The efficacy and safety of a catheter removal only strategy for the treatment of PICC line thrombosis versus standard of care anticoagulation: a retrospective review.

Peripherally-inserted central catheters (PICCs) are commonly used during hospitalization. Unfortunately, their use can be complicated by catheter-related thrombosis (CRT). Current guidelines recommend 3-6 months of anticoagulation for patients with CRT after catheter removal. This recommendation is based on extrapolation of data on lower extremity thrombosis, as data is lacking regarding the efficacy and safety of more specific management strategies. Many providers feel catheter removal alone is a reasonable treatment option, particularly for patients at risk for bleeding. We performed a retrospective analysis of hospitalized adult patients diagnosed with CRT at our center. We determined rates of progressive thrombosis and bleeding in cohorts of patients who underwent catheter removal vs those who had catheters removed and received anticoagulation. Among 83 total patients, 62 were treated with PICC removal alone, while 21 underwent PICC removal followed by therapeutic anticoagulation. Patients treated with PICC removal alone were more likely to have hematologic malignancy, receive chemotherapy, develop thrombocytopenia, and have brachial vein thrombosis. No patients in the PICC removal plus anticoagulation arm developed progressive thrombosis, while 6.4% of patients treated with catheter removal alone developed a secondary VTE event, including one PE, three DVTs, and five patients (8%) who developed progressive symptoms leading to initiation of anticoagulation. Major bleeding was significantly more common in the PICC removal + anticoagulation arm (28.5% vs. 4.8% p = 0.007). Catheter-removal alone results in significantly reduced major bleeding compared with catheter-removal plus anticoagulation. In select patients, catheter removal alone may be an option for CRT.

Cryptogenic acute limb ischemia: a retrospective cohort study defining a previously undescribed clinical entity.

Acute limb ischemia (ALI) is generally secondary to cardioembolism or progression of peripheral vascular disease, however, a discrete population of patients with ALI exists in which no precipitant is ever established. Unlike cryptogenic arterial occlusion in other arenas, such as cryptogenic stroke, cryptogenic acute limb ischemia (cALI) has not been well-described, and no routine management has been established. The aim of this study is to describe patients with cALI, and the risk of recurrence based on the treatment they received. We performed a retrospective cohort study of patients evaluated for ALI at a single academic center, excluding patients with known peripheral artery disease, polytrauma, critical illness, or a history of recent vascular access. Out of 608 individual patients analyzed, 37 were deemed to have cALI on their initial presentation. After extended follow up, 29 patients were eventually found to have a precipitating cause, with 8 patients remaining cryptogenic. On follow up, the overall rate of recurrent ALI was 13% in the group eventually found to have a precipitating cause, and 25% in the cALI group. The median time to recurrence was 16.5 months in the precipitated acute limb ischemia (pALI) group, and 23.3 months in the cALI group. Of pALI patients who recurred, 40% did so despite being therapeutic on anticoagulation. None of the recurring cALI patients were therapeutically anticoagulated. Based on our analysis, nearly 20% of patients presenting with ALI in the absence of known risk factors will remain cryptogenic. Rates of recurrent ALI in patients who present with cALI are significant, particularly in patients who are not maintained on anticoagulation. This suggests that the etiology of ALI in patients without peripheral vascular disease may not have a strong bearing on treatment decisions, and that indefinite anticoagulation may be warranted in patients with no obvious cause on presentation. Future studies are needed to better gauge the risk for bleeding complications and to provide a better understanding of the risks and benefits of recurrence and complications of anticoagulation over time.

Laparoscopic anti-reflux surgery for idiopathic pulmonary fibrosis at a single centre.

We sought to assess whether laparoscopic anti-reflux surgery (LARS) is associated with decreased rates of disease progression in patients with idiopathic pulmonary fibrosis (IPF).The study was a retrospective single-centre study of IPF patients with worsening symptoms and pulmonary function despite antacid treatment for abnormal acid gastro-oesophageal reflux. The period of exposure to LARS was September 1998 to December 2012. The primary end-point was a longitudinal change in forced vital capacity (FVC) % predicted in the pre- versus post-surgery periods.27 patients with progressive IPF underwent LARS. At time of surgery, the mean age was 65 years and mean FVC was 71.7% pred. Using a regression model, the estimated benefit of surgery in FVC % pred over 1 year was 5.7% (95% CI -0.9-12.2%, p=0.088) with estimated benefit in FVC of 0.22 L (95% CI -0.06-0.49 L, p=0.12). Mean DeMeester scores decreased from 42 to 4 (p<0.01). There were no deaths in the 90 days following surgery and 81.5% of participants were alive 2 years after surgery.Patients with IPF tolerated the LARS well. There were no statistically significant differences in rates of FVC decline pre- and post-LARS over 1 year; a possible trend toward stabilisation in observed FVC warrants prospective studies. The ongoing prospective randomised controlled trial will hopefully provide further insights regarding the safety and potential efficacy of LARS in IPF.

Trimodality Treatment of Malignant Pleural Mesothelioma: An Institutional Review.

OBJECTIVE: Malignant pleural mesothelioma (MPM) is a deadly disease with varying treatment options. This study retrospectively describes treatment practices at the University of Washington Medical System from 1980 to 2011, and evaluates the impact of trimodality therapy and radiation (photon and neutron) on survival. METHODS: A retrospective study was conducted on patients treated for MPM. Univariate and multivariate methods were utilized to evaluate potential factors associated with survival. Treatments received and baseline characteristics were included. Survival analysis of trimodality therapy was performed using a propensity score method to control for baseline characteristics. RESULTS: Among 78 eligible patients, the median age at diagnosis was 59 years and the median survival was 13.7 months. On multivariate analysis, the significant predictors of improved survival were age, smoking history, location, and receipt of radiation therapy or chemotherapy. In the 48 patients receiving radiation therapy, the difference in survival between neutron therapy and non-neutron therapy patients was not statistically significant: hazard ratio, 1.20 (95% confidence interval, 0.68-2.13), P=0.52. Patients receiving trimodality therapy were more likely to have early-stage disease (60% vs. 30%) and epithelioid histology (86% vs. 58%). In a propensity score-weighted Cox proportional hazards model, trimodality therapy patients had improved overall survival, hazard ratio 0.45, P=0.004, median 14.6 versus 8.6 months. CONCLUSIONS: Trimodality therapy was significantly associated with prolonged survival in patients with MPM, even when adjusting for baseline patient factors. Radiation therapy was associated with improved survival, but the modality of radiation therapy used was not associated with outcome.