Prescrire international
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Prescrire international · Jan 2014
ReviewScreening for lung cancer. Too many uncertainties, even for smokers.
Lung cancer is the leading cause of death from cancer. It is often diagnosed at an advanced stage when curative treatment is no longer possible. Does organised screening reduce overall mortality andlor lung cancer mortality, especially in current smokers or former heavy smokers? To answer this question, we reviewed the literature using the standard Prescrire methodology. ⋯ Low-dose CT screening carries a risk of adverse effects, including false-positive results in about 20% of patients, and about 90% of the nodules discovered are false-positives. This screening method also carries a risk of invasive diagnostic procedures, and repeated irradiation. In 2013, the harm-benefit balance of lung cancer screening with low-dose CT has not been adequately evaluated to justify its use in individuals with no signs or symptoms suggestive of lung cancer.
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Prescrire international · Dec 2013
ReviewTreatment of ductal carcinoma in situ: an uncertain harm-benefit balance.
Ductal carcinoma in situ develops in the milk ducts without invading the surrounding connective tissue. Progression to invasive carcinoma is slow and infrequent and is thus difficult to predict. Screening mammography has increased the number of women diagnosed with early-stage ductal carcinoma in situ. ⋯ Lumpectomy is associated with a higher risk of recurrence and thus requires closer monitoring. Radiation therapy reduces the risk of recurrence in high-risk situations but has noteworthy adverse effects. Simple clinical monitoring is a valid option for asymptomatic patients: it carries a risk of progression to invasive cancer but avoids exposing many women to the adverse effects of surgery and radiation therapy.
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Prescrire international · Jul 2013
ReviewTrauma and severe bleeding. Tranexamic acid within one hour to reduce mortality.
Tranexamic acid, an antifibrinolytic agent, reduces postoperative transfusion requirements but carries a poorly documented risk of thrombosis. Does tranexamic acid reduce mortality among victims of severe traumatic bleeding? To answer this question, we conducted a review of the literature, using the standard Prescrire methodology. The Crash-2 trial compared the impact of tranexamic acid versus placebo on overall mortality in 20 211 trauma victims with either severe bleeding or a high risk of severe bleeding. ⋯ Cases of thrombosis have also been reported. In 2011, the FDA warned of a risk of convulsions linked to high intravenous doses of this drug. In practice, intravenous tranexamic acid infusion has a favourable harm-benefit balance in patients with severe traumatic bleeding, especially when treatment begins less than 1 hour after injury, in which case it reduces mortality at 4 weeks.
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Prescrire international · Jun 2013
ReviewBleeding with dabigatran, rivaroxaban, apixaban. No antidote, and little clinical experience.
Dabigatran, rivaroxaban and apixaban are oral anticoagulants used to prevent or treat thrombosis in a variety of situations. Like all anticoagulants, these drugs can provoke bleeding. How should patients be managed if bleeding occurs during dabigatran, rivaroxaban or apixaban therapy? How can the risk of bleeding be reduced in patients who require surgery or other invasive procedures? To answer these questions, we reviewed the available literature, using the standard Prescrire methodology. ⋯ In patients at high risk of thrombosis, heparin can be proposed when the anticoagulant is withdrawn. In early 2013, difficulties in the management of bleeding and of situations in which there is a risk of bleeding weigh heavily in the balance of potential harm versus potential benefit of dabigatran, rivaroxaban and apixaban. When an oral anticoagulant is required, it is best to choose warfarin, a vitamin K antagonist, and the drug with which we have the most experience, except in those rare situations in which the INR cannot be maintained within the therapeutic range.
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Prescrire international · May 2013
ReviewDeep venous thrombosis and pulmonary embolism. Part 2--Prevention of recurrences: warfarin or low-molecular-weight heparin for at least 3 months.
In patients with deep venous thrombosis or pulmonary embolism, initial treatment with low-molecular-weight heparin (LMWH) is primarily aimed at preventing thrombus extension. After this initial phase, the goal of treatment is to prevent recurrences, which can be fatal. Is it better to continue treatment of deep venous thrombosis or pulmonary embolism with LMWH or switch to an oral anticoagulant? What is the optimal duration of treatment? To answer these questions, we conducted a review of the literature using the standard Prescrire methodology. ⋯ Various clinical practice guidelines published since 2006 recommend first-line treatment with a vitamin K antagonist for at least 3 months in patients without cancer, and continuation of LMWH therapy in patients with cancer. Overall, LMWH and warfarin have similar harm-benefit balances. In practice, it is best to choose between these drugs on a case-by-case basis, taking into account patient preferences, monitoring constraints, difficulty controlling the INR, the risk of bleeding and interactions, and the cost of treatment.