Amit Nautiyal

Thromboprophylaxis in cancer patients with central venous catheters. A systematic review and meta-analysis.

It was the aim of the review to determine the risks and benefits of primary thromboprophylaxis with anticoagulants in cancer patients with central venous devices. Medline, Central and Google Scholar databases were searched for randomized controlled trials (RCTs) in June 2006. Two reviewers extracted data and appraised the quality of RCTs. Results were expressed as relative risk (RR) with 95% confidence intervals (CI) using random effects model for the outcomes of catheter-related thrombosis, bleeding and thrombocytopenia. Eight RCTs (1,428 patients) were included. There was no statistically significant difference in the risk of catheter-related thrombosis for the use of warfarin versus placebo (3 trials, 425 patients, RR 0.75, 95% CI 0.24-2.35, p = 0.63), heparin versus placebo (4 trials, 886 patients, RR 0.46 95% CI 0.18-1.20, p = 0.06) or warfarin, unfractionated heparin or low-molecular-weight heparin versus placebo (7 trials, 1,311 patients, RR 0.59, 95% CI 0.31-1.13, p = 0.11). Substantial statistical heterogeneity was noted among these trials (I(2) > 50%). The use of anticoagulants showed no statistically significant difference in the risk of overall bleeding (5 trials, 1,193 patients, RR 1.24, 95% CI 0.84-1.82, p = 0.28), and thrombocytopenia for heparin versus placebo (4 trials, 958 patients, RR 0.85, 95% CI 0.49, 1.46, p = 0.55) without any statistical heterogeneity (I(2) = 0%). In cancer patients with central venous devices, thromboprophylaxis has no significant effect on the risk of catheter related thrombosis or bleeding. The use of primary thromboprophylaxis in cancer patients with central venous catheters while not causing any harm provides no benefit.

Painful Horner syndrome as a harbinger of silent carotid dissection.

A painful Horners syndrome should alert clinicians to the possibilty of a silent carotid dissection

Control of cardiovascular risk factors and use of aspirin in diabetic patients remain elusive.

Objectives: Type 2 diabetics are at higher risk for cardiovascular disease. To reduce this risk, the American Diabetes Association recommends traditional cardiovascular disease risk factor modification, reducing hemoglobin A1c (HbA1c), and the use of aspirin for patients over 30 years of age. The goal of this study was to analyze how well these goals were achieved in type 2 diabetics. Methods: Patients with type 2 diabetes from July 2004 to June 2005 were included. Data were collected on demographics, preexisting coronary artery disease (CAD), blood pressure control, HbA1c, low-density lipoprotein cholesterol level, and microalbuminuria. Results: One hundred thirty-nine patients were included (18% had CAD). Blood pressure was controlled in 46.04% of patients; 41.72% reached target HbA1c; 47.48% reached target low-density lipoprotein cholesterol; and 43.88% had microalbuminuria. No significant difference was noted between diabetics with or without CAD. Aspirin was used in 64% of patients with CAD and in 28.15% patients without CAD. Conclusions: Optimal cardiovascular risk modification was achieved in less than 50% of type 2 diabetics. Aspirin remains underused for primary prevention. These results highlight the continued difficulties in achieving control of diabetes to the extent recommended by American Diabetes Association guidelines.

Oral direct-acting antivirals and the incidence or recurrence of hepatocellular carcinoma: a systematic review and meta-analysis

Background The influence of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus on the risk of hepatocellular carcinoma (HCC) is conflicting. Methods We conducted a systematic review and meta-analysis to determine the incidence or recurrence of HCC associated with oral DAA therapy. We searched PubMed, Scopus, Embase from inception to August 2017 to identify observational studies reporting on HCC among patients treated with DAAs. Two independent reviewers extracted data and assessed the risk of bias. Data were pooled by random-effects model. The primary outcome was the proportion of participants with incidence or recurrence of HCC (PROSPERO number CRD42017057040). Results After reviewing 2080 citations, we included 8 controlled studies and 36 uncontrolled studies. The pooled proportion for incident HCC was 1.5 % (95% CI 1.0% to 2.1%; I2=90.1%; n= 542/39 145) from 18 uncontrolled studies and 3.3% (95% CI 1.2% to 9%; I2 =96%; n=109/6909) from 5 controlled studies, respectively. The pooled proportion for recurrent HCC was 16.7% (95% CI 10.2% to 26%; I2=84.8%; n=136/867) from 12 uncontrolled studies and 20.1% (95% CI 5.5% to 52.1%; I2=87.5%; n=36/225) from 3 controlled studies, respectively. There was no statistically significant effect on the risk of recurrent HCC (OR 0.50, 95%CI 0.16 to 1.59; I2 =73.4%) in a meta-analysis of three studies. Conclusions Our findings show low proportion of incident HCC, but high proportion of recurrent HCC on treatment with DAAs. Continued active surveillance for HCC after treatment with DAAs remains prudent.

Do Fluoroquinolones Increase the Risk of Aortic Aneurysms and Aortic Dissection

SEE PAGE 1369 F luoroquinolones are one of the most widely prescribed class of antibiotics. They have been known to cause tendon rupture mediated by their adverse effects on collagenous structures. The aorta is rich in type 1 and type III collagen. The proteolytic activities of matrix metalloproteinase-2 and matrix metalloproteinase-9 have been shown to play a role in the induction of aortic aneurysms in mice (1), and contribute to the development of aortic aneurysms in humans through degradation of the collagen fibril (2). Matrix metalloproteinase inducers may play a role in the development of aortic aneurysms, whereas matrix metalloproteinase inhibitors may oppose the development of aortic aneurysms (3). Ciprofloxacin significantly increased total matrix metalloproteinase activity more than 2-fold in cultured human aortic smooth muscle (4). Human aortic fibroblasts exposed to fluoroquinolones show an increased capacity for extracellular dysregulation by reducing collagen and endogenous protease inhibitors protein expression (5). In a study of mice where stressed aorta were exposed to ciprofloxacin, 79% of mice developed aortic aneurysms and dissection, 67% had aortic dissection, and 15% had fatal rupture compared with 45% (aortic aneurysms and dissection), 24% (aortic dissection), and 0% (fatal rupture) for placebo after 4 weeks (6). The study also showed an increased activity of matrix metalloproteinases and decreased activity of lysl-oxidase enzyme, an enzyme involved in stabilization of the

Drug-Induced Sarcoidosis-Like Reactions

A drug-induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction that is indistinguishable from sarcoidosis and occurs in a temporal relationship with initiation of an offending drug. DISRs typically improve or resolve after withdrawal of the offending drug. Four common categories of drugs that have been associated with the development of a DISR are immune checkpoint inhibitors, highly active antiretroviral therapy, interferons, and tumor necrosis factor-α antagonists. Similar to sarcoidosis, DISRs do not necessarily require treatment because they may cause no significant symptoms, quality of life impairment, or organ dysfunction. When treatment of a DISR is required, standard antisarcoidosis regimens seem to be effective. Because a DISR tends to improve or resolve when the offending drug is discontinued, this is another effective treatment for a DISR. However, the offending drug need not be discontinued if it is useful, and antigranulomatous therapy can be added. In some situations, the development of a DISR may suggest a beneficial effect of the inducing drug. Understanding the mechanisms leading to DISRs may yield important insights into the immunopathogenesis of sarcoidosis.

Second neoplasm: 31-year latency after childhood leukemia

A 33-year-old man presented with a six-week history of headache, nausea, gait imbalance and changes in personality that included apathy and disinhibition. The patient had a history of childhood acute lymphoblastic leukemia that had been diagnosed when he was two years old. He had been given