the cohort of included LSRs. To identify LSRs, we will continually search the following electronic databases: Medline, EMBASE and the Cochrane library. We will also contact groups conducting LSRs to identify eligible studies that we might have missed. We will follow the standard systematic review methodology for study selection and data abstraction. For each LSR update, we will abstract information on the following: 1) general characteristics, 2) systematic review methodology, 3) living approach methodology, 4) results, and 5) editorial and publication processes. We will update the findings of both the surveys and the longitudinal follow-up of included LSRs every 6 months. In addition, we will identify articles addressing LSR methods to be included in an 'LSR methods repository'. Conclusion: The proposed living methodological survey will allow us to monitor how the methods of conduct, and reporting as well as the findings of LSRs change over time. Ultimately this should help with ensuring the quality and transparency of LSRs.

Direct Oral Anticoagulant Drugs: On the Treatment of Cancer-Related Venous Thromboembolism and their Potential Anti-Neoplastic Effect

Cancer patients develop a hypercoagulable state with a four- to seven-fold higher thromboembolic risk compared to non-cancer patients. Thromboembolic events can precede the diagnosis of cancer, but they more often occur at diagnosis or during treatment. After malignancy itself, they represent the second cause of death. Low molecular weight heparins are the backbone of the treatment of cancer-associated thromboembolism. This treatment paradigm is possibly changing, as direct oral anticoagulants (DOACs) may prove to be an alternative therapeutic option. The currently available DOACs were approved during the first and second decades of the 21st century for various clinical indications. Three molecules (apixaban, edoxaban and rivaroxaban) are targeting the activated factor X and one (dabigatran) is directed against the activated factor II, thrombin. The major trials analyzed the effect of these agents in the general population, with only a small proportion of cancer patients. Two published and several ongoing studies are specifically investigating the use of DOACs in cancer-associated thromboembolism. This article will review the current available literature on the use of DOACs in cancer patients. Furthermore, we will discuss published data suggesting potential anti-cancer actions exerted by non-anticoagulant effects of DOACs. As soon as more prospective data becomes available, DOACs are likely to be considered as a potential new therapeutic option in the armamentarium for patients suffering of cancer-associated thromboembolism.

Hypertension in malignancy-an underappreciated problem

Hypertension is one of the most common comorbidities in cancer patients with malignancy, in particular, in the elderly. On the other hand, hypertension is a long-term consequence of antineoplastic treatment, including both chemotherapy and targeted agents. Several chemotherapeutics and targeted drugs may be responsible for development or worsening of the hypertension. The most common side effect of anti-VEGF (vascular endothelial growth factor) treatment is hypertension. However, pathogenesis of hypertension in patients receiving this therapy appears to be associated with multiple pathways and is not yet fully understood. Development of hypertension was associated with improved antitumor efficacy in patients treated with anti-antiangiogenic drugs in some but not in all studies. Drugs used commonly as adjuvants such as steroids, erythropoietin stimulating agents etc, may also cause rise in blood pressure or exacerbate preexisiting hypertension. Hypotensive therapy is crucial to manage hypertension during certain antineoplastic treatment. The choice and dose of antihypertensive drugs depend upon the presence of organ dysfunction, comorbidities, and/or adverse effects. In addition, severity of the hypertension and the urgency of blood pressure control should also be taken into consideration. As there are no specific guidelines on the hypertension treatment in cancer patients we should follow the available guidelines to obtain the best possible outcomes and pay the attention to the individualization of the therapy according to the actual situation.

Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: From systematic review to living systematic review

Background. The Zika virus (ZIKV) outbreak in the Americas has caused international concern due to neurological sequelae linked to the infection, such as microcephaly and Guillain-Barré syndrome (GBS). The World Health Organization stated that there is “sufficient evidence to conclude that Zika virus is a cause of congenital abnormalities and is a trigger of GBS”. This conclusion was based on a systematic review of the evidence published until 30.05.2016. Since then, the body of evidence has grown substantially, leading to this update of that systematic review with new evidence published from 30.05.2016 – 18.01.2017, update 1.

Methods. We review evidence on the causal link between ZIKV infection and adverse congenital outcomes and the causal link between ZIKV infection and GBS or immune-mediated thrombocytopaenia purpura. We also describe the transition of the review into a living systematic review, a review that is continually updated.

Results. Between 30.05.2016 and 18.01.2017, we identified 2413 publications, of which 101 publications were included. The evidence added in this update confirms the conclusion of a causal association between ZIKV and adverse congenital outcomes. New findings expand the evidence base in the dimensions of biological plausibility, strength of association, animal experiments and specificity. For GBS, the body of evidence has grown during the search period for update 1, but only for dimensions that were already populated in the previous version. There is still a limited understanding of the biological pathways that potentially cause the occurrence of autoimmune disease following ZIKV infection.

Conclusions. This systematic review confirms previous conclusions that ZIKV is a cause of congenital abnormalities, including microcephaly, and is a trigger of GBS. The transition to living systematic review techniques and methodology provides a proof of concept for the use of these methods to synthesise evidence about an emerging pathogen such as ZIKV.

Cisplatin induced acute mesenteric ischaemia: A case report and review of the literature

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Arterial thrombosis occurs in 2% of patients having Cisplatin-based chemotherapy.

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There is only one previous report detailing mesenteric ischaemia secondary to cisplatin.

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The mechanism relating to the development of arterial thrombosis is not understood.

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Benefit of prophylactic parenteral anticoagulation during cisplatin chemotherapy is unknown.

Introduction

Cisplatin is a platinum-based chemotherapeutic agent, widely used in cancer therapies for numerous solid tumours. It is becoming more recognised that a potentially life-threatening complication of cisplatin is accelerated arterial and venous thrombosis.

Presentation of case

We describe a case of a 62 year-old with no risk factors for vascular disease who presented with thromboembolic acute mesenteric ischaemia of the small bowel during treatment with cisplatin for head and neck cancer.

Discussion

We review the literature on the incidence and pathogenesis of cisplatin induced arterial thrombosis and discuss current treatment options of acute mesenteric ischaemia detailing our management of this case.

Conclusion

Cisplatin increases the risk of arterial thrombosis and this case report details acute mesenteric ischaemia secondary to its use. We hope to raise clinician awareness of this sequelae which can occur even in patients in the absence of other identifiable risk factors.