Risk Of Aneurysm Recurrence Research Articles

First-ever seizure and eligibility for commercial motor vehicle driving

BackgroundAfter a first-ever seizure, 6 months of seizure freedom is usually required before returning to driving a private motor vehicle, after which the annual risk of seizure recurrence has fallen...

The Vienna Prediction Model for identifying patients at low risk of recurrent venous thromboembolism: a prospective cohort study.

Patients with unprovoked venous thromboembolism (VTE) have a high recurrence risk, and guidelines suggest extended-phase anticoagulation. Many patients never experience recurrence but are exposed to bleeding. The aim of this study was to assess the performance of the Vienna Prediction Model (VPM) and to evaluate if the VPM accurately identifies these patients. In patients with unprovoked VTE, the VPM was performed 3 weeks after anticoagulation withdrawal. Those with a predicted 1-year recurrence risk of ≤5.5% were prospectively followed. Study endpoint was recurrent VTE over 2 years. A total of 818 patients received anticoagulation for a median of 3.9 months. 520 patients (65%) had a predicted annual recurrence risk of ≤5.5%. During a median time of 23.9 months, 52 patients had non-fatal recurrence. The recurrence risk was 5.2% [95% confidence interval (CI) 3.2-7.2] at 1 year and 11.2% (95% CI 8.3-14) at 2 years. Model calibration was adequate after 1 year. The VPM underestimated the recurrence risk of patients with a 2-year recurrence rate of >5%. In a post-hoc analysis, the VPM's baseline hazard was recalibrated. Bootstrap validation confirmed an ideal ratio of observed and expected recurrence events. The recurrence risk was highest in men with proximal deep-vein thrombosis or pulmonary embolism and lower in women regardless of the site of incident VTE. In this prospective evaluation of the performance of the VPM, the 1-year rate of recurrence in patients with unprovoked VTE was 5.2%. Recalibration improved identification of patients at low recurrence risk and stratification into distinct low-risk categories.

Constructing an individualized surveillance framework for nasopharyngeal carcinoma based on a dynamic risk-adapted approach

Background and purposeThis study aims to evaluate the dynamic survival and recurrence hazard of nasopharyngeal carcinoma(NPC) patients after definitive chemoradiotherapy utilizing conditional survival(CS) analysis, and to propose a personalized surveillance strategy at different clinical stages. Materials and MethodsNon-metastatic NPC patients who received curative chemotherapy between June 2005 and December 2011 were included. The Kaplan-Meier method was used to calculate the CS rate. ResultsA total of 1616 patients were analyzed. With the prolongation of survival time, both conditional locoregional recurrence free survival and distant metastatic free survival increased gradually. Changing pattern of annual recurrence risk over time varied among different clinical stages. The annual locoregional recurrence(LRR) risk in stage I-II was always less than 2%, while in stage III-IVa, it was greater than 2% for the first three years and decreased to below 2% only after the third year. The annual distant metastases (DM) risk was always less than 2% in stage I, but higher than 2% in stage II for the first 3 years (2.5–3.8%). For those with stage III-IVa, the annual DM risk retained at a high level(>5%), and only decreased to < 5% after the third year. Based on the dynamic changes in survival probability over time, we established a surveillance plan with different follow-up intensities and frequencies for different clinical stages. ConclusionThe annual risk of LRR and DM decrease over time. Our individual surveillance model will provide critical prognostic information to optimize clinical decision-making, and promote to formulate surveillance counseling and help with resources allocation.

Recurrence of Cryptogenic (ESUS) Strokes in the First Year: Predictors and Outcome-A South Indian Study.

Around 9-25% of ischemic strokes are embolic stroke of undetermined source (ESUS) with an annual recurrence risk of 4.5-5%. Regarding ESUS, studies from India are limited. Here, we studied the prevalence of cryptogenic ESUS among stroke subtypes, recurrence risk and outcome at 1 year, and their predictors. We performed a single-center study of ambispective nature. Patients above 18 years of age with a diagnosis of cryptogenic (ESUS) strokes from January 1, 2017, to December 31, 2020 (4 years), with a 1-year follow-up were recruited in our study. All the patients underwent neuroimaging computerised tomography/magnetic resonance tomography (CT/MRI) with angiography, electrocardiogram (ECG), transthoracic echo (TTE), and rhythm monitoring. Functional outcome was measured using the modified Rankin scale with scores 0-2 taken as good outcome. We had 234 (11.21% of total ischemic strokes) subjects satisfying the criteria for ESUS over the study period with a mean age of 58.2 ± 12.8 years. 46 patients had a history of stroke/transient ischemic attack (TIA) at admission. 9.4% had a recurrent event at 1 year. The most important neuroimaging predictor of recurrent strokes was multiple embolic followed by superficial watershed pattern. Around 10% had more than one marker of atrial cardiopathy positive. While the risk factors, coronary artery disease (CAD), and neuroimaging pattern showed an association with recurrent events at 1 year on bivariate analysis, only the latter two remained significant on multivariate analysis. Our cohort of ESUS had a higher annual recurrence risk than reported before. Though vascular risk factors and ipsilateral vessel abnormalities were more in the recurrent ESUS group, it did not significantly affect the recurrence risk at 1 year. CAD and multiple embolic patterns on imaging showed an association with recurrent strokes, suggesting a possible cardiac substrate in our ESUS population as well.

Microwave Ablation versus Stereotactic Body Radiotherapy for Stage I Non–Small Cell Lung Cancer: A Cost-Effectiveness Analysis

PurposeTo assess the cost effectiveness of microwave ablation (MWA) and stereotactic body radiotherapy (SBRT) for patients with inoperable stage I non–small cell lung cancer (NSCLC). Materials and MethodsA literature search was performed in MEDLINE with broad search clusters. A decision-analytic model was constructed over a 5-year period. The model incorporated treatment-related complications and long-term recurrence. All clinical parameters were derived from the literature with preference to long-term prospective trials. A healthcare payers’ perspective was adopted. Outcomes were measured in quality-adjusted life years (QALYs) extracted from prior studies and U.S. dollars from Medicare reimbursements and prior studies. Base case calculations, probabilistic sensitivity analysis with 10,000 Monte Carlo simulations, and multiple 1- and 2-way sensitivity analyses were performed. ResultsMWA yielded a health benefit of 2.31 QALYs at a cost of $195,331, whereas SBRT yielded a health benefit of 2.33 QALYs at a cost of $225,271. The incremental cost-effectiveness ratio was $1,480,597/QALY, indicating that MWA is the more cost-effective strategy. The conclusion remains unchanged in probabilistic sensitivity analysis with MWA being the optimal cost strategy in 99.84% simulations. One-way sensitivity analyses revealed that MWA remains cost effective when its annual recurrence risk is <18.4% averaged over 5 years, when the SBRT annual recurrence risk is >1.44% averaged over 5 years, or when MWA is at least $7,500 cheaper than SBRT. ConclusionsMWA appears to be more cost effective than SBRT for patients with inoperable stage I NSCLC.

Paediatric Intracranial Aneurysms: Long-term Angiographic and Clinical Outcomes in a Contemporary Series.

ObjectivePaediatric aneurysms are rare and difficult to treat. Studies on the long-term angiographic and clinical outcomes conducted within the past decade are lacking. We aimed to investigate the clinical and radiographic outcomes of paediatric aneurysms treated with different strategies in a contemporary series.MethodsWe performed a retrospective medical record review of paediatric patients examined at our institution between 2011 and 2018. Patient charts were retrospectively reviewed for age, presentation, type and location of the aneurysm, modalities of treatment, complications, and clinical and angiographic outcomes. The rates of aneurysm recurrence and de novo formation were determined.ResultsWe evaluated 61 patients (mean age, 11.6 years; 23 females, 38 males) with 69 intracranial aneurysms. Their presentations included headache, neurological deficits, aneurysmal subarachnoid haemorrhage, incidental aneurysm, and traumatic subarachnoid haemorrhage. Of the aneurysms, 30 (49.2%) were giant. Forty-five (73.8%) patients underwent treatment for their aneurysms, and 16 (26.2%) patients were managed conservatively. The perioperative morbidity rate was 17.8%. There were no deaths. The long-term morbidity rate was 4.6%. The clinical outcomes were favourable in 82.2 and 95.3% at discharge and follow-up, respectively (mean, 41.5 months; range, 1.5–9 years). For treated aneurysms, 2/43 (4.6%) risk of aneurysm recurrence, 1/43 (2.3%) risk of aneurysm bleeding, 1/43 (2.3%) risk of de novo aneurysm formation. The annual bleeding, recurrence, and de novo formation or growth risk were 0.7, 1.4, and 0.7%, respectively.ConclusionsIn neurovascular centres where microsurgical and endovascular options are available, most children with intracranial aneurysms can be successfully treated with low morbidity and mortality. However, they have higher rates of recurrence and a greater risk of de novo formation or growth than their adult counterparts, which mandates lifelong follow-up.

The annual recurrence risk model for tailored surveillance strategy in patients with cervical cancer

PurposeCurrent guidelines for surveillance strategy in cervical cancer are rigid, recommending the same strategy for all survivors. The aim of this study was to develop a robust model allowing for individualised surveillance based on a patient's risk profile. MethodsData of 4343 early-stage patients with cervical cancer treated between 2007 and 2016 were obtained from the international SCCAN (Surveillance in Cervical Cancer) consortium. The Cox proportional hazards model predicting disease-free survival (DFS) was developed and internally validated. The risk score, derived from regression coefficients of the model, stratified the cohort into significantly distinctive risk groups. On its basis, the annual recurrence risk model (ARRM) was calculated. ResultsFive variables were included in the prognostic model: maximal pathologic tumour diameter; tumour histotype; grade; number of positive pelvic lymph nodes; and lymphovascular space invasion. Five risk groups significantly differing in prognosis were identified with a five-year DFS of 97.5%, 94.7%, 85.2% and 63.3% in increasing risk groups, whereas a two-year DFS in the highest risk group equalled 15.4%. Based on the ARRM, the annual recurrence risk in the lowest risk group was below 1% since the beginning of follow-up and declined below 1% at years three, four and >5 in the medium-risk groups. In the whole cohort, 26% of recurrences appeared at the first year of the follow-up, 48% by year two and 78% by year five. ConclusionThe ARRM represents a potent tool for tailoring the surveillance strategy in early-stage patients with cervical cancer based on the patient's risk status and respective annual recurrence risk. It can easily be used in routine clinical settings internationally.

Long-term outcomes after endoscopic treatment for Barrett’s neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period

ObjectiveRadiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett’s oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in...

Recurrent Takotsubo Cardiomyopathy Presenting With Anterior Wall ST-Elevation Myocardial Infarction

Takotsubo cardiomyopathy (TC) or stress cardiomyopathy with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. The recurrence of TC is extremely rare, with an annual recurrence risk of 1.5% and approximately 5% recurrence risk after six years. We present a case of a patient with a history of TC who presented with chest pain and ST-segment elevation in her electrocardiogram and was found to have normal coronaries and diagnosed with recurrent TC.

Thermal ablation versus stereotactic body radiotherapy for stage I non-small cell lung cancer: A cost-effectiveness analysis.

e21061 Background: Stereotactic body radiotherapy (SBRT) and thermal ablation are increasingly used to treat medically inoperable patients with non-small cell lung cancer (NSCLC). The purpose of this study is to assess the cost-effectiveness of microwave (MWA) and stereotactic body radiotherapy (SBRT) for patients with stage I NSCLC. Methods: A decision-analysis model was constructed over a 5-year of Medicare billing data from a health care sector’s perspective using TreeAge Pro Suite 2019 (TreeAge Software LLC, Cambridge, MA). The two evaluated strategies were SBRT and MWA. All clinical, cost and health utility parameters were derived from the literature with preference to long-term prospective trials and assigned appropriate statistical distributions. Costs and health utilities (quantified by quality-adjusted life years (QALY)) associated with procedure, short-term complications, long-term surveillance and disease progression were incorporated. A willingness-to-pay (WTP) threshold of $100,000/QALY was used. One QALY is equivalent to 1 year of life in perfect health. Strategies were compared using incremental cost-effectiveness ratio (ICER). Base case calculations, Monte Carlo Simulations with 10,000 iterations drawing parameters from their respective distributions, and multiple sensitivity analyses were performed. Results: Literature review and interpolation showed that average annual recurrence risk of SBRT and MWA were 4.64% and 10.4% respectively. SBRT yielded 2.33 QALY and MWA yielded 2.31 QALY. The difference in health benefit is equivalent to 1 week of life in perfect health. The overall costs were $225,271 and $195,331. The ICER of MWA in reference to SBRT was $1,480,597/QALY, which is more than 10 times of the WTP threshold currently used in the US, indicating that MWA is the more cost-effective strategy. MWA was the optimal strategy in 99.84% of the Monte Carlo simulations. One-way sensitivity analyses showed that MWA is more cost-effective than SBRT if recurrence risk of MWA is &lt; 18.4% per year or recurrence risk of SBRT is &gt; 1.44% per year, or cost of MWA is lower than or at most $7,500 more than SBRT. One-way sensitivity analysis showed that MWA would achieve a higher health benefit than SBRT if the overall survival after MWA was &gt; 76.9% per year or after SBRT was &lt; 75.6% per year. Conclusions: Our study showed that MWA is more cost-effective than SBRT for medically inoperable stage I NSCLC patients with comparable health benefits based on multiple robust probabilistic and deterministic sensitivity analyses.

Abstract OT1-12-01: Exploration of factors associated with imminent risk of late recurrence in hormone receptor positive breast cancer

Abstract Research objectives: To conduct a prospective observational study of patient and tumor-related factors in women with high risk hormone receptor (HR)+/HER2- breast cancer (BC) following at least 5 years of adjuvant hormonal therapy, in order to identify risk factors for imminent recurrence. Rationale: Many of the life-threatening BC recurrences in women with HR+HER2- BC take place more than 5 years post-diagnosis, often after completion of adjuvant hormonal therapy. The identification of a biomarker(s) for late BC recurrence could lead to interventional trials to evaluate preventive therapies. We will evaluate whether the presence of blood-based biomarkers [(i) Circulating Tumor Cells (CTCs), (ii) circulating tumor DNA (ctDNA), (iii) tumor markers (CA 15-3, CEA)] and patient factors may predict BC recurrence. Trial design: A prospective cohort of eligible women with previously treated HR+HER2- BC who have not experienced a distant recurrence will be enrolled; patient and circulating factors will be measured annually until distant recurrence or study completion. Host factors (including BMI, lifestyle, medical illness, surgery, trauma and stress, as well as circulating PlGF, VEGF-1 and inflammatory markers) that may contribute to exit of BC cells from dormancy will also be assessed. The primary outcome is distant BC recurrence. Any BC event, including loco-regional recurrence, new breast or other primary cancer will be evaluated as a secondary endpoint. Outcomes will be ascertained by regular self-report (via annual telephone calls) and/or physician report and confirmed by medical record review. Key eligibility criteria: i) Diagnosis of ER and/or PR positive (either or both 10% positive), HER2 negative invasive BC, ii) predicted &amp;gt;1.5-2% annual risk of recurrence (T2, T3 or T4 with any N+;T1 N2+; T2N0 or T1 N1 cancers with high risk genomic scores), iii) receipt of adjuvant endocrine therapy for at least 4 years, with discontinuation planned in the next 12 months or completion of endocrine therapy within the last 5 years, iv) prior adjuvant chemotherapy, targeted therapy and bone targeted therapies are allowed provided they have been completed. Specific aims: 1) Determine if the presence of (i) CTCs, (ii) ctDNA, (iii) CA15-3 and CEA are associated with imminent risk (within 1-2 years) of distant recurrence in the study population. 2) Identify host factors associated with these blood-based biomarkers, as well as clinical outcomes. Statistical methods: A matched case control design (matching for time since completion of adjuvant hormone therapy, baseline T, N and grade) will be used to investigate associations of key study variables with imminent risk of distant recurrence within the next 1-2 years. Measurements of patients who do versus do not recur will be compared over the 1-2 years prior to relapse. Each variable will be allocated one third of a study-wide type one error of 0.05 (2-sided). ROC analyses and multivariable modelling will be used to optimize sensitivity, specificity, PPV and NPV. Available questionnaire data will be summarized at all time-points to generate descriptive survivorship data. Accrual: Starting in August 2018, we plan to recruit 1,000 patients over 2 years at selected Canadian cancer centres. Citation Format: Jerzak KJ, Cescon DW, Chia SK, Bratman S, Ennis M, Stambolic V, Chang M, Dowling R, Goodwin PJ. Exploration of factors associated with imminent risk of late recurrence in hormone receptor positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-12-01.

Risk of Venous Thrombosis in Antithrombin Deficiency: A Systematic Review and Bayesian Meta-analysis.

Antithrombin deficiency is a strong risk factor for venous thromboembolism (VTE), but the absolute risk of the first and recurrent VTE is unclear. The objective of this paper is to establish the absolute risks of the first and recurrent VTE and mortality in individuals with antithrombin deficiency. The databases Embase, Medline Ovid, Web of Science, the Cochrane Library, and Google Scholar were systematically searched for case-control and cohort studies. Bayesian random-effects meta-analysis was used to calculate odds ratios (ORs), absolute risks, and probabilities of ORs being above thresholds. Thirty-five publications were included in the systematic review and meta-analysis. Based on 19 studies, OR estimates for the first VTE showed a strongly increased risk for antithrombin deficient individuals, OR 14.0; 95% credible interval (CrI), 5.5 to 29.0. Based on 10 studies, meta-analysis showed that the annual VTE risk was significantly higher in antithrombin-deficient than in non-antithrombin-deficient individuals: 1.2% (95% CrI, 0.8-1.7) versus 0.07% (95% CrI, 0.01-0.14). In prospective studies, the annual VTE risk in antithrombin deficient individuals was as high as 2.3%; 95% CrI, 0.2-6.5%. Data on antithrombin deficiency subtypes are very limited for reliable risk-differentiation. The OR for recurrent VTE based on 10 studies was 2.1; 95% CrI, 0.2 to 4.0. The annual recurrence risk without long-term anticoagulant therapy based on 4 studies was 8.8% (95% CrI, 4.6-14.1) for antithrombin-deficient and 4.3% (95% CrI, 1.5-7.9) for non-antithrombin-deficient VTE patients. The probability of the recurrence risk being higher in antithrombin-deficient patients was 95%. The authors conclude that antithrombin deficient individuals have a high annual VTE risk, and a high annual recurrence risk. Antithrombin deficient patients with VTE require long-term anticoagulant therapy.

Effect of Local Coil Density on Blood Flow Stagnation in Densely Coiled Cerebral Aneurysms: A Computational Study Using a Cartesian Grid Method.

Aneurysm recurrence is the most critical concern following coil embolization of a cerebral aneurysm. Adequate packing density (PD) and coil uniformity are believed necessary to achieve sufficient flow stagnation, which decreases the risk of aneurysm recurrence. The effect of coil distribution on the extent of flow stagnation, however, especially in cases of dense packing (high PD), has received less attention. Thus, the cause of aneurysm recurrence despite dense packing is still an open question. The primary aim of this study is to evaluate the effect of local coil density on the extent of blood flow stagnation in densely coiled aneurysms. For this purpose, we developed a robust computational framework to determine blood flow using a Cartesian grid method, by which the complex fluid pathways in coiled aneurysms could be flexibly treated using an implicit function. This tool allowed us to conduct blood flow analyses in two patient-specific geometries with 50 coil distribution patterns in each aneurysm at clinically adequate PD. The results demonstrated that dense packing in the aneurysm may not necessarily block completely the inflow into the aneurysm and local flow that formed in the neck region, whose strength was inversely related to this local PD. This finding suggests that local coil density in the neck region still plays an important role in disturbing the remaining local flow, which possibly prevents thrombus formation in a whole aneurysm sac, increasing the risk of aneurysm regrowth and subsequent recurrence.

Risk of a seizure recurrence after a breakthrough seizure and the implications for driving: further analysis of the standard versus new antiepileptic drugs (SANAD) randomised controlled trial

ObjectivesA breakthrough seizure is one occurring after at least 12 months seizure freedom while on treatment. The Driver and Vehicle Licensing Agency (DVLA) allows an individual to return to driving...

Techniques and outcomes of microsurgical management of ruptured and unruptured fusiform cerebral aneurysms.

OBJECTIVE Fusiform cerebral aneurysms represent a small portion of intracranial aneurysms; differ in natural history, anatomy, and pathology; and can be difficult to treat compared with saccular aneurysms. The purpose of this study was to examine the techniques of treatment of ruptured and unruptured fusiform intracranial aneurysms and patient outcomes. METHODS In 45 patients with fusiform aneurysms, the authors retrospectively reviewed the presentation, location, and shape of the aneurysm; the microsurgical technique; the outcome at discharge and last follow-up; and the change in the aneurysm at last angiographic follow-up. RESULTS Overall, 48 fusiform aneurysms were treated in 45 patients (18 male, 27 female) with a mean age of 49 years (median 51 years; range 6 months-76 years). Twelve patients (27%) had ruptured aneurysms and 33 (73%) had unruptured aneurysms. The mean aneurysm size was 8.9 mm (range 6-28 mm). The aneurysms were treated by clip reconstruction (n = 22 [46%]), clip-wrapping (n = 18 [38%]), and vascular bypass (n = 8 [17%]). The mean (SD) hospital stay was 19.0 ± 7.4 days for the 12 patients with subarachnoid hemorrhage and 7.0 ± 5.6 days for the 33 patients with unruptured aneurysms. The mean follow-up was 38.7 ± 29.5 months (median 36 months; range 6-96 months). The mean Glasgow Outcome Scale score for the 12 patients with subarachnoid hemorrhage was 3.9; for the 33 patients with unruptured aneurysms, it was 4.8. No rehemorrhages occurred during follow-up. The overall annual risk of recurrence was 2% and that of rehemorrhage was 0%. CONCLUSIONS Fusiform and dolichoectatic aneurysms involving the entire vessel wall must be investigated individually. Although some of these aneurysms may be amenable to primary clipping and clip reconstruction, these complex lesions often require alternative microsurgical and endovascular treatment. These techniques can be performed with acceptable morbidity and mortality rates and with low rates of early rebleeding and recurrence.

Infections des voies urinaires : impact économique de la consommation d’eau

This study aims to estimate the impact of preventing urinary tract infections (UTI), using a strategy of increased water intake, from the payer's perspective in the French health care system. A Markov model enables a comparison of health care costs and outcomes for a virtual cohort of subjects with different levels of daily water intake. The analysis of the budgetary impact was based on a period of 5years. The analysis was based on a 25-year follow-up period to assess the effects of adequate water supply on long-term complications. The authors estimate annual primary incidence of UTI and annual risk of recurrence at 5.3% and 30%, respectively. Risk reduction associated with greater water intake reached 45% and 33% for the general and recurrent populations, respectively. The average total health care cost of a single UTI episode is €1074; for a population of 65 millions, UTI management represents a cost of €3.700 millions for payers. With adequate water intake, the model indicates a potential cost savings of €2.288 millions annually, by preventing 27 million UTI episodes. At the individual level, the potential cost savings is approximately €2915. Preventing urinary tract infections using a strategy of adequate water intake could lead to significant cost savings for a public health care system. Further studies are needed to assess the effectiveness of such an approach.

“Role of D-Dimer in One Year Recurrence of Venous Thromboembolism after Completed Anticoagulation Treatment” Following A First Idiopathic Deep Vein Thrombosis

After oral anticoagulant therapy (OAT) withdrawal, the recurrence of risk is greatest in the first year and gradually diminishes, while the increased bleeding risk may offset the benefits of prolonged OAT. the benefits of extending anticoagulation should be balanced against the risk of bleeding . D-dimer assay and measurement of residual thrombosis on ultrasonography, so-called residual vein obstruction (RVO) were proposed to be effec- tive in selecting patients with idiopathic DVT Materials and methods: This single center prospective study was conducted in patients with a first episode of symptomatic proximal DVT, de - tected by compression ultrasonography (CUS), and who received OAT for at least 3 months. Follow-up was extended from Oct. 2011, to Aug. 2013. After enrollment, patients were re-evaluated at 1st, 6th and 12th months of their follow-up. At the first and 30-day visits, venous blood samples were taken for D-dimer test. All enrolled patients without RVT were stopped OAT. At each follow-up visit, we examined patients and inquired about health status, clinical symptoms or signs of recurrent VTE, bleeding, post-throm- botic manifestations, adherence to treatment, and concomitant analgesic or anti-inflammatory therapy. The end point outcomes were VTE recurrence or complete of this survey follow-ups. Results: A total of 68 eligible patients were enrolled. Four patients (two patients need to using long-term oral anticoagulation, and another two patients for lost to their first follow-up) were excluded. D-dimer and CUS at first was normal in 28 patients (44%) while the remaining 36 patients had abnormal D-dimer but normal CUS while both groups were not consuming their anticoagulant. Total follow-up was 52.5 patient-years. Median follow-up was 11 months (95% CI: 6-17 months). A minimum follow-up of 12 months was avail- able in 44 patients (68%). During follow-up, three recurrent events were recorded (4.6% of patients - 95% CI: 3-7%). All Recurrent events were ipsilateral DVT. Among these index cases, all had an abnormal D-dimer at either T0 and/or T1. The recurrence rate was higher in males than in females (8.6% vs. 2.2%) with an abnormal D-dimer at T0 and/or T1 with a multivariate hazard ratio of 2.1 (95% 1.2-7; p=0.04). Patients older than 65 years had a higher rate of events than younger patients (2/ 12: (16%); 95% CI: 4-24% Vs. 1/ 52: (2%); 95% CI: 0.05-3%) and hazard ratio was about 3.8; (95% CI: 1.95-8.4 p= 0.04). Patients with recurrences had higher mean D-dimer at both T0 and T1 when compared with those without recurrences but the difference was significant only for D-dimer at T1. During follow-up, two patients died (3%). Conclusion: In our cohort of DVT patients, the annual risk of recurrence with an abnormal D-dimer, either during or at one month after VKA withdrawal, was 4.6% which is much lower to the annual risk of recurrence in most studies with idiopathic and provoked VTE. The benefits of extending anticoagulation should be balanced against the risk of bleeding. So according to these results of D-Dimer assay before withdrawal of OAT, this test is helpful for OAT withdrawal decision making.

Effect of fertility concerns on tamoxifen use in young survivors of breast cancer.

572 Background: For premenopausal patients with ER+ breast cancer, a 5-year course of tamoxifen results in a 47% reduction in annual recurrence risk and a 26% reduction in annual mortality. Despite these benefits, adherence rates for tamoxifen are low, particularly among younger women. We hypothesize that fertility concerns are causally related to the poor tamoxifen adherence rates observed among young breast cancer survivors. Methods: With IRB approval, a retrospective analysis of 535 women with breast cancer between 2000-2012 was undertaken. Patients were younger than age 46, premenopausal and had ER+ breast cancer. 138 patients did not complete a 5-year course. Patient and provider factors that influenced tamoxifen initiation and adherence were reviewed: (1) evidence of referral to a fertility specialist; (2) documentation of discussion about tamoxifen-related fertility concerns; (3) agreement to take tamoxifen; (4) duration of tamoxifen use. Phone interviews conducted with 27 patients focused on lack of initiation or early discontinuation. The Log-rank (Mantel-Cox) test was used to compare Kaplan-Meier curves and generate hazard ratios. Results: Of the 138 patients who did not complete 5 years of therapy, 38 (27.5%) failed to initiate or discontinued tamoxifen secondary to fertility concerns. Only 114 (21.3%) charts documented referral to a fertility specialist. Patients who expressed a desire to maintain fertility or to have children in the future (115 patients, 21.5%) were more likely to discontinue tamoxifen treatment (HR=2.7, p=0.001). Other critical factors included being unmarried (HR=1.9, p=0.011) and lack of college education (HR=2.5, p=0.0008). Major themes from phone interviews: (1) patients felt they were not adequately informed about fertility preservation and had to pursue information independently; (2) patients did not initiate/resume tamoxifen postpartum because of inadequate physician guidance. Conclusions: Concerns about fertility have a significant negative impact on the initiation and adherence to tamoxifen for young breast cancer patients. Efforts to improve tamoxifen adherence among young cancer patients should include prioritization of fertility preservation as part of the treatment plan.

Untreated clinical course of cerebral cavernous malformations: a prospective, population-based cohort study

SummaryBackgroundCerebral cavernous malformations (CCMs) are prone to bleeding but the risk of intracranial haemorrhage and focal neurological deficits, and the factors that might predict their occurrence, are unclear. We aimed to quantify these risks and investigate whether they are affected by sex and CCM location.MethodsWe undertook a population-based study using multiple overlapping sources of case ascertainment (including a Scotland-wide collaboration of neurologists, neurosurgeons, stroke physicians, radiologists, and pathologists, as well as searches of registers of hospital discharges and death certificates) to identify definite CCM diagnoses first made in Scottish residents between 1999 and 2003, which study neuroradiologists independently validated. We used multiple sources of prospective follow-up both to identify outcome events (which were assessed by use of brain imaging, by investigators masked to potential predictive factors) and to assess adults' dependence. The primary outcome was a composite of intracranial haemorrhage or focal neurological deficits (not including epileptic seizure) that were definitely or possibly related to CCM.Findings139 adults had at least one definite CCM and 134 were alive at initial presentation. During 1177 person-years of follow-up (completeness 97%), for intracranial haemorrhage alone the 5-year risk of a first haemorrhage was lower than the risk of recurrent haemorrhage (2·4%, 95% CI 0·0–5·7 vs 29·5%, 4·1–55·0; p<0·0001). For the primary outcome, the 5-year risk of a first event was lower than the risk of recurrence (9·3%, 3·1–15·4 vs 42·4%, 26·8–58·0; p<0·0001). The annual risk of recurrence of the primary outcome declined from 19·8% (95% CI 6·1–33·4) in year 1 to 5·0% (0·0–14·8) in year 5 and was higher for women than men (p=0·01) but not for adults with brainstem CCMs versus CCMs in other locations (p=0·17).InterpretationThe risk of recurrent intracranial haemorrhage or focal neurological deficit from a CCM is greater than the risk of a first event, is greater for women than for men, and declines over 5 years. This information can be used in clinical practice, but further work is needed to quantify risks precisely in the long term and to understand why women are at greater risk of recurrence than men.FundingUK Medical Research Council, Chief Scientist Office of the Scottish Government, and UK Stroke Association.

Deep Time: The Long and the Short of Adjuvant Endocrine Therapy for Breast Cancer

Deep Time: The Long and the Short of Adjuvant Endocrine Therapy for Breast Cancer