Background Exercise can ameliorate cancer- and treatment-related toxicities, but poor adherence to exercise regimens is a barrier. Exercise interventions using digital activity trackers (E-DATs) may improve exercise adherence, but data are limited for patients with cancer. We conducted a systematic review examining the feasibility of E-DATs in cancer survivors and effects on activity level, body composition, objective fitness outcomes, health-related quality of life (HRQoL), self-reported symptoms, and biomarkers. Methods We identified randomized controlled trials (RCTs) of E-DATs in adult cancer survivors published in English between January 1, 2008, and July 27, 2017. Two authors independently reviewed article titles (n=160), removed duplicates (n=50), and reviewed the remaining 110 articles for eligibility. Results A total of 12 RCTs met eligibility criteria, including 1,450 patients (mean age, 50–70 years) with the following cancers: breast (n=5), colon or breast (n=2), prostate (n=1), acute leukemia (n=1), or others (n=3). Duration of E-DATs ranged from 4 to 24 weeks, and the follow-up period ranged from 4 to 52 weeks, with retention rates of 54% to 95%. The technology component of E-DATs included pedometers (n=8); pedometers with smartphone application (n=1), Wii Fit (n=1), heart rate monitor (n=1); and a wireless sensor with accelerometer, gyroscope, and magnetometer (n=1). Adherence by at least one measure to E-DATs was >70% in 8 of 8 RCTs. Compared with controls, E-DATs significantly improved patients’ step count in 3 of 5 RCTs, activity level in 6 of 9 RCTs, and HRQoL in 7 of 9 RCTs (all P≤.05), with no significant changes in biomarkers (eg, interleukin 6, tumor necrosis factor α, C-reactive protein, c-peptide, lipid panel) in 3 RCTs. Duration of E-DAT was not significantly correlated with adherence or study retention. Conclusions This systematic review shows that E-DATs are feasible to implement in cancer survivors. Future research should examine the optimal type, dose, and schedule of E-DATs for cancer survivors.
Rivaroxaban, a factor Xa inhibitor, is a direct-acting oral anticoagulant (DOAC) indicated for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and for reducing the risk of DVT and PE recurrence. To our knowledge, no data are presently available to guide DOAC dosing in the postpartum period when pharmacokinetic and pharmacodynamic changes induced by pregnancy have an impact on drug clearance and increase hypercoagulability for a period of 6-8 weeks after delivery. We describe the case of a 35-year-old postpartum woman who presented to the emergency department with a diagnosis of a new multiple segmental PE 5 days after starting rivaroxaban therapy for a diagnosis of DVT. No precipitating cause, including noncompliance, was identified as a source of thrombosis embolization or extension. The patient was admitted, a heparin infusion was started for the management of PE, and rivaroxaban was discontinued. She was transitioned to enoxaparin 1 mg/kg (90 mg) subcutaneously every 12 hours the next day, bridged to warfarin, and discharged home on the overlapping regimen with close follow-up by the pharmacist-managed outpatient Anticoagulation Management Service. To our knowledge, this is the first case report of potential failure associated with rivaroxaban therapy in the postpartum period, possibly due to pharmacokinetic alterations seen in the postpartum period contributing to decreased drug exposure, yielding reduced anticoagulant efficacy. Clinicians should carefully weigh the risks and benefits of DOAC therapy in postpartum patients or other special populations requiring anticoagulation therapy. This report also highlights the need for further research identifying the impact of pharmacokinetic changes induced by special populations and the need to develop monitoring assays for such clinical situations.
A 69-year-old Caucasian woman developed a diffuse, exanthematous rash on day 3 of rivaroxaban treatment. Symptoms abated after rivaroxaban discontinuation and treatment with dexamethasone.
108 Background: Exercise ameliorates cancer and treatment-related toxicities but adherence to exercise is a barrier. Few studies in the general population suggest that E-DAT may improve exercise adherence. We conducted a systematic review to examine the effects of E-DAT on physical function, health-related quality of life (HRQOL), and serum inflammatory markers during and after cancer treatment. Methods: We used PubMed, Embase, and the Cochrane Library to identify RCTs of E-DAT in cancer patients aged ≥18 years published in English between 1/1/2008 and 7/27/2017. Two authors independently reviewed the titles of articles from the search (n = 160), removed duplicates (n = 49), and reviewed the remaining 111 articles for eligibility and substantive results. We excluded RCTs that used digital activity trackers solely for data collection. Results: Twelve RCTs met eligibility criteria, including 1,450 patients (mean age: 50-70 years) with the following cancers: breast (n = 5 RCTs), colon or breast (n = 2), prostate (n = 1), acute leukemia (n = 1) and various type (n = 3). Duration of E-DAT ranged from 4-24 weeks. Follow-up period was 4-24 weeks with retention of 54-95%. Half of the RCTs had E-DAT with in-person exercise training and the rest had self-directed training. The technology component of E-DAT included pedometers (n = 8); pedometers with smart phone application (n = 1), Wii-Fit (n = 1), or heart rate monitor (n = 1); and a wireless sensor with accelerometer, gyroscope, and magnetometer (n = 1). Adherence to E-DAT was > 70% in 5 of 7 RCTs. Compared to controls (exercise interventions without digital activity trackers or standard of care), E-DAT significantly improved the step count in 60% of 5 RCTs, activity level in 56% of 9 RCTs, and HRQOL in 56% of 9 RCTs (all p < 0.05), with no significant changes of inflammatory markers (i.e. TNF, CRP, c-peptide) in 2 RCTs. No significant correlations were found between duration of E-DAT with adherence (Spearman’s r = 0.16; p = 0.75) or study retention (Spearman’s r = -0.42; p = 0.17). Conclusions: This systematic review shows that E-DAT is feasible to implement in cancer patients. Future research should examine the optimal type, dose and schedule of E-DAT.
Background: The ACAP program consists of strategies for implementing ACC/AHA guidelines for various cardiac disorders, one of which is the SELF pathway, which covers the spectrum of care from presentation to discharge in patients with syncope. Patients are stratified according to SELF-1 (Short period, Early onset, Loss of consciousness, Full recovery) and SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia). Methods: 3044 patients were prospectively followed for syncope. They were divided into 4 groups: Group A (SELF +/+) who met both SELF 1 and 2 criteria, Group B (SELF +/-) who met SELF-1 criteria but not SELF-2, Group C (SELF -/+) who met SELF-2 criteria alone and Group D (SELF -/-) who met neither criteria. These groups were further separated into males and females. The primary endpoint was composite of readmission for syncope, myocardial infarction, stroke or death. Follow-up was 5 years. Results: Females were older than males (69+/-21 years), had more hypertension (65% vs. 63%) and syncopal episodes (18% vs. 16%). Males were more likely to be diabetic (25% vs. 24%), have coronary artery disease (21% vs. 16%; p=0.001), heart failure (11% vs. 9%) and smoking (65% vs. 42%; p<0.001). Regardless of sex, Group A patients had worse outcomes (p=0.25) while Group D patients had better outcome with far fewer events (p=0.06). In Group B patients, males were noted to have worse outcome while in Group C, females were noted to have significantly worse long-term outcome. Conclusions: The SELF-pathway for patients with syncope helps identify at-risk subgroups in our patient population. Females with SELF-2 criteria (Structural heart disease, abnormal ECG, arrhythmia) had significantly worse long-term outcome compared to males regardless of manner of syncopal presentation.
Background: In the US, 2 million people are evaluated for syncope annually. Published literature shows that of all ethnicities, African Americans (AA) are more likely to have comorbidities like hypertension, diabetes & lifestyle risk factors that translate to poorer outcome. Having published short-term outcomes showing worse outcome for AA with syncope, we followed up these patients over 5 years to evaluate long-term outcomes. Methods: 3044 patients were prospectively followed after presenting with syncope. Patients were separated into five ethnic groups: Caucasians(30%), AA(30%), Hispanics(20%), Asians(3%) and others(17%). Patients or relatives were interviewed at least yearly during the follow-up period of 5 years. The primary endpoint was a composite of readmission for syncope, myocardial infarction, stroke or death. Results: AA were older with mean age of 68±20 years, had hypertension (72% vs. 60%, p<0.001), higher creatinine levels (1.5mg/dl vs. 1.2mg/dl, p< 0.001), diabetes (28% vs. 23%, p<0.001), heart failure (12% vs. 9%, p=0.04), and smoking (26% vs. 10%; p=0.003). Compared to all other races, AA had significantly worse outcome as seen by the KM curve in the primary endpoint (33% vs. 25%; HR 1.5; 95% CI: 1.25-1.75; p<0.0001). Conclusions: AA who are admitted with unexplained syncope are identified according to the SELF pathway as high risk group that can likely be attributed to the presence of comorbidities and warrants hospitalization for further work-up and optimizing medical management.
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