1,721,155 research outputs found
Combined use of clinical pretest probability and D-dimer test in cancer patients with clinically suspected deep venous thrombosis
No full textBACKGROUND: The value of the D-dimer (DD) test in combination with the clinical
pretest probability (PTP) has not been evaluated in cancer patients with
suspected deep vein thrombosis (DVT), whereas this group of patients usually
accounts for 10-25% of clinically suspected DVT.
METHODS: A cohort of 2066 consecutive patients with clinically suspected DVT was
investigated. Patients were judged to be positive or negative for DVT according
to the outcomes of serial compression ultrasound and a 3-month follow-up period
with imaging test verification of the symptomatic cases. Diagnostic accuracy
indices of the DD test according to the PTP score were assessed in patients with
and without cancer.
RESULTS: Of the cohort, 244 (11%) were known to have cancer at presentation. A
venous thromboembolic event was diagnosed in 41% of the patients with cancer and
in 22% of the patients without malignancy. Among the cancer patients, 17% were
considered to have a low PTP, 35% a moderate and 41% a high PTP. The negative
predictive value (NPV) of the DD test was 100% (95% CI, 85-100) and 97% (95% CI,
88-99) among cancer patients with low PTP or low-moderate PTP. In the absence of
malignancy, the corresponding NPV were 98% and 97%, respectively. The specificity
of the DD test progressively decreased moving from the low to the higher PTP.
CONCLUSIONS: In cancer patients with clinically suspected DVT, a negative DD
might be useful in excluding the diagnosis within the low or low-moderate PTP
groups. More studies are warranted to confirm these findings
Proximal and isolated distal deep vein thrombosis and Wells score accuracy in hospitalized patients
No full textPrimary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy
No full textBACKGROUND: Venous thromboembolism (VTE) often complicates the clinical course of
cancer. The risk is further increased by chemotherapy, but the safety and
efficacy of primary thromboprophylaxis in cancer patients treated with
chemotherapy is uncertain. This is an update of a review first published in
February 2012.
OBJECTIVES: To assess the efficacy and safety of primary thromboprophylaxis for
VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or
no thromboprophylaxis.
SEARCH METHODS: For this update, the Cochrane Peripheral Vascular Diseases Group
Trials Search Co-ordinator searched the Specialised Register (last searched May
2013), CENTRAL (2013, Issue 5), and clinical trials registries (up to June 2013).
SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any oral or
parenteral anticoagulant or mechanical intervention to no intervention or
placebo, or comparing two different anticoagulants.
DATA COLLECTION AND ANALYSIS: Data were extracted on methodological quality,
patients, interventions, and outcomes including symptomatic VTE and major
bleeding as the primary effectiveness and safety outcomes, respectively.
MAIN RESULTS: We identified 12 additional RCTs (6323 patients) in the updated
search so that this update considered 21 trials with a total of 9861 patients,
all evaluating pharmacological interventions and performed mainly in patients
with advanced cancer. Overall, the risk of bias varied from low to high. One
large trial of 3212 patients found a 64% (risk ratio (RR) 0.36, 95% confidence
interval (CI) 0.22 to 0.60) reduction of symptomatic VTE with the ultra-low
molecular weight heparin (uLMWH) semuloparin relative to placebo, with no
apparent difference in major bleeding (RR 1.05, 95% CI 0.55 to 2.00). LMWH, when
compared with inactive control, significantly reduced the incidence of
symptomatic VTE (RR 0.53, 95% CI 0.38 to 0.75; no heterogeneity, Tau(2) = 0%)
with similar rates of major bleeding events (RR 1.30, 95% CI 0.75 to 2.23). In
patients with multiple myeloma, LMWH was associated with a significant reduction
in symptomatic VTE when compared with the vitamin K antagonist warfarin (RR 0.33,
95% CI 0.14 to 0.83), while the difference between LMWH and aspirin was not
statistically significant (RR 0.51, 95% CI 0.22 to 1.17). No major bleeding was
observed in the patients treated with LMWH or warfarin and in less than 1% of
those treated with aspirin. Only one study evaluated unfractionated heparin
against inactive control and found an incidence of major bleeding of 1% in both
study groups while not reporting on VTE. When compared with placebo, warfarin was
associated with a statistically insignificant reduction of symptomatic VTE (RR
0.15, 95% CI 0.02 to 1.20). Antithrombin, evaluated in one study involving
paediatric patients, had no significant effect on VTE nor major bleeding when
compared with inactive control. The new oral factor Xa inhibitor apixaban was
evaluated in a phase-II dose finding study that suggested a promising low rate of
major bleeding (2.1% versus 3.3%) and symptomatic VTE (1.1% versus 10%) in
comparison with placebo.
AUTHORS' CONCLUSIONS: In this update, we confirmed that primary
thromboprophylaxis with LMWH significantly reduced the incidence of symptomatic
VTE in ambulatory cancer patients treated with chemotherapy. In addition, the
uLMWH semuloparin significantly reduced the incidence of symptomatic VTE.
However, the broad confidence intervals around the estimates for major bleeding
suggest caution in the use of anticoagulation and mandate additional studies to
determine the risk to benefit ratio of anticoagulants in this setting. Despite
the encouraging results of this review, routine prophylaxis in ambulatory cancer
patients cannot be recommended before safety issues are adequately addressed
Selective reporting of outcome data: are we following the Cochrane Handbook guidance? [oral]
No full textSplanchnic vein thrombosis: Current perspectives
No full textSplanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: The presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment
Venous thromboembolism in cancer patients receiving neoadjuvant chemotherapy: a systematic review and meta-analysis.
Full text linkBACKGROUND
Venous thromboembolism (VTE) is a frequent complication in cancer patients receiving adjuvant treatment. The risk of VTE during neoadjuvant chemo-radiotherapy remains unclear.
OBJECTIVES
This systematic review evaluated the incidence of VTE in patients with cancer receiving neoadjuvant treatment.
METHODS
MEDLINE and EMBASE databases were searched from inception to October 2017. Search results were supplemented with screening of conference proceedings of the American Society of Clinical Oncology (2009-2016) and the International Society of Thrombosis and Haemostasis (2003-2016). Two review authors independently screened titles and abstracts, and extracted data onto standardized forms.
RESULTS
Twenty-eight cohort studies (7827 cancer patients, range 11 to 1398) were included. Twenty-five had a retrospective design. Eighteen cohorts included patients with gastrointestinal cancer representing over two-thirds of the whole study population (n = 6002, 78%). In total, 508 of 7768 patients were diagnosed with at least one VTE during neoadjuvant treatment for a pooled VTE incidence of 7% (95% CI, 5% to 10%) in absence of substantial between study heterogeneity. Heterogeneity was not explained by site of cancer or study design characteristics. VTE presented as pulmonary embolism in 22% to 96% of cases (16 cohorts), and it was symptomatic in 22% to 100% of patients (11 cohorts). Highest VTE rates were observed in patients with bladder (10.6%) or esophageal (8.4%) cancer.
CONCLUSIONS
This review found a relatively high incidence of VTE in cancer patients receiving neoadjuvant therapy in the presence of some between study variation, which deserves further evaluation in prospective studies. This article is protected by copyright. All rights reserved
Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy
Full text linkBackground
Venous thromboembolism (VTE) oHen complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the
trade-oJ between safety and eJicacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is
the third update of a review first published in February 2012.
Objectives
To assess the eJicacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared
with placebo or no thromboprophylaxis, or an active control intervention.
Search methods
For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular, CENTRAL, MEDLINE, Embase and CINAHL
databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 3 August
2020. We also searched the reference lists of identified studies and contacted content experts and trialists for relevant references.
Selection criteria
Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or
placebo, or comparing two diJerent anticoagulants.
Data collection and analysis
We extracted data on risk of bias, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding
as the primary eJectiveness and safety outcomes, respectively. We applied GRADE to assess the certainty of evidence.
Main results
We identified six additional randomised controlled trials (3326 participants) for this update, bringing the included study total to 32 trials
(15,678 participants), all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic
cancer. The certainty of the evidence ranged from high to very low across the diJerent outcomes and comparisons. The main limiting
factors were imprecision and risk of bias.
Thromboprophylaxis with direct oral anticoagulants (direct factor Xa inhibitors apixaban and rivaroxaban) may decrease the incidence of
symptomatic VTE (RR 0.43, 95% confidence interval (CI) 0.18 to 1.06; 1526 participants, 3 studies; low-certainty evidence); and probably
increase the risk of major bleeding compared with placebo (RR 1.74, 95% CI 0.82 to 3.68; 1494 participants, 3 studies; moderate-certainty
evidence).
When compared with no thromboprophylaxis, low molecular weight heparin (LMWH) reduced the incidence of symptomatic VTE (RR 0.62,
95% CI 0.46 to 0.83; 3931 participants, 11 studies; high-certainty evidence); and probably increased the risk of major bleeding events (RR
1.63, 95% CI 1.12 to 2.35; 7282 participants, 15 studies; moderate-certainty evidence).
In participants with multiple myeloma, LMWH resulted in lower symptomatic VTE compared with the vitamin K antagonist warfarin (RR
0.33, 95% CI 0.14 to 0.83; 439 participants, 1 study; high-certainty evidence), while LMWH probably lowers symptomatic VTE more than
aspirin (RR 0.51, 95% CI 0.22 to 1.17; 781 participants, 2 studies; moderate-certainty evidence). Major bleeding was observed in none of the
participants with multiple myeloma treated with LMWH or warfarin and in less than 1% of those treated with aspirin.
Only one study evaluated unfractionated heparin against no thromboprophylaxis, but did not report on VTE nor major bleeding.
When compared with placebo or no thromboprophylaxis, warfarin may importantly reduce symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20;
311 participants, 1 study; low-certainty evidence) and may result in a large increase in major bleeding (RR 3.82, 95% CI 0.97 to 15.04; 994
participants, 4 studies; low-certainty evidence).
Antithrombin versus no antithrombin was evaluated in one study involving paediatric patients. This study did not report on symptomatic
VTE but did report any VTE (symptomatic and incidental VTE). The eJect of antithrombin on any VTE and major bleeding is uncertain (any
VTE RR 0.84, 95% CI 0.41 to 1.73 and major bleeding RR 0.78, 95% CI 0.03 to 18.57; 85 participants, 1 study; very low-certainty evidence).
Authors' conclusions
In ambulatory cancer patients, primary thromboprophylaxis with direct factor Xa inhibitors may reduce the incidence of symptomatic VTE
(low-certainty evidence) and probably increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo.
LMWH decreased the incidence of symptomatic VTE (high-certainty evidence), but increased the risk of major bleeding (moderate-certainty
evidence) when compared with placebo or no thromboprophylaxis. Evidence for the use of thromboprophylaxis with anticoagulants other
than direct factor Xa inhibitors and LMWH is limited. More studies are warranted to evaluate the eJicacy and safety of primary prophylaxis
in specific types of chemotherapeutic agents and types of cancer, such as gastrointestinal or genitourinary cancer
24 weeks of Pilates-aerobic and educative training to improve body fat mass in elderly Serbian women
Full text linkAnne WS Rutjes,1 Marcello Di Nisio2,31Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; 2Department of Medical, Oral, and Biotechnological Sciences, University G D'Annunzio of Chieti-Pescara, Chieti, Italy; 3Department of Vascular Medicine, Academic Medical Center, Amsterdam, the NetherlandsWe read with interest the article by Ruiz-Montero et al, in which the authors used a before-and-after study design to examine changes in body composition (fat mass and lean body mass) related to an aerobic-Pilates program in elderly Serbian women.1 The authors concluded that "a combined program of aerobic and Pilates, carried out under the supervision of an instructor, at least twice a week, produces health benefits in functionally independent women over the age of 60". This conclusion is overly optimistic and not supported by the evidence provided. View original paper by Ruiz-Montero and colleagues
Non-O blood group and outcomes of in vitro fertilization.
Full text linkPURPOSE
Retrospective and cross-sectional studies suggested that non-O blood group may be associated with failures of in vitro fertilization (IVF), but data remain controversial. The aim of this observational cohort study was to prospectively evaluate the effect of non-O blood type on clinical outcomes of IVF.
METHODS
Women < 40 years who underwent IVF and had ABO blood type recorded as part of the routine workup were eligible. The primary study outcome was live birth. Secondary outcomes included spontaneous abortion, positive pregnancy test, and clinical pregnancy.
RESULTS
A total of 497 women with a mean age of 34.6 (standard deviation 3.2) years were included. The mean number of embryos transferred was 2.3 (standard deviation 0.6). The most common ABO blood types were O (n = 213, 42.9%) and A (n = 203, 40.8%), while 63 (12.7%) and 18 (3.6%) women had the B and AB blood types, respectively. Differences in live birth (21.8 vs. 24.3%, odds ratio [OR] 1.17; 95% confidence intervals [CI], 0.76 to 1.78), positive pregnancy test (37.9 vs. 36.6%, OR 0.96; 95% CI, 0.66 to 1.38), clinical pregnancy (35.1 vs. 33.8%, OR 0.95; 95% CI, 0.66 to 1.39), and spontaneous abortion (12.3 vs. 9.2%, OR 0.72; 95% CI, 0.41 to 1.29) between women with O and non-O blood type were not statistically significant.
CONCLUSIONS
In a prospective cohort study, we confirmed the lack of a significant association between non-O blood type and clinical outcomes of IVF. Further studies are needed to clarify whether non-O blood group has any prognostic relevance in women undergoing IVF
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