Treatment of submassive and massive pulmonary embolism: a clinical practice survey from the second annual meeting of the Pulmonary Embolism Response Team Consortium

There is a paucity of robust clinical trial data to guide the treatment of acute pulmonary embolism (PE) thus the clinical guidelines rely heavily on expert opinion. Pulmonary Embolism Response Teams (PERT) have been developed to streamline the care of patients with acute PE. We conducted a survey among 100 experts in the field of PE during the second annual meeting of the PERT Consortium. Respondents were queried with respect to their demographic information, clinical practice questions and clinical vignettes. Clinical practice questions were focused questions about the risk stratification and treatment of patients with acute submassive PE, anticoagulation strategies for patients receiving thrombolysis and the use of inferior vena cava filters. Clinical vignettes were designed to assess participants’ preferred choice of treatment for a variety of commonly encountered clinical scenarios. Among physicians affiliated with a PERT, there is overall agreement with regards to the criteria used for risk classification of patients with PE and its application to patients in the provided clinical vignettes. In contrast, there is substantial variability in the treatment strategies of patients presenting with commonly encountered clinical scenarios. The results of this survey highlight the need for more clinical trial data along with accepted algorithms for treatment of acute PE. In the absence of this, PERTs can facilitate multidisciplinary discussions in order to standardize treatment and provide evidence-based therapies to patients with acute PE.     

Evaluation of direct thrombin inhibitors during a critical heparin shortage

Journal of Thrombosis and Thrombolysis - A recent heparin shortage related to an outbreak of African Swine Flu in China led to substantial increase in the use of direct thrombin inhibitors (DTI) as...     

Liver cirrhosis mortality in Mexico. I. Relevant epidemiological characteristics]

Previous studies have emphasized the impact of alcoholism on public health, especially on the incidence of liver cirrhosis, which ranks among one of the main causes of death in Mexico. Accordingly, the epidemiologic features of liver cirrhosis mortality (LCM) are examined, highlighting its historical trends, its geographical distribution and other risk factors like age and sex. The data show a consistently high LCM rate over time, male rates moving slightly up and female rates down. Proportional mortality has been increasing. The significant risk increment with age has determined LCM to be the leading cause of death for both sexes in the 30-64 years age group. A particularly interesting finding relates to the continuous excess of LCM seen in Mexico City and four surrounding states; on the contrary, in the northern states, LCM is considerably low. This difference is valid for women too. Comparing all states, a gradient of LCM rates from high to low mortality areas is observed. The social and health implications of LCM regional distribution demand the conduction of epidemiological studies to identify possible explanatory variables related to the pattern of alcohol consumption or other risk factors. Nonetheless, these data alone justify the implementation of an effective action plan in the high-risk areas to deal with this health problem, inherently associated with individual and social behaviors.     

Implementing multiplexed genotyping of non-small-cell lung cancers into routine clinical practice

BackgroundPersonalizing non-small-cell lung cancer (NSCLC) therapy toward oncogene addicted pathway inhibition is effective. Hence, the ability to determine a more comprehensive genotype for each case is becoming essential to optimal cancer care.MethodsWe developed a multiplexed PCR-based assay (SNaPshot) to simultaneously identify >50 mutations in several key NSCLC genes. SNaPshot and FISH for ALK translocations were integrated into routine practice as Clinical Laboratory Improvement Amendments-certified tests. Here, we present analyses of the first 589 patients referred for genotyping.ResultsPathologic prescreening identified 552 (95%) tumors with sufficient tissue for SNaPshot; 51% had ≥1 mutation identified, most commonly in KRAS (24%), EGFR (13%), PIK3CA (4%) and translocations involving ALK (5%). Unanticipated mutations were observed at lower frequencies in IDH and β-catenin. We observed several associations between genotypes and clinical characteristics, including increased PIK3CA mutations in squamous cell cancers. Genotyping distinguished multiple primary cancers from metastatic disease and steered 78 (22%) of the 353 patients with advanced disease toward a genotype-directed targeted therapy.ConclusionsBroad genotyping can be efficiently incorporated into an NSCLC clinic and has great utility in influencing treatment decisions and directing patients toward relevant clinical trials. As more targeted therapies are developed, such multiplexed molecular testing will become a standard part of practice.     

RESEARCH REPORT Male drinking and violence-related injury in the emergency room

Abstract Aims. To present epidemiological measures of associations between violence-related injuries (assaults and fights), alcohol consumption prior to the event, and drinking patterns among males attending hospital emergency rooms (ERs) in Mexico City. Design. All patients were interviewed and breath tested for alcohol consumption. The data were analyzed using a case-control design. Setting. Eight ERs in Mexico City that were representative of the types of emergency care systems available in that city (from public, private and social security systems hospitals). Participants. Cases were males patients ( n= 445) admitted to the ER because of a fight or an assault. The control group was comprised of patients ( n= 320) admitted to the ER because of accidents that are less frequently reported as alcohol-related (i.e. work-place accidents, animal bites or recreational accidents excluding near drowning). Measurements. A breath sample to estimate BAC, as well as an interviewer-administered questionnaire were used. Findings. Alcohol consumption prior to injury was found to be a more important risk factor than usual drinking for injuries resulting from violence, while quantity of usual alcohol consumption was more predictive of violence-related injuries than frequency of drinking. Conclusions. These data suggest the importance of using more appropriate control groups when estimating associations of alcohol and violence-related injuries so that associations will not be underestimated. More research is needed to establish unbiased estimates of alcohol-related violence.     

Temporal Trends in Inpatient Oncology Census Before and During the COVID-19 Pandemic and Rates of Nosocomial COVID-19 Among Patients with Cancer at a Large Academic Center

BackgroundThe coronavirus disease 2019 (COVID‐19) pandemic has significantly impacted health care systems. However, to date, the trend of hospitalizations in the oncology patient population has not been studied, and the frequency of nosocomial spread to patients with cancer is not well understood. The objectives of this study were to evaluate the impact of COVID‐19 on inpatient oncology census and determine the nosocomial rate of COVID‐19 in patients with cancer admitted at a large academic center.Materials and MethodsMedical records of patients with cancer diagnosed with COVID‐19 and admitted were reviewed to evaluate the temporal trends in inpatient oncology census during pre–COVID‐19 (January 2019 to February 2020), COVID‐19 (March to May 2020), and post–COVID‐19 surge (June to August 2020) in the region. In addition, nosocomial infection rates of SARS‐CoV‐2 were reviewed.ResultsOverall, the daily inpatient census was steady in 2019 (median, 103; range, 92–118) and until February 2020 (median, 112; range, 102–114). However, there was a major decline from March to May 2020 (median, 68; range, 57–104), with 45.4% lower admissions during April 2020. As the COVID‐19 surge eased, the daily inpatient census over time returned to the pre–COVID‐19 baseline (median, 103; range, 99–111). One patient (1/231, 0.004%) tested positive for SARS‐CoV‐2 13 days after hospitalization, and it is unclear if it was nosocomial or community spread.ConclusionIn this study, inpatient oncology admissions decreased substantially during the COVID‐19 surge but over time returned to the pre–COVID‐19 baseline. With aggressive infection control measures, the rates of nosocomial transmission were exceedingly low and should provide reassurance to those seeking medical care, including inpatient admissions when medically necessary.Implications for PracticeThe COVID‐19 pandemic has had a major impact on the health care system, and cancer patients are a vulnerable population. This study observes a significant decline in the daily inpatient oncology census from March to May 2020 compared with the same time frame in the previous year and examines the potential reasons for this decline. In addition, nosocomial rates of COVID‐19 were investigated, and rates were found to be very low. These findings suggest that aggressive infection control measures can mitigate the nosocomial infection risk among cancer patients and the inpatient setting is a safe environment, providing reassurance.     

Alcohol consumption and casualties: a comparison of emergency room populations in the United States and Mexico

This study compares alcohol consumption and casualties in probability samples of emergency room populations in the U.S. and Mexico: four hospitals representative of a Bay Area California county (N = 3,609) and eight hospitals representative of Mexico City (N = 2,507). Both studies used similar methods and data collection instruments. Patients were breath analyzed and interviewed regarding self-reported alcohol consumption 6 hours prior to the injury or illness event, usual drinking patterns and alcohol-related problems. Similar associations of alcohol consumption and casualties were found between the two populations with positive admission breath-analyzer readings and moderate consumption being positively associated with injuries. Both samples reported higher rates of heavy drinking, drunkenness and alcohol-related problems than that found in general surveys of their respective populations. Differences found between the two samples were largely due to varying drinking patterns in the two cultures and to differing uses of the emergency room for treatment.     

The creation and implementation of an outpatient pulmonary embolism treatment protocol

The ability to rapidly and accurately risk-stratify patients with venous thromboembolism (VTE), and the availability of direct acting oral anticoagulants have reduced the need for intravenous anticoagulation for patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). Emergency physicians are generally reluctant to discharge patients with VTE without defined and reliable follow up in place, and VTE patients treated with anticoagulants can be at risk for complications related to recurrent VTE and bleeding. In addition, screening for associated diseases (e.g. cancer, hypercoagulable states) may be indicated. Therefore, the outpatient treatment of low risk VTE requires coordinated effort and reliable follow up. By leveraging detailed outcome data and collaborative relationships, we have created a protocol for the safe outpatient treatment of patients with low risk DVT and PE. Our protocol is data driven and designed to address barriers to outpatient VTE management. We expect our protocol to result in improved patient satisfaction, more efficient emergency department (ED) throughput, and decreased cost. Applied nationally, the outpatient treatment of select patients with DVT and PE could have major public health and economic impact.     

Catheter-related thrombosis in cancer patients: pathophysiology, diagnosis, and management

Central venous catheters (CVCs) are commonly used in oncology patients. Up to 50% of CVCs are complicated by thrombosis within the catheter or the blood vessel. These thrombi are the result of local tissue damage, the catheter itself, and the thrombophilia of cancer. Frequent flushes with saline or heparin may reduce the frequency of catheter dysfunction but do not reduce the rate of deep venous thrombosis (DVT) in the catheterized blood vessel. Efforts to use prophylactic heparin or warfarin to reduce catheter-related DVT have not been rewarding.