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Austin TR, Nethander M, Fink HA, Törnqvist AE, Jalal DI, Buzkova P, Barzilay JI, Carbone L, Gabrielsen ME, Grahnemo L, Lu T, Hveem K, Jonasson C, Kizer JR, Langhammer A, Mukamal KJ, Gerszten RE, Psaty BM, Robbins JA, Sun YV, Skogholt AH, Kanis JA, Johansson H, Åsvold BO, Valderrabano RJ, Zheng J, Richards JB, Coward E, Ohlsson C. A plasma protein-based risk score to predict hip fractures. NATURE AGING 2024; 4:1064-1075. [PMID: 38802582 PMCID: PMC11333168 DOI: 10.1038/s43587-024-00639-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
As there are effective treatments to reduce hip fractures, identification of patients at high risk of hip fracture is important to inform efficient intervention strategies. To obtain a new tool for hip fracture prediction, we developed a protein-based risk score in the Cardiovascular Health Study using an aptamer-based proteomic platform. The proteomic risk score predicted incident hip fractures and improved hip fracture discrimination in two Trøndelag Health Study validation cohorts using the same aptamer-based platform. When transferred to an antibody-based proteomic platform in a UK Biobank validation cohort, the proteomic risk score was strongly associated with hip fractures (hazard ratio per s.d. increase, 1.64; 95% confidence interval 1.53-1.77). The proteomic risk score, but not available polygenic risk scores for fractures or bone mineral density, improved the C-index beyond the fracture risk assessment tool (FRAX), which integrates information from clinical risk factors (C-index, FRAX 0.735 versus FRAX + proteomic risk score 0.776). The developed proteomic risk score constitutes a new tool for stratifying patients according to hip fracture risk; however, its improvement in hip fracture discrimination is modest and its clinical utility beyond FRAX with information on femoral neck bone mineral density remains to be determined.
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Grants
- U01HL130114 U.S. Department of Health & Human Services | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- U01 HL080295 NHLBI NIH HHS
- U01 HL130114 NHLBI NIH HHS
- HHSN268200800007C NHLBI NIH HHS
- R01HL144483 U.S. Department of Health & Human Services | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- N01HC85086 NHLBI NIH HHS
- KAW 2015.0317 Knut och Alice Wallenbergs Stiftelse (Knut and Alice Wallenberg Foundation)
- LU2021-0096 IngaBritt och Arne Lundbergs Forskningsstiftelse (Ingabritt and Arne Lundberg Research Foundation)
- N01HC85083 NHLBI NIH HHS
- 2020-01392 Vetenskapsrådet (Swedish Research Council)
- N01HC85080 NHLBI NIH HHS
- N01HC85081 NHLBI NIH HHS
- N01HC55222 NHLBI NIH HHS
- U01HL080295 U.S. Department of Health & Human Services | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- HHSN268201200036C NHLBI NIH HHS
- R01 HL144483 NHLBI NIH HHS
- HHSN268201800001C NHLBI NIH HHS
- 75N92021D00006 NHLBI NIH HHS
- N01HC85082 NHLBI NIH HHS
- N01HC85079 NHLBI NIH HHS
- R01 AG023629 NIA NIH HHS
- the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-720331 and ALFGBG-965235)
- U.S. Department of Health & Human Services | NIH | National Heart, Lung, and Blood Institute (NHLBI)
- U.S. Department of Health & Human Services | U.S. Department of Health and Human Services, Administration for Community Living | National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR)
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Affiliation(s)
- Thomas R Austin
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, US
| | - Maria Nethander
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Bioinformatics and Data Center, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, MN, US
- Department of Medicine, University of Minnesota, Minneapolis, MN, US
| | - Anna E Törnqvist
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Diana I Jalal
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, Iowa City, IA, US
- Iowa City VA Medical Center, Iowa City, IA, US
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, WA, US
| | - Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, Atlanta, GA, US
| | - Laura Carbone
- Charlie Norwood VAMC, Augusta, GA, US
- Division of Rheumatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, US
| | - Maiken E Gabrielsen
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Louise Grahnemo
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tianyuan Lu
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
- Quantitative Life Sciences Program, McGill University, Montreal, Quebec, Canada
- 5 Prime Sciences Inc, Montreal, Quebec, Canada
| | - Kristian Hveem
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Centre, NTNU, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Christian Jonasson
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jorge R Kizer
- Cardiology Section, San Francisco VA Health Care System, San Francisco, CA, US
- Department of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, US
| | - Arnulf Langhammer
- HUNT Research Centre, NTNU, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Brookline, MA, US
| | - Robert E Gerszten
- Department of Medicine, Beth Israel Deaconess Medical Center, Brookline, MA, US
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, US
- Departments of Medicine, Epidemiology, and Health Systems and Population Health, University of Washington, Seattle, WA, US
| | - John A Robbins
- Department of Medicine, University of California, Davis, CA, US
| | - Yan V Sun
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, US
| | - Anne Heidi Skogholt
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Helena Johansson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Bjørn Olav Åsvold
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Rodrigo J Valderrabano
- Research Program in Men's Health, Aging and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, US
| | - Jie Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, Shanghai Digital Medicine Innovation Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - J Brent Richards
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
- Quantitative Life Sciences Program, McGill University, Montreal, Quebec, Canada
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Twin Research, King's College London, London, UK
| | - Eivind Coward
- HUNT Center for Molecular and Clinical Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Claes Ohlsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Drug Treatment, Gothenburg, Sweden.
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Bisharat MB, Ichinose EJ, Veerina KK, Khetarpaul V, Azene EM, Plotnik AN, Hnath J, Trestman E, Harlin SA, Bhat A, Li S, Long GW, O’Connor D, Winokur RS, Zia S, Dexter DJ. One-Year Clinical Outcomes Following Mechanical Thrombectomy for Deep Vein Thrombosis: A CLOUT Registry Analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101307. [PMID: 39131784 PMCID: PMC11308810 DOI: 10.1016/j.jscai.2024.101307] [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: 09/28/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 08/13/2024]
Abstract
Background Mechanical thrombectomy is a promising treatment option for deep vein thrombosis; however, long-term data are lacking. Here, we report for the first time the 1-year clinical outcomes from the completely enrolled ClotTriever Outcomes (CLOUT) registry evaluating mechanical thrombectomy with the ClotTriever System (Inari Medical). Methods The CLOUT registry (NCT03575364) is a prospective, multicenter, single-arm study that enrolled 500 patients with proximal lower extremity deep vein thrombosis. Prespecified 1-year outcomes include Villalta score and corresponding postthrombotic syndrome (PTS) severity, duplex ultrasound findings of patency (defined as the presence of flow with normal or partial compressibility), Revised Venous Clinical Severity Score, and quality of life (QoL). Results In CLOUT, the median age was 61.9 years and 50.5% of patients were women. A total of 310 patients completed the 1-year visit. The 1-year PTS rate (Villalta score ≥ 5) was 19.3% and the moderate-to-severe PTS rate (Villalta score ≥ 10) was 8.8%. Median Villalta score decreased from 9.0 (IQR, 5.0-14.0) at baseline to 1.0 (IQR, 0.0-4.0) at 1 year (P < .0001). Similar rates of PTS and moderate-to-severe PTS were observed among limbs assessed at all study time points. Patency was observed in 94.2% of limbs. Median Revised Venous Clinical Severity Score was 6.0 (IQR, 3.0-9.0) at baseline and 3.0 (IQR, 1.0-4.0) at 1 year (P < .0001). Additionally, 90.4% of patients experienced improvements in QoL. Conclusions One-year outcomes from the CLOUT registry demonstrate low PTS rates and preserved patency accompanied by improved symptom relief and QoL. Study follow-up through 2 years is ongoing.
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Affiliation(s)
| | | | | | | | | | - Adam N. Plotnik
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | | | | | - Shuo Li
- University of Kansas-Wichita, Wichita, Kansas
| | - Graham W. Long
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - David O’Connor
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Saqib Zia
- Rutgers New Jersey Medical School, Newark, New Jersey
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Frischmuth T, Tøndel BG, Brækkan SK, Hansen JB, Morelli VM. The Risk of Incident Venous Thromboembolism Attributed to Overweight and Obesity: The Tromsø Study. Thromb Haemost 2024; 124:239-249. [PMID: 37549694 DOI: 10.1055/s-0043-1772212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Obesity is a well-established risk factor for venous thromboembolism (VTE). However, data on the proportion of incident VTEs attributed to overweight and obesity in the general population are limited. OBJECTIVE To investigate the population attributable fraction (PAF) of VTE due to overweight and obesity in a population-based cohort with repeated measurements of body mass index (BMI). METHODS Participants from the fourth to seventh surveys of the Tromsø Study (enrolment: 1994-2016) were followed through 2020, and all incident VTEs were recorded. In total, 36,341 unique participants were included, and BMI measurements were updated for those attending more than one survey. BMI was categorized as <25 kg/m2, 25-30 kg/m2 (overweight), and ≥30 kg/m2 (obesity). Time-varying Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). The PAF was estimated based on age- and sex-adjusted HRs and the prevalence of BMI categories in VTE cases. RESULTS At baseline, the prevalence of overweight and obesity was 37.9 and 13.8%, respectively. During a median follow-up of 13.9 years, 1,051 VTEs occurred. The age- and sex-adjusted HRs of VTE were 1.40 (95% CI: 1.21-1.61) for overweight and 1.86 (95% CI: 1.58-2.20) for obesity compared with subjects with BMI <25 kg/m2. The PAF of VTE due to overweight and obesity was 24.6% (95% CI: 16.6-32.9), with 12.9% (95% CI: 6.6-19.0) being attributed to overweight and 11.7% (95% CI: 8.5-14.9) to obesity. Similar PAFs were obtained in analyses stratified by sex and VTE subtypes (provoked/unprovoked events, deep vein thrombosis, pulmonary embolism). CONCLUSION Our findings indicate that almost 25% of all VTE events can be attributed to overweight and obesity in a general population from Norway.
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Affiliation(s)
- Tobias Frischmuth
- Thrombosis Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
| | - Birgitte G Tøndel
- Thrombosis Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Sigrid K Brækkan
- Thrombosis Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
| | - Vânia M Morelli
- Thrombosis Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
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Machin M, Whittley S, Norrie J, Burgess L, Hunt BJ, Bolton L, Shalhoub J, Everington T, Gohel M, Whiteley MS, Rogers S, Onida S, Turner B, Nandhra S, Lawton R, Stephens-Boal A, Singer C, Dunbar J, Carradice D, Davies AH. Evaluating pharmacological THRomboprophylaxis in Individuals undergoing superficial endoVEnous treatment across NHS and private clinics in the UK: a multi-centre, assessor-blind, randomised controlled trial-THRIVE trial. BMJ Open 2024; 14:e083488. [PMID: 38367965 PMCID: PMC10875503 DOI: 10.1136/bmjopen-2023-083488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION Endovenous therapy is the first choice management for symptomatic varicose veins in NICE guidelines, with 56-70 000 procedures performed annually in the UK. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a known complication of endovenous therapy, occurring at a rate of up to 3.4%. Despite 73% of UK practitioners administering pharmacological thromboprophylaxis to reduce VTE, no high-quality evidence supporting this practice exists. Pharmacological thromboprophylaxis may have clinical and cost benefit in preventing VTE; however, further evidence is needed. This study aims to establish whether when endovenous therapy is undertaken: a single dose or course of pharmacological thromboprophylaxis alters the risk of VTE; pharmacological thromboprophylaxis is associated with an increased rate of bleeding events; pharmacological prophylaxis is cost effective. METHODS AND ANALYSIS A multi-centre, assessor-blind, randomised controlled trial (RCT) will recruit 6660 participants from 40 NHS and private sites across the UK. Participants will be randomised to intervention (single dose or extended course of pharmacological thromboprophylaxis plus compression) or control (compression alone). Participants will undergo a lower limb venous duplex ultrasound scan at 21-28 days post-procedure to identify asymptomatic DVT. The duplex scan will be conducted locally by blinded assessors. Participants will be contacted remotely for follow-up at 7 days and 90 days post-procedure. The primary outcome is imaging-confirmed lower limb DVT with or without symptoms or PE with symptoms within 90 days of treatment. The main analysis will be according to the intention-to-treat principle and will compare the rates of VTE at 90 days, using a repeated measures analysis of variance, adjusting for any pre-specified strongly prognostic baseline covariates using a mixed effects logistic regression. ETHICS AND DISSEMINATION Ethical approval was granted by Brent Research Ethics Committee (22/LO/0261). Results will be disseminated in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN18501431.
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Affiliation(s)
- Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Whittley
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Level 2, NINE Edinburgh BioQuarter, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Laura Burgess
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' Foundation Trust, London, UK
| | - Layla Bolton
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Joseph Shalhoub
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Manjit Gohel
- Cambridge Vascular Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Steven Rogers
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Sandip Nandhra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Lawton
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Annya Stephens-Boal
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Carolyn Singer
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Joanne Dunbar
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - A H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Yap JF, Moy FM, Wan Ahmad WA, Lim YC. Assessing the effect of cardiovascular disease on work productivity and financial loss among school teachers in Peninsular Malaysia: a nested case-control study. PeerJ 2024; 12:e16906. [PMID: 38361766 PMCID: PMC10868520 DOI: 10.7717/peerj.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/17/2024] [Indexed: 02/17/2024] Open
Abstract
Background School teachers may have an increased risk of cardiovascular disease (CVD), potentially affecting their work productivity. However, limited data exists on the impact of CVD on teachers' productivity in Malaysia. Our objectives were to assess work productivity loss (absenteeism and presenteeism) as well as to determine the associated annual monetary loss among school teachers who experienced incident CVD in Peninsular Malaysia. Methods We adopted a nested case-control design within a cohort of school teachers. Working teachers from six states of Peninsular Malaysia, and had experienced incident CVD before a right-censored date (31st December 2021) were defined as cases. Incident CVD was operationally defined as the development of non-fatal acute coronary syndrome (ACS), stroke, congestive cardiac failure, deep vein thrombosis or peripheral arterial disease before the censored date. Controls were working teachers who did not acquire an incident CVD before the similar right-censored date. All controls were randomly selected, with a ratio of one case to four controls, from among the working teachers in one of the states in Peninsular Malaysia. We used a shortened version of the Malay-validated World Health Organization-Health and Work Performance Questionnaire (WHO-HPQ) to estimate the workplace productivity effect among teachers with incident CVD (cases). The same questionnaire was distributed to teachers in a single state of Peninsular Malaysia who did not experience incident CVD (controls). Absenteeism, presenteeism and annual monetary loss were computed based on the scoring rules in the WHO-HPQ. Analysis of covariance was performed with covariate adjustment using propensity scores. The bootstrapping method was applied to obtain better estimates of marginal mean differences, along with standard errors (SE) and appropriate effect sizes. Results We recruited 48 cases (baseline mean age = 42.4 years old, 54.2% females) and 192 randomly selected controls (baseline mean age = 36.2 years old, 99.0% females). The majority of the cases had ACS (73.9%). No significant difference was observed in absenteeism between cases and controls. The mean self-rated job performance score was lower for cases (7.63, SE = 0.21) compared to controls (8.60, SE = 0.10). Marginal mean scores of absolute presenteeism among cases (76.30) were lower (p < 0.05, eta squared = 0.075) than controls (85.97). The marginal mean annual cost of presenteeism was higher in cases (MYR 21,237.52) compared to controls (MYR 12,089.74) (p < 0.05, eta squared = 0.082). Conclusion Absolute presenteeism was lower among school teachers who experienced incident CVD and the annual cost of presenteeism was substantial. Implementing supportive work strategies in school settings is recommended to increase absolute presenteeism, which can lead to a reduction in the annual cost of presenteeism among teachers experiencing incident CVD.
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Affiliation(s)
- Jun Fai Yap
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Foong Ming Moy
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Wan Azman Wan Ahmad
- Cardiology Unit, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Yin Cheng Lim
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Barnes GD, Obi AT. Catheter-Directed Thrombolysis for Deep Vein Thrombosis: Serving at Break Point. Thromb Haemost 2024; 124:105-107. [PMID: 37813373 DOI: 10.1055/s-0043-1776009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Andrea T Obi
- Division of Vascular Surgery, Department of Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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8
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Zou B, Zou F, Cai J. An efficient machine learning framework to identify important clinical features associated with pulmonary embolism. PLoS One 2023; 18:e0292185. [PMID: 37768933 PMCID: PMC10538737 DOI: 10.1371/journal.pone.0292185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023] Open
Abstract
A misdiagnosis of pulmonary embolism (PE) can have severe consequences such as disability or death. It's crucial to accurately identify key clinical features of PE in clinical practice to promptly identify potential PE patients who may present asymptomatically, and to prevent misdiagnosing PE as asthma exacerbation in patients with symptoms like dyspnea or chest pain. However, reliably identifying these important features can be challenging due to many factors influencing the likelihood of PE development in complex fashions (e.g., the interactions among these factors). To address this difficulty, we presented an effective framework using the deep neural network (DNN) model and the permutation-based feature importance test (PermFIT) procedure, i.e., PermFIT-DNN. We applied the PermFIT-DNN framework to the analysis of data from a PE study for asthma exacerbation patients. Our analysis results show that the PermFIT-DNN framework can robustly identify key features for classifying PE status. The important features identified can also aid in accurately predicting the PE risk.
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Affiliation(s)
- Baiming Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Fei Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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9
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Weekes AJ, Davison J, Lupez K, Raper JD, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Murphy K, Ockerse PM, Leech S, Johnson J, Abrams E, Kelly C, O'Connell NS. Quality of life 1 month after acute pulmonary embolism in emergency department patients. Acad Emerg Med 2023; 30:819-831. [PMID: 36786661 DOI: 10.1111/acem.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The Pulmonary Embolism Quality-of-Life (PEmb-QoL) questionnaire assesses quality of life (QoL) after pulmonary embolism (PE). We aimed to determine whether any clinical or pathophysiologic features of PE were associated with worse PEmb-QoL scores 1 month after PE. METHODS In this prospective multicenter registry, we conducted PEmb-QoL questionnaires. We determined differences in QoL domain scores for four primary variables: clinical deterioration (death, cardiac arrest, respiratory failure, hypotension requiring fluid bolus, catecholamine support, or new dysrhythmia), right ventricular dysfunction (RVD), PE risk stratification, and subsequent rehospitalization. For overall QoL score, we fit a multivariable regression model that included these four primary variables as independent variables. RESULTS Of 788 PE patients participating in QoL assessments, 156 (19.8%) had a clinical deterioration event, 236 (30.7%) had RVD of which 38 (16.1%) had escalated interventions. For those without and with clinical deterioration, social limitations had mean (±SD) scores of 2.07 (±1.27) and 2.36 (±1.47), respectively (p = 0.027). For intensity of complaints, mean (±SD) scores for patients without RVD (4.32 ± 2.69) were significantly higher than for those with RVD with or without reperfusion interventions (3.82 ± 1.81 and 3.83 ± 2.11, respectively; p = 0.043). There were no domain score differences between PE risk stratification groups. All domain scores were worse for patients with rehospitalization versus without. By multivariable analysis, worse total PEmb-QoL scores with effect sizes were subsequent rehospitalization 11.29 (6.68-15.89), chronic obstructive pulmonary disease (COPD) 8.17 (3.91-12.43), and longer index hospital length of stay 0.06 (0.03-0.08). CONCLUSIONS Acute clinical deterioration, RVD, and PE severity were not predictors of QoL at 1 month post-PE. Independent predictors of worsened QoL were rehospitalization, COPD, and index hospital length of stay.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jaron D Raper
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alyssa M Thomas
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Department, Houston Methodist Baytown Hospital, Houston, Texas, USA
| | - Carly A Cox
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Medicine of Idaho, Meridian, Idaho, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Patrick M Ockerse
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Christopher Kelly
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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10
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Abstract
Venous thromboembolism, that consists of the interrelated conditions deep-vein thrombosis and pulmonary embolism, is an under-appreciated vascular disease. In Western regions, approximately 1 in 12 individuals will be diagnosed with venous thromboembolism in their lifetime. Rates of venous thromboembolism are lower in Asia, but data from other regions are sparse. Numerous risk factors for venous thromboembolism have been identified, which can be classified as acute or subacute triggers (provoking factors that increase the risk of venous thromboembolism) and basal or acquired risk factors (which can be modifiable or static). Approximately 20% of individuals who have a venous thromboembolism event die within 1 year (although often from the provoking condition), and complications are common among survivors. Fortunately, opportunities exist for primordial prevention (prevention of the development of underlying risk factors), primary prevention (management of risk factors among individuals at high risk of the condition) and secondary prevention (prevention of recurrent events) of venous thromboembolism. In this Review, we describe the epidemiology of venous thromboembolism, including the incidence, risk factors, outcomes and opportunities for prevention. Meaningful health disparities exist in both the incidence and outcomes of venous thromboembolism. We also discuss these disparities as well as opportunities to reduce them.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - Neil A Zakai
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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11
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de Jong CMM, Rosovsky RP, Klok FA. Outcomes of venous thromboembolism care: future directions. J Thromb Haemost 2023; 21:1082-1089. [PMID: 36863565 DOI: 10.1016/j.jtha.2023.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
The complete picture of the outcomes of venous thromboembolism (VTE) care consists of conventional binary clinical outcomes (death, recurrent VTE, and bleeding), patient-centered outcomes, and society-level outcomes. Combined, these allow for the introduction of outcome-driven patient-centered health care. The emerging concept of valuing health care from such a holistic point of view, ie, value-based health care, holds a huge potential to revolutionize-and improve-the organization and evaluation of care. The ultimate goal of this approach was to achieve a high value for patients, ie, the best possible clinical outcomes at the right cost, providing a framework for evaluation and comparisons of different management strategies, patient pathways, or even complete health care delivery systems. To facilitate this, outcomes of care from a patient perspective, such as symptom burden, functional limitations, and quality of life, need to be routinely captured in clinical practice and trials, complementary to the conventional clinical outcomes, to fully capture the patients' values and needs. The aim of this review was to discuss the relevant outcomes of VTE care, explore value in VTE care from different perspectives, and propose future directions to inspire change. This is a call to action to shift the focus to outcomes that matter and make a larger difference in the lives of patients.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Rachel P Rosovsky
- Department of Medicine, Division of Haematology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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12
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Dawwas GK, Cuker A, Rothstein A, Hennessy S. Trends in post-discharge prophylactic anticoagulant use among stroke patients in the United States between 2006 and 2019. J Stroke Cerebrovasc Dis 2022; 31:106700. [PMID: 35964533 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Stroke is an independent risk factor for venous thromboembolism (VTE). Although the risk of VTE persists after hospital discharge, information on the utilization of anticoagulants among stroke patients after discharge remains limited. OBJECTIVE To evaluate changes in post-discharge thromboprophylaxis among stroke patients between 2006 and 2019. METHODS We conducted a retrospective repeated cross-sectional analysis using a commercial healthcare insurance database in the United States. We included patients aged ≥ 18 years with incident stroke diagnosis and assessed prophylactic use of anticoagulants in the 30 days following hospital discharge including low-molecular-weight heparin (enoxaparin ≤40 mg/day, dalteparin ≤5000 IU/day), unfractionated heparin ≤5000 IU/ twice daily or 3 times a day, apixaban 2.5 mg twice daily, and rivaroxaban 10 mg/day. Patients with atrial fibrillation, VTE, mechanical heart valves, cancer, antiphospholipid antibody syndrome, and users of therapeutic doses of anticoagulants were excluded. We used the Cochrane-Armitage test to assess changes in the use of anticoagulants across the study period. RESULTS There was a small increase in the overall use of post-discharge prophylactic anticoagulants among stroke patients between 2006 and 2019 from 0.5% to 1.9%. The use of heparin decreased from 0.5% in 2006 to 0.3% in 2019 (P-value for trend = 0.001). In contrast, the use of apixaban or rivaroxaban increased from 0.1% in 2013 to 1.6% in 2019 (P-value for trend < 0.001). Apixaban was more commonly used than rivaroxaban. CONCLUSIONS In this population-based study of stroke patients, we found that post-discharge anticoagulant use remains low through 2019. Prophylactic use of heparin or rivaroxaban was relatively low but the use of apixaban increased over the study period. Further research is needed to determine if these agents are safe and effective for VTE prevention in stroke patients.
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Affiliation(s)
- Ghadeer K Dawwas
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104-4865, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania , Philadelphia, PA, United States
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104-4865, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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13
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Ambra N, Mohammad OH, Naushad VA, Purayil NK, Mohamedali MG, Elzouki AN, Khalid MK, Illahi MN, Palol A, Barman M, Sharif M, Chalihadan S, Punnorath A, Mostafa A, Al Hariri B, Khidir TGM, Varikkodan I. Venous Thromboembolism Among Hospitalized Patients: Incidence and Adequacy of Thromboprophylaxis - A Retrospective Study. Vasc Health Risk Manag 2022; 18:575-587. [PMID: 35912018 PMCID: PMC9333096 DOI: 10.2147/vhrm.s370344] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/07/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose We aimed to determine the incidence of venous thromboembolism among hospitalized patients in Qatar as well as to analyze the adequacy of VTE assessment and prophylaxis in hospitalized patients. Design Retrospective observational study. Setting Four hospitals under Hamad Medical Corporation, Qatar. Participants Patients over the age of 18 who were hospitalized between January 2015 and December 2019 and developed venous thromboembolism during hospitalization or within a month after discharge were included. Results During the study period, 641,994 individuals were admitted to hospitals. The inclusion criteria were satisfied by 209 of them. The mean age was 51.25 years and 54.5% were males. Hypertension and diabetes mellitus were the most common comorbidities found in the overall group. The incidence of VTE was 32.55 [95% CI 28.4, 37.3] per 100,000 admission per year [0.032%]. The annual incidence was least in 2015 (17.8 per 100,000 admissions) and highest in 2018 (44.4 per 100,000 admissions). Eighty-six subjects had DVT, and 109 had PE, whereas 14 had both. And, 67.5% of the patients developed VTE during admission while, 32.5% developed within 1 month of discharge. Moreover, 22.9% of the patients with PE developed pulmonary embolism after discharge from the hospital. VTE assessment was performed on 64.7% of the patients, and 69.7% received VTE prophylaxis in accordance with guidelines. Conclusion Although the occurrence of VTE among hospitalized patients in Qatar is low, healthcare providers need additional education and knowledge of VTE assessment and prophylaxis to follow guidelines for all patients at the time of admission. Furthermore, risk assessment for VTE should be done for all patients at the time of discharge to decide on post-discharge prophylaxis so that incidence of VTE after discharge can be minimized. Future studies should focus on patients who developed VTE after discharge from the hospital as well as on various risk factors.
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Affiliation(s)
- Naseem Ambra
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Osama Hashim Mohammad
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar
| | - Vamanjore A Naushad
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar.,Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Nishan K Purayil
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar.,Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mohamed G Mohamedali
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar
| | - Abdel Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar.,Clinical Department, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Memon Noor Illahi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar
| | - Azeez Palol
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Manish Barman
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar
| | - Muhammad Sharif
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Clinical Medicine, Weill Cornell Medicine -Qatar, Doha, Qatar
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14
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Jørgensen H, Horváth-Puhó E, Laugesen K, Braekkan SK, Hansen JB, Sørensen HT. The Interaction Between Venous Thromboembolism and Socioeconomic Status on the Risk of Disability Pension. Clin Epidemiol 2022; 14:489-500. [PMID: 35444466 PMCID: PMC9015050 DOI: 10.2147/clep.s361840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Helle Jørgensen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
- Correspondence: Helle Jørgensen, Email
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Kristina Laugesen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Sigrid K Braekkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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15
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Jørgensen H, Horváth-Puhó E, Laugesen K, Brækkan S, Hansen JB, Sørensen HT. Risk of a permanent work-related disability pension after incident venous thromboembolism in Denmark: A population-based cohort study. PLoS Med 2021; 18:e1003770. [PMID: 34464405 PMCID: PMC8443033 DOI: 10.1371/journal.pmed.1003770] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 09/15/2021] [Accepted: 08/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Long-term complications of venous thromboembolism (VTE) hamper physical function and impair quality of life; still, it remains unclear whether VTE is associated with risk of permanent work-related disability. We aimed to assess the association between VTE and the risk of receiving a permanent work-related disability pension and to assess whether this association was explained by comorbidities such as cancer and arterial cardiovascular disease. METHODS AND FINDINGS A Danish nationwide population-based cohort study consisting of 43,769 individuals aged 25 to 66 years with incident VTE during 1995 to 2016 and 218,845 birth year-, sex-, and calendar year-matched individuals from the general population, among whom 45.9% (N = 120,540) were women, was established using Danish national registries. The cohorts were followed throughout 2016, with permanent work-related disability pension as the outcome. Hazard ratios (HRs) with 95% confidence intervals (CIs) for disability pension were computed and stratified by sex and age groups (25 to 34, 35 to 44, 45 to 54, and 55 to 66 years of age) and adjusted for comorbidities and socioeconomic variables. Permanent work-related disability pensions were granted to 4,415 individuals with VTE and 9,237 comparison cohort members (incidence rates = 17.8 and 6.2 per 1,000 person-years, respectively). VTE was associated with a 3-fold (HR 3.0, 95% CI: 2.8 to 3.1) higher risk of receiving a disability pension. Adjustments for socioeconomic status and comorbidities such as cancer and cardiovascular diseases reduced the estimate (HR 2.3, 95% CI: 2.2 to 2.4). The risk of disability pension receipt was slightly higher in men than in women (HR 2.5, 95% CI: 2.3 to 2.6 versus HR 2.1, 95% CI: 2.0 to 2.3). As this study is based on medical and administrative registers, information on post-VTE care, individual health behavior, and workplace factors linked to disability pension in the general population are lacking. Furthermore, as disability pension schemes vary, our results might not be directly generalizable to other countries or time periods. CONCLUSIONS In this study, incident VTE was associated with increased risk of subsequent permanent work-related disability, and this association was still observed after accounting for comorbidities such as cancer and cardiovascular diseases. Our results emphasize the social consequences of VTE and may help occupational and healthcare professionals to identify vulnerable individuals at risk of permanent exclusion from the labor market after a VTE event.
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Affiliation(s)
- Helle Jørgensen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- * E-mail:
| | | | - Kristina Laugesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sigrid Brækkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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16
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Di Minno MND, Calcaterra I, Papa A, Lupoli R, Di Minno A, Maniscalco M, Ambrosino P. Diagnostic accuracy of D-Dimer testing for recurrent venous thromboembolism: A systematic review with meta-analysis.: VTE recurrence and D-dimer. Eur J Intern Med 2021; 89:39-47. [PMID: 33933338 DOI: 10.1016/j.ejim.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) recurrence is a major concern after a first symptomatic episode, potentially impacting survival and healthcare needs in community, hospital and rehabilitation settings. We evaluated the association of D-Dimer positivity after oral anticoagulant therapy (OAT) discontinuation with VTE recurrence. METHODS PubMed, Web of Science, Scopus and EMBASE databases were systematically searched. Differences were expressed as Odds Ratio (OR) with 95% confidence intervals (95%CI). Pooled sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), and summary ROC (sROC) curve were calculated. RESULTS Twenty-six articles on 10,725 VTE patients showed that the absolute risk of recurrence was 16.1% (95%CI: 13.2%-19.5%) among 4,049 patients with a positive D-Dimer and 7.4% (95%CI: 6.0%-9.0%) in 6,676 controls (OR: 2.1, 95%CI: 1.7-2.8, P<0.001), with an attributable risk of 54.0%. sROC curve of the association between positive D-Dimer and recurrence showed a diagnostic AUC of 63.8 (95%CI: 60.3-67.4), with a pooled sensitivity of 54.3% (95%CI: 51.3%-57.3%), specificity of 64.2% (95%CI: 63.2-65.1), PLR of 1.53 (95%CI: 1.37-1.72), and NLR of 0.71 (95%CI: 0.60-0.84). Subgroup and meta-regression analyses suggested that a positive D-Dimer may have a higher discriminatory ability for patients with provoked events, confirmed by better pooled diagnostic indexes for recurrence and a diagnostic AUC of 70.6 (95%CI: 63.8-77.4). Regression models showed that the rate of OAT resumption after the evidence of D-Dimer positivity was inversely associated with VTE recurrence (Z-score: -3.91, P<0.001). CONCLUSIONS D-Dimer positivity after OAT may identify VTE patients at higher risk of recurrence, with a better diagnostic accuracy for provoked events.
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Affiliation(s)
| | - Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology Federico II University, Naples, Italy
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17
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Nymberg P, Stenman E, Calling S, Sundquist J, Sundquist K, Zöller B. Self-rated health and venous thromboembolism among middle-aged women: a population-based cohort study. J Thromb Thrombolysis 2021; 49:344-351. [PMID: 31745859 PMCID: PMC7145782 DOI: 10.1007/s11239-019-01995-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Venous thromboembolism (VTE) is one of the most common types of cardiovascular diseases (CVDs) and is associated with increased mortality-risk. Poor-self rated health (SHR) has been associated with elevated inflammatory markers and CVDs. However, little is known about as a predictor of incident VTE. To examine the association between self-rated health, lifestyle and incident VTE among middle-aged women. 6917 women aged 50–64 years, followed for 20 years in the Women’s Health In the Lund Area (WHILA) study. After exclusion of those who medicated with anticoagulants, were living in nursing homes or suffered from cancer, stroke, VTE or CHD before baseline, a cohort of 5626 women remained. Cox regression was used to analyse the relationship between self-rated health and time to VTE, censored for any of the previous mentioned diseases during follow-up. Data were collected by questionnaires, physical examinations and Swedish registers. In total, 220 women were affected by VTE corresponding to an incidence rate of 3.9 per 1000 person-years. Adjustment for self-rated health did not significantly predict incident VTE, and neither did any of the lifestyle-related habits (e.g. physical activity and dietary habits including alcohol consumption), besides smoking. This study supports previous results with varicose veins and waist circumference as strong predictors of VTE. Poor self-rated health does not seem to be a valid predictor of VTE. Among lifestyle-related parameters, smoking was significantly associated with risk of VTE. We could also confirm the effect of the other already known risk factors.
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Affiliation(s)
- Peter Nymberg
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden.
| | - Emelie Stenman
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden
| | - Susanna Calling
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden
| | - Jan Sundquist
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden
| | - Kristina Sundquist
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden
| | - Bengt Zöller
- Region Skåne, Center for Primary Health Care Research, Jan Waldenströms gata 35, Skåne University Hospital Malmö, University Hospital, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden
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18
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Lutsey PL, Windham BG, Misialek JR, Cushman M, Kucharska-Newton A, Basu S, Folsom AR. Long-Term Association of Venous Thromboembolism With Frailty, Physical Functioning, and Quality of Life: The Atherosclerosis Risk in Communities Study. J Am Heart Assoc 2020; 9:e015656. [PMID: 32476561 PMCID: PMC7429054 DOI: 10.1161/jaha.119.015656] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Relatively little is known about the long‐term consequences of venous thromboembolism (VTE) on physical functioning. We compared long‐term frailty status, physical function, and quality of life among survivors of VTE with survivors of coronary heart disease (CHD) and stroke, and with those without these diseases. Methods and Results Cases of VTE, CHD, and stroke were continuously identified since ARIC (Atherosclerosis Risk in Communities Study) recruitment during 1987 to 1989. Functional measures were objectively captured at ARIC clinic visits 5 (2011–2013) and 6 (2016–2017); quality of life was self‐reported. The 6161 participants at visit 5 were, on average, 75.7 (range, 66–90) years of age. By visit 5, 3.2% had had a VTE, 6.9% CHD, and 3.4% stroke. Compared with those without any of these conditions, VTE survivors were more likely to be frail (odds ratio [OR], 3.11; 95% CI, 1.80–5.36) and have low (<10) versus good scores on the Short Physical Performance Battery (OR, 3.59; 95% CI, 2.36–5.47). They also had slower gait speed, less endurance, and lower physical quality of life. VTE survivors were similar to coronary heart disease and stroke survivors on categorical frailty and outcomes on Short Physical Performance Battery assessment. When score on the Short Physical Performance Battery instrument was modeled continuously, VTE survivors performed better than stroke survivors but worse than CHD survivors. Conclusions VTE survivors had triple the odds of frailty and poorer physical function than those without the vascular diseases considered. Their function was somewhat worse than that of CHD survivors, but better than stroke survivors. These findings suggest that VTE patients may benefit from additional efforts to improve postevent physical functioning.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - B Gwen Windham
- Division of Geriatrics Department of Medicine University of Mississippi Medical Center Jackson MS
| | - Jeffrey R Misialek
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
| | - Mary Cushman
- Division of Hematology and Oncology Department of Medicine University of Vermont Colchester VT
| | - Anna Kucharska-Newton
- Division of Epidemiology College of Public Health University of Kentucky Lexington KY.,Department of Epidemiology Gillings School of Public Health University of North Carolina, Chapel Hill NC
| | - Saonli Basu
- Division of Biostatistics School of Public Health University of Minnesota Minneapolis MN
| | - Aaron R Folsom
- Division of Epidemiology and Community Health School of Public Health University of Minnesota Minneapolis MN
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Abstract
Management of pulmonary embolism (PE) has become more complex due to the expanded role of catheter-based therapies, surgical thrombectomies, and cardiac assist technologies, such as right ventricular assist devices and extracorporeal support. Due to the heterogeneity of PE, a multidisciplinary team approach is necessary. The manifestation of PE response teams are in response to this complex need and similar to the proliferation of stroke, trauma, and rapid response teams. Intensive care units are an ideal location for formulating a comprehensive treatment plan that necessitates an interaction between multiple specialties. This article addresses the unique needs of critically ill patients with PE.
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Affiliation(s)
- Michael Baram
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA.
| | - Bharat Awsare
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA
| | - Geno Merli
- Department of Medicine and Surgery, Division of Vascular Medicine, Jefferson University Hospital, 111 South 11th Street Suite 6210, Philadelphia, PA 19107, USA
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Barco S, Mahmoudpour SH, Valerio L, Klok FA, Münzel T, Middeldorp S, Ageno W, Cohen AT, Hunt BJ, Konstantinides SV. Trends in mortality related to pulmonary embolism in the European Region, 2000–15: analysis of vital registration data from the WHO Mortality Database. THE LANCET RESPIRATORY MEDICINE 2020; 8:277-287. [DOI: 10.1016/s2213-2600(19)30354-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 01/04/2023]
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21
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Hiedemann B, Vernon E, Bowie BH. Re-Examining Genetic Screening and Oral Contraceptives: A Patient-Centered Review. J Pers Med 2019; 9:E4. [PMID: 30650548 PMCID: PMC6462992 DOI: 10.3390/jpm9010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/09/2019] [Accepted: 01/11/2019] [Indexed: 11/16/2022] Open
Abstract
The World Health Organization classifies combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation but advises against routine thrombophilia screening before initiating combined oral contraceptives (COCs) on the grounds of high screening costs and low prevalence. From the perspective of patient-centered care, we examine cost, prevalence, and other published arguments for and against thrombophilia screening before initiating COCs. Our patient-centered review draws on relevant empirical evidence concerning the advantages and disadvantages of thrombophilia screening, while placing the discussion in the broader context of evolving attitudes toward genetic testing and a shifting policy landscape that provides many women direct access to COCs and/or thrombophilia screening. Given variation in prior probabilities of thrombophilia, expected exposure to other risk factors for venous thromboembolism, attitudes towards risk, expected reactions to a positive test result, ability to pay, and concerns about genetic discrimination, we conclude that the current one-size-fits-most approach is not consistent with patient-centered care. Instead, we advocate for greater patient and provider education concerning the implications of thrombophilia screening. Moreover, we recommend offering patients optional thrombophilia screening before initiating COCs.
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Affiliation(s)
- Bridget Hiedemann
- Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA 98122, USA.
| | - Erin Vernon
- Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA 98122, USA.
| | - Bonnie H Bowie
- College of Nursing, Seattle University, 901 12th Avenue, Seattle, WA 98122, USA.
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22
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Testosterone Therapy, Thrombophilia, Venous Thromboembolism, and Thrombotic Events. J Clin Med 2018; 8:jcm8010011. [PMID: 30577621 PMCID: PMC6352146 DOI: 10.3390/jcm8010011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 01/24/2023] Open
Abstract
In our sequential studies of 67 and 21 patients, testosterone therapy (TT) interacted with thrombophilia⁻hypofibrinolysis, leading to venous thromboembolism (VTE). Compared to 111 VTE controls not taking TT (VTE-no TT), the 67 and 21 cases were more likely (p < 0.05 for all) to have Factor V Leiden (FVL) heterogeneity (24% and 33% vs. 12%), the lupus anticoagulant (14% and 33% vs. 4%), and high lipoprotein(a) (33% vs. 13%, n = 21). After a first VTE and continuing TT, 11 thrombophilic cases had a second VTE despite adequate anticoagulation, 6 of whom, still anticoagulated, had a third VTE. The greatest density of thrombotic events was at three months after starting TT, with a rapid decline by 10 months. From <1 to 8 months after starting TT, 65% of VTE occurred, which may reflect TT-induced depletion of susceptible thrombophilic patients, leaving a winnowed residual group with fewer VTE events despite the continuation of TT. Before starting TT, we suggest screening for FVL, lipoprotein(a), and the lupus anticoagulant to identify patients at increased VTE risk, with an adverse risk-to-benefit ratio for TT. We suggest that TT should not be started in patients with known thrombophilia⁻hypofibrinolysis, and should not be continued after a first VTE. When TT is given to patients with thrombophilia⁻hypofibrinolysis, VTE may occur and then recur despite adequate anticoagulation.
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23
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Willich SN, Chuang LH, van Hout B, Gumbs P, Jimenez D, Kroep S, Bauersachs R, Monreal M, Agnelli G, Cohen A. Pulmonary embolism in Europe - Burden of illness in relationship to healthcare resource utilization and return to work. Thromb Res 2018; 170:181-191. [PMID: 30199784 DOI: 10.1016/j.thromres.2018.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/26/2018] [Accepted: 02/13/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pulmonary embolism (PE) is associated with a substantial economic burden. However evidence from patients in Europe is scarce. The aim of this study was to report the impacts of PE on healthcare resource utilization (HCRU) and return to work using the PREFER in VTE registry. METHODS The PREFER in VTE registry was a prospective, observational, multicenter study in seven European countries, aiming to provide data concerning treatment patterns, HCRU, mortality, quality of life and work-loss. Patients with a first-time or recurrent PE were included and followed up at 1, 3, 6 and 12 months. Treatment patterns, re-hospitalization rates, length of hospital stays (LOS), and ambulatory/office visits, as well as proportion of patients returning to work, were assessed. Subgroups by country and with/without active cancer were examined separately. Zero-inflated negative binomial and Cox regression were applied to investigate the relationship between baseline characteristics and LOS and return to work, respectively. RESULTS Amongst 1399 patients with PE, 53.2% were male and the average age was 62.3 ± 17.1 years old. Overall, patients were treated with combinations of heparin, vitamin K antagonists (VKA) and the non-VKA oral anticoagulants (NOACs) (50.0% treated with the combination of heparin with VKA). Patients with active cancer were primarily treated with heparin (84.9%). NOACs were used more frequently in DACH (Germany, Austria and Switzerland) and France (55.2% and 32.6%) compared to Italy and Spain (4.5% and 6.1%). The VTE-related re-hospitalization rate within 12 months and the average LOS varied substantially between countries, from 26.2% in UK to 12.3% in France, and from 12.9 days in Italy to 3.9 days in France. PE patients were often co-managed by general practitioners in France and DACH (>84%), and less frequently in other countries (<47%). The regression results confirmed the country variation of HCRU. Of the employed patients (n = 385), 60% returned to work at 1 month but 27.8% had not after one year. PE patients with DVT were more likely to return to work. Active cancer was a significant predictor for not returning to work, as well as smoking history. CONCLUSIONS Medical treatment of PE differed between patients with active cancer and patients without active cancer. VTE-related resource utilization differed markedly between countries. While the reported 'not return to work' was high for patients with PE, this may at least in part reflect the presence of co-morbidities such as cancer.
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Affiliation(s)
| | | | - Ben van Hout
- University of Sheffield, Sheffield, United Kingdom
| | | | - David Jimenez
- Ramon y Cajal Hospital IRYCIS, Madrid, Spain; Alcala de Henares University, Madrid, Spain
| | - Sonja Kroep
- Pharmerit International, Rotterdam, Netherlands
| | | | - Manuel Monreal
- Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
| | | | - Alexander Cohen
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
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24
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Dhillon NK, Smith EJ, Gillette E, Mason R, Barmparas G, Gewertz BL, Ley EJ. Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose? Int J Surg 2018; 51:128-132. [DOI: 10.1016/j.ijsu.2018.01.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/30/2017] [Accepted: 01/04/2018] [Indexed: 01/26/2023]
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25
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Glueck CJ, Goldenberg N, Wang P. Thromboembolism peaking 3 months after starting testosterone therapy: testosterone–thrombophilia interactions. J Investig Med 2017; 66:733-738. [DOI: 10.1136/jim-2017-000637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
We assessed time of thrombotic events (venous thromboembolism (VTE)) after starting testosterone therapy (TT) in 21 men who sustained 23 VTE. The density of thrombotic events was greatest at 3 months after starting TT, with a rapid decline in events by 10 months. The 21 cases with VTE on TT differed from 110 patient controls with unprovoked VTE, not taking TT (VTE-no TT) for Factor V Leiden heterozygosity (FVL) (33 per cent vs 13 per cent, P=0.037), for high lipoprotein (a) (Lp(a)) (55 per cent vs 17 per cent, P=0.012), and for the lupus anticoagulant (33 per cent vs 4 per cent, P=0.003). These differences between cases and VTE-no TT controls were independent of age and gender. TT can interact with underlying thrombophilia–hypofibrinolysis promoting VTE. We suggest that TT should not be started in subjects with known thrombophilia. Coagulation screening, particularly for the FVL , Lp(a), and the lupus anticoagulant should be considered before starting TT, to identify men at high VTE risk who have an adverse risk/benefit ratio for TT.
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26
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Kort D, van Rein N, van der Meer FJM, Vermaas HW, Wiersma N, Cannegieter SC, Lijfering WM. Relationship between neighborhood socioeconomic status and venous thromboembolism: results from a population-based study. J Thromb Haemost 2017; 15:2352-2360. [PMID: 29027356 DOI: 10.1111/jth.13868] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Indexed: 11/28/2022]
Abstract
Essentials Literature on socioeconomic status (SES) and incidence of venous thromboembolism (VTE) is scarce. We assessed neighborhood SES with VTE risk in a population of over 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. These findings are helpful to inform policy and resource allocation in health systems. SUMMARY Background The association between socioeconomic status and arterial cardiovascular disease is well established. However, despite its high burden of disability-adjusted life years, little research has been carried out to determine whether socioeconomic status is associated with venous thromboembolism. Objective To determine if neighborhood socioeconomic status is associated with venous thromboembolism in a population-based study from the Netherlands. Methods We identified all patients aged 15 years and older with a first event of venous thromboembolism from inhabitants who lived in the urban districts of The Hague, Leiden and Utrecht in the Netherlands in 2008-2012. Neighborhood socioeconomic status was based on the status score, which combines educational level, income and unemployment on a four-digit postal code level. Incidence rate ratios of venous thromboembolism were calculated for different levels of neighborhood socioeconomic status, with adjustments for age and sex. Results A total of 7373 patients with a first venous thromboembolism (median age 61 years; 50% deep vein thrombosis) were identified among more than 1.4 million inhabitants. Higher neighborhood SES was associated with lower incidence of VTE. In the two highest status score groups (i.e. the 95-99th and > 99th percentile), the adjusted incidence rate ratios were 0.91 (95% confidence interval [CI], 0.84-1.00) and 0.80 (95% CI, 0.69-0.93), respectively, compared with the reference status score group (i.e. 30-70th percentile). Conclusions High neighborhood socioeconomic status is associated with a lower risk of first venous thromboembolism.
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Affiliation(s)
- D Kort
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - N van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - F J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - H W Vermaas
- Anticoagulation Clinic The Hague, The Hague, the Netherlands
| | - N Wiersma
- Anticoagulation Clinic Utrecht, Utrecht, the Netherlands
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - W M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Fleck D, Albadawi H, Shamoun F, Knuttinen G, Naidu S, Oklu R. Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations. Cardiovasc Diagn Ther 2017; 7:S228-S237. [PMID: 29399526 DOI: 10.21037/cdt.2017.09.15] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Deep vein thrombosis (DVT) is a major health problem worldwide. The risk of pulmonary embolism following DVT is well established, but the long-term vascular sequelae of DVT are often underappreciated, costly to manage, and can have extremely detrimental effects on quality of life. Treatment of DVT classically involves oral anticoagulation, which reduces the risk of pulmonary embolism but does not remove the clot. Anticoagulation therefore does little to prevent the venous damage and scarring that occurs following DVT, leaving the patient at risk for permanent venous insufficiency and development of post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) is a minimally invasive endovascular treatment that is used as an adjunct to anticoagulation. CDT lowers the risk of PTS by reducing clot burden and protecting against valvular damage. A catheter is advanced directly to the site of thrombosis under fluoroscopy followed by a slow, prolonged infusion of a relatively low dose of thrombolytic agent. CDT restores venous patency faster than anticoagulation, which hastens the relief of acute symptoms. Adjunctive CDT modalities have become increasingly popular among interventional radiologists, allowing for additional mechanical thrombectomy or ultrasound-enhanced thrombolysis at the time of catheter placement. These pharmacomechanical CDT (PCDT) techniques have the potential to reduce treatment time and associated healthcare costs. Numerous observational and retrospective studies have consistently shown a benefit of CDT plus anticoagulation over anticoagulation alone for prevention of PTS. Patients with long life expectancy and acute thrombosis involving the iliac and proximal femoral veins (iliofemoral DVT) have the greatest benefit from CDT, which may decrease the risk of PTS and/or decrease the severity of PTS symptoms if they do occur. Randomized controlled trials remain limited but generally support the observational data. CDT also plays an important role in those with acute limb-threatening venous occlusion or severe symptoms from DVT. Although adverse outcomes are rare, a potential devastating outcome is intracranial bleeding. While the available literature suggests the risk of serious morbidity from bleeding is quite rare, the absolute risk of bleeding is not clear and will require outcomes data from randomized trials. Future studies should also examine the cost-effectiveness of CDT for PTS prevention, particularly with respect to quality-adjusted life years, and compare the effectiveness of available PCDT devices.
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Affiliation(s)
- Drew Fleck
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Hassan Albadawi
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Fadi Shamoun
- Division of Vascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sailendra Naidu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Division of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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Dhillon NK, Smith EJT, Ko A, Harada MY, Yang AR, Patel KA, Barmparas G, Ley EJ. The risk factors of venous thromboembolism in massively transfused patients. J Surg Res 2017; 222:115-121. [PMID: 29273362 DOI: 10.1016/j.jss.2017.09.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/02/2017] [Accepted: 09/28/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. METHODS A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. RESULTS Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). CONCLUSIONS The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.
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Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J T Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey R Yang
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita A Patel
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Croles FN, Nasserinejad K, Duvekot JJ, Kruip MJ, Meijer K, Leebeek FW. Pregnancy, thrombophilia, and the risk of a first venous thrombosis: systematic review and bayesian meta-analysis. BMJ 2017; 359:j4452. [PMID: 29074563 PMCID: PMC5657463 DOI: 10.1136/bmj.j4452] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To provide evidence to support updated guidelines for the management of pregnant women with hereditary thrombophilia in order to reduce the risk of a first venous thromboembolism (VTE) in pregnancy.Design Systematic review and bayesian meta-analysis.Data sources Embase, Medline, Web of Science, Cochrane Library, and Google Scholar from inception through 14 November 2016.Review methods Observational studies that reported on pregnancies without the use of anticoagulants and the outcome of first VTE for women with thrombophilia were eligible for inclusion. VTE was considered established if it was confirmed by objective means, or when the patient had received a full course of a full dose anticoagulant treatment without objective testing. Results 36 studies were included in the meta-analysis. All thrombophilias increased the risk for pregnancy associated VTE (probabilities ≥91%). Regarding absolute risks of pregnancy associated VTE, high risk thrombophilias were antithrombin deficiency (antepartum: 7.3%, 95% credible interval 1.8% to 15.6%; post partum: 11.1%, 3.7% to 21.0%), protein C deficiency (antepartum: 3.2%, 0.6% to 8.2%; post partum: 5.4%, 0.9% to 13.8%), protein S deficiency (antepartum: 0.9%, 0.0% to 3.7%; post partum: 4.2%; 0.7% to 9.4%), and homozygous factor V Leiden (antepartum: 2.8%, 0.0% to 8.6%; post partum: 2.8%, 0.0% to 8.8%). Absolute combined antepartum and postpartum risks for women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutations, or compound heterozygous factor V Leiden and prothrombin G20210A mutations were all below 3%. Conclusions Women with antithrombin, protein C, or protein S deficiency or with homozygous factor V Leiden should be considered for antepartum or postpartum thrombosis prophylaxis, or both. Women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation, or compound heterozygous factor V Leiden and prothrombin G20210A mutation should generally not be prescribed thrombosis prophylaxis on the basis of thrombophilia and family history alone. These data should be considered in future guidelines on pregnancy associated VTE risk.
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Affiliation(s)
- F Nanne Croles
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Marieke Jha Kruip
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Centre, University of Groningen, Groningen, Netherlands
| | - Frank Wg Leebeek
- Department of Hematology, Erasmus University Medical Centre, Postbus 2040, 3000 CA, Rotterdam, Netherlands
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30
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Vernon E, Hiedemann B, Bowie BH. Economic Evaluations of Thrombophilia Screening Prior to Prescribing Combined Oral Contraceptives: A Systematic and Critical Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:583-595. [PMID: 28290105 DOI: 10.1007/s40258-017-0318-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Combined oral contraceptives (COCs) increase the risk of venous thromboembolism (VTE), particularly among women with inherited clotting disorders. The World Health Organization classifies combined hormonal contraception as an "unacceptable health risk" for women with thrombogenic mutations but advises against universal thrombophilia screening before prescribing COCs given the low prevalence of thrombophilia and high screening costs. OBJECTIVE Through the lens of lifetime costs and benefits, this paper systematically and critically reviews all published economic evaluations of thrombophilia screening prior to prescribing COCs. METHODS We searched relevant databases for economic evaluations of thrombophilia screening before prescribing COCs. After extracting the key study characteristics and economic variables, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments. RESULTS Seven economic evaluations of thrombophilia screening before prescribing COCs met our inclusion criteria. Only the two economic evaluations focusing exclusively on selective screening exceeded the 75-point threshold for high-quality economic studies based on the QHES instrument, whereas only one of these exceeded the 85% CHEERS threshold. Only three of the seven economic evaluations performed sensitivity analysis on key parameters. Most studies underestimated the benefits of thrombophilia screening by comparing one-time costs of genetic screening against benefits per person-year, thus implicitly assuming a 1-year duration of COC use, neglecting the long-term implications of VTE and/or neglecting the lifetime benefits of awareness of inherited thrombophilia. CONCLUSION Our review highlights the lack of methodologically rigorous economic evaluations of universal thrombophilia screening before prescribing COCs.
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Affiliation(s)
- Erin Vernon
- Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA
| | - Bridget Hiedemann
- Department of Economics, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA.
| | - Bonnie H Bowie
- College of Nursing, Seattle University, 901 12th Avenue, Seattle, WA, 98122, USA
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Abstract
In the United States, venous thromboembolism is associated with high mortality and morbidity affecting as many as 900 000 people (1-2 per 1000) each year. Estimates suggest that 60 000 to 100 000 Americans die of deep venous thrombosis/pulmonary embolism and 10% to 30% die within 1 month of diagnosis, with sudden death being the first symptom in approximately 25% of population with pulmonary embolism. One-half of the patients with deep venous thrombosis will have postthrombotic syndrome, which includes swelling, pain, discoloration, and scaling in the affected limb. Approximately 33% of patients will have a recurrence within 10 years. It is important to understand the anatomy of the pulmonary circulation and the pathophysiology of the disease as it leads to understanding of the potential devastating clinical consequences.
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Cost-of-illness models for venous thromboembolism: One size does not fit all. Thromb Res 2016; 145:65-6. [PMID: 27494774 DOI: 10.1016/j.thromres.2016.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 11/20/2022]
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