Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week

Patients with active cancer are at an increased risk of arterial and venous thromboembolism (VTE) and bleeding events. Historically, in patients with cancer, low molecular weight heparins have been preferred for treatment of VTE, whereas warfarin has been the standard anticoagulant for stroke prevention in patients with atrial fibrillation (AF). More recently, direct oral anticoagulants (DOACs) have been demonstrated to reduce the risk of venous and arterial thromboembolism in large randomized clinical trials of patients with VTE and AF, respectively, thus providing an attractive oral dosing option that does not require routine laboratory monitoring. In this review, we summarize available clinical trial data and guideline recommendations, and outline a practical approach to anticoagulation management of VTE and AF in cancer.     

Premature Ticagrelor Discontinuation in Secondary Prevention of Atherosclerotic CVD: JACC Review Topic of the Week

Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor.     

The first biallelic missense mutation in the FXN gene in a consanguineous Turkish family with Charcot-Marie-Tooth-like phenotype

neurogenetics - Charcot-Marie-Tooth (CMT) disease is the most common inherited neuropathy with a prevalence of 1 in 2500 individuals worldwide. Here, we report three Turkish siblings from...     

Single-Port Robotic-Assisted Adrenalectomy: Feasibility,Safety, and Cost-Effectiveness

Methods:We performed a matched-cohort study comparing 16 single-port robotic-assisted adrenalectomies with 16 patients from a pool of 148 laparoscopic adrenalectomies, matched for age, gender, operative side, pathology, and body mass index. All were operated on by 1 surgeon.Results:The pathology included aldosteronoma in 44% of patients, adrenocorticotropic hormone–dependent Cushing syndrome (bilateral adrenalectomy) in 19%, pheochromocytoma in 13%, and other pathology in 24%. The operative time was 183 ± 33 minutes for single-port robotic-assisted adrenalectomy and 173 ± 40 minutes for laparoscopic adrenalectomy (P = .58). The total time in the operating room was 246 ± 33 minutes for single-port robotic-assisted adrenalectomy and 240 ± 39 minutes for laparoscopic adrenalectomy (P = .57). There was 1 conversion to open adrenalectomy (6%) in each group, both because of bleeding on the right side during bilateral adrenalectomy. Two right-sided single-port robotic-assisted adrenalectomy patients required conversion to laparoscopic adrenalectomy, one because of poor visualization. There were no deaths. Complications occurred in 2 patients in each group (intensive care unit admission, prolonged ileus). Both groups had similar pain scores (mean of 3.7 on a scale from 1 to 10) on postoperative day 1, and patients in the single-port robotic-assisted adrenalectomy group used less narcotic pain medication in the first 24 hours after surgery (43 mg vs 84 mg in laparoscopic adrenalectomy group, P < .001). The differences between the single-port robotic-assisted adrenalectomy group and laparoscopic adrenalectomy group in length of stay (2.3 ± 0.5 days vs 3.1 ± 0.9 days, P = .23), percentage of patients discharged on postoperative day 1 (56% vs 31%, P = .10), and hospital cost (16% lower in single-port robotic-assisted adrenalectomy group, P = .17) did not reach statistical significance.Conclusion:Single-port robotic adrenalectomy is feasible; patients require less narcotic pain medication whereas costs appear equivalent compared with laparoscopic adrenalectomy.