Publications

The US Multi-Society Task Force has developed updated recommendations to guide health care providers with the surveillance of patients after colorectal cancer (CRC) resection with curative intent. This document is based on a critical review of the literature regarding the role of colonoscopy, flexible sigmoidoscopy, endoscopic ultrasound, fecal testing and CT colonography in this setting. The document addresses the effect of surveillance, with focus on colonoscopy, on patient survival after CRC resection, the appropriate use and timing of colonoscopy for perioperative clearing and for postoperative prevention of metachronous CRC, specific considerations for the detection of local recurrence in the case of rectal cancer, as well as the place of CT colonography and fecal tests in post-CRC surveillance.

Adults aged 50 and older make up half of individuals experiencing homelessness and have high rates of morbidity and mortality. They may have different life trajectories and reside in different environments than do younger homeless adults. Although the environmental risks associated with homelessness are substantial, the environments in which older homeless individuals live have not been well characterized. We classified living environments and identified associated factors in a sample of older homeless adults. From July 2013 to June 2014, we recruited a community-based sample of 350 homeless men and women aged fifty and older in Oakland, California. We administered structured interviews including assessments of health, history of homelessness, social support, and life course. Participants used a recall procedure to describe where they stayed in the prior six months. We performed cluster analysis to classify residential venues and used multinomial logistic regression to identify individual factors prior to the onset of homelessness as well as the duration of unstable housing associated with living in them. We generated four residential groups describing those who were unsheltered (n = 162), cohabited unstably with friends and family (n = 57), resided in multiple institutional settings (shelters, jails, transitional housing) (n = 88), or lived primarily in rental housing (recently homeless) (n = 43). Compared to those who were unsheltered, having social support when last stably housed was significantly associated with cohabiting and institution use. Cohabiters and renters were significantly more likely to be women and have experienced a shorter duration of homelessness. Cohabiters were significantly more likely than unsheltered participants to have experienced abuse prior to losing stable housing. Pre-homeless social support appears to protect against street homelessness while low levels of social support may increase the risk for becoming homeless immediately after losing rental housing. Our findings may enable targeted interventions for those with different manifestations of homelessness.

OBJECTIVE

To review current literature for anticoagulation in patients with cirrhosis and provide a summary of the effects of cirrhosis on the coagulation cascade, therapeutic monitoring through interpretation of antifactor Xa (anti-Xa), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) as well as current prophylaxis and treatment recommendations in cirrhotic patients.

METHODS

A systematic electronic literature search was conducted in PubMed using the key termsanticoagulation, warfarin, low-molecular-weight heparin(LMWH),unfractionated heparin(UFH),target-specific oral anticoagulants, deep-vein thrombosis(DVT),pulmonary embolism(PE),portal vein thrombosis(PVT),venous thromboembolism, anti-Xa, activated partial thromboplastin time, anticoagulation therapeutic monitoring, coagulopathy, coagulation cascade, chronic liver disease, cirrhosis, anddecompensated liver disease

STUDY SELECTION

Studies written in the English language from January 2000 to December 2015 were considered for this review article. All search results were reviewed, and the relevance of each article was determined by authors independently.

CONCLUSIONS

Patients with cirrhosis are at higher risk for both bleeding and thrombosis-related complications. Cirrhosis affects production of both procoagulant and anticoagulant factors, thus resulting in increased INR and aPTT levels and decreased anti-Xa levels. LMWH is the treatment of choice for the prevention and treatment of DVT/PE/PVT in patients with cirrhosis, and monitoring with anti-Xa levels for dose adjustment is not recommended. UFH is an alternative in cirrhotic patients for shorter-term use and in cases of severe renal dysfunction and/or hemodynamic instability. Cirrhotic patients on anticoagulation therapy should be monitored closely for signs and symptoms of bleeding and thrombosis.