Effectiveness of a multidisciplinary care program for the management of venous thromboembolism in cancer patients: a pilot study.

INTRODUCTION: Treatment of Venous thromboembolism (VTE) in cancer patients is challenging due to higher risk of VTE recurrence or bleeding under anticoagulants. We assessed the effectiveness of a dedicated "Allo-Thrombosis Cancer" multidisciplinary care program (AlloTC-MCP) that incorporated individualized care, regular follow-ups, telephone counselling, and a patient education program. METHODS AND MATERIALS: From September 2017 to October 2019, 100 consecutive cancer patients with new VTE onset were enrolled in this observational single-center prospective pilot study and received standard (control group, n = first 50 patients enrolled) or AlloTC-MCP care (n = next 50 patients enrolled) over a 6-month VTE treatment follow-up period. Primary end-point was the percentage of adherence to the International Clinical Practice Guidelines (ITAC-CPGs) at 6 (M6) month follow-up. RESULTS: Among the 100 patients with different cancer types (22% genitourinary, 19% breast, 16% gastrointestinal, 15% lymphoma, 11% lung and 17% others), 51 patients (61%) had metastatic disease and 31 (31%) received chemotherapy alone. Main baseline cancer and VTE clinical characteristics did not differ between the 2 groups. Adherence rates to ITAC-CPGs was significantly higher in the AlloTC-MCP group (100% (M0), 72% (M3) and 68% (M6)) compared with the control group (84% (M0), 8% (M3) and 16% (M6)). Quality of Life (QoL) was significantly improved in the AlloTC-MCP group 6 months after inclusion. CONCLUSION: The "AlloTC-MCP" was associated with improved adherence to ITAC-CPGs and merits further expansion.

Time to and differential time to blood culture positivity for assessing catheter-related yeast fungaemia: A longitudinal, 7-year study in a single university hospital.

BACKGROUND: Time to positivity (TTP) and differential time to positivity (DTTP) between central and peripheral blood cultures are commonly used for bacteraemia to evaluate the likelihood of central venous catheter (CVC)-related bloodstream infection. Few studies have addressed these approaches to yeast fungaemia. OBJECTIVES: This study aimed to evaluate TTP and DTTP to assess CVC-related yeast fungaemia (CVC-RYF). PATIENTS/METHODS: We retrospectively analysed the results from 105 adult patients with incident fungaemia, with CVC removed and cultured, collected from 2010 to 2017. The bottles were incubated in a BioMérieux BacT/ALERT 3D and kept for at least 5 days. RESULTS: Of the 105 patients included, most were oncology patients (85.7%) and had of long-term CVC (79.6%); 32 (30.5%) had a culture-positive CVC (defined as CVC-RYF) with the same species as in blood culture, and 69.5% had culture-negative CVC (defined as non-CVC-RYF, NCVC-RYF). Candida albicans represented 46% of the episodes. The median TTP was statistically different between CVC-RYF and NCVC-RYF (16.8 hours interquartile range (IQR) [9.7-28.6] vs 29.4 hours [IQR 20.7-41.3]; P = .001). A TTP <10 hours had the best positive likelihood ratio (21.5) for CVC-RYF, although the sensitivity was only 28%. DTTP was available for 52 patients. A DTTP >5 hours had a sensitivity of 100% and a specificity of 71% for CVC-RYF. CONCLUSIONS: Since the median TTP was 17 hours and the most performing DTTP >5 hours, these delays are too long to take a decision in the same operational day. More rapid methods for detecting infected catheters should be tested to avoid unnecessary CVC withdrawal.

Totally implantable port management: impact of positive pressure during needle withdrawal on catheter tip occlusion (an experimental study).

BACKGROUND: Totally implanted ports (TIP) have become a standard part of patient care, providing long-term central venous access for treatment administration and other procedures. Despite overall the safety and effectiveness of TIP, complications still occur. Negative pressure created during needle withdrawal induces blood reflux and subsequent catheter occlusion. Application of positive pressure during needle withdrawal is thought to largely prevent such reflux, but supporting data are limited. PURPOSE OF RESEARCH: To quantify the role of positive pressure, using a test model designed to simulate physiological conditions. METHODS: Reflux associated with needle withdrawal with and without applied positive pressure was tested using various TIP models from different manufacturers mounted on a specially designed test bench. In addition to the presence or absence of positive pressure during needle withdrawal, study variables comprised of needle type (safety and standard), needle gauge and port septum diameter. RESULTS: Application of positive pressure during needle withdrawal reduced the incidence of reflux during needle withdrawal by nearly 80% (22% vs. 99%, p<0.001). When reflux did occur, the mean residual volume was half that observed without positive pressure. In the absence of positive pressure, mean reflux increased with septum diameter and needle gauge to a statistically significant extent. None of these variables significantly affected reflux in the context of needle withdrawal under positive pressure. CONCLUSION: The results of this study support the use of positive pressure during needle withdrawal to prevent blood reflux potentially leading to catheter tip occlusion.

Incidence, risk factors, and outcomes of central venous catheter-related thromboembolism in breast cancer patients: the CAVECCAS study.

Previous epidemiologic studies investigating central venous catheter (CVC)-related venous thromboembolism (CRT) were conducted in heterogenous cancer populations and data in breast cancer (BC) remain limited. To investigate the Doppler ultrasound (DUS)-CRT incidence, risk factors and outcomes in BC, we designed a prospective, multicenter cohort of nonmetastatic invasive BC patients undergoing insertion of a CVC for chemotherapy. All patients underwent double-blind DUS before, 7, 30, and 90 days after CVC insertion and a 6 months clinical follow-up. Symptomatic DUS-CRT were treated by anticoagulants. D-Dimers, thrombin generation, and platelet-derived microparticles were measured before and 2 days after CVC placement. In DUS-CRT patients, a nested case-control study analyzed the role of thrombophilia. Among 524 patients, the DUS-CRT (14 symptomatic, 46 asymptomatic) cumulative probability was 9.6% at 3 months and 11.5% at 6 months (overall incidence rate: 2.18/100 patient-months). Ten/14 symptomatic DUS-CRT were detected on double-blind DUS before the clinical symptoms, and 3/14 had a simultaneous pulmonary embolism. No clinical thrombotic event subsequently occurred in untreated asymptomatic DUS-CRT. Age >50 years (OR, 1.80; 95% CI, 1.01-3.22), BMI >30 kg/m² (OR, 2.64; 95% CI, 1.46-4.76) and comorbidities (OR, 2.05; 95% CI, 1.18-3.56) were associated with DUS-CRT. No biomarkers was found to predict DUS-CRT. In multivariate analysis, BMI >30 kg/m² (OR, 2.66; 95%CI, 1.46-4.84) and lobular carcinoma histology (OR, 2.56; 95%CI, 1.32-4.96) remained the only significant DUS-CRT risk factors. Thrombophilia did not account for DUS-CRT. Only clinical parameters identified high risk DUS-CRT patients who may be considered for thromboprophylaxis.

Evolution of Hemodynamic and Functional Human Kidney Graft Dose Response to Dopamine Using an Implantable Doppler Device.

OBJECTIVES: The relation between dopamine infusion and renal hemodynamics and function has not been studied in renal allografts during early recovery. We analyzed the dose response of dopamine infusion on renal blood flow and function in human kidney transplant recipients at reperfusion and during early graft recovery. MATERIALS AND METHODS: Phasic and mean renal blood flow was measured by the pulsed Doppler technique using implantable Doppler microprobes in contact with the graft artery. Systemic and renal parameters were recorded on dopamine infusion (0, 3, 5, and 10 µg·kg⁻¹·min⁻¹) immediately after transplant (day 0) in 13 patients and at day 6 in 7/13 patients with early graft recovery. Results are expressed as median and interquartile range between the 25th and 75th percentiles. RESULTS: At day 0, 3 µg·kg⁻¹·min⁻¹) dopamine did not increase mean renal blood flow over baseline (580 mL/min [219-663 mL/min] vs 542 mL/min [207-686 mL/min]; P = .84). There was an absence of effect with higher dopamine doses, whereas cardiac output, heart rate, and systolic and mean arterial pressure were significantly increased. Urinary sodium excretion, creatinine clearance, and urine output increased dose dependently, with a positive correlation between the increase in urine output and mean arterial pressure (r = 0.48, P < .001). At day 6, 3 µg·kg⁻¹·min⁻¹ dopamine increased mean renal blood flow over baseline (318 mL/min [234-897 mL/min] vs 191 mL/min [173-706 mL/min]; P = .016), with no further increase at higher doses. CONCLUSIONS: Immediately after transplant, kidney grafts with ischemic-reperfusion injury are fully dilated and do not respond to dopamine. The specific renal effects observed are due to systemic hemodynamic status. Vascular responsiveness to a "renal dopamine dose" returns on graft recovery.

Guidelines on the use of ultrasound guidance for vascular access.

Insertion of vascular access is a common procedure with potential for iatrogenic events, some of which can be serious. The spread of ultrasound scanners in operating rooms, intensive care units and emergency departments has made ultrasound-guided catheterisation possible. The first guidelines were published a decade ago but are not always followed in France. The French Society of Anaesthesia and Intensive Care has decided to adopt a position on this issue through its Guidelines Committee in order to propose a limited number of simple guidelines. The method used was the GRADE(®) method using the most recently published meta-analyses as the source of references. The level of evidence found ranged from low to high and all the positive aspects associated with ultrasound guidance, i.e. fewer traumatic complications at puncture, probably or definitely outweigh the potential adverse consequences regardless of whether an adult or child is involved and regardless of the site of insertion.

Lessons from French National Guidelines on the treatment of venous thrombosis and central venous catheter thrombosis in cancer patients.

Increased prevalence of Venous thromboembolism (VTE), as defined by deep-vein thrombosis (DVT), central venous catheter (CVC) related thrombosis or pulmonary embolism (PE) in cancer patients has become a major therapeutic issue. Considering the epidemiology and each national recommendations on the treatment of VTE in cancer patients, we analysed guidelines implementation in clinical practice. Thrombosis is the second-leading cause of death in cancer patients and cancer is a major risk factor of VTE, due to activation of coagulation, use of long-term CVC, the thrombogenic effects of chemotherapy and anti-angiogenic drugs. Three pivotal trials (CANTHANOX, LITE and CLOT) and several meta-analysis led to recommend the long term (3 to 6 months) use of LMWH during for treating VTE in cancer patients with a high level of evidence. The Italian Association of Medical Oncology (AIOM), the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), the French "Institut National du Cancer" (INCa), the European Society of Medical Oncology (ESMO) and the American College of Chest Physicians (ACCCP) have published specific guidelines for health care providers regarding the prevention and treatment of cancer-associated VTE. Critical appraisal of these guidelines, difficulties in implementation of prophylaxis regimen, tolerance and cost effectiveness of long term use of LMWH may account for large heterogenity in daily clinical practice. Homogenization of these guidelines in international consensus using an adapted independent methodological approach followed by educational and active implementation strategies at each national level would be very valuable to improve the care of VTE in cancer patients.