A comprehensive review of DOACs for cancer associated VTE prophylaxis or treatment

Cancer is a leading cause of venous thromboembolism (VTE), which contributes to significant morbidity and mortality in these patients. Increased thrombotic risk in cancer patients is modified by tumor-specific biology, disease-directed interventions, and individual comorbidities. Risk stratification for prophylaxis and treatment requires regular reevaluation of these factors, which can be facilitated by validated prediction tools. This review also discusses large clinical trial data (SELECT-D, HOKUSAI-VTE, ADAM VTE, CARAVAGGIO) demonstrating that direct oral anticoagulants (DOACs) are effective in the treatment of cancer-associated VTE, with comparable efficacy to the traditional choice of low molecular weight heparin. In the prophylactic setting derived from patients with cancer with increased VTE risk, DOACs also reduced the incidence of VTE with only modest increases in bleeding risk. The ease of DOAC administration and acceptable risk profile in the carefully selected patient make them an appealing choice for anticoagulation. In instances where the risk of gastrointestinal bleeding is of concern, apixaban, in particular, may still be a suitable option in place of LMWH. These improvements in our anticoagulation approach to cancer-associated VTE are well-timed to accompany the recent advances in disease-directed therapies that are enabling patients to live longer with cancer and therefore at increased risk of complications such as VTE.

A retrospective analysis of risk factors associated with catheter-related thrombosis: a single-center study

BACKGROUND

Catheter-related thrombosis may lead to catheter infections and failure, further deep venous thrombosis, and pulmonary embolism. Recognizing the risk factors for catheter-related thrombosis is extremely important to inform the development of catheter care guidelines.

METHODS

Data were collected from a total of 1,532 patients who had undergone venous catheterization, including indwelling catheterization from 19 March 2019 to 30 March 2019 in the Sun Yat-sen Memorial Hospital. The factors for which data were to be collected included the patients' physical characteristics, catheter-related factors, and catheter care-related factors. Logistic regression analysis, the chi-squared test, Fisher's exact test, and the t-test were used to analyze the data.

RESULTS

Of the 1,532 patients studied, 28 developed intraductal thrombi, and of the factors analyzed, malignancy, a catheterization history, a history of thrombophilia, surgery during the week before catheterization, the catheterization duration, and anticoagulant therapy were significant risk factors associated with catheter-related thrombosis (all p < 0.05). There were no significant associations between the catheter brand, the number of lumens, the insertion direction, or the factors associated with catheter care and catheter-related thrombosis (all p > 0.05).

CONCLUSION

Our study incorporated clear and systematic risk factors associated with catheter-related thrombosis. Malignancy, history of thrombophilia, history of catheterization, surgery during the week before catheterization, and catheterization duration were associated with increased risks of catheter-related thrombosis. Prophylactic anticoagulation was effective for preventing and treating catheter-related thrombosis.

Critical appraisal of dabigatran in the treatment of deep vein thrombosis and pulmonary embolism

OBJECTIVE

To compare the safety and efficacy of dabigatran to warfarin for the treatment of deep vein thrombosis and pulmonary embolism.

BACKGROUND

Venous thromboembolism (VTE) is a disease comprised of two conditions: deep vein thrombosis and pulmonary embolism. VTE is a major cause of morbidity and mortality worldwide with an annual incidence estimated at 1-3 cases per 1,000 individuals. This incidence increases with age from 0.1 per 1,000 in adolescence to eight per 1,000 in those 80 years of age and older. As the proportion of patients 65 years of age and older expands, the number of patients presenting with VTE will also increase. Anticoagulation remains the cornerstone of VTE treatment. Traditionally, vitamin K antagonists have been used to minimize the risk of thrombus extension and for secondary prevention. Unpredictable pharmacokinetics and pharmacodynamics, routine monitoring, drug-food and drug-drug interactions, and potentially severe adverse events have all been cited as barriers to optimal care. Dabigatran has been proposed as a suitable alternative to warfarin therapy in the treatment of VTE. Therefore, a critical appraisal of dabigatran's safety and efficacy is necessary to determine its role in therapy.

CONCLUSION

Dabigatran remains an alternative to warfarin therapy for the treatment of VTE. However, dabigatran also has distinct disadvantages that warrant consideration. Clinicians must ensure that drug characteristics align with patient characteristics to optimize patient outcomes.

Pulmonary embolism teaching file: a simple pilot study for rapidly increasing pulmonary embolism recognition among new residents using interactive cross-sectional imaging

RATIONALE AND OBJECTIVES

Chest radiographs can be demanding, making this an area of focus during most first-year resident chest rotations. This often comes at a cost of cross-sectional imaging, and new residents are often not initially comfortable with reading chest computed tomographic angiograms (CTAs) for pulmonary embolisms (PEs). We created a teaching file of CTAs to improve the detection of PEs.

MATERIALS AND METHODS

For initial testing, we used videos of 25 cases, which played for 90 seconds (to allow multiple passes) to residents with and without call experience. The presence and location of PEs and the readers' confidence scores were recorded. After initial testing, first-year residents without call experience were given 20 separate known positive CTA videos to scroll through on their own. The goal of this was to allow for individual review and development of individual search strategies. A second testing was done with all levels of residents with the same initial 25 cases, re-randomized to evaluate for improvement.

RESULTS

Initially, first-year residents without call experience identified an average of 14.7 of 18 examinations positive for PEs (versus 15.8 for more senior residents; P < .04). After reviewing the 20 known positive cases, the first-year residents improved, averaging 16.6 (versus 14.7 earlier; P < .01).

CONCLUSIONS

We created a fast, simple way to expose novice residents to CTA examinations and increase their accuracy in identifying PEs. After using a teaching file, the ability to recognize PEs improved significantly, and scores were no longer significantly different from those of residents with call experience.