Preventing Venous Thromboembolism in Ambulatory Cancer Patients: The ONKOTEV Study.

BACKGROUND: The efficacy of risk model scores to predict venous thromboembolism (VTE) in ambulatory cancer patients is under investigation, aiming to stratify on an individual risk basis the subset of the cancer population that could mostly benefit from primary thromboprophylaxis. MATERIALS AND METHODS: We prospectively assessed 843 patients with active cancers, collecting clinical and laboratory data. We screened all the patients with a duplex ultrasound (B-mode imaging and Doppler waveform analysis) of the upper and lower limbs to evaluate the right incidence of VTE (both asymptomatic and symptomatic). The efficacy of the existing Khorana risk model in preventing VTE was also explored in our population. Several risk factors associated with VTE were analyzed, leading to the construction of a risk model. The Fine and Gray model was used to account for death as a competing risk in the derivation of the new model. RESULTS: The risk factors significantly associated with VTE at univariate analysis and further confirmed in the multivariate analysis, after bootstrap validation, were the presence of metastatic disease, the compression of vascular/lymphatic structures by tumor, a history of previous VTE, and a Khorana score >2. Time-dependent receiving operating characteristic (ROC) curve analysis showed a significant improvement in the area under the curve of the new score over the Khorana model at 3 months (71.9% vs. 57.9%, p = .001), 6 months (75.4% vs. 58.6%, p < .001), and 12 months (69.8% vs. 58.3%, p = .014). CONCLUSION: ONKOTEV score steps into history of cancer-related-VTE as a promising tool to drive the decision about primary prophylaxis in cancer outpatients. The validation represents the goal of the prospective ONKOTEV-2 study, endorsed and approved by the European Organization for Research and Treatment of Cancer Young Investigators Program. The Oncologist 2017;22:601-608 IMPLICATIONS FOR PRACTICE: Preventing venous thromboembolism in cancer outpatients with a risk model score will drive physicians' decision of starting thromboprophylaxis in high-risk patients.

The challenge of diagnosing pulmonary embolism in children, pregnant women, and elderly patients: a descriptive review of the literature.

The prompt and accurate diagnosis of pulmonary embolism (PE) greatly influences patient outcomes. However, diagnosing PE is one of the most difficult challenges confronting physicians, even more so when the clinical suspicion is addressed in children, during pregnancy, or in elderly patients. In these patient groups, symptoms and signs from concomitant conditions or diseases may mimic PE and make difficult defining clinical probability categories for PE as usually applied to general adult patients. Moreover, the diagnostic techniques show wider, specific limitations in these settings. PE is considered rare in children. The diagnostic management of a child with suspected PE is largely extrapolated from the knowledge achieved in adult patients. An increased risk of venous thromboembolism is reported in all trimesters of pregnancy and in the puerperium. An accurate diagnosis of PE in pregnancy has important implications, including the need for prolonged anticoagulation, delivery planning, and prophylaxis during future pregnancies, as well as concerns about future oral contraceptive use and estrogen therapy. Although incidence, morbidity, and mortality increase steadily with age, PE remains an underdiagnosed disease in elderly patients. About 40% of PE found at necropsy were not suspected antemortem. In the present article, challenges in diagnosing PE in children, during pregnancy, and in the elderly will be discussed, reviewing the available clinical, laboratory, and instrumental diagnostic strategies.

Mesoglycan: clinical evidences for use in vascular diseases.

Vascular glycosaminoglycans (GAG) are essential components of the endothelium and vessel wall and have been shown to be involved in several biologic functions. Mesoglycan, a natural GAG preparation, is a polysaccharide complex rich in sulphur radicals with strong negative electric charge. It is extracted from porcine intestinal mucosa and is composed of heparan sulfate, dermatan sulfate, electrophoretically slow-moving heparin, and variable and minimal quantities of chondroitin sulfate. Data on antithrombotic and profibrinolytic activities of the drug show that mesoglycan, although not indicated in the treatment of acute arterial or venous thrombosis because of the low antithrombotic effect, may be useful in the management of vascular diseases, when combined with antithrombotics in the case of disease of cerebral vasculature, and with antithrombotics and vasodilator drugs in the case of chronic peripheral arterial disease. The protective effect of mesoglycan in patients with venous thrombosis and the absence of side effects, support the use of GAG in patients with chronic venous insufficiency and persistent venous ulcers, in association with compression therapy (zinc bandages, multiple layer bandages, etc.), elastic compression stockings, and local care, and in the prevention of recurrences in patients with previous DVT following the standard course of oral anticoagulation treatment.

Treatment of hemophilia: a review of current advances and ongoing issues.

Replacement of the congenitally deficient factor VIII or IX through plasma-derived or recombinant concentrates is the mainstay of treatment for hemophilia. Concentrate infusions when hemorrhages occur typically in joint and muscles (on-demand treatment) is able to resolve bleeding, but does not prevent the progressive joint deterioration leading to crippling hemophilic arthropathy. Therefore, primary prophylaxis, ie, regular infusion of concentrates started after the first joint bleed and/or before the age of two years, is now recognized as first-line treatment in children with severe hemophilia. Secondary prophylaxis, whenever started, aims to avoid (or delay) the progression of arthropathy and improve patient quality of life. Interestingly, recent data suggest a role for early prophylaxis also in preventing development of inhibitors, the most serious complication of treatment in hemophilia, in which multiple genetic and environmental factors may be involved. Treatment of bleeds in patients with inhibitors requires bypassing agents (activated prothrombin complex concentrates, recombinant factor VIIa). However, eradication of inhibitors by induction of immune tolerance should be the first choice for patients with recent onset inhibitors. The wide availability of safe factor concentrates and programs for comprehensive care has now resulted in highly satisfactory treatment of hemophilia patients in developed countries. Unfortunately, this is not true for more than two-thirds of persons with hemophilia, who live in developing countries.

Advanced algorithms can lead to electrocardiographic misinterpretations.

We observed a patient with syncope, who implanted a pacemaker with advanced algorithms such as "atrial-tachy response" and "dynamic atrio-ventricular delay". After one year, conventional ECG Holter showed pacemaker malfunction, wrongly attributed to exposure to electromagnetic field. In fact, telemetry revealed an inappropriate programming and solved our case. Holter monitoring is commonly performed in the evaluation of pacemaker malfunction, albeit it remains a quite shallow diagnostic method especially to detect electromagnetic interferences. New algorithms seem important, but it is reasonable to obtain more suitable analytical tools, too.

Bioterrorismo / Bioterrorism

Durante años se ha considerado el bioterrorismo como un arma letal que ha sido utilizada para atacar y causar terror en la población mundial. Es despuésde algunas décadas cuando sentimos esta amenaza nuevamente. Dentro del gran armamento que se ha utilizado para este tipo de amenaza, sehace mención a las principales formas de ataque biológico que han producido enfermedades con consecuencias devastadoras para la humanidad,dejando a su paso secuelas físicas y psicológicas, que en nuestro tiempo vuelven a centrar su atención por la gran cantidad de agentes que se encuentranal alcance.Siendo así el agente biológico ideal debería ser altamente letal, producido fácilmente y en grandes cantidades, estable, de transmisión en forma deaerosol o de persona a persona, resistente a antibióticos standard y que no sea prevenible con vacunación. Esto limita la lista de posibles agentes biológicosa ciertas bacterias: Bacillus antraccis, Brucella spp, clostridium botulinum, yersinia pestis y francisella tularensis, y a ciertos virus que mencionaremosen este documento

During years has been consider bioterrorism as a lethal weapon which has been used to attack and cause terror in world population . Is just after somedecades when we feeling this treat again.Within of big amount of weapons used for this treat, mention to the main forms of biological attack is done that have produced illnesses with devastatingconsequences for the humanity, leaving their step psychological and physical consequences, that in our time they center again their attentionby the great quantity of agents that are found al reach.Being thus the ideal biological agent should be highly deadly, produced easily and in large quantities, stable, of broadcast in the shape of person toperson, resistant to antibiotic standard and that be not prevenible with vaccination. This limits the list of possible biological agents to certain bacteria:Bacillus antraccis, Brucella spp, clostridium botulinum, yersinia pestistis and Francisella tularensis, and to certain virus that we will mention in thisdocument