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Elias A, Weber T, Green DA, Harris KM, Laws JM, Greaves DK, Kim DS, Mazzolai-Duchosal L, Roberts L, Petersen LG, Limper U, Bergauer A, Elias M, Winnard A, Goswami N. Systematic review of the use of ultrasound for venous assessment and venous thrombosis screening in spaceflight. NPJ Microgravity 2024; 10:14. [PMID: 38316814 PMCID: PMC10844233 DOI: 10.1038/s41526-024-00356-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/17/2024] [Indexed: 02/07/2024] Open
Abstract
The validity of venous ultrasound (V-US) for the diagnosis of deep vein thrombosis (DVT) during spaceflight is unknown and difficult to establish in diagnostic accuracy and diagnostic management studies in this context. We performed a systematic review of the use of V-US in the upper-body venous system in spaceflight to identify microgravity-related changes and the effect of venous interventions to reverse them, and to assess appropriateness of spaceflight V-US with terrestrial standards. An appropriateness tool was developed following expert panel discussions and review of terrestrial diagnostic studies, including criteria relevant to crew experience, in-flight equipment, assessment sites, ultrasound modalities, and DVT diagnosis. Microgravity-related findings reported as an increase in internal jugular vein (IJV) cross-sectional area and pressure were associated with reduced, stagnant, and retrograde flow. Changes were on average responsive to venous interventions using lower body negative pressure, Bracelets, Valsalva and Mueller manoeuvres, and contralateral IJV compression. In comparison with terrestrial standards, spaceflight V-US did not meet all appropriateness criteria. In DVT studies (n = 3), a single thrombosis was reported and only ultrasound modality criterion met the standards. In the other studies (n = 15), all the criteria were appropriate except crew experience criterion, which was appropriate in only four studies. Future practice and research should account for microgravity-related changes, evaluate individual effect of venous interventions, and adopt Earth-based V-US standards.
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Affiliation(s)
- Antoine Elias
- Cardiology and Vascular Medicine, Sainte Musse Hospital, Toulon Hospital Centre, Toulon, France.
- Clinical Research and Innovation, Sainte Musse Hospital, Toulon Hospital Centre, Toulon, France.
- Investigation Network On Venous Thrombo-Embolism | French Clinical Research Infrastructure Network (INNOVTE | F-CRIN), Toulon, France.
| | - Tobias Weber
- Space Medicine Team (HRE-OM), European Astronaut Center (EAC), European Space Agency (ESA), Cologne, Germany
- KBR, Cologne, Germany
| | - David A Green
- Space Medicine Team (HRE-OM), European Astronaut Center (EAC), European Space Agency (ESA), Cologne, Germany
- KBR, Cologne, Germany
- Centre of Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Katie M Harris
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Jonathan M Laws
- University of Northumbria at Newcastle, Newcaslte-upon-Tyne, United Kingdom
- Space Biomedicine Systematic Review Methods Group, Wylam, United Kingdom
| | | | - David S Kim
- Space Medicine Team (HRE-OM), European Astronaut Center (EAC), European Space Agency (ESA), Cologne, Germany
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Lara Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Lonnie G Petersen
- Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ulrich Limper
- German Aerospace Center (DLR), Institute of Aerospace Medicine, Cologne, Germany
- University of Witten / Herdecke, Department of Anaesthesiology and Critical Care Medicine, Merheim Medical Center, Hospitals of Cologne, Cologne, Germany
| | - Andrej Bergauer
- Department of Surgery, LKH Südsteiermark, Wagna, Austria
- Gravitational Physiology and Medicine Research Unit, Division of Physiology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Michael Elias
- Critical Care Medicine, St. Vincent's Medical Center, Hartford Healthcare, Bridgeport, CT, USA
- The Frank H. Netter MD School of Medicine, North Haven, CT, USA
| | - Andrew Winnard
- Space Biomedicine Systematic Review Methods Group, Wylam, United Kingdom
| | - Nandu Goswami
- Division of Physiology, Otto Loewi Research Center of Vascular Biology, Immunity and Inflammation, Medical University of Graz, Graz, Austria
- Mohammed Bin Rashid University of Medicine and Applied Health Sciences, Dubai, United Arab Emirates
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Phelan DM, Mayer SA, Stainback RF. Point-of-Care Ultrasonography. N Engl J Med 2022; 386:196. [PMID: 35020996 DOI: 10.1056/nejmc2118252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Dermot M Phelan
- Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC
| | - Susan A Mayer
- Saint Luke's Mid America Heart Institute, Kansas City, MO
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Mastoraki A, Mastoraki S, Schizas D, Patras R, Krinos N, Papanikolaou IS, Lazaris A, Liakakos T, Arkadopoulos N. Facing the challenge of venous thromboembolism prevention in patients undergoing major abdominal surgical procedures for gastrointestinal cancer. World J Gastrointest Oncol 2018; 10:328-335. [PMID: 30364706 PMCID: PMC6198300 DOI: 10.4251/wjgo.v10.i10.328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/22/2018] [Accepted: 08/28/2018] [Indexed: 02/05/2023] Open
Abstract
Venous thromboembolism (VTE) refers to a hypercoagulable state that remains an important and preventable factor in the surgical treatment of malignancies. VTE includes two identical entities with regards to deep vein thrombosis and pulmonary embolism. The incidence of VTE after major abdominal interventions for gastro-intestinal, hepato-biliary and pancreatic neoplastic disorders is as high as 25% without prophylaxis. Prophylactic use of classic or low-molecular-weight heparin, anti-Xa factors, antithrombotic stocking, intermittent pneumatic compression devices and early mobilization have been described. Nevertheless, thromboprophylaxis is often discontinued after discharge, although a serious risk may persist long after the initial triggering event, as the coagulation system remains active for at least 14 d post-operatively. The aim of this review is to evaluate the results of the current practice of VTE prevention in cancer patients undergoing major abdominal surgical operations, with special attention to adequately elucidated guidelines and widely accepted protocols. In addition, the recent literature is presented in order to provide an update on the current concepts concerning the surgical management of the disease.
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Affiliation(s)
- Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Sotiria Mastoraki
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Raphael Patras
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Nikolaos Krinos
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Ioannis S Papanikolaou
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens 12462, Greece
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Agnelli G, Bounameaux H. Symptoms and clinical relevance: A dilemma for clinical trials on prevention of venous thromboembolism. Thromb Haemost 2017; 109:585-8. [DOI: 10.1160/th12-08-0627] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/23/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe outcomes of thromboprophylactic trials have been debated for decades. Recently, the 9th edition of the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines based their strong recommendations only on patient-important outcomes. Practically, symptoms were considered the crucial element. Consequently, studies that primarily aimed at reducing venographic thrombi were considered less pertinent than studies that focused on symptomatic thrombosis. In the present viewpoint, we challenge the argument that “symptomatic” and “clinically relevant” are interchangeable. In particular, the case is made that asymptomatic events may be clinically relevant and that asymptomatic venographically detected thrombosis is a clinically relevant surrogate outcome for fatal pulmonary embolism.
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Kahan BC, Feagan B, Jairath V. A comparison of approaches for adjudicating outcomes in clinical trials. Trials 2017; 18:266. [PMID: 28595589 PMCID: PMC5465459 DOI: 10.1186/s13063-017-1995-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 05/17/2017] [Indexed: 01/13/2023] Open
Abstract
Background Incorrect classification of outcomes in clinical trials can lead to biased estimates of treatment effect and reduced power. Ensuring appropriate adjudication methods to minimize outcome misclassification is therefore essential. While there are many reported adjudication approaches, there is little consensus over which approach is best. Methods Under the assumption of non-differential assessment (i.e. that misclassification rates are the same in each treatment arm, as would typically be the case when outcome assessors are blinded), we use simulation and theoretical results to address four different questions about outcome adjudication: (a) How many assessors should be used? (b) When is it better to use onsite or central assessment? (c) Should central assessors adjudicate all outcomes, or only suspected events? (d) Should central assessment with multiple assessors be done independently or through group consensus? Results No one adjudication approach performs optimally in all settings. The optimal approach depends on the misclassification rates of site and central assessors, and the correlation between assessors. We found: (a) there will generally be little incremental benefit to using more than three assessors and, for outcomes with very high correlation between assessors, using one assessor is sufficient; (b) when choosing between site and central assessors, the assessor with the smallest misclassification rate should be chosen; when these rates are unknown, a combination of one site assessor and two central assessors will provide good results across a range of scenarios; (c) having central assessors adjudicate only suspected events will typically increase bias, and should be avoided, unless the threshold for sending outcomes for central assessment is extremely low; (d) central assessors can adjudicate either independently or in a group, and the preferred option should be dictated by whichever is expected to have the lowest misclassification rate. Conclusions Outcome adjudication is of critical importance to ensure validity of trial results, although no one approach is optimal across all settings. Investigators should choose the best strategy based on the specific characteristics of their trial. Regardless of the adjudication strategy chosen, assessors should be qualified and receive appropriate training.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, 58 Turner St, London, E1 2AB, UK.
| | - Brian Feagan
- Robarts Clinical Trials, London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Vipul Jairath
- Robarts Clinical Trials, London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Rau AS, Harry BL, Leem TH, Song JI, Deleyiannis FWB. Evidence for Extending the Duration of Chemoprophylaxis following Free Flap Harvest from the Lower Extremity: Prospective Screening for Deep Venous Thrombosis. Plast Reconstr Surg 2017; 138:500-508. [PMID: 27064230 DOI: 10.1097/prs.0000000000002399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the incidence of symptomatic and asymptomatic deep venous thrombosis in patients undergoing harvest of a free flap from the lower extremity who were receiving standard chemoprophylaxis while hospitalized. METHODS A retrospective review of 65 consecutive patients undergoing surgery between 2011 and 2013 was performed to determine the incidence of symptomatic deep venous thrombosis. These patients were screened for deep venous thrombosis based on development of symptoms. Prospective evaluation of a similar consecutive population of 37 patients between 2014 and 2015 was then performed to determine the incidence of asymptomatic deep venous thrombosis. These patients underwent routine duplex ultrasonography of both legs at postoperative weeks 1 and 4. RESULTS Symptomatic deep venous thrombosis occurred in 2.9 percent of all patients. In the prospective cohort, 8.1 percent of the patients were found to have an acute deep venous thrombosis by postoperative week 1. At postoperative week 4, 16.7 percent of the patients developed a new, acute deep venous thrombosis. The estimated costs of screening and treating deep venous thrombosis in the retrospective group and the prospective group were $222 and $2259, respectively. The cost of routine chemoprophylaxis without duplex screening for an additional 14 days after discharge was $125 per patient. CONCLUSIONS The rate of asymptomatic deep venous thrombosis may be much higher than previously appreciated in this population of very high-risk patients, especially during the 2 weeks after discharge. Extending the duration of chemoprophylaxis to 4 weeks after surgery may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Aline S Rau
- Aurora, Colo.,From the Division of Plastic Surgery, Department of Surgery, and the Department of Otolaryngology, University of Colorado
| | - Brian L Harry
- Aurora, Colo.,From the Division of Plastic Surgery, Department of Surgery, and the Department of Otolaryngology, University of Colorado
| | - Ted H Leem
- Aurora, Colo.,From the Division of Plastic Surgery, Department of Surgery, and the Department of Otolaryngology, University of Colorado
| | - John I Song
- Aurora, Colo.,From the Division of Plastic Surgery, Department of Surgery, and the Department of Otolaryngology, University of Colorado
| | - Frederic W-B Deleyiannis
- Aurora, Colo.,From the Division of Plastic Surgery, Department of Surgery, and the Department of Otolaryngology, University of Colorado
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7
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Zhao W, Pauls K. Architecture design of a generic centralized adjudication module integrated in a web-based clinical trial management system. Clin Trials 2015; 13:223-33. [PMID: 26464429 DOI: 10.1177/1740774515611889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Centralized outcome adjudication has been used widely in multicenter clinical trials in order to prevent potential biases and to reduce variations in important safety and efficacy outcome assessments. Adjudication procedures could vary significantly among different studies. In practice, the coordination of outcome adjudication procedures in many multicenter clinical trials remains as a manual process with low efficiency and high risk of delay. Motivated by the demands from two large clinical trial networks, a generic outcome adjudication module has been developed by the network's data management center within a homegrown clinical trial management system. In this article, the system design strategy and database structure are presented. METHODS A generic database model was created to transfer different adjudication procedures into a unified set of sequential adjudication steps. Each adjudication step was defined by one activate condition, one lock condition, one to five categorical data items to capture adjudication results, and one free text field for general comments. Based on this model, a generic outcome adjudication user interface and a generic data processing program were developed within a homegrown clinical trial management system to provide automated coordination of outcome adjudication. RESULTS By the end of 2014, this generic outcome adjudication module had been implemented in 10 multicenter trials. A total of 29 adjudication procedures were defined with the number of adjudication steps varying from 1 to 7. The implementation of a new adjudication procedure in this generic module took an experienced programmer 1 or 2 days. A total of 7336 outcome events had been adjudicated and 16,235 adjudication step activities had been recorded. In a multicenter trial, 1144 safety outcome event submissions went through a three-step adjudication procedure and reported a median of 3.95 days from safety event case report form submission to adjudication completion. In another trial, 277 clinical outcome events were adjudicated by a six-step procedure and took a median of 23.84 days from outcome event case report form submission to adjudication procedure completion. CONCLUSION A generic outcome adjudication module integrated in the clinical trial management system made the automated coordination of efficacy and safety outcome adjudication a reality.
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Affiliation(s)
- Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Keith Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
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8
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Chen W, Zhang Y, Yang Y, Zhai Z, Wang C. Prognostic significance of arterial and venous thrombosis in resected specimens for non-small cell lung cancer. Thromb Res 2015; 136:451-5. [PMID: 26099644 DOI: 10.1016/j.thromres.2015.06.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/03/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous thromboembolism(VTE) is common after pneumonectomy for malignancy and predicts poor survival. Routine screening for VTE with noninvasive tests has low sensitivity and specificity. Biopsy of lung has a place in establishing the nature and severity of the vascular alterations. In this study, we investigated the incidence, clinical and pathological characteristics of thrombosis in excised specimens after pneumonectomy, and its association with survival rate in patients with non-small cell lung cancer (NSCLC). METHODS The studied population consisted 94 consecutive patients after pneumonectomy for NSCLC in Beijing Chao-Yang Hospital, The excised tissue specimens were stained by haematoxylin & eosin staining (HE) to observe thrombosis events. All the patients were followed up for 2years. The survival data was analyzed by Kaplan-Meier analysis. RESULTS Overall thrombosis events occurred in 56 (59.6%) of 94 NSCLC cases, pulmonary arterial thrombosis was found in 24 cases, and pulmonary venous thrombosis was found in 32 cases. Furthermore, 30 of 56 cases with thrombosis were accompanied by tumor emboli or tumor vascular infiltrating. Thrombosis risk was associated with cancer grade (P=0.005). Kaplan-Meier analysis showed that patients with thrombosis had lower survival rate than those without thrombosis (P=0.025). CONCLUSIONS The incidence of thrombosis in excised tissue after pneumonectomy was high in patients with NSCLC, and it may be a marker of poor outcome.
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Affiliation(s)
- Whenhui Chen
- Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yuhui Zhang
- Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yuanhua Yang
- Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhenguo Zhai
- Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Chen Wang
- Department of Respiratory Medicine, Capital Medical University, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Yinghua Dongjie, Hepingli Beijing 100029, China.
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Larsen AC, Brøndum Frøkjaer J, Wishwanath Iyer V, Vincents Fisker R, Sall M, Yilmaz MK, Kuno Møller B, Kristensen SR, Thorlacius-Ussing O. Venous thrombosis in pancreaticobiliary tract cancer: outcome and prognostic factors. J Thromb Haemost 2015; 13:555-62. [PMID: 25594256 DOI: 10.1111/jth.12843] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 01/08/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND The differences in outcome among cancer patients with incidental vs. symptomatic venous thromboembolism (VTE) are unknown. In this study, patients with extrahepatic pancreaticobiliary tract cancer (PBC) were selected for a prospective cohort study between February 2008 and February 2011. METHODS At the time of cancer diagnosis, all patients were examined for deep vein thrombosis with bilateral compression ultrasonography (biCUS). Computed tomography pulmonary angiography was also performed to diagnose pulmonary embolisms. After inclusion, the patients were followed up with clinical examinations, blood collections, and biCUS. RESULTS A total of 121 PBC patients were enrolled. At the time of cancer diagnosis, 15 patients had experienced a VTE (12.4%, 95% confidence interval [CI] 7.1-19.6), including six symptomatic and nine incidental cases. A total of 25 first-time VTE events were identified (20.7%; 95% CI 13.8-29.0). Patients with a VTE had reduced survival, with a median overall survival (OS) of 4.4 months (95% CI 2.2-11.5). The median OS of the patients with incidental VTE was 3.0 months (95% CI 0.1-15.0), which was not different from the median OS of the patients with symptomatic VTE (5.0 months; 95% CI 2.1-14.5). The median OS was 11.9 months (95% CI 8.1-14.7) in the PBC patients with no VTEs. CONCLUSION The occurrence of a VTE event in a PBC patient within the first months of the disease is associated with significantly increased mortality.
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Affiliation(s)
- A C Larsen
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
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10
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Larsen AC, Frøkjær JB, Fisker RV, Iyer V, Mortensen PB, Yilmaz MK, Møller B, Kristensen SR, Thorlacius-Ussing O. Treatment-related frequency of venous thrombosis in lower esophageal, gastro-esophageal and gastric cancer--a clinical prospective study of outcome and prognostic factors. Thromb Res 2015; 135:802-8. [PMID: 25743885 DOI: 10.1016/j.thromres.2015.01.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/24/2014] [Accepted: 01/18/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Prospective studies of chemotherapy-associated VTE in cancer patients undergoing neoadjuvant chemotherapy in combination with curative intended surgery have not been reported for upper gastrointestinal cancer. In this clinical prospective study, we sought to estimate the incidence of VTE in esophagogastric cancer (OEC) patients scheduled for a specific perioperative chemotherapy regime: oxaliplatin, capecitabine, and epirubicin, (EXE) and curative intended surgery. MATERIAL AND METHODS A total of 129 consecutive OEC patients were examined using state-of-the-art bilateral compression ultrasound (biCUS) for deep vein thrombosis (DVT) before undergoing preoperative chemotherapy, surgery, and postoperative chemotherapy. In addition 79 were also consecutively scanned at baseline for pulmonary embolism (PE) using state-of-the-art computer tomography pulmonary angiography (CTPA). RESULTS There were 21 VTE cases throughout the course of treatment (16%, 95% confidence interval [95% CI]: 10 - 24%) among the patients examined using both biCUS and CTPA. Fourteen of 21 VTE was incidental (68%, 95% CI: 43 -85) and 7 VTE events was symptomatic (33%, 15 - 57). The median overall survival was 18months (95% CI: 13 - 24) in patients without any VTE and 14months (95% CI: 7 -30, P = 0.820) in patients with VTE. The cancer stage (adjusted odds ratio [OR]: 5.2, 95% CI: 1 - 21, p=0.002) and gastric cancer (OR 6.4, 95% CI: 2 - 21, P = 0.002) was a significant predictor of VTE. CONCLUSION The incidence of VTE in patients undergoing EXE neoadjuvant chemotherapy was high, particularly among patients with initial stage III and IV cancers. In addition, a substantial number of chemotherapy-related VTE cases were asymptomatic.
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Affiliation(s)
- Anders Christian Larsen
- Department of Gastrointestinal Surgery, Clinical Cancer Research Center, Aalborg University Hospital, Denmark.
| | - Jens Brøndum Frøkjær
- Department of Radiology, Clinical Cancer Research Center, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Denmark
| | - Rune Vincents Fisker
- Department of Nuclear Medicine, Clinical Cancer Research Center, Aalborg University Hospital, Denmark; Department of Radiology, Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Victor Iyer
- Department of Nuclear Medicine, Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Peter Brøndum Mortensen
- Department of Gastrointestinal Surgery, Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Mette Karen Yilmaz
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Bjarne Møller
- Department of Immunology, Skejby Hospital, Aarhus University Hospital, Denmark
| | - Søren Risom Kristensen
- Department of Clinical Biochemistry, Centre of Cardiovascular Research, and Clinical research Center, Aalborg University Hospital, Denmark
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Clinical Cancer Research Center, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Denmark
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Samama CM, Lecoules N, Kierzek G, Claessens YE, Riou B, Rosencher N, Mismetti P, Sautet A, Barrellier MT, Apartsin K, Jonas M, Caeiro JR, Van der veen AH, Roy PM. Étude comparant le fondaparinux à une héparine de bas poids moléculaire dans la prévention de la maladie thromboembolique veineuse en cas d’immobilisation rigide ou semi-rigide après traumatisme isolé non chirurgical du membre inférieur au-dessous du genou. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0405-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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Larsen AC, Dabrowski T, Frøkjær JB, Fisker RV, Iyer VV, Møller BK, Kristensen SR, Thorlacius-Ussing O. Prevalence of venous thromboembolism at diagnosis of upper gastrointestinal cancer. Br J Surg 2014; 101:246-53. [PMID: 24446107 DOI: 10.1002/bjs.9353] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) in patients with upper gastrointestinal (GI) cancer increases morbidity and mortality. This study aimed to determine the prevalence of VTE at diagnosis of upper GI cancer. METHODS Patients admitted between February 2008 and February 2011 with upper GI cancer (pancreatic, extrahepatic biliary, lower oesophageal, gastro-oesophageal junction or gastric cancer) were investigated in a cross-sectional cohort study. At cancer diagnosis, all patients were examined for deep vein thrombosis (DVT) by means of bilateral compression ultrasonography. From February 2009 and onwards, computed tomographic pulmonary angiography (CTPA) was also performed for the diagnosis of pulmonary embolism (PE). RESULTS Some 250 patients had ultrasonography; CTPA was performed in 143 patients on admission. DVT was detected in 13 (5·2 per cent) of the 250 patients, eight (3·2 per cent) of whom were asymptomatic. DVT was correlated with tumour location in the pancreaticobiliary tract (odds ratio (OR) 6·27, 95 per cent confidence interval 1·18 to 33·38; P = 0·031) and tumour stage IV (OR 19·34, 2·33 to 160·70; P = 0·006). PE was detected in 11 (7·7 per cent) of 143 patients, eight (5·6 per cent) of whom were asymptomatic. PE embolism was also significantly more common in patients with pancreaticobiliary tract cancer (OR 7·81, 1·28 to 47·62; P = 0·026) and in those with stage IV disease (OR 17·19, 1·83 to 161·50; P = 0·013). CONCLUSION The prevalence of VTE at cancer diagnosis was significantly higher in patients with pancreaticobiliary tract cancer than in those with other forms of upper GI cancer, and in patients with advanced cancer stage.
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Affiliation(s)
- A C Larsen
- Department of Gastrointestinal Surgery, Aarhus University Hospital, Aalborg, Denmark
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Samama CM, Lecoules N, Kierzek G, Claessens YE, Riou B, Rosencher N, Mismetti P, Sautet A, Barrellier MT, Apartsin K, Jonas M, Caeiro JR, van der Veen AH, Roy PM. Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury. J Thromb Haemost 2013; 11:1833-43. [PMID: 23965181 DOI: 10.1111/jth.12395] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries. OBJECTIVES To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU. PATIENTS AND METHODS In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding. RESULTS We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up. CONCLUSIONS Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors.
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Affiliation(s)
- C M Samama
- Department of Anesthesia and Intensive Care Medicine, Hôtel Dieu and Cochin University Hospitals, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Descartes University, Paris, France
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Stein PD, Goodman LR, Hull RD, Dalen JE, Matta F. Diagnosis and Management of Isolated Subsegmental Pulmonary Embolism: Review and Assessment of the Options. Clin Appl Thromb Hemost 2011; 18:20-6. [DOI: 10.1177/1076029611422363] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We assessed the potential safety of withholding treatment of pulmonary embolism (PE) limited to subsegmental branches. Literature review showed that untreated patients with mostly subsegmental PE had no fatal recurrences in 1 to 3 months and no nonfatal recurrences of PE in 3 months. Patients with suspected PE who had nondiagnostic ventilation/perfusion lung scans, adequate cardiorespiratory reserve or low or moderate clinical probability, and negative serial noninvasive leg tests were shown not to require treatment. It appears safe, therefore, to withhold treatment of subsegmental PE providing (1) pulmonary–respiratory reserve is good; (2) no evidence of deep venous thrombosis (DVT) on serial testing; (3) major risk factor for PE was transient and no longer present; (4) no history of central venous catheterization or atrial fibrillation; and (5) willingness to return for serial venous ultrasound. After fully informing patients, some may choose to be treated and some may choose not to be treated.
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Affiliation(s)
- Paul D. Stein
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
- Department of Internal Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | | | - Russell D. Hull
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James E. Dalen
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Fadi Matta
- Department of Research, St. Mary Mercy Hospital, Livonia, MI, USA
- Department of Internal Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
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