Venous thromboembolism as the first sign of malignancy

BACKGROUND

Venous thromboembolism (VTE) is commonly associated with hypercoagulability in patients with cancer; however, there have been few investigations of VTE as the first sign of malignancy and even fewer performed in the United States. The aim of our study was to evaluate the incidence and predictors of unrecognized malignancy in patients presenting with VTE.

METHODS

We performed a 1-year retrospective analysis of the Nationwide Readmission Database, including patients aged 18 years or older, presenting with a primary diagnosis of deep vein thrombosis (DVT) or a pulmonary embolism (PE). Patients known to have preexisting malignant diseases were excluded. Outcomes included the rate of newly diagnosed malignancy within 6 months from the discovery of VTE and demographic or associated illness predictors for the diagnosis of malignancy. A regression analysis was performed, based on which a VTE malignancy score was developed.

RESULTS

A total of 116,048 patients were identified with VTE (49.8% DVT, 41.7% PE, 8.6% DVT and PE), 16% (n = 18,294) with malignancy. Of the remaining 97,754 patients, 31% were readmitted within 6 months. The incidence of newly diagnosed malignancy within 6 months was 2.4% (n = 2354). The most common malignancies were gastrointestinal in origin (29.2%). Demographic and diagnostic predictors for malignancy included age 65 years or older, female sex, inferior vena cava (IVC) thrombus, upper extremity thrombus, and a Charlson Comorbidity Index score of 5 or more. Receiver operating characteristic curve analysis found a cutoff VTE Malignancy score of 3 (sensitivity, 86%; specificity, 89%) to be predictive of an increased risk of a newly discovered malignancy within 6 months.

CONCLUSIONS

VTE can be a risk indicator of underlying malignancy. Validation of a patient risk stratification score using multiple demographic or comorbid predictors for VTE on index admission may offer an opportunity for earlier diagnosis of occult malignancy.

Predictors of FabAV use in copperhead envenomation

CONTEXT

Crotaline snake envenomation is a serious medical condition affecting thousands of Americans each year. Variation in the treatment of Crotaline snakebites exists among physicians in the United States. Management of copperhead snakebites is controversial with some experts advocating minimal intervention, rarely necessitating antivenom use and, even more rarely, surgical intervention. This study assessed the use of Crotaline Polyvalent Immune Fab antivenom (Ovine) (FabAV) and explored factors influencing the decision to prescribe antivenom for copperhead envenomation in patients in Northeastern Oklahoma.

METHODS

A retrospective cohort study examining electronic medical records of patients with copperhead snakebites from July 1, 2014 to August 31, 2019. Data collected included: patient demographics, transfer information, snake species, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities, and treatment strategy. Associations between patient variables and treatment were evaluated using the chi-square test of independence, median test, and logistic regression analysis. Associations were statistically significant if p < 0.05.

DISCUSSION

Of the 130 patients bitten by a copperhead, a majority (75%) received FabAV. Symptoms of copperhead envenomation were mostly limited to the progression of tissue damage. Predictors of treatment with FabAV included progression of venom effects across major joints, younger age, comorbidities, and upper extremity bites.

CONCLUSIONS

Patients who have multiple comorbidities, upper extremity bites and progression of venom effects across major joints are more likely to be treated with FabAV. The high usage of FabAV at the study site underscores the need for continued work to optimize the use of antivenom for copperhead envenomations.