Galia Spectre

The Effect of Combined Aspirin and Clopidogrel Treatment on Cancer Incidence

BACKGROUNDnMultiple studies have shown an association between aspirin treatment and a reduction in newly diagnosed cancer. Conversely, there are conflicting clinical and laboratory data on the effect of combined clopidogrel and aspirin therapy on cancer incidence, including analyses suggesting an increased cancer risk. No large-scale cohort study has been performed to address this issue in a heterogeneous real-world scenario. We investigated the effect of clopidogrel and aspirin on cancer incidence compared with aspirin alone and no antiplatelet therapy.nnnMETHODSnA population-based historical cohort study of subjects aged ≥50 years covered by Clalit Health Services, an Israeli health maintenance organization, was performed. Patients treated with the newer antiplatelet drugs, prasugrel or ticagrelor, which, like clopidogrel, inhibit adenosine diphosphate receptors, and those with prior cancer were excluded. Prescription records of antiplatelet medication were retrieved.nnnRESULTSnThe cohort included 183,912 subjects diagnosed with 21,974 cancer cases based upon the International Classification of Diseases, Ninth Revision. Dual aspirin and clopidogrel was prescribed in 9.6%, while 49% received aspirin alone and 41% used neither. Compared with nonusers, there was a lower risk of cancer in subjects exposed to aspirin with (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.44-0.49) or without clopidogrel (HR 0.54; 95% CI, 0.52-0.56), on long-term follow-up. Combined treatment was associated with a lower cancer risk than the aspirin-only group (HR 0.92; 95% CI, 0.86-0.97).nnnCONCLUSIONSnDual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study generates the hypothesis that clopidogrel may reduce cancer incidence.

Pregnancy and non-pregnancy related ovarian vein thrombosis: Clinical course and outcome.

OBJECTIVEnTo collect and summarize demographic, clinical, laboratory and radiologic characteristics, as well as management and follow-up data, of patients diagnosed with ovarian vein thrombosis.nnnMETHODSnA multicenter retrospective review of all patients diagnosed with ovarian vein thrombosis between January 2000 and May 2015 at three university hospitals.nnnRESULTSnData of 74 women were analyzed. Mean age was 31±9years. Sixty (81.1%) cases were pregnancy-related. The presence of at least one underlying risk factor (most commonly active infection or surgery) was more common among pregnancy than non-pregnancy related cases (61.7% vs. 14.3%, P=0.002). Anticoagulation therapy was administered in 98.6% of patients and adjunctive antibiotic therapy in 39 (52.7%). At a median follow-up of 40±38months, only one recurrent thrombotic event was observed, and no events of death. Median duration of anticoagulation treatment tended to be longer among patients with non-pregnancy related OVT (6months [3-14] vs. 3months [3-6], P=0.1). Thrombophilic evaluation detected any thrombophilic risk factor in 12 (20%) and 6 (42.9%) women with pregnancy and non-pregnancy related ovarian vein thrombosis, respectively (P=0.09).nnnCONCLUSIONnPregnancy-related ovarian vein thrombosis is characterized by a provoked nature and a high rate of resolution after short term treatment. Treatment of three months duration of anticoagulation following this condition appeared in this study to be safe, with no recurrences encountered during a median follow up of 40months. Thrombophilia seems to have an important role in ovarian vein thrombosis and should be evaluated in non-pregnancy related cases.

Assessment of procoagulant potential in patients with reactive thrombocytosis and its association with platelet count

We aimed to determine hemostatic changes and characterize the procoagulant potential among patients with reactive thrombocytosis (RT).

Characterization of surface antigens of reticulated immature platelets

Reticulated platelets (RPs) are immature platelets with high dense granules content and a residual amount of megakaryocyte-derived of mRNA. Increased level of RPs has been found to be an independent predictor of cardiovascular ischemic events, and has been associated with impaired response to various anti-platelet drugs. The study aimed to characterize and compare the surface antigenic properties of reticulated versus mature platelets. Platelets from healthy individuals and diabetic patients were tested at rest and after activation with adenosine diphosphate (ADP). For each patient, we calculated the proportion of RPs and mature platelets using flow cytometry analysis with thiazole orange staining (for RPs) and CD42b platelet-specific antibody. We also tested the surface expression of P-selectin and Annexin V, by double staining flow cytometry in RPs versus mature platelets. A total of 20 subjects were recruited (10 healthy individuals, 10 diabetics). Activation with ADP did not cause a significant change in the proportion of RPs. Following activation, RPs demonstrated a significant increase in the expression of both P-selectin and Annexin V, while mature platelets exhibited a non-significant increase in both markers. These findings were consistent in both healthy subjects and patients with diabetes. In conclusion, RPs have a significantly higher capacity to increase the expression of platelet activation markers compared with mature platelets.

Screening for occult cancer in idiopathic venous thromboembolism — Systemic review and meta-analysis

BACKGROUNDnIdiopathic venous thromboembolism (VTE) may be associated with an occult malignancy. Early detection of cancer might be translated to a better prognosis for these patients. However, the efficacy of extensive screening for cancer in patients with idiopathic VTE is controversial.nnnMATERIALS AND METHODSnSystemic review and meta-analysis of all available prospective trials comparing extensive to limited screening for occult malignancies in patients with idiopathic VTE.nnnPRIMARY OUTCOMEnall-cause mortality.nnnSECONDARY OUTCOMESncancer related mortality, early cancer diagnosis, cancer diagnosis at the end of follow up and cancer diagnosis at an early stage. Risk ratios (RR) with 95% confidence intervals (CIs) were estimated and pooled.nnnRESULTSnThe study included five trials and 2287 patients. Extensive screening did not affect all-cause mortality at the end of follow up [RR 0.86 (95% CI 0.58-1.27)] or cancer-related mortality [RR 0.93 (95% CI 0.54-1.58)]. Yet, it yielded more diagnoses of cancer [RR 2.17 (95% CI 1.42-3.32)]. Rates of cancer diagnosis at an early stage did not differ statistically between the two groups [RR 1.49 (95% CI 0.86-2.56)]. However, analysis of the randomized controlled trials alone showed a tendency towards early stage cancer at diagnosis in extensive screening group in, with results almost statistically significant [RR 2.14 (95% CI 0.98-4.67), p=0.06].nnnCONCLUSIONSnExtensive screening for malignancy after idiopathic VTE does not affect mortality rates. Yet, it yields more cancer diagnoses shortly after the VTE event. Further research is needed to determine whether extensive screening might be proper for specific high risk populations.

Thromboembolic Events Following Splenectomy: Risk Factors, Prevention, Management and Outcomes

BackgroundThromboembolic events following splenectomy are not uncommon. However, the role of thromboprophylaxis and risk factors for thrombosis, as well as the clinical course and outcomes, are not well characterized.MethodsA retrospective review of individuals who underwent splenectomy between January 2006 and December 2015 in two university hospitals.ResultsOverall, 297 patients underwent splenectomy [open splenectomy (nxa0=xa0199), laparoscopic splenectomy (nxa0=xa098)]. Mechanical (thigh-length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40xa0mg enoxaparin daily, starting 12xa0h after surgery until discharge) was provided for all patients. One hundred and sixteen patients (39%) also received an extended thromboprophylaxis course of enoxaparin for 2–4xa0weeks after discharge. Twenty-three patients (7.7%) experienced thrombotic complications following splenectomy, including 16 cases (5.4%) of portal-splenic mesenteric venous thrombosis (PSMVT), 5 (1.7%) pulmonary embolism and 2 (0.7%) deep vein thrombosis. Longer operative time (mean operative time of 405 vs. 273xa0min, Pxa0=xa00.03) was independently associated with PSMVT. Post-splenectomy thrombocytosis was not associated with thrombosis (Pxa0=xa00.41). The overall thrombosis rate was significantly lower in patients who received an extended thromboprophylaxis course following splenectomy (3.4 vs. 10.5%, Pxa0=xa00.02). Complete resolution of thrombosis was observed in most cases (nxa0=xa020, 87.0%), with no recurrent thrombosis during a mean follow-up of 38xa0±xa025xa0months.ConclusionsThromboembolic complications, mainly PSMVT, are common following splenectomy. Longer operative time was associated with thrombosis. Significantly lower rates of thrombosis were found in patients who received an extended thromboprophylaxis course.

Assessment of the procoagulant potential after laparoscopic sleeve gastrectomy: a potential role for extended thromboprophylaxis

BACKGROUNDnBariatric surgery is associated with increased thromboembolic risk, which may extend well beyond hospital stay. The hemostatic mechanisms implicated in this risk are not well established.nnnOBJECTIVESnWe aimed to determine the dynamics of hemostatic changes and procoagulant potential among patients undergoing laparoscopic sleeve gastrectomy, during both the early and late postoperative periods.nnnSETTINGnA university hospital.nnnMETHODSnPatients who underwent laparoscopic sleeve gastrectomy were recruited consecutively to this study. Blood samples were taken preoperatively, before discharge (postoperative day [POD] 3), and at the first follow-up visit (POD10). All samples were tested for complete blood count, C-reactive protein, von Willebrand factor, factor VIII, fibrinogen, and thrombin generation.nnnRESULTSnThe median preoperative body mass index of the 26 participants was 41.3 (38.7-43.3) kg/m2. Compared with preoperative evaluation, fibrinogen, von Willebrand factor antigen and activity, and factor VIII levels were significantly higher at POD3 and POD10 (P<.0001 for all comparisons). Peak thrombin levels and endogenous thrombin potential (ETP) were higher at POD3 (P = .005 for both comparisons) and POD10 (P = .0009 and<.0001) compared with baseline. ETP and peak thrombin, as well as fibrinogen, von Willebrand factor, and factor VIII levels, were comparable between POD3 and POD10. Multivariate analysis showed that the only predictor of postoperative ETP was the preoperative ETP level (β = .55, P = .007).nnnCONCLUSIONSnAs determined by thrombin generation, laparoscopic sleeve gastrectomy was associated with hypercoagulability, which persisted during POD10. This finding suggests a possible benefit of extended thromboprophylaxis. Nevertheless, our results should be interpreted with caution due to the lack of a control group.

Sleeve Gastrectomy Postoperative Hemorrhage is Linked to Type-2 Diabetes and Not to Surgical Technique

BackgroundThe degree, prevalence, and risk factors linked to sleeve gastrectomy (SG) postoperative hemorrhage (POH) have not been fully defined.MethodsAn analysis was conducted on a prospectively collected database of 394 consecutive primary SGs performed in a single practice from January 2014 to December 2015. End points: (1) acute POH, defined by red blood cell (RBC) transfusion and/or re-exploration; (2) subclinical POH, defined by postoperative hemoglobin drop (HgbD) >one standard deviation above mean. Variables tested included three surgical techniques: normal stapling (nxa0=xa0137), “tight” stapling, (nxa0=xa0142) and oversewing, (nxa0=xa0115); age; gender; body mass index (BMI); co-morbidities; and elevated postoperative systolic blood pressure.ResultsAcute POH occurred in 11/394 patients (2.8%) and subclinical POH (HgbDxa0>xa02.2xa0g/dL) was detected in 27/312 (7.7%) of patients with available HgbD data. Acute POH patients had a mean HgbD of 5.43xa0±xa01.40xa0g/dl (pxa0<xa00.001) reflecting approximately 38.6%xa0±xa010.0% of total blood volume. No difference in prevalence of POH was observed for the different surgical techniques. Compared with non-bleeders (nxa0=xa0312), acute and subclinical POH patients (nxa0=xa038) had 52.6 vs. 27.2% prevalence type-2 diabetes (T2D) and 60.5 vs. 40.1% prevalence of dyslipidemia and higher mean preoperative hemoglobin 14.3xa0±xa011 vs.13.5xa0±xa01.2 (pxa0<xa00.05 for all). On regression analysis, only T2D (OR 2.6; 95% CI 1.2–5.6) and higher level of preoperative hemoglobin (OR 1.7; 95% CI 1.3–2.4) were independent risk factors for POH.ConclusionIn this study, acute and subclinical POH were primarily linked to T2D and not to surgical techniques. Special consideration is recommended for patients with T2D undergoing SG.

Intravenous immunoglobulin-induced acute thrombocytopenia: IVIG-INDUCED THROMBOCYTOPENIA

Intravenous immunoglobulin (IVIG) has known efficacy in various hematologic conditions, including immune thrombocytopenic purpura.

The effect on thrombin generation and anti-Xa levels of thromboprophylaxis dose adjustment in post-cesarean obese patients - A prospective cohort study

OBJECTIVEnTo examine the laboratory anticoagulant effect of two thromboprophylactic low-molecular weight heparin (LMWH) regimens in post-cesarean obese patients.nnnMETHODSnA prospective cohort study, performed during 2017-2018 at a university hospital, of post-cesarean obese (>90u202fkg) patients receiving 40u202fmg/day (nu202f=u202f30) or 60u202fmg/day (nu202f=u202f30) enoxaparin, and a control group of non-obese (nu202f=u202f30) post-cesarean patients receiving 40u202fmg/day enoxaparin. Thrombin generation and anti-Xa were measured twice on the third postoperative day: prior to and 3.5-4u202fh following the third LMWH dose.nnnRESULTSnAge, parity, weight and body mass index were comparable between the obese study groups. Compared to the control non-obese group, the 40u202fmg obese and 60u202fmg obese groups showed increased baseline thrombin generation: medians 491, 581, 571u202fnM, respectively (Pu202f=u202f0.001 and Pu202f=u202f0.04, respectively). At peak LMWH activity, thrombin generation was higher in the 40u202fmg than in the 60u202fmg obese and control groups: medians 2599, 2391, 2229u202fnM, respectively (Pu202f=u202f0.01 and Pu202f<u202f0.0001, respectively); and thrombin generation was comparable between the 60u202fmg obese and the control groups (Pu202f=u202f0.58). Similarly, a significantly lower proportion of patients in the 40u202fmg obese group (10%) had anti-Xa levels within the recommended prophylactic range (0.2-0.5u202fIU/mL) than in the other groups (Pu202f<u202f0.0001 for both comparisons).nnnCONCLUSIONnAs determined by thrombin generation and anti-Xa testing, post-cesarean obese patients have an increased procoagulant potential, which was diminished only in those receiving higher dosages of LMWH. These findings support the need for clinical evaluation of LMWH dose adjustment in this setting.