Erica A. Peterson

Treatment of cancer-associated thrombosis

Therapeutic options for the management of venous thromboembolism (VTE) in patients with cancer remain very limited. Although low-molecular-weight heparin monotherapy has been identified as a simple and efficacious regimen compared with an initial parenteral anticoagulant followed by long-term therapy with a vitamin K antagonist, many clinical questions remain unanswered. These include optimal duration of anticoagulant therapy, treatment of recurrent VTE, and the treatment of patients with concurrent bleeding or those with a high risk of bleeding. Treatment recommendations from consensus clinical guidelines are largely based on retrospective reports or extrapolated data from the noncancer population with VTE, as randomized controlled trials focused on cancer-associated thrombosis are sorely lacking. Furthermore, with improvements in imaging technology and extended survival duration of patients with cancer, we are encountering more unique challenges, such as the management of incidental VTE. Clinicians should be aware of the limitations of the novel oral anticoagulants and avoid the use of these agents because of the paucity of evidence in the treatment of cancer-associated thrombosis.

Predictors of attempted inferior vena cava filters retrieval in a tertiary care centre

BACKGROUND Retrieval rates of optional recovery inferior vena cava (IVC) filters in US hospitals range from 11 - 70%. We conducted a retrospective study in a Canadian tertiary care centre to determine retrieval rates and predictors of filter removal. METHODS Consecutive patients who had a retrievable IVC filter inserted or removed between January 2007 and December 2010 were identified. Data collected included baseline demographics, indications for filter insertion and removal, documentation of an IVC filter management plan, reasons for non-retrieval, complications, and death. RESULTS 275 patients with a median age of 60years were followed in hospital for a median of 17 patient-days (range 1-876). Indications for filter placement were acute or prior VTE with contraindication to anticoagulation (72.4%), high risk of PE (11.3%) and primary prophylaxis (13.8%). Retrieval was attempted in 165 patients (60%) and was successful in 146 patients (53.1%). The most common reason for failed retrieval was filter thrombus. Predictors of attempted retrieval included documentation of filter plan (odds ratio [OR] 16.7; p<0.001), surgical indication for IVC filter insertion (OR 4.8; p=0.002), age ≤70years (OR 3.8; p=0.001), Hematology service involvement (OR 3.0; p=0.006), and presence of metastatic cancer (OR 0.2; p=0.001). Thrombotic complications occurred in 48 patients, including 3 patients who died of fatal PE. CONCLUSION Our filter retrieval rate is suboptimal. Improvements in follow-up documentation or a dedicated clinical service may help increase retrieval rates.

Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline

Venous thromboembolism, presenting as deep vein thrombosis (DVT) or pulmonary embolism, affects over 35 000 Canadians each year.[1][1] It is associated with substantial morbidity, mortality and burden on the Canadian health care system, with one-month mortality rates estimated at 6% for DVT and 12%

Published guidelines versus real-life practice in the diagnosis and treatment of essential thrombocythemia.

intensity [RIC]), primary disease, and status at transplant. Thrombocytopenia was distinguished as persistent or transient in the presence of a or <30 day duration of platelet count reduction, respectively. Clinical conditions related or associated with the development of thrombocytopenia (i.e. cGVHD, infectious complications, relapse, microangiopathy, or other) were evaluated. Quantitative variables were tested for normal distribution using the Shapiro-Wilk test. Comparisons between groups were performed with t test or U-Mann Whitney test, depending on Shapiro-Wilk test results. g tests were used to analyze categorical values; when assumptions for g test were not verified, Fisher’s exact test was used. Survival curves were estimated using the Kaplan-Meier method. Overall survival (OS) was analyzed using log-rank tests and Cox proportional hazard models, after the proportional hazards assumption had been verified.

Clinical practice guidelines on cancer-associated thrombosis: a review on scope and methodology.

Cancer-associated thrombosis is a well-recognized complication in patients with cancer. It imposes significant patient morbidity and anxiety, increases personal and societal financial burden, and is the second-leading cause of death in this population. There have been increasing research efforts to reduce the incidence of venous thromboembolism (VTE) and optimize its treatment but the quality of evidence is diverse. To assist clinicians in providing care based on best-available evidence, many international and national organizations have issued clinical practice guidelines. Among these, the most highly cited resources include those developed by the American College of Chest Physicians, the American Society of Clinical Oncology and the European Society of Medical Oncology. Nationally-based guidelines have also been published by various groups, including the Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the French National Federation of the League of Centers Against Cancer, and the British Committee for Standards in Haematology. This review will cover fundamental aspects of clinical practice guideline development and evaluation, summarize the scope and methodology of published guidelines on the management of cancer-associated thrombosis and assess the quality of selected, international guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Areas of consensus and uncertainties will be briefly highlighted.

Risk stratification for the development of venous thromboembolism in hospitalized patients with cancer

Essentials The Khorana score is validated for risk of venous thromboembolism (VTE) in cancer outpatients. We conducted a multicenter analysis of medically hospitalized cancer patients. Patients with a higher Khorana score on admission were more likely to develop VTE. The Khorana score is predictive of in‐hospital, symptomatic VTE development.