News in brief: Cardiovascular risk with VEGFi and ICI combination therapy; DOAC underdosing in AF patients; Avoid stigmatising language in medical records;

Tuesday, 27 Jul 2021

VEGFi and ICI combination therapy will be accompanied by a substantial increase in cardiovascular risk

The anticipated rise in VEGF inhibitors and immune checkpoint inhibitor combination therapy has prompted oncologists to warn of the cardiovascular toxicities associated with the anti-cancer therapies.

Writing in Clinical Science oncologists and pharmacologists from Erasmus University Medical Center in the Netherlands said while currently the combination therapy is recommended for the treatment of advanced renal cell carcinoma, it has shown ‘promising’ treatment efficacy in other tumour types well – signalling its role as an important therapeutic strategy for various malignancies.

But, despite their ‘unprecedented’ anti-tumour effects, the combinatory approach is expected to be accompanied by a substantial increase in cardiovascular risk, as both types of agents could act synergistically to induce cardiovascular sequelae, including hypertension, congestive heart failure, myocarditis and acceleration of atherosclerosis, the oncologists add.

As part of a detailed review of the currently registered VEGFis and ICIs the group has argued that a comprehensive baseline assessment and monitoring by specialised cardio-oncology teams is essential in case these agents are used in combination, particularly in high-risk patients.

The review which also discusses the main vascular and cardiac toxicity profiles of approved agents and future directions for various clinical situations can be accessed here.

DOAC underdosing in almost one in four AF patients

High rates of inappropriate inpatient DOAC dosing in AF have been  identified in a study covering six South Australian public hospitals.

A retrospective analysis of hospital records for 1882 inpatients from December 2013 to November 2019  found that 544 (29 %) were inappropriately dosed.

Underdosing was the most common form of inappropriate dosing with rates of 23% (n = 295) for apixaban, 7.1 % (n = 7) for dabigatran and 25.1 % (n = 124) for rivaroxaban.

Risk factors for underdosing included older age , frailty and polypharmacy, according to study investigators from the Royal Adelaide Hospital, writing in the Journal of Thrombosis and Thrombolysis.

Physicians urged to avoid stigmatising language in medical records

When writing in a patient’s medical record, physicians should be conscious of the use of language that reinforces negative and stigmatising attitudes toward patients that may influence the decisions of other clinicians subsequently caring for that patient, according to the authors of a US study.

An analysis of 600 medical records written by 138 physicians at a major hospital identified five types of negative and judgmental language used to describe patient encounters that encompassed racial and class stereotyping, personal disapproval of their actions, questioning a patient’s credibility and portraying them as a difficult or non-compliant. The stigmatising attitudes found in medical notes also included the use of authoritative and paternalistic language by physicians in which they recorded themselves as ‘instructing’ patients, according to researchers from Johns Hopkins University.

In their article, published in JAMA Network Open, they offered six examples of how physicians could use positive and collaborative language in medical records including compliments, approval of positive behaviours and noting of humanising personal details, in addition to acknowledgement of the physician’s own negative attitude and explaining non-adherence in a non-judgmental way.

“Just as we have developed a greater understanding about microaggressions and micro-inequities, this study’s findings suggest that we must raise consciousness about how we write and read medical records,” they said.

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