101
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Khan SA, Logan P, Asokan A, Handford C, Rajgor HD, Khadabadi NA, Moores T, Targett J. The incidence of venous thromboembolism in total joint replacement during COVID-19 pandemic: has lockdown had an influence? Bone Jt Open 2020; 1:751-756. [PMID: 33367283 PMCID: PMC7750738 DOI: 10.1302/2633-1462.112.bjo-2020-0144.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Aims As the first wave of the COVID-19 pandemic began to dip, restarting elective orthopaedics became a challenge. Protocols including surgery at ‘green’ sites, self-isolation for 14 days, and COVID-19 testing were developed to minimize the risk of transmission. In this study, we look at risk effects of 14-day self-isolation on the incidence of venous thromboembolism (VTE) in our green site hospital among patients undergoing total joint replacement (TJR). Methods This retrospective cohort study included 50 patients who underwent TJR. Basic demographic data was collected including, age, sex, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), type of surgery, and complications at two and four weeks. Univariate and multivariate analysis were used to identify risk factors associated with an increased risk of VTE. Results A total of 50 patients were included in our study, with 24 males and 26 females. The mean age was 67.86 (SD 11.803). Overall, 8% of patients suffered a VTE complication; symptomatic non-fatal pulmoary embolism was confirmed in 6% of patients (n = 3) as an inpatient, and symptomatic deep vein thrombosis was diagnosed in 2% of patients (n = 1) within two weeks of their operation. All patients were found to be female (p < 0.001), had a BMI > 30 (p = 0.317), and were immobile prior to their operation using walking aids (p = 0.016). Conclusion The incidence we report is much higher than the reported incidence in the literature, which we believe is related to the 14-day self-isolation period and immobility prior to their operation. We recommend that all patients undergoing TJR that require a period of self-isolation, are pre-assessed prior to self-isolation for their risk of VTE, potentially using mechanical and chemical prophylaxis to reduce the likelihood of developing VTE. Cite this article: Bone Jt Open 2020;1-12:751–756.
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Affiliation(s)
- Shehzaad A Khan
- Trauma and Orthopaedics, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK.,Trauma and Orthopaedics, Nuffield Health Brentwood Hospital, Brentwood, UK
| | - Peter Logan
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, UK
| | - Ajay Asokan
- Trauma and Orthopaedics, Nuffield Health Brentwood Hospital, Brentwood, UK
| | | | | | | | - Thomas Moores
- Trauma and Orthopaedics, Walsall Manor Hospital, Walsall, UK
| | - John Targett
- Trauma and Orthopaedics, Nuffield Health Brentwood Hospital, Brentwood, UK
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102
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Rochefort CM, Abrahamowicz M, Biron A, Bourgault P, Gaboury I, Haggerty J, McCusker J. Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study. J Adv Nurs 2020; 77:1567-1577. [PMID: 33305473 PMCID: PMC7898788 DOI: 10.1111/jan.14710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 12/27/2022]
Abstract
Aims We describe an innovative research protocol to: (a) examine patient‐level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing. Design A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015–December 2019. Methods Patients in the cohort will be followed from admission until 30‐day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time‐varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high‐impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure‐to‐rescue; (b) in‐hospital falls; (c) hospital‐acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non‐linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020. Discussion To our knowledge, this study is the first multisite patient‐level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.
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Affiliation(s)
- Christian M Rochefort
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche Charles-LeMoyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Michal Abrahamowicz
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Alain Biron
- McGill University Health Centre, Montréal, QC, Canada.,Ingram School of Nursing, McGill University, Montréal, QC, Canada
| | - Patricia Bourgault
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Isabelle Gaboury
- Centre de recherche Charles-LeMoyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada.,Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada.,Département de médecine de famille et de médecine d'urgence, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jeannie Haggerty
- Department of Family Medicine, McGill University, Montreal, QC, Canada.,St. Mary's Research Centre, Montréal, QC, Canada
| | - Jane McCusker
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada.,St. Mary's Research Centre, Montréal, QC, Canada
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103
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Kampouraki E, Abohelaika S, Avery P, Biss T, Murphy P, Wynne H, Kamali F. Elderly people are inherently sensitive to the pharmacological activity of rivaroxaban: implications for DOAC prescribing. J Thromb Thrombolysis 2020; 52:170-178. [PMID: 33131001 PMCID: PMC8282548 DOI: 10.1007/s11239-020-02326-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
According to both trial and clinical data on direct oral anticoagulants (DOACs) elderly patients are at greatest risk of bleeding. It is unclear whether age intrinsically affects anticoagulation response. To investigate the age-related sensitivity to DOACs, we compared the pharmacological activity of the direct factor Xa inhibitor, rivaroxaban, between young and elderly subjects ex-vivo. 36 fit elderly and 30 fit young subjects [median (IQR) age: 83(75–87) vs 30(26–38) years] provided a blood sample. Clotting parameters were measured in the resultant plasma samples incubated with rivaroxaban (100–500 ng/ml). Parametric, non-parametric tests and regression lines adjusted for rivaroxaban concentration and baseline values were used to compare data. Rivaroxaban produced a greater prolongation of both Prothrombin Time (PT) and modified Prothrombin Time (mPT) (both p < 0.001) in the elderly compared to young subjects (with difference in mean PT increasing from 1.6 to 6.1s and for mPT from 23.5 to 71.1s at 100 ng/ml and 500 ng/ml plasma rivaroxaban concentration, respectively). Factor X and factor II activity was significantly lower in the elderly in the presence of rivaroxaban (p < 0.001 for both). Rivaroxaban prolonged time-based parameters and suppressed the amount of thrombin generation to a significantly greater extent in the elderly compared to young subjects [%change from baseline for Endogenous Thrombin Potential (ETP): − 35.0 ± 4.4 vs − 29.8 ± 7.4 nM*min; p = 0.002]. The use of validated DOAC assays will be of considerable benefit for monitoring elderly patients who, because of their increased sensitivity to rivaroxaban, may require lower doses of the drug for therapeutic anticoagulation.
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Affiliation(s)
- Emmanouela Kampouraki
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Salah Abohelaika
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter Avery
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tina Biss
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul Murphy
- Department of Hematology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hilary Wynne
- Older People's Medicine, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Farhad Kamali
- Translational and Clinical Research Institute, Newcastle University, and Newcastle upon Tyne Hospitals, NHS Foundation Trust, NE1 7RU, Newcastle upon Tyne, United Kingdom.
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104
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Aleidan FAS. The Cumulative Incidence and Risk Factors of Recurrent Venous Thromboembolism in the Elderly. Vasc Health Risk Manag 2020; 16:437-443. [PMID: 33116554 PMCID: PMC7585262 DOI: 10.2147/vhrm.s264814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/29/2020] [Indexed: 12/02/2022] Open
Abstract
Background Incidence and outcomes of recurrent venous thromboembolism (VTE) in the elderly are still not fully elucidated. The purpose of this study was to determine the incidence and identify the risk factors of VTE recurrence in this population. Methods A prospective cohort study of a one-year follow-up of 277 patients aged ≥65 years with primary VTE was performed at King Abdulaziz Medical City, a tertiary care teaching hospital in Riyadh, Saudi Arabia. Demographic data, risk factors, and the consequences of VTE (recurrence, bleeding, and mortality) were recorded. Results Of the 277 VTE patients, 39 (14%) were diagnosed with recurrent VTE over a median follow-up period of 12 months. The cumulative incidence of recurrent VTE was 12.75 per hundred patient-year (95% CI, 8.24–17.36). In multivariate Cox regression, malignancy (hazard ratio [HR], 2.87, 95% CI, 1.32–6.24, p=0.008) and surgery (HR 2.78, 95% CI, 1.36–5.67, p=0.005) were identified as independent risk factors for recurrent VTE. Metformin had a significant independent protection effect (HR, 0.16, 95% CI, 0.08–0.33, p<0.001). During follow-up, two patients in the recurrent VTE group and five patients in the group with no recurrent VTE, all of whom were minor bleeding cases, reported no major bleeding. Seven (18%) patients in the recurrent VTE group and nine (4%) patients in the group with no recurrent VTE died (p<0.001). Conclusion The findings of this study show that elderly patients with initial VTE have a recurrent rate (14%), with a cumulative incidence rate of 12.75 per hundred patient-year. Malignancy and surgery were the most important clinical risk factors to impact significantly the development of recurrent VTE in our elderly population. Metformin may have a protective effect against recurrent VTE in the elderly population, and a larger study is needed to validate our findings.
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Affiliation(s)
- Fahad A S Aleidan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Anticoagulation Clinic, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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105
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Poh C, Brunson A, Keegan T, Wun T, Mahajan A. Incidence of Upper Extremity Deep Vein Thrombosis in Acute Leukemia and Effect on Mortality. TH OPEN 2020; 4:e309-e317. [PMID: 33134806 PMCID: PMC7593117 DOI: 10.1055/s-0040-1718883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
The cumulative incidence, risk factors, rate of subsequent venous thromboembolism (VTE) and bleeding and impact on mortality of isolated upper extremity deep vein thrombosis (UE DVT) in acute leukemia are not well-described. The California Cancer Registry, used to identify treated patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) diagnosed between 2009 and 2014, was linked with the statewide hospitalization database to determine cumulative incidences of UE DVT and subsequent VTE and bleeding after UE DVT diagnosis. Cox proportional hazards regression models were used to assess the association of UE DVT on the risk of subsequent pulmonary embolism (PE) or lower extremity deep vein thrombosis (LE DVT) and subsequent bleeding, and the impact of UE DVT on mortality. There were 5,072 patients identified: 3,252 had AML and 1,820 had ALL. Three- and 12-month cumulative incidences of UE DVT were 4.8% (95% confidence interval [CI]: 4.1–5.6) and 6.6% (95% CI: 5.8–7.5) for AML and 4.1% (95% CI: 3.2–5.1) and 5.9% (95% CI: 4.9–7.1) for ALL, respectively. Twelve-month cumulative incidences of subsequent VTE after an incident UE DVT diagnosis were 5.3% for AML and 12.2% for ALL. Twelve-month cumulative incidences of subsequent bleeding after an incident UE DVT diagnosis were 15.4% for AML and 21.1% for ALL. UE DVT was associated with an increased risk of subsequent bleeding for both AML (hazard ratio [HR]: 2.07; 95% CI: 1.60–2.68) and ALL (HR: 1.62; 95% CI: 1.02–2.57) but was not an independent risk factor for subsequent PE or LE DVT for either leukemia subtype. Isolated incident UE DVT was associated with increased leukemia-specific mortality for AML (HR: 1.42; 95% CI: 1.16–1.73) and ALL (HR: 1.80; 95% CI: 1.31–2.47). UE DVT is a relatively common complication among patients with AML and ALL and has a significant impact on bleeding and mortality. Further research is needed to determine appropriate therapy for this high-risk population.
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Affiliation(s)
- Christina Poh
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States.,Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington, United States
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
| | - Theresa Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States.,UC Davis Clinical and Translational Science Center, University of California, Davis, Sacramento, California, United States
| | - Anjlee Mahajan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, California, United States
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106
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Appel CW, Balle AM, Krintel MM, Vittrup A, Nielsen AH, Vedsted P. Direct-access to sonographic diagnosis of deep vein thrombosis in general practice: a descriptive cohort study. BMC FAMILY PRACTICE 2020; 21:195. [PMID: 32957932 PMCID: PMC7507741 DOI: 10.1186/s12875-020-01267-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/10/2020] [Indexed: 11/10/2022]
Abstract
Background Suspicion of deep vein thrombosis (DVT) is common and requires urgent and efficient investigation due to hazardous prognosis. The traditional diagnostic pathway can be complex and time-consuming, and innovative solutions may provide easy access to diagnostics and better use of healthcare resources. We aimed to describe use, clinical outcomes and time used when providing general practitioners (GPs) with a direct-access pathway to hospital-based, single whole-leg compression ultrasound (CUS) for patients with suspected DVT. Furthermore we aimed to describe the resources used in the new direct-access pathway and compare it with the previous pathway. Methods We conducted a 2-year descriptive cohort study (2016–2017) including 449 consecutively referred patients for diagnosis of DVT in a Danish regional hospital. The previous pathway included pre-test at the medical department, a proximal leg CUS if required based on the pre-test and a re-scan if the first CUS was negative. The new pathway included two strategies: 1) a ‘yes-no strategy’, where GPs referred patients directly to whole-leg CUS and if positive, treated at the medical department and if negative, discharged to the GP, 2) a ‘follow-up strategy’ where GPs could require that patients were seen at the medical department, irrespective of the CUS result. Data included extractions from the Radiology Information and Patient Administrative Systems, and mean salaries of healthcare professionals at Silkeborg Regional Hospital, Denmark. Descriptive statistics were used to describe prevalence, timelines and costs. Results GPs referred 318 (71%) patients through the yes-no strategy and 131 (29%) via the follow-up strategy with DVT diagnosed in 48 (15%) and 51 (39%) patients, respectively (p < 0.001). For the 263 patients completed after CUS in the yes-no strategy, median pathway time was 24 min (IQI: 16–36), and for those with DVT (including both strategies) 202 min (IQI: 158–273). Direct-access pathway costs were €49.7 less per patient than the previous pathway. Conclusion Direct-access to CUS for suspected DVT was achievable, had short time intervals and required fewer resources. The difference in DVT prevalence indicates that GPs distinguish between patients with low and high risk of DVT.
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Affiliation(s)
- Charlotte W Appel
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Annette M Balle
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads M Krintel
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Axel Vittrup
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Agnete H Nielsen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Vedsted
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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107
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Torii Y, Kusunose K, Zheng R, Yamada H, Amano R, Matsumoto R, Hirata Y, Nishio S, Yamada N, Ise T, Yamaguchi K, Tobiume T, Fukuda D, Yagi S, Soeki T, Wakatsuki T, Okayama Y, Sata M. Association between Sarcopenia/Lower Muscle Mass and Short-Term Regression of Deep Vein Thrombosis Using Direct Oral Anticoagulants. Int Heart J 2020; 61:787-794. [PMID: 32684602 DOI: 10.1536/ihj.20-032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advanced age, obesity, and muscle weakness are independent factors in the onset of deep vein thrombosis (DVT). Recently, an association between sarcopenia and DVT has been reported. We hypothesized that sarcopenia related factors, observed by ultrasonography, are associated with the regression effect on the thrombus following anticoagulation therapy. The present study focused on gastrocnemius muscle (GCM) thickness and the GCM's internal echogenic brightness. We examined the association with DVT regression following direct oral anticoagulants (DOACs) treatment.The prospective cohort study period was between October 2017 and August 2018. We enrolled 46 patients diagnosed with DVT by ultrasonography, who were aged >60 years old and treated with DOACs. Sarcopenia was evaluated using the Asian Working Group for Sarcopenia flowchart. The average DOACs treatment period was 94 days, and 29 patients exhibited thrombus regression. On univariate logistic regression analysis, sarcopenia, average GCM diameter index, and gastrocnemius integrated backscatter index were significantly associated with thrombus regression. In a multivariate model, only the average GCM diameter index correlated with thrombus regression.The average GCM diameter index is associated with DVT regression treated with DOACs. Considering the GCM diameter during DVT treatment can be a marker to make a decision for the treatment of DVT.
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Affiliation(s)
- Yuta Torii
- Ultrasound Examination Center, Tokushima University Hospital
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences
| | - Rie Amano
- Ultrasound Examination Center, Tokushima University Hospital
| | | | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital
| | - Susumu Nishio
- Ultrasound Examination Center, Tokushima University Hospital
| | - Nao Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takeshi Tobiume
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Yoshihiro Okayama
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital
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108
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Hwang HG, Kim YK, Kim MS, Lim GI, Schulman S. Prophylaxis of Venous Thromboembolism in Patients with Infectious Disease. Tuberc Respir Dis (Seoul) 2020; 83:255-256. [PMID: 32578414 PMCID: PMC7362753 DOI: 10.4046/trd.2020.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hun-Gyu Hwang
- Division of Respiratory and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Yang-Ki Kim
- Division of Respiratory and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Myung-Shin Kim
- Division of Respiratory and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Gune-Il Lim
- Division of Respiratory and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Sam Schulman
- Division of Hematology and Thromboembolism, Department of Medicine, Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences (Hamilton General Site), McMaster University, Hamilton, ON, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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109
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Wu H, Cao H, Song Z, Xu X, Tang M, Yang S, Liu Y, Qin L. Rivaroxaban treatment for young patients with pulmonary embolism (Review). Exp Ther Med 2020; 20:694-704. [PMID: 32742315 PMCID: PMC7388139 DOI: 10.3892/etm.2020.8791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
Pulmonary embolism (PE) is a serious, life-threatening condition that affects young populations (>18 and <50 years old, according to most literature reviews) with improved recognition of its clinical manifestations and the widespread use of sensitive imaging techniques, PE is increasingly diagnosed in younger patients. At present, there is limited understanding of the clinical features and adequate anticoagulant treatment options for this population. Most studies to date have yet to demonstrate significant differences in PE pathophysiology or symptoms between young and elderly patients. Although the overall incidence of PE is lower in young populations compared with elderly patients, important risk factors also apply for young patients. Hereditary thrombophilia is common and is a major cause of PE in younger patients. Immobilization, trauma, obesity, smoking and infection are also becoming increasingly frequent in young patients with PE. Among female patients, oral contraceptive use, pregnancy and postpartum status are predominant risk factors underlying PE. Rivaroxaban is a direct oral anticoagulant with a rapid onset of action that is associated with less drug-drug interactions compared with other therapies. Because the drug is administered at fixed doses with no requirement for routine coagulation monitoring, it is becoming an attractive option for anticoagulation treatment in young patients with PE. Therefore, the present literature review focuses on the clinical characteristics of PE and rivaroxaban therapy in younger patients.
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Affiliation(s)
- Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Zikai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Xiaoyan Xu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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Long-term safety and efficacy of subcutaneous C1-inhibitor in older patients with hereditary angioedema. Ann Allergy Asthma Immunol 2020; 125:334-340.e1. [PMID: 32445670 DOI: 10.1016/j.anai.2020.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients aged 65 years and older with hereditary angioedema (HAE) owing to C1-inhibitor (C1-INH) deficiency may have an altered response to treatment and are at higher risk for treatment-related adverse events (AEs) because of comorbidities and polypharmacy. OBJECTIVE To investigate the safety and efficacy of subcutaneous C1 esterase inhibitor (C1-INH) in patients aged 65 years and older treated in an open-label extension of a phase 3 trial. METHODS Eligible patients (≥4 attacks for more than 2 consecutive months) were randomized to receive twice-weekly subcutaneous C1-INH with a dosage of 40 IU/kg or 60 IU/kg for 52 to 140 weeks. Safety end points and efficacy outcomes were evaluated for patients aged 65 years and above and younger than 65 years. RESULTS Of the 126 patients treated, 10 were 65 years and older (mean age [range], 68 [65-72 years]). A total of 8 of 10 patients had multiple comorbidities, and 6 of these 10 patients were taking more than 5 non-HAE-related drugs concomitantly. AEs occurring in more than 1 patient included injection site bruising (n = 2, related), injection site pain (n = 2, related), urinary tract infection (n = 2, unrelated), and diarrhea (n = 2, unrelated). No thromboembolic events or cases of anaphylaxis were reported. Two patients aged 65 years and older experienced unrelated serious AEs (dehydration and hypokalemia in 1 and pneumonia and an HAE attack leading to hospitalization in another). A total of 6 of 9 evaluable patients were responders, with a greater than or equal to 50% reduction in HAE attacks vs prestudy; 6 of 10 patients had less than 1 attack over 4 weeks and 3 were attack-free (median attack rate, 0.52 attacks per month). CONCLUSION Subcutaneous C1-INH was well-tolerated and effective in the management of HAE in patients aged 65 years and older with multiple comorbid conditions and polypharmacy.
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Physical Activity in the Hospital: Documentation and Influence on Venous Thromboembolism Prophylaxis. J Aging Phys Act 2020; 28:306-310. [PMID: 31743088 DOI: 10.1123/japa.2018-0462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 11/18/2022]
Abstract
This study describes the availability of physical activity information in the electronic health record, explores how electronic health record documentation correlates with accelerometer-derived physical activity data, and examines whether measured physical activity relates to venous thromboembolism (VTE) prophylaxis use. Prospective observational data comes from community-dwelling older adults admitted to general medicine (n = 65). Spearman correlations were used to examine association of accelerometer-based daily step count with documented walking distance and with duration of VTE prophylaxis. Only 52% of patients had documented walking in nursing and/or physical therapy/occupational therapy notes during the first three hospital days. Median daily steps recorded via accelerometer was 1,370 (interquartile range = 854, 2,387) and correlated poorly with walking distance recorded in physical therapy/occupational therapy notes (median 33 feet/day [interquartile range = 12, 100]; r = .24; p = .27). Activity measures were not associated with use or duration of VTE prophylaxis. VTE prophylaxis use does not appear to be directed by patient activity, for which there is limited documentation.
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112
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Song ZK, Cao H, Wu H, Wei Q, Tang M, Yang S, Liu Y, Qin L. Current status of rivaroxaban in elderly patients with pulmonary embolism (Review). Exp Ther Med 2020; 19:2817-2825. [PMID: 32256765 PMCID: PMC7086161 DOI: 10.3892/etm.2020.8559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/22/2020] [Indexed: 01/14/2023] Open
Abstract
Acute pulmonary embolism (PE) occurs with a high incidence rate in elderly patients, demonstrating complex clinical manifestations, as well as a difficult anticoagulant treatment strategy. Currently, there is limited understanding of the selection criteria for anticoagulant treatment in elderly patients with PE. In fact, the vitamin K antagonist warfarin, a commonly prescribed anticoagulant, has multiple disadvantages, including a narrow therapeutic range, unpredictable pharmacokinetics, multiple food and drug interactions and genetic polymorphisms resulting in poor response to this therapy; therefore, routine laboratory monitoring is required. Most elderly patients with PE fail to adhere to the treatment regimen or even discontinue it, and clinicians are equally hesitant to initiate oral anticoagulants in elderly patients with PE. This leads to a dilemma regarding the use of anticoagulation therapies and a worse prognosis for the patients. Rivaroxaban, a direct Xa factor inhibitor, has demonstrated considerable practical and clinical advantages, exhibits fast-start action pharmacokinetic and pharmacodynamic characteristics, and has an enhanced predictable anticoagulant effect with fewer drug-drug interactions. Based on randomized controlled trials and real-world clinical practice, rivaroxaban has also been recognized as a safe and effective anticoagulant, and these advantages have improved the therapeutic compliance of elderly patients with PE. Thus, this review focused on the current status of rivaroxaban treatment for elderly patients with PE, and described its significance in changing the current anticoagulation treatment regimens for patients. It is expected that rivaroxaban will become a good choice for the treatment of PE in elderly patients.
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Affiliation(s)
- Zi-Kai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Qi Wei
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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Nakanishi K, Kanda T, Kobata T, Mori M, Yamada S, Kasamaki Y. New score including daily life independence levels with dementia is associated with the onset of deep vein thrombosis in frail older adults. Geriatr Gerontol Int 2020; 20:414-421. [PMID: 32077247 DOI: 10.1111/ggi.13873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 12/24/2019] [Accepted: 01/07/2020] [Indexed: 11/29/2022]
Abstract
AIM The detailed risk factors of deep vein thrombosis (DVT) remain unknown, and no efficient tool to assess the risk of the development of DVT among older adults has been established. This study aimed to clarify the risk factors, including the level of daily life independence, and develop an assessment score for DVT in older patients. METHODS We recruited 252 patients aged ≧65 years with suspected deep vein thrombosis. Risk factors for deep vein thrombosis, cognitive impairment, laboratory data and level of daily life independence were analyzed to calculate the odds ratios for the onset of DVT with logistic regressions. The Himi score was generated with factors significantly related to DVT by adjusting the respective odds ratios. The discrimination accuracy of the Himi score associated with the onset of DVT was compared with those of conventional scores (Wells score, Padua score) based on the area under the receiver operating characteristic curve. RESULTS Low levels of daily life independence, D-dimer level >3.0 μg/mL, anticoagulant use, cancer and immobilization or symptoms of the lower limbs were associated with the onset of DVT. The discrimination accuracy of Himi scores composed of these related factors was significantly higher than those of the Wells and Padua scores. CONCLUSIONS Achieving a better performance than did the Wells and Padua scores, the Himi score could be used to assess the risk of DVT in frail older adults. Geriatr Gerontol Int 2020; 20: 414-421.
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Affiliation(s)
- Keisuke Nakanishi
- Department of Rehabilitation, Kanazawa Medical University Himi Municipal Hospital, Toyama, Japan.,Community Medicine, Kanazawa Medical University Graduate School of Medical Sciences, Uchinada, Japan
| | - Tsugiyasu Kanda
- Department of Community Medicine, Kanazawa Medical University, Uchinada, Japan
| | - Takashi Kobata
- Community Medicine, Kanazawa Medical University Graduate School of Medical Sciences, Uchinada, Japan.,Department of Cardiovascular Surgery, Kanazawa Medical University Himi Municipal Hospital, Toyama, Japan
| | - Masayuki Mori
- Department of Rehabilitation, Kanazawa Medical University Himi Municipal Hospital, Toyama, Japan
| | - Shinya Yamada
- Community Medicine, Kanazawa Medical University Graduate School of Medical Sciences, Uchinada, Japan.,Department of Respiratory Medicine, Kanazawa Medical University Hospital, Uchinada, Japan
| | - Yuji Kasamaki
- Community Medicine, Kanazawa Medical University Graduate School of Medical Sciences, Uchinada, Japan.,Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, Toyama, Japan
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Volokitina E, Antropova I, Yershov A, Chelchushev D, Kutepov S. Effect of age on the functioning of hemostasis system during hip joint endoprosthesis. BIO WEB OF CONFERENCES 2020. [DOI: 10.1051/bioconf/20202201014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The study was performed on 109 osteoarthritis patients who underwent hip joint endoprosthetics; the effect of age on changes in hemostasis system, blood loss level and deep veins thrombosis development in the background of standard prevention with low-molecular heparins were studied. Before the surgery, it was determined that 56 elderly patients (60.3 ± 6.4 years) compared to 53 middle-aged patients (41.8 ± 6.8 years) had a significantly higher initial and postoperative endothelial dysfunction, higher fibrin formation and lower anticoagulant potential; however, it was found that on the background of pharmacological anticoagulant therapy the changes in the hemostasis functioning in elderly patients did not lead to an increase of either blood loss or the number of thromboses.
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Brenner B, Arya R, Beyer-Westendorf J, Douketis J, Hull R, Elalamy I, Imberti D, Zhai Z. Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in at-risk patient groups: pregnancy, elderly and obese patients. Thromb J 2019; 17:24. [PMID: 31889915 PMCID: PMC6935082 DOI: 10.1186/s12959-019-0214-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) accounts for an estimated 900,000 cases per year in the US alone and constitutes a considerable burden on healthcare systems across the globe. OBJECTIVE To understand why the burden is so high, qualitative and quantitative research was carried out to gain insights from experts, guidelines and published studies on the unmet clinical needs and therapeutic strategies in VTE prevention and treatment in three populations identified as being at increased risk of VTE and in whom VTE prevention and treatment were regarded as suboptimal: pregnant women, the elderly and obese patients. METHODOLOGY A gap analysis methodology was created to highlight unmet needs in VTE management and to discover the patient populations considered most at risk. A questionnaire was devised to guide qualitative interviews with 44 thrombosis and haemostasis experts, and a review of the literature on VTE in the specific patient groups from 2015 to 2017 was completed. This was followed by a Think Tank meeting where the results from the research were discussed. RESULTS This review highlights the insights gained and examines in detail the unmet needs with regard to VTE risk-assessment tools, biomarkers, patient stratification methods, and anticoagulant and dosing regimens in pregnant women, the elderly and obese patients. CONCLUSIONS Specifically, in pregnant women at high risk of VTE, low-molecular-weight heparin (LMWH) is the therapy of choice, but it remains unclear how to use anticoagulants when VTE risk is intermediate. In elderly patients, evaluation of the benefit of VTE prophylaxis against the bleeding risk is particularly important, and a head-to-head comparison of efficacy and safety of LMWH versus direct oral anticoagulants is needed. Finally, in obese patients, lack of guidance on anticoagulant dose adjustment to body weight has emerged as a major obstacle in effective prophylaxis and treatment of VTE.
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Affiliation(s)
- Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, UK
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital ‘Carl Gustav Carus’ Dresden, Dresden, Germany
- King’s Thrombosis Service, Department of Haematology, King’s College London, London, UK
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario Canada
| | - Russell Hull
- Foothills Medical Centre and Thrombosis Research Unit, University of Calgary, Calgary, Canada
| | - Ismail Elalamy
- Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, INSERM U938, Sorbonne University, Paris, France
| | | | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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Hlavacek P, Guo JD, Rosenblatt L, Keshishian A, Russ C, Mardekian J, Ferri M, Poretta T, Yuce H, McBane R. Safety, effectiveness, and health care cost comparisons among elderly patients with venous thromboembolism prescribed warfarin or apixaban in the United States Medicare population. Curr Med Res Opin 2019; 35:2043-2051. [PMID: 31387467 DOI: 10.1080/03007995.2019.1653067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: To compare safety, effectiveness, and healthcare costs of major bleeding (MB), clinically relevant non-major (CRNM) bleeding, recurrent venous thromboembolism (VTE), and all-cause hospitalization among elderly Medicare VTE patients prescribed warfarin vs apixaban.Methods: Using 100% Medicare data, elderly patients prescribed apixaban or warfarin within 30 days after a VTE encounter were identified. Patients had continuous health plan enrollment and no parenteral or oral anticoagulant use ≤6 months preceding the VTE encounter. Cohorts were balanced using 1:1 propensity score matching (PSM). Cox proportional hazard models were used to assess the risk of MB, CRNM bleeding, recurrent VTE, and all-cause hospitalization. Generalized linear and two-part models were used to estimate MB-, recurrent VTE-, and all-cause related costs (per patient per month [PPPM]).Results: In the pre-matched cohort, 25,284 (66.9%) patients were prescribed warfarin and 12,515 (33.1%) apixaban. After 1:1 PSM, 11,363 matched pairs of apixaban-warfarin patients were included for a mean follow-up of 4.0 and 4.4 months, respectively. Matched cohorts had a mean age of 78 years and mean Charlson Comorbidity Index score of 2.9. Warfarin was associated with a higher risk of MB (hazard ratio [HR] = 1.31; 95% confidence interval [CI] = 1.10-1.57) and CRNM bleeding (HR = 1.31; 95% CI = 1.19-1.43) vs apixaban. The risks of recurrent VTE (HR = 0.96; 95% CI = 0.70-1.33) and all-cause hospitalization (HR = 1.05; 95% CI = 0.99-1.12) were similar among warfarin and apixaban patients. Warfarin patients had higher MB-related ($147 vs $75; p = .003) and all-cause costs PPPM ($3,267 vs $3,033; p < .001), but similar recurrent VTE-related medical costs PPPM ($30 vs $36; p = .516) vs apixaban patients.Conclusions: Warfarin was associated with significantly higher risk of MB and CRNM bleeding as well as higher MB-related and all-cause costs vs apixaban patients. Recurrent VTE risk and costs were similar among warfarin and apixaban patients.
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Affiliation(s)
| | - Jennifer D Guo
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - Lisa Rosenblatt
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - Allison Keshishian
- Health Economics and Outcomes Research, SIMR, LLC, Ann Arbor, MI, USA
- New York City College of Technology, City University of New York, New York, NY, USA
| | - Cristina Russ
- Patient & Health Impact, Pfizer Inc, New York, NY, USA
| | | | - Mauricio Ferri
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - Tayla Poretta
- US Health Economics and Outcomes Research, Bristol-Myers Squibb Company, Princeton, NJ, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
| | - Robert McBane
- Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Prevalence and Risk Factors of Preoperative Deep Vein Thrombosis in Patients with End-Stage Knee Osteoarthritis. Ann Vasc Surg 2019; 64:175-180. [PMID: 31626936 DOI: 10.1016/j.avsg.2019.08.089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 07/11/2019] [Accepted: 08/20/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND The purpose of this study is to determine the prevalence and the risk factors of DVT in end-stage OA patients. METHODS From March 2015 to June 2017, 521 patients with knee degenerative osteoarthritis undergoing knee arthroplasty were enrolled; 458 patients (87.9%) were admitted for primary total knee arthroplasty and 63 patients (12.1%) were admitted for unicompartmental knee arthroplasty. Parameters were compared using χ2 or t-test for both the groups. Binary logistic regression analysis was used to determine risk factors. RESULTS The incidence of preoperative DVT was 6.7% (n = 35). Age in preoperative DVT group was significantly more than the non-DVT group (72.54 ± 6.53 vs. 68.65 ± 7.35, P = 0.002). Preoperative D-dimer >0.5 μg/mL (P < 0.001) was also associated with preoperative DVT in knee osteoarthritis patients. The incidence increased with age significantly (2.17% in <65 years, 6.86% in ≥65 <75 years, and 12.26% in ≥75 years) (P = 0.008). Thus, age (P = 0.041, OR 1.075, 95% CI [1.002-1.110]) and D-dimer >0.5 μg/mL (P < 0.001, OR 4.441, 95% CI [1.942-10.153]) were the independent risk factors for preoperative DVT in knee osteoarthritis patients. CONCLUSIONS The incidence of DVT in end-stage osteoarthritis was 6.7%. The results suggest that older people aged over 75 and D-dimer > 0.5 μg/mL were risk factors for DVT among patients admitted to the hospital for total knee arthroplasty. Instrumental screening should be encouraged, especially in subgroups at higher risk for preoperative DVT.
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Liang H, Danwada R, Guo D, Curtis JR, Kilpatrick RD, Hendrickson B, Islam SS. Incidence of inpatient venous thromboembolism in treated patients with rheumatoid arthritis and the association with switching biologic or targeted synthetic disease-modifying antirheumatic drugs (DMARDs) in the real-world setting. RMD Open 2019; 5:e001013. [PMID: 31673413 PMCID: PMC6803007 DOI: 10.1136/rmdopen-2019-001013] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives To assess incidence rates (IRs) of VTE in patients with rheumatoid arthritis (RA) on different DMARDs and DMARD switchers. Methods Adults with RA on a DMARD between 2007 and 2017 were studied in a US claims database. Conventional synthetic DMARD (csDMARD) users, first biologic/targeted synthetic DMARD (b/tsDMARD) users and b/tsDMARD switchers (from a b/tsDMARD to another b/tsDMARD) were followed for inpatient VTE (pulmonary embolism (PE)/deep vein thrombosis (DVT)). Crude and adjusted IR and 95% CIs of VTE were estimated. HRs for VTE were estimated via Cox regression. VTE risk was also evaluated by number of switches between b/tsDMARDs and in patients without a VTE history. Results The age and sex standardised IR (95% CI) of VTE (per 100 person-years) was 0.86 (0.70 to 1.03), 0.60 (0.52 to 0.68) and 0.58 (0.51 to 0.65) for b/tsDMARD switchers, first b/tsDMARD users and csDMARD users, respectively. After adjustment, b/tsDMARD switchers had an increased risk of VTE, compared with csDMARD users, HRadj (95% CI) being 1.36 (1.16 to 1.58), 1.36 (1.13 to 1.63) and 1.47 (1.18 to 1.83) for VTE, DVT and PE, respectively. Compared with first b/tsDMARD users, the HRadj (95% CI) for VTE was 1.35 (1.15 to 1.60) for first b/tsDMARD switchers and 1.48 (1.19 to 1.85) for second b/tsDMARD switchers. Conclusions In RA, b/tsDMARD switchers have a higher VTE risk compared with csDMARD users and first b/tsDMARD users. Switching b/tsDMARDs may be a proxy for higher disease severity or poorly controlled RA and an important confounder to consider in obtaining unbiased estimates of VTE risk in observational RA safety studies.
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Affiliation(s)
- Huifang Liang
- Global Epidemiology, Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
| | - Raghava Danwada
- Global Epidemiology, Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
| | - Dianlin Guo
- Global Epidemiology, Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan D Kilpatrick
- Global Epidemiology, Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
| | - Barbara Hendrickson
- Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
| | - Syed S Islam
- Global Epidemiology, Pharmacovigilance and Patient Safety, AbbVie Inc, North Chicago, Illinois, USA
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Morella P, Sacco M, Carafa M, Ferro G, Curcio F, Gargiulo G, Testa G, Liguori I, Russo G, Cacciatore F, Tocchetti CG, Bonaduce D, Abete P. Permanent atrial fibrillation and pulmonary embolism in elderly patients without deep vein thrombosis: is there a relationship? Aging Clin Exp Res 2019; 31:1121-1128. [PMID: 30374888 DOI: 10.1007/s40520-018-1060-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/16/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIM Permanent Atrial Fibrillation (pAF) is associated with increased risk of embolic complications. The relationship between pAF and pulmonary embolism (PE) has not been extensively investigated in elderly patients. Here, we aim at verifying whether pAF is associated to an increased risk of PE in a cohort of elderly patients with and without Deep Vein Thrombosis (DVT). METHODS 235 patients older than 65 years with PE with or without pAF were retrospectively enrolled and stratified by the absence or presence of DVT. The diagnosis of PE was performed by computed tomography angiography (CTA). Right echocardiographic parameters were monitored. The severity of PE was evaluated by CTA quantization (PE score = 1, involvement of main branches of pulmonary artery) and by dimer-D (> 3000 µg/L). RESULTS DVT was identified only in 51 cases of PE (21.7%). pAF prevalence was higher in PE without than in those with DVT (64.9% vs. 35.1%, p < 0.01). PE severity was more evident in pAF patients without than in those with DVT. Multivariate analysis of the role of pAF on PE severity confirms these results (RR = 3.41 for PE score = 1, and 8.55 for dimer-D > 3000 µg/L). CONCLUSIONS We conclude that in elderly patients with PE, the prevalence of pFA was doubled, in the absence of DVT, and it is associated with a more severe PE in the absence than in the presence of DVT. Thus, in the absence of DVT, pFA should be considered as cause of PE.
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Affiliation(s)
| | - Maurizio Sacco
- U.O.C. Medicina DEA, AORN Antonio Cardarelli, Naples, Italy
| | - Mariano Carafa
- U.O.C. Medicina DEA, AORN Antonio Cardarelli, Naples, Italy
| | - Gaetana Ferro
- U.O.C. Medicina DEA, AORN Antonio Cardarelli, Naples, Italy
| | - Francesco Curcio
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
| | - Gaetano Gargiulo
- Division of Internal Medicine, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Gianluca Testa
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Ilaria Liguori
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
| | - Gennaro Russo
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
- Heart Transplantation Unit, Azienda Ospedaliera dei Colli, Monaldi Hospital, Naples, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy
| | - Pasquale Abete
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini, 80131, Naples, Italy.
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Busti F, Marchi G, Lira Zidanes A, Castagna A, Girelli D. Treatment options for anemia in the elderly. Transfus Apher Sci 2019; 58:416-421. [DOI: 10.1016/j.transci.2019.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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121
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TNF-α-driven inflammation and mitochondrial dysfunction define the platelet hyperreactivity of aging. Blood 2019; 134:727-740. [PMID: 31311815 DOI: 10.1182/blood.2019000200] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 07/02/2019] [Indexed: 12/11/2022] Open
Abstract
Aging and chronic inflammation are independent risk factors for the development of atherothrombosis and cardiovascular disease. We hypothesized that aging-associated inflammation promotes the development of platelet hyperreactivity and increases thrombotic risk during aging. Functional platelet studies in aged-frail adults and old mice demonstrated that their platelets are hyperreactive and form larger thrombi. We identified tumor necrosis factor α (TNF-α) as the key aging-associated proinflammatory cytokine responsible for platelet hyperreactivity. We further showed that platelet hyperreactivity is neutralized by abrogating signaling through TNF-α receptors in vivo in a mouse model of aging. Analysis of the bone marrow compartments showed significant platelet-biased hematopoiesis in old mice reflected by increased megakaryocyte-committed progenitor cells, megakaryocyte ploidy status, and thrombocytosis. Single-cell RNA-sequencing analysis of native mouse megakaryocytes showed significant reprogramming of inflammatory, metabolic, and mitochondrial gene pathways in old mice that appeared to play a significant role in determining platelet hyperreactivity. Platelets from old mice (where TNF-α was endogenously increased) and from young mice exposed to exogenous TNF-α exhibited significant mitochondrial changes characterized by elevated mitochondrial mass and increased oxygen consumption during activation. These mitochondrial changes were mitigated upon TNF-α blockade. Similar increases in platelet mitochondrial mass were seen in platelets from patients with myeloproliferative neoplasms, where TNF-α levels are also increased. Furthermore, metabolomics studies of platelets from young and old mice demonstrated age-dependent metabolic profiles that may differentially poise platelets for activation. Altogether, we present previously unrecognized evidence that TNF-α critically regulates megakaryocytes resident in the bone marrow niche and aging-associated platelet hyperreactivity and thrombosis.
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Della Bella S, Calcaterra F, Bacci M, Carenza C, Pandolfo C, Ferrazzi P, Uva P, Pagani M, Lodigiani C, Mavilio D. Pathologic up-regulation of TNFSF15–TNFRSF25 axis sustains endothelial dysfunction in unprovoked venous thromboembolism. Cardiovasc Res 2019; 116:698-707. [DOI: 10.1093/cvr/cvz131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/23/2019] [Accepted: 05/10/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Aims
The pathogenetic mechanisms underlying unprovoked venous thromboembolism (uVTE) are largely unknown. In this study, we investigated the molecular mechanisms involved in uVTE pathogenesis by using ex vivo expanded endothelial colony-forming cells (ECFCs), which represent a valuable non-invasive tool for the assessment of endothelial function.
Methods and results
We isolated and expanded ECFCs from the peripheral blood of uVTE patients and observed that these cells underwent earlier senescence and showed lower growth rate compared with ECFCs obtained from healthy donors. Through microarray expression profiling, we demonstrated that 2905 genes were differentially expressed between patients and controls. Among them, the anti-angiogenic cytokine TNF superfamily member 15 (TNFSF15) and its death-receptor TNFRSF25 were up-regulated in uVTE ECFCs, and this finding was validated by RT-qPCR. TNFSF15 up-regulation was confirmed at the protein level in ECFC supernatants, and the in vivo relevance of these findings was further corroborated by demonstrating that also the plasmatic levels of TNFSF15 are increased in uVTE patients. After proving that exogenous TNFSF15 exerts pro-apoptotic and anti-proliferative activity on control ECFCs, we demonstrated through blocking experiments that TNFSF15 up-regulation contributes to impaired survival and proliferation of uVTE ECFCs.
Conclusion
By providing evidence that TNFSF15 impairs ECFC functions crucial to endothelial repair, and that uVTE patients have increased TNFSF15 levels both ex vivo and in vivo, the results of this study suggest that pathologic up-regulation of TNFSF15–TNFRSF25 axis may contribute to uVTE pathogenesis, and may represent the target for novel therapeutic strategies aimed at preventing recurrences in uVTE patients.
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Affiliation(s)
- Silvia Della Bella
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center—IRCCS, via Manzoni 113, Rozzano, Milan, Italy
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Francesca Calcaterra
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center—IRCCS, via Manzoni 113, Rozzano, Milan, Italy
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Monica Bacci
- Thrombosis and Haemorragic Diseases Center, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Claudia Carenza
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center—IRCCS, via Manzoni 113, Rozzano, Milan, Italy
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
| | - Chiara Pandolfo
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center—IRCCS, via Manzoni 113, Rozzano, Milan, Italy
| | - Paola Ferrazzi
- Thrombosis and Haemorragic Diseases Center, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Paolo Uva
- Center for Advanced Studies, Research and Development in Sardinia (CRS4), Science and Technology Park Polaris, Pula, Cagliari, Italy
| | - Massimiliano Pagani
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
- INGM-National Institute of Molecular Genetics “Romeo ed Enrica Invernizzi” Milan, Milan, Italy
| | - Corrado Lodigiani
- Thrombosis and Haemorragic Diseases Center, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Domenico Mavilio
- Unit of Clinical and Experimental Immunology, Humanitas Clinical and Research Center—IRCCS, via Manzoni 113, Rozzano, Milan, Italy
- Department of Medical Biotechnologies and Translational Medicine, University of Milan, Milan, Italy
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Zhou H, Wei Q, Wu H, Tang M, Yang S, Liu Y, Qin L. Efficacy of low-dose rivaroxaban in an 88-year-old female with pulmonary embolism: A case report. Medicine (Baltimore) 2019; 98:e15705. [PMID: 31096518 PMCID: PMC6531187 DOI: 10.1097/md.0000000000015705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
RATIONALE Rivaroxaban has numerous advantages over traditional anticoagulation therapy. Fixed doses can be administered without requiring routine monitoring of coagulation, and anticoagulation efficacy is more predictable. Safety, including fewer drug interactions, and reduced bleeding, is also improved with rivaroxaban based on current recommendations. The goal of this report was to explore if low-dose rivaroxaban 10 mg once daily was effective in an elderly patient who developed minor bleeding when treated with rivaroxaban (10 mg twice daily) for a pulmonary embolism. PATIENT CONCERNS We present an 88-year-old female with dyspnea and fatigue, which became increasingly worse over a month in the absence of medication. Her weight was 64 kg. Routine coagulation assays and renal function were normal at time of admission. DIAGNOSIS Deep vein thrombosis and pulmonary embolism were confirmed by venous compression ultrasonography and computed tomography pulmonary angiography. INTERVENTIONS Oral rivaroxaban 10 mg twice daily was administered, but the patient developed hemoptysis and gum bleeding 5 days later. The dose of rivaroxaban was reduced to 10 mg once daily, and bleeding gradually disappeared after 3 days. OUTCOME At follow-up 90 days after treatment, the patient reported no discomfort. Venous compression ultrasonography and computed tomography pulmonary angiography showed normal results; therefore, treatment was terminated. LESSONS Elderly patients exhibit variable tolerance of anticoagulants, warranting careful consideration of the risk of bleeding. Low-dose rivaroxaban was an effective treatment for pulmonary embolism in the elderly patient presented here.
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Brenner B, Hull R, Arya R, Beyer-Westendorf J, Douketis J, Elalamy I, Imberti D, Zhai Z. Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in high-risk patient groups: cancer and critically ill. Thromb J 2019; 17:6. [PMID: 31011294 PMCID: PMC6466798 DOI: 10.1186/s12959-019-0196-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/02/2019] [Indexed: 12/15/2022] Open
Abstract
Background Clinical practice shows that venous thromboembolism (VTE) presents a substantial burden in medical patients, and awareness and advocacy for its primary and secondary prevention remains inadequate. Specific patient populations, such as those with cancer and the critically ill, show elevated risk for VTE, bleeding or both, and significant gaps in VTE prophylaxis and treatment exist in these groups. Objective To present novel insights and consolidated evidence collected from experts, clinical practice guidelines and original studies on the unmet needs in thromboprophylaxis, and on the treatment of VTE in two high-risk patient groups: patients with cancer and the critically ill. Methodology To identify specific unmet needs in the management of VTE, a methodology was designed and implemented that assessed gaps in prophylaxis and treatment of VTE through interviews with 44 experts in the field of thrombosis and haemostasis, and through a review of current guidelines and seminal studies to substantiate the insights provided by the experts. The research findings were then analysed, discussed and consolidated by a multidisciplinary group of experts. Results The gap analysis methodology identified shortcomings in the VTE risk assessment tools, patient stratification approaches for prophylaxis, and the suboptimal use of anticoagulants for primary prophylaxis and treatment. Conclusions Specifically, patients with cancer need better VTE risk assessment tools to tailor primary thromboprophylaxis to tumour types and disease stages, and the potential for drug–drug interactions needs to be considered. In critically ill patients, unfractionated heparin is not advised as a first-line treatment option, and the strength of evidence is increasing for direct oral anticoagulants as a treatment option over low-molecular-weight heparins. Electronic supplementary material The online version of this article (10.1186/s12959-019-0196-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin Brenner
- 1Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Russell Hull
- 2Foothills Medical Centre and Thrombosis Research Unit, University of Calgary, Calgary, Canada
| | - Roopen Arya
- 3King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jan Beyer-Westendorf
- 3King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK.,4Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital 'Carl Gustav Carus' Dresden, Dresden, Germany
| | - James Douketis
- 5Department of Medicine, McMaster University, Hamilton, Ontario Canada.,6Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario Canada
| | - Ismail Elalamy
- 7Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, Paris, France
| | - Davide Imberti
- 8Haemostasis and Thrombosis Center, Hospital of Piacenza, Piacenza, Italy
| | - Zhenguo Zhai
- 9Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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How I manage anticoagulant therapy in older individuals with atrial fibrillation or venous thromboembolism. Blood 2019; 133:2269-2278. [PMID: 30926593 DOI: 10.1182/blood-2019-01-846048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/26/2019] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant therapy is the most effective strategy to prevent arterial and venous thromboembolism, but treating older individuals is challenging, because increasing age, comorbidities, and polypharmacy increase the risk of both thrombosis and bleeding. Warfarin and non-vitamin K antagonist oral anticoagulants are underused and often underdosed in the prevention of stroke in older patients with atrial fibrillation because of concerns about the risk of bleeding. Poor adherence to anticoagulant therapy is also an issue for older patients with atrial fibrillation and those at risk of recurrent pulmonary embolism. In this review, we present 5 clinical cases to illustrate common challenges with anticoagulant use in older patients and discuss our approach to institute safe and effective antithrombotic therapy.
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The endothelial tumor suppressor p53 is essential for venous thrombus formation in aged mice. Blood Adv 2019; 2:1300-1314. [PMID: 29891592 DOI: 10.1182/bloodadvances.2017014050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/11/2018] [Indexed: 12/24/2022] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in elderly people. Increased expression of tumor suppressor protein 53 (p53) has been implicated in vascular senescence. Here, we examined the importance of endothelial p53 for venous thrombosis and whether endothelial senescence and p53 overexpression are involved in the exponential increase of VTE with age. Mice with conditional, endothelial-specific deletion of p53 (End.p53-KO) and their wild-type littermates (End.p53-WT) underwent subtotal inferior vena cava (IVC) ligation to induce venous thrombosis. IVC ligation in aged (12-month-old) End.p53-WT mice resulted in higher rates of thrombus formation and greater mean thrombus size vs adult (12-week-old) End.p53-WT mice, whereas aged End.p53-KO mice were protected from vein thrombosis. Analysis of primary endothelial cells from aged mice or human vein endothelial cells after induction of replicative senescence revealed significantly increased early growth response gene-1 (Egr1) and heparanase expression, and plasma factor Xa levels were elevated in aged End.p53-WT, but not in End.p53-KO mice. Increased endothelial Egr1 and heparanase expression also was observed after doxorubicin-induced p53 overexpression, whereas p53 inhibition using pifithrin-α reduced tissue factor (TF) expression. Importantly, inhibition of heparanase activity using TF pathway inhibitor-2 (TFPI2) peptides prevented the enhanced venous thrombus formation in aged mice and restored it to the thrombotic phenotype of adult mice. Our findings suggest that p53 accumulation and heparanase overexpression in senescent endothelial cells are critically involved in mediating the increased risk of venous thrombosis with age and that heparanase antagonization may be explored as strategy to ameliorate the prothrombotic endothelial phenotype with age.
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Abstract
Gynecologic surgery offers unique challenges, as pelvic surgery places patients at an increased risk of venous thromboembolism (VTE). Prevention of VTE is a goal of patients, policy makers, and surgeons. In this review, we address the current research and recommendations for VTE prophylaxis.
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Frequency of venous thrombotic events in patients with myelodysplastic syndrome and 5q deletion syndrome during lenalidomide therapy. Ann Hematol 2018; 98:331-337. [DOI: 10.1007/s00277-018-3509-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/02/2018] [Indexed: 12/27/2022]
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Preoperative Evaluation of Soleal Vein Diameter by Ultrasound Is Beneficial for Prophylaxis of Deep Vein Thrombosis after Total Knee or Hip Arthroplasty. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3417648. [PMID: 30211219 PMCID: PMC6120296 DOI: 10.1155/2018/3417648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/06/2018] [Indexed: 11/18/2022]
Abstract
Purpose The purpose of this retrospective study was to determine the association between preoperative soleal vein (SV) diameter and deep vein thrombosis (DVT) following total joint arthroplasty (TJA). Methods A total of 402 patients were enrolled, with 229 patients undergoing total knee arthroplasty (TKA) and 173 patients undergoing total hip arthroplasty (THA). Ultrasonography was performed 1-3 days preoperatively, on postoperative days 1, 3, and 7, or before discharge and during follow-up. The SV diameter was assessed preoperatively. Univariate analysis and multivariate logistic regression analysis were used to compare parameters between the DVT group and the non-DVT group. Results 78 patients (19.4%) were found to have DVT during hospitalization and after discharge and 14 patients (3.5%) developed symptomatic DVT. Multiple regression analysis showed that SV diameter, advanced age, and surgery type were independent predictors of postoperative DVT. In the logistic regression analysis for symptomatic DVT, SV diameter was found to be the only predictor. In the receiver operating characteristics (ROC) analysis for the value of SV diameter in diagnosing DVT, the area under curve (AUC) was 0.701 ((95% CI 0.636-0.766), P<0.001) and when the cut-off value of SV diameter was set at 0.57 cm, the sensitivity and specificity of SV diameter were 62.7% and 72.1%, respectively. Conclusions SV diameter was an independent risk factor for total and symptomatic DVT after TJA. Preoperative ultrasound screening of the SV diameter may be beneficial for the prevention of postoperative DVT.
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Ibrahim NA, Hassan FM, Elgari MM, Abdalla SE. Risk factors for deep vein thrombosis of lower extremities in Sudanese women. Vasc Health Risk Manag 2018; 14:157-164. [PMID: 30154662 PMCID: PMC6108343 DOI: 10.2147/vhrm.s170556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim In this study, we aimed to analyze the genetic and acquired risk factors for deep vein thrombosis (DVT) of the lower extremities among Sudanese women. Methods A total of 136 women were enrolled in the study, including 75 DVT patients and 61 healthy controls. Demographic and clinical data were collected using a specific questionnaire. Citrated blood samples of patients and controls were used for coagulation assays, and DNAs isolated from EDTA-blood samples were used for the detection of Factor V Leiden and prothrombin G20210A mutations using multiplex polymerase chain reaction-restriction fragment length polymorphism analysis. Results Both gene mutations were found to be absent from all 136 subjects, and therefore did not account for the incidence of DVT in Sudanese women. Of the 75 DVTs, 70 (93.3%) were localized in the left leg and 5 (6.7%) in the right leg. Additionally, 84% of the DVTs were proximal and 16% were distal. Among the 75 patients, 22 (29.33%) were postpartum, 7 (9.33%) were pregnant, and 46 (61.33%) were nonpregnant. Levels of prothrombin fragment 1+2, prothrombin time, activated partial thromboplastin time, and D-dimer were significantly higher in DVT patients than in healthy controls (P<0.0001). Conclusion Risk factors that most significantly affected patients in the 18–45 years age group were pregnancy and oral contraceptive usage, whereas those that most significantly affected patients in the 66–90 years age group were immobility, heart disease, and history of DVT.
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Affiliation(s)
- Nadir Ahmed Ibrahim
- Department of Hematology and Immunohematology, College of Medical Laboratory Science, Sudan University of Science and Technology, Khartoum, Sudan, .,Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia,
| | - Fathelrahman M Hassan
- Department of Clinical Laboratory Science, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mahmoud Mohamed Elgari
- Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Taibah University, Medina, Saudi Arabia,
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Lu HY, Liao KM. Increased risk of deep vein thrombosis in end-stage renal disease patients. BMC Nephrol 2018; 19:204. [PMID: 30115029 PMCID: PMC6097196 DOI: 10.1186/s12882-018-0989-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 07/20/2018] [Indexed: 02/07/2023] Open
Abstract
Background Previous studies have shown that chronic kidney disease increases the risk of deep vein thrombosis (DVT). DVT is the risk of pulmonary embolism among persons with end-stage renal disease (ESRD). Information on the incidence of DVT in ESRD is limited, and no studies have been conducted in the Asian population. The aim of our study was to investigate the incidence of DVT in Asian ESRD patients by comparing with the non-ESRD patients and to identify the associated risk factors. Methods This study retrieved patients who were diagnosed with ESRD (ICD-9-CM codes 585 or 586) between January 1, 2004, and December 31, 2010, from the National Health Insurance Research Database in Taiwan. All ESRD patients had received a catastrophic illness card from the Ministry of Health and Welfare in Taiwan, with the major illness identified as ESRD. Patients who had DVT before the index date or who had incomplete records were excluded from the analysis. A total of 4865 ESRD patients were enrolled. There are 3564 ESRD patients included after exclusion of patients with previous DVT and patients with incomplete records. The control subjects were randomly selected as the patients without ESRD by matching study subjects according to age (±3 years), gender, and the year of admission at a 2:1 ratio from the same dataset. Results The incidence rate of DVT was substantially higher in the ESRD group than in the without-ESRD group (20.9 vs. 1.46 per 10^4 person-years). The adjusted hazard ratio (aHR 13.92; 95% CI 9.25–20.95) of DVT for the ESRD patients was 13.92 times that for the non-ESRD patients. ESRD patients older than 50 years had a higher risk of DVT (aHR 1.65; 95% CI 1.13–2.40; P = 0.01). Hyperlipidemia was significantly associated with an increased risk of DVT (aHR 1.73; 95% CI 1.08–2.78; P = 0.02). ESRD patients with three or more comorbidities were substantially more likely to have DVT (aHR 1.45; 95% CI 1.03–2.03; P = 0.03). Conclusions ESRD patients had a higher risk of DVT than non-ESRD patients. Among the ESRD patients, being older than 50 years and having dyslipidemia increased the risk of DVT.
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Affiliation(s)
- Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National, Yunlin University of Science and Technology, Yun-Lin, Taiwan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan.
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Rosko AE, Olin RL, Artz A, Wildes TM, Stauder R, Klepin HD. A call to action in hematologic disorders: A report from the ASH scientific workshop on hematology and aging. J Geriatr Oncol 2018; 9:287-290. [PMID: 29759912 DOI: 10.1016/j.jgo.2018.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/25/2018] [Indexed: 01/22/2023]
Affiliation(s)
| | - Rebecca L Olin
- University of California, San Francisco, CA, United States
| | - Andrew Artz
- University of Chicago, Chicago, IL, United States
| | - Tanya M Wildes
- Washington University School of Medicine, St. Louis, MO, United States
| | | | - Heidi D Klepin
- Wake Forest School of Medicine, Winston-Salem, NC, United States
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Poredos P, Mavric A, Leben L, Poredos P, Jezovnik MK. Total Hip Replacement Provokes Endothelial Dysfunction. Angiology 2018; 69:871-877. [DOI: 10.1177/0003319718774660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgery represents an increased risk of different perioperative complications. Endothelial function (EF) is a key mechanism responsible for cardiovascular homeostasis and is involved in thromboembolic complications. We aimed to follow changes of EF in an early postoperative period in patients undergoing total hip replacement (THR). Endothelial function was assessed noninvasively in 70 consecutive patients who underwent an elective THR under spinal anesthesia. Flow-mediated dilation (FMD) and low flow-mediated constriction capability of the brachial artery, which are indicators of EF were measured before the operation (baseline), 24 hours after the operative procedure, and 5 to 7 days postoperatively. Baseline FMD was 12.3% and decreased a day after surgery to 7.3% ( P < .001). After 5 to 7 days, it gradually increased to 9.2%. However, on average, it was lower than before surgery ( P < .001). The median duration of THR was 85.0 (65.0-100.0) minutes, the average hospital length of stay was 7 days. Total hip replacement is associated with an immediate decrease in FMD which remains significantly decreased 5 to 7 days after the surgery compared with the preoperative value. These results indicate that surgery provokes endothelial dysfunction and deteriorates cardiovascular homeostasis. This effect could be involved in cardiovascular complications in the postoperative period.
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Affiliation(s)
- Peter Poredos
- Department of Anaesthesiology and Perioperative Intensive Care, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ana Mavric
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Lara Leben
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mateja Kaja Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, USA
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Tana C, Lauretani F, Ticinesi A, Prati B, Nouvenne A, Meschi T. Molecular and Clinical Issues about the Risk of Venous Thromboembolism in Older Patients: A Focus on Parkinson's Disease and Parkinsonism. Int J Mol Sci 2018; 19:ijms19051299. [PMID: 29701703 PMCID: PMC5983741 DOI: 10.3390/ijms19051299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 01/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a common and potentially life-threatening condition which includes both deep-vein thrombosis (DVT) and pulmonary embolism (PE). VTE has a significant clinical and epidemiological impact in the elderly, and its incidence increases to more than 1% per year in older patients, suggesting the presence of specific age-related risk factors in this population. Immobilization seems to predominate as the main cause in patients admitted for medical acute illness in medicine wards, and there is evidence of a high risk in older patients with immobilization resulting from advanced forms of Parkinson’s disease (PD), regardless of the presence of an acute medical condition. In this review, we would to discuss the recent evidence on clinical, molecular and epidemiological features of VTE in older frail subjects focusing on patients with PD and parkinsonism. We also discuss some therapeutic issues about the risk prevention and we suggest a thorough comprehensive geriatric assessment that can represent an optimal strategy to identify and prevent the VTE risk in these patients.
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Affiliation(s)
- Claudio Tana
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Fulvio Lauretani
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
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Röhrig G, Kolb G. Thromboembolieprophylaxe im Alter. Z Gerontol Geriatr 2018; 51:349-363. [DOI: 10.1007/s00391-018-1384-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/07/2018] [Accepted: 03/08/2018] [Indexed: 11/29/2022]
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Jobski K, Hoffmann F, Herget-Rosenthal S, Dörks M. Use of oral anticoagulants in German nursing home residents: drug use patterns and predictors for treatment choice. Br J Clin Pharmacol 2018; 84:590-601. [PMID: 29148592 DOI: 10.1111/bcp.13474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 10/17/2017] [Accepted: 11/06/2017] [Indexed: 12/27/2022] Open
Abstract
AIMS Information on utilization of oral anticoagulants (OACs) in nursing homes is scarce. This study aimed to (i) describe OAC use in German nursing home residents, (ii) examine factors influencing whether treatment is initiated with vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) and (iii) assess which conditions predict switching to NOAC instead of continuing VKA. METHODS Using claims data (2010-2014), we studied a cohort of new nursing home residents aged ≥65 years receiving OAC. Further, OAC use in patients with atrial fibrillation (AF) was examined over the years. RESULTS Overall, 16 804 patients (median age: 85 years, 75% female, 44% with renal disease) were included. The majority received phenprocoumon as first OAC (58.0%), followed by rivaroxaban (28.1%). Over the study period, NOAC use increased substantially. Initiating NOAC instead of VKA was predicted by a previous stroke (adjusted odds ratio: 1.76; 95% confidence interval: 1.49-2.08). In contrast, renal disease predicted VKA initiation (0.66; 0.59-0.75) as did the presence of a prosthetic heart valve. Switching from VKA to NOAC was predicted by a stroke (2.55; 2.00-3.24), bleeding events and a recent hospitalization. During 2010-2014, the proportion of AF patients with a CHADS2 score ≥2 receiving OAC increased from 27% to 46%. CONCLUSIONS NOACs are increasingly used in German nursing homes, both for initial anticoagulation but also in VKA pre-treated patients. Switching from VKA to NOAC was substantially influenced by aspects such as intended higher effectiveness and safety but probably also practicability due to less blood monitoring.
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Affiliation(s)
- Kathrin Jobski
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Michael Dörks
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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138
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Vanassche T, Verhamme P, Wells PS, Segers A, Ageno W, Brekelmans MPA, Chen CZ, Cohen AT, Grosso MA, Medina AP, Mercuri MF, Winters SM, Zhang G, Weitz JI, Raskob GE, Büller HR. Impact of age, comorbidity, and polypharmacy on the efficacy and safety of edoxaban for the treatment of venous thromboembolism: An analysis of the randomized, double-blind Hokusai-VTE trial. Thromb Res 2017; 162:7-14. [PMID: 29248859 DOI: 10.1016/j.thromres.2017.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/21/2017] [Accepted: 12/10/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Many patients with venous thromboembolism (VTE) are elderly, have multiple comorbidities and take several concomitant medications. Physicians may prefer warfarin over direct oral anticoagulants (DOACs) in such patients because comparative data are lacking. This analysis was designed to determine the effects of advanced age, comorbidities, and polypharmacy on the efficacy and safety of edoxaban and warfarin in patients with VTE. METHODS Using data from the Hokusai-VTE study, we report rates of recurrent VTE and of clinically relevant bleeding by age category (<65, 65-75, and ≥75; <80 versus ≥80years), and by number of comorbidities (0, 1-2, >2) and concomitant medications (<3, 3-5, >5). Hazard ratios (HR) and corresponding 95% confidence intervals (CI) for edoxaban versus warfarin were determined and Kaplan-Meier methodology was used to construct time-to-event curves. At 3months, pre- and postdose levels of edoxaban were measured using mass spectrometry. For warfarin-treated patients, the time in therapeutic range was calculated. The study was approved by institutional review boards; informed consent was obtained. RESULTS Recurrent VTE increased with advanced age, multiple comorbidities, and polypharmacy in warfarin-treated patients but not with edoxaban. Edoxaban was more effective than warfarin in patients ≥75years of age and in those with multiple comorbidities. In the 517 patients over 80years of age, recurrent VTE occurred in 2.8% given edoxaban and in 5.7% given warfarin (HR 0.51, 95% CI 0.21-1.24). Bleeding increased with age, comorbidity, and polypharmacy regardless of treatment, but the relative safety of edoxaban versus well-managed warfarin was maintained. Age, comorbidity, and polypharmacy did not impact edoxaban concentrations. CONCLUSIONS These data suggest that a once-daily fixed dose of edoxaban is more effective and at least as safe as warfarin in high-risk VTE patients identified by older age, more comorbidities, and polypharmacy. CLINICAL TRIAL REGISTRATION NCT00986154.
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Affiliation(s)
- Thomas Vanassche
- University Hospitals Leuven, Dept. of Cardiovascular Sciences, Leuven, Belgium.
| | - Peter Verhamme
- University Hospitals Leuven, Dept. of Cardiovascular Sciences, Leuven, Belgium
| | - Philip S Wells
- University of Ottawa, Ottawa Hospital Research Institute, Department of Medicine, Ottawa, Ontario, Canada
| | | | - Walter Ageno
- University of Insubria, Department of Clinical and Experimental Medicine, Varese, Italy
| | | | - Cathy Z Chen
- Daiichi Sankyo Inc., Basking Ridge, NJ, United States
| | - Alexander T Cohen
- Guy's and St Thomas' Hospitals, King's College, Department of Haematological Medicine, London, United Kingdom
| | - Michael A Grosso
- Daiichi Sankyo Pharma Development, Basking Ridge, NJ, United States
| | - Andria P Medina
- University of Oklahoma Health Science Center, College of Medicine, Oklahoma City, OK, United States
| | | | | | - George Zhang
- Daiichi Sankyo Pharma Development, Basking Ridge, NJ, United States
| | - Jeffrey I Weitz
- Thrombosis & Atherosclerosis Research Institute and McMaster University, Hamilton, Canada
| | - Gary E Raskob
- University of Oklahoma Health Science Center, College of Public Health, Oklahoma City, OK, United States
| | - Harry R Büller
- Academic Medical Center, Department of Vascular Medicine, Amsterdam, The Netherlands
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139
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Affiliation(s)
- Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA.
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140
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Ambrosino P, Tarantino L, Criscuolo L, Nasto A, Celentano A, Di Minno MN. The risk of venous thromboembolism in patients with hepatitis C. Thromb Haemost 2017; 116:958-966. [DOI: 10.1160/th16-03-0185] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/07/2016] [Indexed: 12/31/2022]
Abstract
SummarySome studies suggest that patients with hepatitis C virus (HCV) infection have an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Unfortunately, available data on this association are contrasting. A systematic review and meta-analysis of literature studies was performed to evaluate the risk of venous thromboembolism (VTE) associated with HCV. Studies reporting on VTE risk associated with HCV were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. Six studies (10 data-sets) showed a significantly increased VTE risk in 100,364 HCV patients as compared with 8,471,176 uninfected controls (odds ratio [OR]: 1.900; 95 % confidence interval [CI]: 1.406, 2.570; p<0.0001). These results were confirmed when specifically considering the risk of DVT (6 studies, OR: 1.918; 95 %CI: 1.351, 2.723; p<0.0001), whereas a trend towards an increased risk of PE was documented in HCV patients (4 studies, OR: 1.811; 95 %CI: 0.895, 3.663; p=0.099). The increased VTE risk associated with HCV infection was consistently confirmed when analysing four studies reporting adjusted risk estimates (OR: 1.876; 95 %CI: 1.326, 2.654; P<0.0001), and after excluding studies specifically enrolling populations exposed to transient risk factors for VTE (4 studies, OR: 1.493; 95 %CI: 1.167, 1.910; p=0.001). Meta-regression models suggested that age and male gender may significantly impact on the risk of VTE associated with HCV-positivity. Results of our metaanalysis suggest that HCV-infected subjects may exhibit an increased risk of VTE. However, further high quality studies are needed to extend and confirm our findings.Supplementary Material to this article is available online at www.thrombosis-online.com.
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141
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Hull RD, Schellong SM, Tapson VF, Monreal M, Samama MM, Chen M, Deslandes B, Turpie AGG, Yusen RD. Impact of age on the efficacy and safety of extended-duration thromboprophylaxis in medical patients. Thromb Haemost 2017; 110:1152-63. [DOI: 10.1160/th13-02-0170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 08/13/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe EXCLAIM study enrolled hospitalised acutely ill medical patients with age >40 years and recently-reduced mobility into a trial of extended-duration anticoagulant thromboprophylaxis. This post-hoc analysis evaluated the impact of age on patient outcomes. After completion of open-label therapy with enoxaparin 40 mg once-daily (10 ± 4 days), eligible patients underwent randomisation to receive double-blind therapy of enoxaparin (n=2,975) or placebo (n=2,988) for 28 ± 4 days. During follow-up, the venous thromboembolism (VTE) risk increased with age in both treatment groups. In patients with age >75 years, those who received extended-duration enoxaparin had lower incidence of VTE (2.5% vs 6.7%; absolute difference [AD] [95% confidence interval]: −4.2% [−6.5, −2.0]), proximal deep-vein thrombosis (2.5% vs 6.6%; AD −4.1 % [−6.2, −2.0]), and symptomatic VTE (0.3% vs 1.5%; AD −1.2% [−2.2, −0.3]), in comparison to those who received placebo. In patients with age ≤75 years, those who received enoxaparin had reduced VTE (2.4% vs 2.8%; AD −0.4% [−1.5, 0.7]) and symptomatic VTE (0.2% vs 0.7%; AD −0.6% [−1.0, −0.1]) in comparison to those who received placebo. In both age subgroups, patients who received enoxaparin had increased rates of major bleeding versus those who received placebo: age >75 years (0.6% vs 0.2%; AD +0.3% [−0.2, 0.9], respectively); age ≤75 years (0.7% vs 0.2%; AD +0.5% [0.1, 0.9]). Patients in both age subgroups that received enoxaparin had similar low bleeding rates (0.6% and 0.7%, respectively). VTE risk increased with age, though the bleeding risk did not. Patients with age >75 years had a more favourable benefit-to-harm profile than younger patients.
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142
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Raskob G. Thrombosis: A major contributor to global disease burden. Thromb Haemost 2017; 112:843-52. [DOI: 10.1160/th14-08-0671] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/05/2022]
Abstract
SummaryThrombosis is a common pathology underlying ischaemic heart disease, ischaemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischaemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden due to VTE in low, middle and high income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1,000 individuals in the population. The incidence increased to between 2 and 7 per 1,000 among those 70 years of age or more. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalisation was the leading cause of disability-adjusted-lifeyears (DALYs) lost in low and middle income countries, and second in high income countries, responsible for more DALYs lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events. VTE causes a major burden of disease across low, middle, and high income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate if improved utilisation of preventive measures will reduce the burden.Note: The copyright for the article is being held by the International Society on Thrombosis and Haemostasis under a CC-BY-NC-ND license.
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143
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Shakeel M, Thachil J. Dilemmas in the management of venous thromboembolism in older patients. Br J Hosp Med (Lond) 2017; 78:552-557. [PMID: 29019726 DOI: 10.12968/hmed.2017.78.10.552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Venous thromboembolism most commonly affects older patients. Despite the high incidence in this population, challenges remain in terms of the understanding of its presentation, diagnosis and management. Old age is associated with multi-morbidities which may complicate the diagnosis of venous thromboembolism as signs or symptoms may be attributed to underlying medical conditions. The presence of certain comorbidities (such as congestive cardiac failure and chronic obstructive pulmonary disease) also increases the risk of venous thromboembolism, but could mimic the clinical features of pulmonary embolism. In addition, the physiological processes associated with ageing and factors such as immobility and malignancy, which are more common in older people, will further increase the thrombotic risk. Dilemmas also exist with treatment decisions because of the concomitant increased risk of bleeding, comorbidities, polypharmacy, frailty and the risk of falls.
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Affiliation(s)
- Musfira Shakeel
- Medical Student, University of Manchester, Manchester M13 9WL
| | - Jecko Thachil
- Consultant Haematologist, Department of Haematology, Manchester Royal Infirmary, Manchester
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144
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Fuentes F, Palomo I, Fuentes E. Platelet oxidative stress as a novel target of cardiovascular risk in frail older people. Vascul Pharmacol 2017; 93-95:14-19. [PMID: 28705733 DOI: 10.1016/j.vph.2017.07.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/18/2017] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
The average lifespan of humans and the percentage of people entering the 65 and older age group are growing rapidly. Within this age group, cardiovascular diseases (CVD) increase steeply and are the most common cause of death. During aging, experimental and clinical studies support the pivotal role played by reactive oxidant species in the mechanism of platelet activation. Frailty has been implicated as a causative and prognostic factor in patients with CVD. Oxidative stress is increased in frail older people, and may lead to accelerated aging and higher incidence of oxidative diseases such as CVD. The present article aims to highlight the relative contribution of platelet oxidative stress as a key target of frailty in elderly people with CVD.
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Affiliation(s)
- Francisco Fuentes
- Becario Obstetricia y Ginecología Universidad Católica del Maule, Talca, Chile
| | - Iván Palomo
- Platelet Research Center, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Interdisciplinary Excellence Research Program on Healthy Aging (PIEI-ES), Universidad de Talca, Talca, Chile.
| | - Eduardo Fuentes
- Platelet Research Center, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Interdisciplinary Excellence Research Program on Healthy Aging (PIEI-ES), Universidad de Talca, Talca, Chile; Núcleo Científico Multidisciplinario, Universidad de Talca, Talca, Chile.
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145
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Tritschler T, Aujesky D. Venous thromboembolism in the elderly: A narrative review. Thromb Res 2017; 155:140-147. [DOI: 10.1016/j.thromres.2017.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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146
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Engbers MJ, Blom JW, Cushman M, Rosendaal FR, van Hylckama Vlieg A. Functional Impairment and Risk of Venous Thrombosis in Older Adults. J Am Geriatr Soc 2017; 65:2003-2008. [PMID: 28598535 DOI: 10.1111/jgs.14964] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the role of age-specific risk factors for thrombosis in older age, such as functional impairment. DESIGN Case-control study. SETTING The Age and Thrombosis-Acquired and Genetic risk factors in the Elderly Study, a two-center study conducted in the Netherlands and the United States from 2008 to 2011. PARTICIPANTS Individuals aged 70 and older with a first-time deep venous thrombosis in the leg or pulmonary embolism (n = 401) and controls aged 70 and older (n = 431) without a history of thrombosis. Exclusion criteria were active malignancy and severe cognitive disorders. MEASUREMENTS The thrombotic risk associated with functional impairment, defined as impairment in two or more activities of daily living (ADLs), impaired mobility (inability to walk outside), sedentary lifestyle (≥20 h/d sleeping or sitting), and low handgrip strength (<15th percentile), was assessed. Odds ratios (ORs) adjusted for age, sex, and study center with 95% confidence intervals (95% CI) and population attributable risks (PAR) were calculated. RESULTS Risk of venous thrombosis was 2.9 times greater (OR = 2.9, 95% CI = 1.6-5.3) in individuals with impairment in ADLs, three times as great (OR = 3.0, 95% CI = 1.9-4.7) in those with impaired mobility, four times as great (OR = 4.0, 95% CI = 2.5-6.3) in those with a sedentary life style, and 2.3 times as great (OR = 2.3, 95% CI = 1.5-3.4) in those with weak handgrip strength. PARs were 8% for ADL disability, 13% for inability to walk outside for 15 minutes, 29% for sedentary lifestyle, and 13% for weak hand grip strength. CONCLUSION In individuals aged 70 and older, functional impairments are a major risk factor for venous thrombosis. These findings may help providers caring for older people be more aware of venous thrombosis risk.
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Affiliation(s)
- Marissa J Engbers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Mary Cushman
- Department of Medicine, University of Vermont Medical Centre, Burlington, Vermont
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands.,Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
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147
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Le Pogam MA, Quantin C, Reich O, Tuppin P, Fagot-Campagna A, Paccaud F, Peytremann-Bridevaux I, Burnand B. Geriatric Patient Safety Indicators Based on Linked Administrative Health Data to Assess Anticoagulant-Related Thromboembolic and Hemorrhagic Adverse Events in Older Inpatients: A Study Proposal. JMIR Res Protoc 2017; 6:e82. [PMID: 28495660 PMCID: PMC5445236 DOI: 10.2196/resprot.7562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/13/2017] [Accepted: 04/14/2017] [Indexed: 11/13/2022] Open
Abstract
Background Frail older people with multiple interacting conditions, polypharmacy, and complex care needs are particularly exposed to health care-related adverse events. Among these, anticoagulant-related thromboembolic and hemorrhagic events are particularly frequent and serious in older inpatients. The growing use of anticoagulants in this population and their substantial risk of toxicity and inefficacy have therefore become an important patient safety and public health concern worldwide. Anticoagulant-related adverse events and the quality of anticoagulation management should thus be routinely assessed to improve patient safety in vulnerable older inpatients. Objective This project aims to develop and validate a set of outcome and process indicators based on linked administrative health data (ie, insurance claims data linked to hospital discharge data) assessing older inpatient safety related to anticoagulation in both Switzerland and France, and enabling comparisons across time and among hospitals, health territories, and countries. Geriatric patient safety indicators (GPSIs) will assess anticoagulant-related adverse events. Geriatric quality indicators (GQIs) will evaluate the management of anticoagulants for the prevention and treatment of arterial or venous thromboembolism in older inpatients. Methods GPSIs will measure cumulative incidences of thromboembolic and bleeding adverse events based on hospital discharge data linked to insurance claims data. Using linked administrative health data will improve GPSI risk adjustment on patients’ conditions that are present at admission and will capture in-hospital and postdischarge adverse events. GQIs will estimate the proportion of index hospital stays resulting in recommended anticoagulation at discharge and up to various time frames based on the same electronic health data. The GPSI and GQI development and validation process will comprise 6 stages: (1) selection and specification of candidate indicators, (2) definition of administrative data-based algorithms, (3) empirical measurement of indicators using linked administrative health data, (4) validation of indicators, (5) analyses of geographic and temporal variations for reliable and valid indicators, and (6) data visualization. Results Study populations will consist of 166,670 Swiss and 5,902,037 French residents aged 65 years and older admitted to an acute care hospital at least once during the 2012-2014 period and insured for at least 1 year before admission and 1 year after discharge. We will extract Swiss data from the Helsana Group data warehouse and French data from the national health insurance information system (SNIIR-AM). The study has been approved by Swiss and French ethics committees and regulatory organizations for data protection. Conclusions Validated GPSIs and GQIs should help support and drive quality and safety improvement in older inpatients, inform health care stakeholders, and enable international comparisons. We discuss several limitations relating to the representativeness of study populations, accuracy of administrative health data, methods used for GPSI criterion validity assessment, and potential confounding bias in comparisons based on GQIs, and we address these limitations to strengthen study feasibility and validity.
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Affiliation(s)
- Marie-Annick Le Pogam
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital and University of Bourgogne Franche-Comté, Dijon, France.,Inserm, CIC 1432, Clinical epidemiology / clinical trials unit, Dijon University Hospital, Dijon, France.,Inserm, UMR 1181, B2PHI: Biostatistics, Biomathematics, PHarmacoepidemiology and Infectious diseases, Institut Pasteur and Université de Versailles St-Quentin-en-Yvelines, Université Paris-Saclay, Paris, France
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Anne Fagot-Campagna
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Fred Paccaud
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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148
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Wendelboe AM, Raskob GE. Global Burden of Thrombosis: Epidemiologic Aspects. Circ Res 2017; 118:1340-7. [PMID: 27126645 DOI: 10.1161/circresaha.115.306841] [Citation(s) in RCA: 736] [Impact Index Per Article: 105.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
Abstract
Thromboembolic conditions were estimated to account for 1 in 4 deaths worldwide in 2010 and are the leading cause of mortality. Thromboembolic conditions are divided into arterial and venous thrombotic conditions. Ischemic heart disease and ischemic stroke comprise the major arterial thromboses and deep-vein thrombosis and pulmonary embolism comprise venous thromboembolism. Atrial fibrillation is a major risk factor for stroke and systemic arterial thromboembolism. Estimates of the global burden of disease were obtained from Global Burden of Disease Project reports, recent systematic reviews, and searching the published literature for recent studies reporting measures of incidence, burden, and disability-adjusted life-years. Estimates per 100 000 of the global incidence rate (IR) for each condition are ischemic heart disease, IR=1518.7; myocardial infarction, IR=139.3; ischemic stroke, IR=114.3; atrial fibrillation, IR=77.5 in males and 59.5 in females; and venous thromboembolism, IR=115 to 269. Mortality rates (MRs) for each condition are ischemic heart disease, MR=105.5; ischemic stroke, MR=42.3; atrial fibrillation, MR=1.7; and venous thromboembolism, MR=9.4 to 32.3. Global public awareness is substantially lower for pulmonary embolism (54%) and deep-vein thrombosis (44%) than heart attack (88%) and stroke (85%). Over time, the incidence and MRs of these conditions have improved in developed countries, but are increasing in developing countries. Public health efforts to measure disease burden and increase awareness of symptoms and risk factors need to improve, particularly in low- and middle-income regions to address this leading cause of morbidity and mortality.
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Affiliation(s)
- Aaron M Wendelboe
- From the University of Oklahoma Health Sciences Center, College of Public Health, Oklahoma City.
| | - Gary E Raskob
- From the University of Oklahoma Health Sciences Center, College of Public Health, Oklahoma City
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149
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Wexels F, Dahl OE, Pripp AH, Seljeflot I. Thrombin Generation in Patients With Suspected Venous Thromboembolism. Clin Appl Thromb Hemost 2017; 23:416-421. [DOI: 10.1177/1076029617700999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Increasing number of patients with clinically suspected venous thromboembolism is referred to radiological departments for definitive diagnosis. A simple assay to exclude the diagnosis and avoid radiological examinations is needed. We have reported correlations between D-dimer and prothrombin fragment 1 + 2 measured in plasma and urine. To further develop an analysis based on urine, more understanding of thrombin generation in these patients is needed. The aim of this study was to compare ex vivo thrombin generation with in vivo markers in plasma and urine in patients with and without venous thromboembolism. Urine and blood samples were collected from patients with suspected venous thromboembolism. Commercially available enzyme-linked immunosorbent assay (ELISA) kits were used to analyze the samples for in vivo thrombin generation. The ex vivo thrombogram parameters were measured by the calibrated automated thrombogram assay. Venous thromboembolism was verified with compression ultrasound of the lower extremity deep veins or with computer tomography of the pulmonary arteries. Venous thromboembolism was diagnosed in 117 of 591 patients, and they had significantly higher levels of urine and plasma prothromin fragment 1 + 2, D-dimer, lag time, time to peak, and endogenous thrombin potential when adjusted for covariates. The pattern of ex vivo and in vivo thrombin generation in patients with suspected venous thromboembolism was comparable when adjusted for covariates. Prothrombin fragment 1 + 2 in plasma and urine reflects thrombin generation ex vivo in the same manner. This indicates that urine may be an alternative substrate to quantify a procoagulant state.
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Affiliation(s)
- Fredrik Wexels
- Department of Radiology, Vestre Viken Hospital Trust, Drammen, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ola E. Dahl
- Centre of Medical Science, Education and Innovation, Innlandet Hospital Trust, Brumunddal, Norway
- Thrombosis Research Institute, London, UK
| | - Are H. Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Ingebjørg Seljeflot
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Oslo, Norway
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150
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Incidence of venous thromboembolism in care homes: a prospective cohort study. Br J Gen Pract 2017; 67:e130-e137. [PMID: 28093420 DOI: 10.3399/bjgp17x688873] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/10/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Care home residents have venous thromboembolism (VTE) risk profiles similar to medical inpatients; however, the epidemiology of VTE in care homes is unclear. AIM To determine the incidence of VTE in care homes. DESIGN AND SETTING Observational cohort study of 45 care homes in Birmingham and Oxford, UK. METHOD A consecutive sample of care home residents was enrolled and followed up for 12 months. Data were collected via case note reviews of care home and GP records; mortality information was supplemented with Health and Social Care Information Centre (now called NHS Digital) cause of death data. All potential VTE events were adjudicated by an independent committee according to three measures of diagnostic certainty: definite VTE (radiological evidence), probable VTE (high clinical indication but no radiological evidence), or possible VTE (VTE cannot be ruled out). (Study registration number: ISTCTN80889792.) RESULTS: There were 1011 participants enrolled, and the mean follow-up period was 312 days (standard deviation 98 days). The incidence rate was 0.71 per 100 person years of observation (95% confidence interval [CI] = 0.26 to 1.54) for definite VTE, 0.83 per 100 person years (95% CI = 0.33 to 1.70) for definite and probable VTE, and 2.48 per 100 person years (95% CI = 1.53 to 3.79) for definite, probable, and possible VTE. CONCLUSION The incidence of VTE in care homes in this study (0.71-2.48 per 100 person years) is substantial compared with that in the community (0.117 per 100 person years) and in people aged ≥70 years (0.44 per 100 person years). Further research regarding risk stratification and VTE prophylaxis in this population is needed.
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