Thromboprophylaxis in the oldest old with atrial fibrillation: Between Scylla and Charybdis

Within a few decades half of the patients with non-valvular atrial fibrillation (AF) will be older than 80 years. These patients are at particularly high risk of thromboembolism (Scylla) but also of the hemorrhagic complications of thromboprophylaxis (Charybdis). A frequent compromise is to use as antithrombotic agents instead of vitamin-K antagonists aspirin or other antiplatelet drugs, which are ineffective for thromboprophylaxis in the oldest old and definitely not free from a high risk of severe bleeding. All the new direct anticoagulants currently licensed (dabigatran, rivaroxaban, apixaban) are at least as effective as warfarin for thromboprophylaxis in AF, but the risk of the intracranial bleeding, the most feared complication of anticoagulant therapy, is at least halved. In the oldest patients of 80 years of age or more preliminary data, available so far only for dabigatran, indicate that the favorable outcomes of direct anticoagulants are also present in this subgroup, often left untreated for fear of intracranial bleeding. The choice between the different direct anticoagulants is driven by the presence or not of renal insufficiency, the presence and degree of multimorbidity and polypharmacy and by the likelihood or not of poor treatment adherence in patients who are often frail and with some degree of cognitive impairment.     

Benefits and shortcomings of superselective transarterial embolization of renal tumors before zero ischemia laparoscopic partial nephrectomy

AimsTo report feasibility, safety and effectiveness of “zero-ischemia” laparoscopic partial nephrectomy (LPN) following preoperative superselective transarterial embolization (STE) for clinical T1 renal tumors.MethodsWe retrospectively reviewed perioperative data of 23 consecutive patients, who underwent STE prior LPN between March 2010 and November 2012 for incidental clinical T1 renal mass. STE was performed by two experienced radiologists the day before surgery. Surgical procedures were performed in extended flank position, transperitoneally, by a single surgeon.ResultsMean patients age was 68 years (range 56–74), mean tumor size was 3.5 cm (range 2.2–6.3 cm). STE was successfully completed in 16 patients 12–15 h before surgery. In 4 cases STE failed to provide a complete occlusion of all feeding arteries, while in 3 cases the ischemic area was larger than expected.LPN was successfully completed in all patients but one where open conversion was necessary; a “zero-ischemia” approach was performed in 19/23 patients (82.6%) while hilar clamp was necessary in 4 cases, with a mean warm-ischemia time of 14.8 min (range 5–22).Mean operative time was 123 min (range 115–130) and mean intraoperative blood loss was 250 mL (range 20–450).No patient experienced postoperative acute renal failure and no patient developed new onset IV stage chronic kidney disease at 1-yr follow-up.ConclusionsSTE is a viable option to perform “zero-ischemia” LPN at beginning of learning curve; however, hilar clamp was necessary to achieve a relatively blood-less field in 17.4% of cases.     

Systematic framework to evaluate the status of physical activity research for persons with multiple sclerosis

BackgroundExploring the current state of health behavior research for individuals with multiple sclerosis is essential to understanding the next steps required to reducing preventable disability. A way to link research to translational health promotion programs is by utilizing the Behavioral Epidemiological Framework, which describes a sequence of phases used to categorize health-related behavioral research.ObjectiveThis critical audit of the literature examines the current state of physical activity research for persons with multiple sclerosis by utilizing the proposed Behavioral Epidemiological Framework.MethodsAfter searching MEDLINE, PUBMED, PsycINFO, Google Scholar and several major areas within EBSCOHOST (2000 to present), retrieved articles were categorized according to the framework phases and coding rules.ResultsOf 139 articles, 49% were in phase 1 (establishing links between behavior and health), 18% phase 2 (developing methods for measuring behavior), 24% phase 3 (identifying factors influencing behavior and implications for theory), and 9% phase 4 and 5 (evaluating interventions to change behavior and translating research into practice).ConclusionsEmphasis on phase 1 research indicates the field is in its early stages of development. Providing those with multiple sclerosis with necessary tools through health promotion programs is needed to reduce secondary conditions and co-morbidities. Reassessment of the field of physical activity and multiple sclerosis in the future could provide insight into whether the field is evolving over time or remaining stagnant.     

Long-Term Follow-Up of R-CHOP With Bevacizumab as Initial Therapy for Mantle Cell Lymphoma: Clinical and Correlative Results

BackgroundEmerging evidence indicates that MCL has increased angiogenesis within the tumor microenvironment. We initiated a phase II trial to determine if the addition of bevacizumab to the standard R-CHOP regimen could enhance antitumor effects in patients with previously untreated MCL.Patients and MethodsEleven patients with previously untreated MCL received bevacizumab at 15 mg/kg on day 1, and standard CHOP-21 (CHOP given every 21 days per cycle) with rituximab (375 mg/m² per cycle) on day 3 of each cycle for a total of 6 cycles. Planned study end points included safety and efficacy assessment, and exploratory analysis of angiogenic profiles. The study was suspended in August of 2010 based on safety findings in DLBCL (diffuse large B-cell lymphoma) of increased cardiovascular events with the regimen.ResultsBeyond the standard R-CHOP safety profile, Grade 3 left ventricular dysfunction developed in 2 patients (18%), Grade 1/2 hypertension, proteinuria, and bleeding each developed in 1 patient (9%). The overall response rate was 82% with 36% complete response (CR)/complete response unconfirmed (CRu). The median progression-free survival (n = 11) was 18 months (95% confidence interval, 3-not reached), and 3-year overall survival rate was 82%. Correlative studies showed increased vascular endothelial growth factor receptor 1 expression in tumor cells at baseline, and elevated levels of plasma vascular endothelial growth factor (VEGF) throughout treatment.ConclusionThe addition of bevacizumab to the standard R-CHOP regimen did not appear to significantly improve efficacy beyond that observed from previous studies using R-CHOP alone. Therapeutic strategies that provide sustained inhibition on VEGF-related and VEGF-independent targets within the tumor microenvironment might further improve antiangiogenic effects and warrant further exploration in MCL.