Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial.

INTRODUCTION: Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS: In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS: Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS: Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.

Thromboembolic risk stratification by TRiP(cast) score to rationalise thromboprophylaxis in patients with lower leg trauma requiring immobilisation: a study protocol of the casting stepped-wedge cluster randomised trial.

INTRODUCTION: Patients with lower limb trauma requiring orthopaedic immobilisation may be at risk of venous thromboembolism but opinions differ about who may benefit from thromboprophylactic anticoagulant treatment.The aim of this CASTING study is to demonstrate the safety of thromboprophylaxis based on the Thrombosis Risk Prediction for patients with cast immobilisation (TRiP(cast) score with regards to the 3-month incidence of symptomatic venous thromboembolism events in low-risk patients not receiving thromboprophylaxis, as well as the usefulness of this strategy on the rate of patients receiving anticoagulant treatment in comparison to current practice. METHODS AND ANALYSIS: CASTING will be a stepped-wedge cluster randomised controlled clinical trial, performed in 15 emergency departments in France and Belgium. With their informed consent, outpatients admitted to one of the participating emergency departments for a lower limb trauma requiring orthopaedic immobilisation without surgery will be included. All centres will begin the trial with the 'observational period' and, every 2 weeks, 1 centre will be randomly assigned to switch to the 'interventional period' and to apply the TRiP(cast) score, in which only patients with a score ≥7 will receive thromboprophylactic anticoagulant treatment. The primary endpoint is the rate of clinical thromboembolic events within 90 days following the inclusion of low-risk patients not receiving thromboprophylaxis. ETHICS AND DISSEMINATION: The protocol has been approved by the Comité de Protection des Personnes Sud I (Ethics Review ID-RCB: 2019-A01829-48) for France and the Comité d'éthique hôpital-facultaire Saint Luc (N° B403201941338) for Belgium. It is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The findings of this study will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04064489.

Compartment syndrome of the forearm with life-threatening bleeding after fasciotomy as the presenting sign of postpartum acquired hemophilia A: a case report.

: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies against clotting factor VIII. Although the cause of this disorder remains obscure, it is often linked to malignancies, drug administration, autoimmune diseases and pregnancy. In pregnancy-associated AHA, hemorrhagic symptoms usually present 1-4 months peripartum, however they may occur up to 1-year postpartum. Compartment syndrome of the forearm is also very uncommon complication of AHA but can have devastating consequences. We report a rare case of a compartment syndrome of the forearm in a 30-year-old woman 2.5 months postpartum as the presentation of pregnancy-associated AHA.

Derivation and validation of a multivariate model to predict mortality from pulmonary embolism with cancer: The POMPE-C tool.

BACKGROUND: Clinical guidelines recommend risk stratification of patients with acute pulmonary embolism (PE). Active cancer increases risk of PE and worsens prognosis, but also causes incidental PE that may be discovered during cancer staging. No quantitative decision instrument has been derived specifically for patients with active cancer and PE. METHODS: Classification and regression technique was used to reduce 25 variables prospectively collected from 408 patients with AC and PE. Selected variables were transformed into a logistic regression model, termed POMPE-C, and compared with the pulmonary embolism severity index (PESI) score to predict the outcome variable of death within 30 days. Validation was performed in an independent sample of 182 patients with active cancer and PE. RESULTS: POMPE-C included eight predictors: body mass, heart rate >100, respiratory rate, SaO2%, respiratory distress, altered mental status, do not resuscitate status, and unilateral limb swelling. In the derivation set, the area under the ROC curve for POMPE-C was 0.84 (95% CI: 0.82-0.87), significantly greater than PESI (0.68, 0.60-0.76). In the validation sample, POMPE-C had an AUC of 0.86 (0.78-0.93). No patient with POMPE-C estimate ≤ 5% died within 30 days (0/50, 0-7%), whereas 10/13 (77%, 46-95%) with POMPE-C estimate >50% died within 30 days. CONCLUSION: In patients with active cancer and PE, POMPE-C demonstrated good prognostic accuracy for 30 day mortality and better performance than PESI. If validated in a large sample, POMPE-C may provide a quantitative basis to decide treatment options for PE discovered during cancer staging and with advanced cancer.

Mondor disease: a case report in ED.

Mondor disease is a form of superficial thrombophlebitis affecting the subcutaneous veins, specifically of the anterolateral thoracoabdominal wall. Clinical presentation is commonly a subcutaneous, tender, painful cordlike induration, usually founded in the breast or axilla. It affects typically middle-aged women. A 36-year-old patient was admitted to the emergency department to a chest discomfort and to discovery of a palpable, nonerythematous, and painful cordlike structure running from the inferior pole of her left breast to the left iliac pit. She had no history of trauma, injury, or intensive physical activity. Ultrasonography confirmed thrombosis of the thoracoepigastric vein. A thrombophilic workup performed 2 years ago was normal. The patient was treated by enoxaparin 1 mg/kg per day for 30 days. Evolution was favorable. The etiology of Mondor disease remains unclear. Predisposing factors are mainly trauma, excessive physical activity, surgery, infections. Ultrasonography is used to confirm the diagnosis. Coagulation tests should be performed to exclude hypercoagulability condition. In the past, symptomatic approach with anti-inflammatory drugs was proposed. Recent guidelines suggest prophylactic or intermediate doses of low-molecular-weight heparin for at least 4 weeks. Although uncommon, Mondor disease has to be recognized to avoid useless diagnosis testing and to deliver a specific treatment.

Cytogenetic analyses in Paspalum L. reveal new diploid species and accessions / Análises citogenéticas em Paspalum L. revelam novas espécies e acessos diplóides

Chromosome numbers were counted in 126 new accessions of 50 Paspalum species from Brazil, Argentina, Paraguay and Bolivia. The chromosome numbers 2n=12, 20, 24, 30, 40, 50, 60, 80 were confirmed. Chromosome numbers for P. arenarium (2n=20), P. barretoi (2n=20), P. aff. ceresia (2n=40), P. corcovadense (2n=20), P. crispulum (2n=20), P. flaccidum (2n=40), P. nummularium (2n=20), P. scalare (2n=20), P. vescum (2n=20) and P. rectum (2n=20) and a diploid cytotype of P. malacophyllum are reported for the first time. The predominance of tetraploid accessions (43.6 percent) was confirmed, but an unusually high number of diploid species (44 percent) and accessions (35.7 percent) was found. These results open new perspectives for breeding programs, phylogenetic studies, and for research on apomixis control, since diploids of Paspalum are typically sexual.

O número cromossômico foi determinado para 126 novos acessos de 50 espécies de Paspalum do Brasil, Argentina, Paraguai e Bolívia. Foram verificados os números somáticos 2n=12, 20, 24, 30, 40, 50, 60 e 80. Estas são as primeiras contagens para P. arenarium (2n=20), P. barretoi (2n=20), P. aff. ceresia (2n=40), P. corcovadense (2n=20), P. crispulum (2n=20), P. flaccidum (2n=40), P. nummularium (2n=20), P. scalare (2n=20), P. vescum (2n=20) e P. rectum (2n=20). O nível diplóide (2n=20) é reportado pela primeira vez para P. malacophyllum. Os dados confirmam a predominância de acessos tetraplóides (43,6 por cento) no gênero e mostram um número incomumente elevado de espécies (44 por cento) e acessos diplóides (35,7 por cento). Estes resultados trazem novas perspectivas para programas de melhoramento, para estudos filogenéticos e para pesquisa orientada ao controle da apomixia, já que em Paspalum as plantas diplóides são tipicamente sexuais.

Novos biótipos pentaplóides do grupo Dilatata de Paspalum L. (Gramineae) no Sul do Brasil / New pentaploid biotypes of the Dilatata group of Paspalum L. (Gramineae) from Southern Brazil

Paspalum dilatatum é uma gramínea nativa da América do Sul subtropical, com bom valor forrageiro e ampla variabilidade intraespecífica. Distintos tipos morfológicos, citológicos e reprodutivos têm sido citados para esta espécie. Paspalum dilatatum "Comum" é o biótipo de maior interesse agronômico. A constatação da importância da espécie como componente da produção de forragem de boa qualidade em campos naturais vem resultando em contínuo interesse pela possibilidade de seu melhor aproveitamento em cultivo. Entre o material do grupo Dilatata submetido à análise, seis acessos de classificação taxonômica não definida apresentaram morfologia distinta dos demais. Acredita-se que sejam resultantes de processos de hibridação natural em combinações antes desconhecidas. A análise mitótica evidenciou que todos possuem 2n=50 cromossomos. Três destes acessos mostraram características morfológicas intermediárias entre os biótipos "Virasoro" (4x, sexual) e "Uruguaiana" (6x, apomítico). A confirmação de ocorrência geográfica próxima reforça a hipótese de hibridação e evidencia uma ampliação da área de ocorrência do biótipo sexual envolvido neste cruzamento. Os outros acessos são, provavelmente, híbridos naturais entre P. dilatatum "Torres" e P. urvillei. Tais acessos mostram a inflorescência com eixo mais longo e com mais ramos que as plantas típicas do biótipo "Torres". A caracterização morfológica e citológica do material discrepante poderá levar ao estabelecimento de parâmetros seguros para sua diferenciação, que permitam sua inclusão em categorias taxonômicas adequadas. Sugere-se a origem destes novos biótipos pentaplóides distintos do "Comum", a partir de cruzamentos ocorridos no Sul do Brasil entre outros dois biótipos e espécies do grupo.