Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial

INTRODUCTION

Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE.

METHODS

In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization.

RESULTS

Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74).

CONCLUSIONS

Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.

Triaging acute pulmonary embolism for home treatment by Hestia or simplified PESI criteria: the HOME-PE randomized trial

AIMS

The aim of this study is to compare the Hestia rule vs. the simplified Pulmonary Embolism Severity Index (sPESI) for triaging patients with acute pulmonary embolism (PE) for home treatment.

METHODS AND RESULTS

Normotensive patients with PE of 26 hospitals from France, Belgium, the Netherlands, and Switzerland were randomized to either triaging with Hestia or sPESI. They were designated for home treatment if the triaging tool was negative and if the physician-in-charge, taking into account the patient's opinion, did not consider that hospitalization was required. The main outcomes were the 30-day composite of recurrent venous thrombo-embolism, major bleeding or all-cause death (non-inferiority analysis with 2.5% absolute risk difference as margin), and the rate of patients discharged home within 24 h after randomization (NCT02811237). From January 2017 through July 2019, 1975 patients were included. In the per-protocol population, the primary outcome occurred in 3.82% (34/891) in the Hestia arm and 3.57% (32/896) in the sPESI arm (P = 0.004 for non-inferiority). In the intention-to-treat population, 38.4% of the Hestia patients (378/984) were treated at home vs. 36.6% (361/986) of the sPESI patients (P = 0.41 for superiority), with a 30-day composite outcome rate of 1.33% (5/375) and 1.11% (4/359), respectively. No recurrent or fatal PE occurred in either home treatment arm.

CONCLUSIONS

For triaging PE patients, the strategy based on the Hestia rule and the strategy based on sPESI had similar safety and effectiveness. With either tool complemented by the overruling of the physician-in-charge, more than a third of patients were treated at home with a low incidence of complications.

Predictive value of the heart-type fatty acid-binding protein and the Pulmonary Embolism Severity Index in patients with acute pulmonary embolism in the emergency department

OBJECTIVES

Heart-type fatty acid-binding protein (h-FABP), sensitive troponins, natriuretic peptides, and clinical scores such as the Pulmonary Embolism Severity Index (PESI) are candidates for risk stratification of patients with acute pulmonary embolism (PE). The aim was to compare their respective prognostic values to predict an adverse outcome at 1 month.

METHODS

The authors prospectively included 132 consecutive patients with confirmed acute PE. On admission to the emergency department (ED), plasma concentrations of h-FABP, sensitive cardiac troponin I-Ultra (cTnI-Ultra), and brain natriuretic peptide (BNP) were measured and the PESI calculated in all patients. The combined 30-day outcomes of interest were death, cardiac arrest, mechanical ventilation, use of catecholamines, and recurrence of acute PE.

RESULTS

During the first 30 days, 14 (10.6%) patients suffered complications. Among the biomarkers, h-FABP above 6 μg/L was a stronger predictor of an unfavorable outcome (odds ratio [OR] = 17.5, 95% confidence interval [CI] = 4.2 to 73.3) than BNP > 100 pg/mL (OR = 5.7, 95% CI = 1.6 to 20.4) or cTnI-Ultra > 0.05 μg/L (OR = 3.4, 95% CI = 1.1 to 10.9). The PESI classified 83 of 118 patients (70.3%) with favorable outcomes and only one of 14 (7%) with adverse outcomes in low class I or II (OR = 30.8, 95% CI = 3.2 to 299.7). The areas under the receiver operating characteristic (ROC) curves (AUCs) were 0.90 (95% CI = 0.81 to 0.98) for h-FABP, 0.89 (95% CI = 0.82 to 0.96) for PESI, 0.79 (95% CI = 0.67 to 0.90) for BNP, and 0.76 (95% CI = 0.64 to 0.87) for cTnI-Ultra. The combination of h-FABP with PESI was a particularly useful prognostic indicator because none of the 79 patients (59.8%) with h-FABP < 6 ng/mL and PESI class < III had an adverse outcome.

CONCLUSIONS

h-FABP and the PESI are superior to BNP and cTnI-Ultra as markers for risk stratification of patients with acute PE. The high sensitivity of their combination identified a large number of low-risk patients in the ED.

[Non-complicated Horton's disease: initial treatment with methylprednisolone 500 mg/day bolus for three days followed by 20 mg/day prednisone-equivalent. Evaluation of 15 patients]

PURPOSE

To assess the efficacy and tolerance of three methylprednisolone boluses (500 mg/d) followed by a standard dose of prednisolone, 20 mg/d, as the initial treatment of non-complicated giant-cell arteritis.

METHOD

A retrospective study of 15 cases.

RESULTS

Six men and nine women with a mean age of 70.9 years were treated and followed for 41.5 months. Initial mean ESR was 83 mm; mean C-reactive protein level was 94.6 mg/L. The boluses were well tolerated, excepted in one patient who developed acute psychosis. After initiating the oral treatment, two patients presented signs of clinical relapse during the first month, and were given higher doses of corticosteroids. At 1 month, 12 patients were asymptomatic, nine of whom had normalized ESR and CRP. Mean ESR was 23; mean CRP was 13 mg/L. At 3 months, the mean prednisone dose delivered was 18.2 mg/d. Mean ESR was 12 mm. The cumulative prednisone dose given during the first year was 5,349 (+/- 2,512) mg. In the 13 patients who necessitated no more than 20 mg/d prednisone, no sequelae of giant-cell arteritis, no fractures nor major treatment intolerance occurred-during the first 2 years of treatment. Treatment was stopped in eight patients after a mean duration of 48.6 months.

CONCLUSION

Treatment with pulse methylprednisolone 500 mg/d for 3 days followed by 20 mg/d oral prednisone could be a valuable corticosteroid-sparing strategy in many patients with uncomplicated temporal arteritis.

[Treatment of non-complicated Horton's disease]

Non-complicated giant-cell arteritis is defined by the absence of ischemic complications, a remarkable response to corticosteroid treatment, and the absence of corticodependence. It is the most common type of giant-cell arteritis. Treatment relies on corticosteroids (prednisone or prednisolone) at an initial dosage of 0.7 mg/kg/j. The median duration of treatment is 2 years, but many patients need a more prolonged course. Side effects are frequent, especially atherosclerosis and osteoporosis. There is no demonstrated efficiency of corticosteroid sparing agents such as hydroxychloroquine or methotrexate. Dapsone may be efficient, but is not indicated because of its serious side-effects.

Erythrocyte hyperaggregation and thrombogenic dysfibrinogenemia

Erythrocyte aggregation was measured in 12 patients with congenital dysfibrinogenemia. The results showed hyperaggregation in four patients who had presented a thrombotic disorder, while aggregation was entirely normal in patients with asymptomatic dysfibrinogenemia. None of the four symptomatic patients had any other anomaly of hemostasis, in particular no coagulation inhibitor deficit or anti-phospholipid antibodies. The possible involvement of erythrocyte hyperaggregation in the thrombotic process is discussed.

Relation between HLA DRB1 alleles and corticosteroid resistance in giant cell arteritis

OBJECTIVE

To evaluate the clinical usefulness of genomic HLA typing during the first two years of established giant cell arteritis (GCA).

METHODS

HLA typing was performed by PCR-SSO in 41 selected white patients with GCA confirmed by biopsy. Patient data were compared with those of a control group of 384 bone marrow donors (relative risk, p value and chi 2 test for each allele). Clinical features at onset and response to treatment over a two year period were evaluated in relation to the genetic pattern.

RESULTS

DRB1*04 was significantly increased in the GCA group (frequency of 48.78% compared with 19.79% in controls, p < 0.001). The distribution of the DRB1*04 subtypes in the GCA group was similar to that in controls. No clinical or biological differences were found in association with HLA at the time of diagnosis. Over the two year follow up, nine patients presented resistance to corticosteroid treatment and eight of these (88.88%) had DRB1*04 (p < 0.001).

CONCLUSIONS

GCA seems to be associated with HLA DRB1*04 (regardless of the subtype) and this association appears to be accompanied by corticosteroid resistance, suggesting that genomic typing may be useful to identify patients eligible for early alternative treatment to corticosteroid drugs.

[Systemic manifestations of primary Gougerot-Sjögren syndrome. Nature and incidence apropos of 34 cases]

OBJECTIVES

Assess the systemic manifestations observed in patients with primary Sjörgen's syndrome and the correlation between clinical findings and paraclinical data.

METHODS

This retrospective study included patients who met the preliminary European criteria established in 1993.

RESULTS

Among the 34 patients with primary Sjögren's syndrome (32 women, 2 men, mean age 54.9 years), systemic manifestations were observed as the inaugural sign in 25 (73.5%) and 31 cases (91%) during a mean 43-month follow-up. Clinical signs in 23 patients were: neuropsychiatric disorders including depressive syndromes (n = 17) and peripheral neuropathies (n = 13), joint and muscle disorders (n = 16), Raynaud's phenomenon (n = 8), pulmonary disorders (n = 8), digestive disorders (n = 8) including two cases of chronic autoimmune hepatitis, skin disease (n = 7), and renal (n = 3) and thyroid (n = 8) disorders. Antinuclear antibodies were found in 20 cases and anti-SSA antibodies in 5 associated with anti-SSB in 4. Eight patients had hematologic disorders. There was a correlation between the number of systemic signs (at least 2) and positive Rose-Bengal test (p = 0.045).

DISCUSSION

Different systemic manifestations were found at percentages comparable with data in the literature except for Raynaud's syndrome which was less frequent and neurological disorders which were more frequent.

[Prevalence of hypothyroidism and hyperthyroidism in temporal arteritis and rhizomelic pseudopolyarthritis. A controlled study of 104 cases]

The aim of this study was to assess the prevalence of hyperthyroidism and hypothyroidism in giant cell arteritis and polymyalgia rheumatica. The prevalence of thyroid dysfunction in giant cell arteritis and polymyalgia rheumatica patients was determined retrospectively from 1976 through 1984 and prospectively from 1984 through 1991. A control group was composed of patients over 55 years of age consecutively admitted to the same hospital department for another condition. Patients were screened for thyroid dysfunction using a thyrotropin assay. Abnormal results were evaluated by T3 and T4 assays and, if needed, a TRH test. Among the 68 giant cell arteritis patients (mean age 72.6 +/- 7 years), of which 41 were included in the prospective arm of the study, 6 had hypothyroidism and 3 had hyperthyroidism. Corresponding figures were 4 and 4 among the 36 patients with polymyalgia rheumatica (mean age 71.7 +/- 8.3 years), of which 18 were evaluated prospectively. Among the 305 controls (mean age 71.6 +/- 9.4 years), 16 had hypothyroidism and 10 had hyperthyroidism. Prevalences of hypothyroidism, hyperthyroidism, and antithyroid antibodies were not significantly different in the control and case groups. Data fail to support previous suggestions that giant cell arteritis or polymyalgia rheumatica patients may be an increased risk for hypothyroidism or hyperthyroidism. They lend no indirect support to the hypothesis that giant cell arteritis and polymyalgia rheumatica may be autoimmune disorders.

[Neoplastic hypercalcemia: prognostic factors of survival of patients; from 51 cases seen in internal medicine]

In our Internal Medicine department, we conducted a retrospective study of prognostic factors in patients with malignant hypercalcaemia. The records of 51 patients who had both hypercalcaemia and a histologically proven cancer were analyzed; 42 had a solid tumour and 9 had a myeloma. In 61% of the patients cancer had been revealed by hypercalcaemia. The main warning signs were alteration of the general condition (68.6%), pain in the bones (54.9%) and polyuria with dehydration (58.8%). Osteolysis was observed in 75% of the cases. The overall median survival was 86 days. Patients with myeloma had a significantly longer survival than patients with other tumours (312 versus 60 days; p < 0.05). Patients who had received a causal treatment had a longer survival (176 versus 36 days, p < 0.001). In patients with solid tumours we found a negative correlation between survival and initial calcaemia, and a positive correlation between phosphoraemia, albuminaemia and survival. Multivariate analysis showed that the initial calcaemia level and the possibility of causal treatment were the two cardinal prognostic factors. Although the overall survival rate is mediocre, we believe that hospitalization of patients with malignant hypercalcaemia is justified for their better survival comfort and for the possibility of discovering a neoplasia that could benefit from an effective causal treatment, which is the principal factor of improved prognosis.

[Neurologic and psychiatric manifestations of primary hyperparathyroidism. Study of 5 cases]

Among 8 of the 20 records of primary hyperparathyroidism examined in search of neurological and/or psychiatric manifestations, the authors extracted 5 clinical cases reported here. These 5 cases were selected because these manifestations had been well evaluated before and after curative surgery of the disease. Among the manifestations reported, there was one corpus striatum syndrome, one cervical myelopathy and three cases of "chronic" psychiatric disorders of several years duration completely cured after parathyroidectomy. The authors underline that such psychiatric disorders should be taken into account in the discussion of treatment.

[Generalized edema caused by licorice: a new syndrome. Apropos of 3 cases]

Licorice abuse is a wellknown cause of high blood pressure, myopathy, and cardiac rhythm trouble. It should be considered as a cause of diffuse acute edema, as shown in the three following case-reports.