Chief’s Inquiry Corner – 11/29/2021

November 29, 2021

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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  To date, there are no studies that suggest screening women with transvaginal ultrasound (TVUS) has an impact on ovarian cancer mortality. The sensitivity of TVUS is highly variable and operator dependent. A recent randomized trial in the UK of women ages 50-74 who were of average risk examined outcomes of receiving annual TVUS. After following up for a median of 16 years, they found a similar percent of cancers detected at an earlier stage in those screened as those who were not screened, and they found no reduction in mortality. Multimodal testing with CA-125 and TVUS has been evaluated in women of both average and high risk; there has been no demonstrated mortality benefit in average risk women, and studies in high risk patients have been largely limited to observational data.

References: Ovarian cancer population screening and mortality after long-term follow-up in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial
  When patients with atrial fibrillation suffer from an acute ischemic stroke, it is important to weigh the risk of hemorrhagic transformation against the risk of recurrent ischemic stroke in the immediate post-stroke period. It is unclear what the optimal timing of re-initiation is, and most guidelines are based on observational data with limited randomized controlled trials. One large international trial estimated a risk of 4.9% for recurrent stroke within 14 days of acute ischemic stroke in patients with atrial fibrillation, while an estimated risk of recurrent stroke in the first two weeks was 0.5-1.3% per day. Predictive factors included left atrial enlargement, older age, higher CHADS2VASC, and larger ischemic lesion size of the initial stroke. In predicting hemorrhagic transformation, it seems both the size of the lesion and the use of reperfusion therapy increased risk. Though there is limited data for the optimal timing of initiation, particularly with DOACs, one study (RAF-NOACs) seemed to suggest that initiation within 2 days of the ischemic event had a higher rate of major bleeding and stroke recurrence than initiation after 2 days; subsequent pooled analyses examined patients who all had a DOAC restarted within 14 days of the initial event, which has played a role in current guidelines. There are several ongoing randomized controlled trials examining this question, and results are anticipated in 2022. 

References: Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation
 The management of portal vein thrombosis (PVT) remains somewhat controversial, particularly because of the various presentations and underlying etiologies (whether associated with cirrhosis, malignancy, or hypercoagulable states). The prognosis and natural history will vary as well, based on the clinical context as well as clot characteristics (including factors such as size and degree of thrombotic occlusion). In patients with cirrhosis who develop acute, symptomatic PVT, the guidelines are generally clear in recommending anti-coagulation in these patients. Asymptomatic thrombosis in patients with cirrhosis becomes more complicated, taking into account factors such as whether the patient is a potential transplant candidate. In patients without cirrhosis, resolution without any intervention is rare, and anticoagulation is generally a key therapy. If thrombus progresses despite medical therapy, you may consider endovascular thrombolysis or surgical intervention. 

References: Update on Management of Portal Vein Thrombosis and the Role of Novel Anticoagulants