Harry Fuentes

Cancer-associated thrombosis.

Venous thromboembolism (VTE) is one of the three most common cardiovascular diseases in the United States. It is also a leading cause of death among patients with cancer. Cancerassociated thrombosis is a topic of increased interest and importance. The goal of this review is to explore the increased risk of thrombosis among patients with cancer and to identify and discuss the various options for prophylaxis and treatment.

Evaluation of the prognostic value of platelet to lymphocyte ratio in patients with hepatocellular carcinoma

Background Hepatocellular carcinoma (HCC) is increasingly common, potentially fatal cancer type globally. Platelet-lymphocyte ratio (PLR) as a biomarker for systemic inflammation has recently been recognized as a valuable prognostic marker in multiple cancer types. The aim of the present study was to assess the prognostic value of PLR in HCC patients and determine the optimal cut-off value for risk stratification. Methods We retrospectively analyzed patients with diagnosis of HCC (screened by ICD-9 code, confirmed with radiographic examination and/or biopsy) at a large public hospital during 15 years (Jan 2000 through July 2015). PLR, among other serology laboratory values were collected at diagnosis of HCC. Its association with overall survival was evaluated with Cox proportional hazard model. Results Among 270 patients with HCC, 57 (21.1%) patients died within an average follow-up of 11.9 months. PLR at diagnosis was significantly different between survivors and deceased (128.9 vs. 186.7; P=0.003). In multivariate analysis, aspartate transaminase (AST) (HR 2.022, P<0.001) and PLR (HR 1.768, P=0.004) independently predicted mortality. The optimal cut-off value for PLR was determined to be 220 by receiver-operating characteristics curve, and high PLR group had significantly higher mortality (HR 3.42, P<0.001). Conclusions Our results indicated that elevated PLR at diagnosis above 220 predicted poor prognosis in HCC patients. PLR is a low-cost and convenient tool, which may serve as a useful prognostic marker for HCC.

Predictors of Early Mortality in Cancer-Associated Thrombosis: Analysis of the RIETE Database

Cancer-associated thrombosis (CT) carries a high, heterogeneous, and poorly predicted likelihood of mortality. Thus, we aimed to define predictors of 30-day mortality in 10,025 patients with CT. In a randomly selected derivation cohort, we used recursive partitioning analysis to detect variables that select for a risk of mortality within 30 days. In a validation cohort, we evaluated our results using Cochran–Armitage test. The most common types of cancer were lung (16%), breast (14%), and colorectal (14%); median age was 69 years (range, 14–101); most had metastatic disease (63%); 13% of patients died within 30 days. In the derivation cohort ( n  = 6,660), a white blood cell (WBC) count in the highest quartile predicted early mortality (odds ratio, 7.8; 95% confidence interval [CI], 4.6–13.1); and the presence of metastatic disease, pulmonary embolism (PE), and immobility defined the risk of those with normal WBC count. We defined death risk according four sequential questions: (1) Does the patient have an elevated WBC count? (Yes, group D). (2) If no, does the patient have metastasis? (No, group A). (3) If yes, is the patient immobile? (Yes, group D). (4) If no, does the patient have a PE? (Yes, group C; no, group B). In the validation cohort ( n  = 3,365), the 30-day risk of death was 2.9% in group A (95% CI, 1.9–4.3), compared with 25% in group D (95% CI, 22.5–27.5), and there was a rate escalation between groups ( p for trend < 0.01). In conclusion, with four sequential questions, the risk of death in CT can be easily stratified. An elevated WBC count at baseline predicted 30-day mortality better than metastases, PE, or immobility.

COMPLETE HEART BLOCK AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT: TRENDS IN INCIDENCE AND IN-HOSPITAL OUTCOMES

Complete heart block (CHB) is a frequent complication after transcatheter aortic valve replacement (TAVR). Trends in incidence of CHB, subsequent permanent pacemaker (PPM) implantation, and outcomes of patients with CHB after TAVR are lacking. We queried the 2012-2014 national inpatient sample

Validation of a Patient-Completed Caprini Risk Assessment Tool for Spanish, Arabic, and Polish Speakers

Targeted prophylaxis for venous thromboembolism (VTE) using the Caprini risk score (CRS) is effective reducing postoperative VTE. Despite its availability as preventive strategy, risk scoring remains underutilized. Critics to the CRS contend the time it takes to complete, and its limitation to English language. Aim is to create and validate patient-completed CRS tools for Spanish, Arabic, and Polish speakers. We translated the first patient-completed CRS to Spanish, Arabic, and Polish. We conducted a pilot study followed by the validation study. Using PASS version 11, we determined that a sample size of 37 achieved a power of 80%, to detect a difference of 0.1 between the null hypothesis correlation of 0.5 and the alternative hypothesis correlation of 0.7 using a 2-sided hypothesis test, significance level of .05. We tabulated and categorized scores using SPSS version 23 to estimate κ, linear correlation, and Bland Altman test. κ value >0.8 was defined as “almost perfect agreement.” From 129 recruited patients, 50 (39%) spoke Spanish, 40 (31%) spoke Arabic, and 39 (30%) spoke Polish; average age 51 (16.69) years, 58 (45%) were men, with less than college education (67%). Mean (standard deviation) CRS was 5 (3.90), the majority (63%) above moderate VTE risk. We report excellent agreement comparing physician and patient results (κ = 0.93) and high correlation 0.97 (P < .01) for the overall score. Bland Altman did not show trend for extreme values. We created and validated the first Spanish, Arabic, and Polish versions of the patient-completed CRS, with excellent correlation and agreement when compared to CRS-trained physician-completed form. Based on these results, the physician needs to calculate the body mass index. Completing the form was not time-consuming.

Performance of Current Thromboembolism Risk Assessment Tools in Patients With Gastric Cancer and Validity After First Treatment

Patients with gastric cancer (GC) are at higher risk of thromboembolism when compared to other solid tumors. We aim to determine the predictive performance of current venous thromboembolism (VTE) predictive tools and their variability and validity after first treatment. Single institution cohort of GC-treated patients (2010*15). We abstracted predictive tools, validated for VTE prediction in patient with cancer; including the Khorana Score (KRS), platelet to lymphocyte ratio (PLR), and neutrophil to lymphocyte ratio (NLR). The primary outcome was CAT prediction. We included 112 patients who were predominantly men (66%), 58 (51-64)-year-olds, with adenocarcinoma (84%) and advanced disease (59%). The median follow-up was 21.3 months (9.5-42.6). The VTE occurrence was 12%. The median time from diagnosis to VTE occurrence was 59 days (36-258). In our cohort, performance status (PS; hazard ratio [HR], 8.02; 95% confidence interval [CI], 2.37-27.14; P < .01) was an independent predictor of VTE whereas KRS (univariate HR, 2.3; 95% CI, 0.7-7.4; P = .17), PLR (univariate HR, 0.8; 95% CI, 0.2-3.1; P = .8), and NLR (univariate HR, 0.8; 95% CI, 0.3-2.5; P = .8) at baseline were not associated with VTE risk. The posttreatment KRS was an independent predictor of VTE (HR, 3.69; 95% CI, 1.17-11.65; P = .25) along with PS (HR, 7.58; 95% CI, 2.27-25.33; P = .01). Posttreatment KRS appears as a valid tool to identify patients with GC at high risk of VTE after first cancer treatment.

Primary liver diffuse large B-cell lymphoma following complete response for hepatitis C infection after direct antiviral therapy.

Introduction: Hepatitis C infection is highly prevalent worldwide and has a well-known association with B-cell lymphoid malignancies. Antiviral therapy has successfully decreased the rate of liver cirrhosis and improved the outcome in patients with hepatitis C-associated lymphomas. However, although there are a few case reports of aggressive lymphomas after successful hepatitis C therapy, the mechanism behind this association remains unclear. Case Presentation: We present the case of a 55-year-old man with chronic hepatitis C infection and liver cirrhosis who received antiviral therapy with sofosbuvir and ribavirin and achieved a sustained complete virological response. One year after successful therapy, there was an unexplained decline of his liver function and atypical liver nodularity, which led to the diagnosis of a primary liver diffuse large B-cell lymphoma. Discussion: We review the evidence supporting possible mechanisms of lymphomagenesis after successful hepatitis C therapy, particularly involving late “second-hit” mutations after viral-induced DNA damage and antiviral therapy facilitating the emergence of latent malignant B-cell clones by decreasing local inflammation and immune surveillance. More reports may help elucidate any association between hepatitis C antiviral therapy and late lymphoid malignancies.