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Glise Sandblad K, Svensson CJ, Svennerholm K, Philipson J, Pivodic A, Schulman S, Tavoly M. Time Trends and Excess Mortality Compared to Population Controls after a First-Time Pulmonary Embolism or Deep Vein Thrombosis. Thromb Haemost 2024. [PMID: 39178882 DOI: 10.1055/a-2402-6192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
BACKGROUND Recent data on temporal trends in excess mortality for patients with pulmonary embolism (PE) and deep vein thrombosis (DVT) compared with the general population are scarce. METHODS A nationwide Swedish register study conducted from 2006 to 2018 including 68,960 PE and 70,949 DVT cases matched with population controls. Poisson regression determined relative risk (RR) for 30-day and 1-year mortality trends while Cox regression determined adjusted hazard ratios (aHRs). A significance level of 0.001 was applied. RESULTS In PE cases, both 30-day mortality (12.5% in 2006 to 7.8% in 2018, RR: 0.95 [95% CI: 0.95-0.96], p < 0.0001) and 1-year mortality (26.5 to 22.1%, RR: 0.98 [0.97-0.98], p < 0.0001) decreased during the study period. Compared with controls, no significant change was seen in 30-day (aHR: 33.08 [95% CI: 25.12-43.55] to 24.64 [95% CI: 18.81-32.27], p = 0.0015 for interaction with calendar year) or 1-year (aHR: 5.85 [95% CI: 5.31-6.45] to 7.07 [95% CI: 6.43-7.78], p = 0.038) excess mortality. The 30-day excess mortality decreased significantly (aHR: 39.93 [95% CI: 28.47-56.00) to 24.63 [95% CI: 17.94-33.83], p = 0.0009) in patients with PE without known cancer before baseline, while the excess 1-year mortality increased (aHR: 3.55 [95% CI: 3.16-3.99] to 5.38 [95% CI: 4.85-5.98], p < 0.0001) in PE cases surviving to fill a prescription of anticoagulation. In DVT cases, 30-day and 1-year mortality declined, while excess mortality compared with controls remained stable. CONCLUSION In general, the improved mortality following PE and DVT paralleled population trends. However, PE cases without cancer had decreasing excess 30-day mortality, whereas those surviving to fill a prescription for anticoagulant medication showed increasing excess 1-year mortality.
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Affiliation(s)
- Katarina Glise Sandblad
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Carl Johan Svensson
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Philipson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | | | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mazdak Tavoly
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
- Department of Research, Østfold Hospital, Sarpsborg, Norway
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Bertoletti L, Di Micco P, Poénou G, Falgá C, Zdraveska M, Lima J, Rivera-Civico F, Muixi JF, Monreal M. Clinical Presentation and Outcomes of Patients With Cancer-Associated Isolated Distal Deep Vein Thrombosis. J Clin Oncol 2024; 42:529-537. [PMID: 37471683 DOI: 10.1200/jco.23.00429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT
- Cardiovascular Research Foundation (CRF), New York, NY
| | - Laurent Bertoletti
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fate bene fratelli, Naples, Italy
| | - Géraldine Poénou
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Marija Zdraveska
- University Clinic of Pneumology and Allergy Skopje, Skopje, Republic of Macedonia
| | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Lonnberg F, Roos A, Farm M, Heurlin A, Okas M, Gigante B, Siddiqui AJ. Causes of death after first time venous thromboembolism. Thromb J 2024; 22:16. [PMID: 38303070 PMCID: PMC10832181 DOI: 10.1186/s12959-024-00586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Causes of death after first time community-acquired venous thromboembolism (VTE) diagnosed in unselected patients at the emergency department (ED) was investigated. MATERIALS AND METHODS The study consists of all patients > 18 years of age who had a visit for any medical reason to any of 5 different ED in Stockholm County, Sweden from 1st January 2016 to 31st December 2017. We have identified all patients with a first registered incident VTE; deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during the study period. Cox regression models were used to estimate hazards ratios (HR) with 95% confidence intervals (CIs) for all-cause mortality and cause-specific death in patients with DVT or PE using all other patients as the reference group. RESULTS In total, 359,884 patients had an ED visit during the study period of whom about 2.1% were diagnosed with VTE (DVT = 4,384, PE = 3,212). The patients with VTE were older compared to the control group. During a mean follow up of 2.1 years, 1567 (21%) and 23,741(6.7%) patients died within the VTE and reference group, respectively. The adjusted risk of all-cause mortality was nearly double in patients with DVT (HR 1.7; 95% CI, 1.5-1.8) and more than 3-fold in patients with PE (HR 3.4; 95% CI, 3.1-3.6). While the risk of cancer related death was nearly 3-fold in patient with DVT (HR 2.7; 95% CI, 2.4-3.1), and 5-fold in PE (HR 5.4; 95% CI, 4.9-6.0 respectively). The diagnosis of PE during the ED visit was associated with a significantly higher risk of cardiovascular death (HR 2.2; 95% CI, 1.9-2.6). CONCLUSION Patients with VTE have an elevated risk of all-cause mortality, including cardiovascular death.
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Affiliation(s)
- Frida Lonnberg
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Roos
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Farm
- Karolinska University, Solna, Sweden
- Karolinska University Hospital, Solna, Sweden
| | - André Heurlin
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Mantas Okas
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Bruna Gigante
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
| | - Anwar J Siddiqui
- Department of Medicine, Karolinska Institute, Solna, Sweden.
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
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Earle W, Misra S, Wester A, Herzig M, Abdallah G, Ross CB, Secemsky EA, Carroll BJ. Cause of death in patients with acute pulmonary embolism. Vasc Med 2023; 28:586-588. [PMID: 37756320 DOI: 10.1177/1358863x231199488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Affiliation(s)
- William Earle
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Boston, MA, USA
| | - Shantum Misra
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Boston, MA, USA
| | - Alexander Wester
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Matthew Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - George Abdallah
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Eric A Secemsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Boston, MA, USA
| | - Brett J Carroll
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Boston, MA, USA
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Marx CE, Schenker C, Xu Y, Salvatore SP, Kahn SR, Garcia D, Delluc A, Kraaijpoel N, Langlois N, Girard P, Le Gal G, Tritschler T. Accuracy and interrater agreement of death event adjudications by physician trainees: validation of the ISTH definition of pulmonary embolism-related death in an autopsy cohort. J Thromb Haemost 2023; 21:2908-2912. [PMID: 37517478 DOI: 10.1016/j.jtha.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/02/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND We previously determined good agreement and high specificity of the International Society on Thrombosis and Haemostasis (ISTH) definition of pulmonary embolism (PE)-related death among an expert central adjudication committee (CAC). CACs are often composed of experts in the corresponding research field. Involving physician trainees in CACs would allow investigators to divide the workload and foster trainees' research experience. OBJECTIVE To evaluate the accuracy of the ISTH definition of PE-related death for PE- versus non-PE-related deaths as confirmed by autopsy and its interrater agreement among physician trainees. METHODS This retrospective autopsy cohort included all patients with PE-related deaths between January 2010 and July 2019 as well as patients who died in 2018 from a cause other than PE at the New York-Presbyterian Hospital. Based on premortem clinical summaries, two physician trainees independently determined the cause of death using the ISTH definition of PE-related death. We calculated the sensitivity and specificity of the ISTH definition to identify autopsy-confirmed PE-related death and its interrater agreement. RESULTS Overall, 126 death events were adjudicated (median age, 68 years; 60 [48%] women), of which 29 (23%) were due to PE, as confirmed by autopsy. Sensitivity and specificity of the ISTH definition for autopsy-confirmed PE-related death was 48% (95% CI, 29-67) and 100% (95% CI, 96-100), respectively. Interrater reliability for PE-related death was good (percentage agreement, 93%; 95% CI, 87-96, Cohen's Kappa, 0.67; 95% CI, 44-85). CONCLUSION Our findings are consistent with our previous validation study. They further support the use of the ISTH definition of PE-related death and revealed high agreement between adjudicators with varied experience.
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Affiliation(s)
- Caterina E Marx
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carla Schenker
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yan Xu
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Steven P Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, Quebec, Canada; Divisions of Internal Medicine and Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, Canada
| | - David Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Aurélien Delluc
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris; Institut Mutualiste Montsouris, Paris, France
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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Milos RI, Bartha C, Röhrich S, Heidinger BH, Prayer F, Beer L, Wassipaul C, Kifjak D, Watzenboeck ML, Pochepnia S, Prosch H. Imaging in patients with acute dyspnea when cardiac or pulmonary origin is suspected. BJR Open 2023; 5:20220026. [PMID: 37035768 PMCID: PMC10077421 DOI: 10.1259/bjro.20220026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 01/13/2023] Open
Abstract
A wide spectrum of conditions, from life-threatening to non-urgent, can manifest with acute dyspnea, thus presenting major challenges for the treating physician when establishing the diagnosis and severity of the underlying disease. Imaging plays a decisive role in the assessment of acute dyspnea of cardiac and/or pulmonary origin. This article presents an overview of the current imaging modalities used to narrow the differential diagnosis in the assessment of acute dyspnea of cardiac or pulmonary origin. The current indications, findings, accuracy, and limits of each imaging modality are reported. Chest radiography is usually the primary imaging modality applied. There is a low radiation dose associated with this method, and it can assess the presence of fluid in the lung or pleura, consolidations, hyperinflation, pneumothorax, as well as heart enlargement. However, its low sensitivity limits the ability of the chest radiograph to accurately identify the causes of acute dyspnea. CT provides more detailed imaging of the cardiorespiratory system, and therefore, better sensitivity and specificity results, but it is accompanied by higher radiation exposure. Ultrasonography has the advantage of using no radiation, and is fast and feasible as a bedside test and appropriate for the assessment of unstable patients. However, patient-specific factors, such as body habitus, may limit its image quality and interpretability. Advances in knowledge This review provides guidance to the appropriate choice of imaging modalities in the diagnosis of patients with dyspnea of cardiac or pulmonary origin.
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Affiliation(s)
- Ruxandra-Iulia Milos
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Sebastian Röhrich
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Benedikt H. Heidinger
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Florian Prayer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lucian Beer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Wassipaul
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Martin L Watzenboeck
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Svitlana Pochepnia
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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Roy PM, Moumneh T, Penaloza A, Schmidt J, Charpentier S, Joly LM, Riou J, Douillet D. Diagnostic Strategy for Suspected Pulmonary Embolism in Emergency Departments Based on the 4-Level Pulmonary Embolism Clinical Probability Score: Study Protocol of SPEED&PEPS Trial. Diagnostics (Basel) 2022; 12:3101. [PMID: 36553108 PMCID: PMC9777430 DOI: 10.3390/diagnostics12123101] [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: 10/29/2022] [Revised: 11/17/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction: Several strategies have been devised to safely limit the use of thoracic imaging in patients suspected of pulmonary embolism (PE). However, they are based on different rules for clinical probability (CP) assessment, rendering their combination difficult. The four-level pulmonary embolism probability score (4PEPS) allows the combination of all other strategies using a single CP assessment. Methods and analysis: Pragmatic cluster-randomized trial in 20 EDs. Patients with suspected PE will be included and followed for 90 days (number of patients to be included: 2560, 1280 in each arm). Ten centers will be allocated to the control group where physicians will be free to do as they see fit but they will be given the recommendation to apply a validated strategy. Ten centers will be allocated to the interventional group where the physicians will be given the recommendation to apply the 4PEPS strategy. The primary objective will be to demonstrate that the application of the 4PEPS strategy by the emergency physicians, in comparison to current practices, (i) does not increase the risk of serious events related to diagnostic strategies and (ii) significantly reduces the use of thoracic imaging. Ethics and dissemination: The study will be submitted for approval to an institutional ethics review board for all participating centers. If successful, the SPEED&PEPS trial will have an important impact for patients suspected of PE limiting their irradiation and for public health in substantial savings in terms of the direct cost of diagnostic investigations and the indirect cost of hospitalizations due to waiting times or delayed harmful effects. Funding: This work is funded by a French Public Health grant (PREPS-N 2019). The funding source plays no role in the study design, data collection, analysis, interpretation or the writing of the manuscript. Trial registration: ongoing. Trial status: not started.
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Affiliation(s)
- Pierre-Marie Roy
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
| | - Thomas Moumneh
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
| | - Andrea Penaloza
- Cliniques Universitaires St-Luc, Emergency Department, Université Catholique de Louvain, 1200 Bruxelles, Belgium
| | - Jeannot Schmidt
- Clermont-Ferrand University Hospital—Gabriel Montpied, Emergency Department, FCRIN, INNOVTE, 63000 Clermont-Ferrand, France
| | | | - Luc-Marie Joly
- Rouen University Hospital, Emergency Department, 76031 Rouen, France
| | - Jérémie Riou
- Angers University Hospital, Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, Univ Angers, MINT UMR INSERM 1066—CNRS 6021, 49000 Angers, France
| | - Delphine Douillet
- Angers University Hospital, Emergency Department, Univ Angers, MitoVasc UMR CNRS 6015—INSERM 1083, FCRIN, INNOVTE, 49000 Angers, France
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Klemen ND, Feingold PL, Hashimoto B. Reply to R.A. Snyder et al. J Clin Oncol 2022; 40:2512-2513. [PMID: 35580286 PMCID: PMC9467674 DOI: 10.1200/jco.22.00320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nicholas D Klemen
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Paul L Feingold
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Barry Hashimoto
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
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9
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Klemen ND, Feingold PL, Hashimoto B. How Strong Is the Evidence Supporting Thromboprophylaxis in Surgical Oncology? J Clin Oncol 2022; 40:320-323. [PMID: 34871037 PMCID: PMC9851687 DOI: 10.1200/jco.21.01934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Nicholas D. Klemen
- Surgery Branch, National Cancer Institute, Bethesda, MD,Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, National Institutes of Health, 10 Center Dr, CRC, Building 10, Bethesda, MD 20892; e-mail:
| | - Paul L. Feingold
- Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Barry Hashimoto
- Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
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10
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Tritschler T, Salvatore SP, Kahn SR, Garcia D, Delluc A, Kraaijpoel N, Langlois N, Girard P, Le Gal G. ISTH definition of pulmonary embolism-related death and classification of the cause of death in venous thromboembolism studies: Validation in an autopsy cohort. J Thromb Haemost 2021; 19:2514-2521. [PMID: 34255928 DOI: 10.1111/jth.15458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/09/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The International Society on Thrombosis and Haemostasis (ISTH)'s Scientific and Standardization Committee (SSC) recently proposed a definition of pulmonary embolism (PE)-related death. OBJECTIVES To evaluate the accuracy and interrater reliability of the ISTH definition of PE-related death in an autopsy cohort. METHODS We reviewed reports of 1064 consecutive adult autopsies that were performed at the NewYork-Presbyterian Hospital from January 2010 until July 2019. We included all patients with autopsy-confirmed PE-related death (cases) during that time frame, combined with patients who died in 2018 from a cause other than PE (controls). Based on clinical summaries, two adjudicators independently adjudicated the cause of death in each patient using the ISTH classification for the cause of death, blinded to the case/control status and ratio. The primary outcome was autopsy-confirmed PE-related death. We determined the sensitivity and specificity of the ISTH definition to identify autopsy-confirmed PE-related death, and its interrater reliability using the percentage agreement and Cohen's kappa. RESULTS A total of 126 patients who underwent autopsy were included in the analysis (median age, 68 years [range, 21-94], 60 [48%] women), of which 29 (23%) had died from PE as confirmed by autopsy. The ISTH definition's sensitivity and specificity for autopsy-confirmed PE-related death were 45% (95% CI, 26-64) and 99% (95% CI, 94-100), respectively. Interrater reliability for PE-related death was substantial (percentage agreement, 94% [95% CI, 89-97]; kappa, 0.73 [95% CI, 0.55-0.97]). CONCLUSION Adjudication of the cause of death using the ISTH definition resulted in very high specificity, moderate sensitivity, and good interrater reliability for PE-related death.
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Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steven P Salvatore
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Divisions of Internal Medicine and Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - David Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Aurélien Delluc
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris; Institut Mutualiste Montsouris, Paris, France
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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11
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Tan Y, Yan M, Cheng Z, Pan X. Pulmonary Thromboembolism in Immune Thrombocytopenia: A Report of Five Cases and a Review of the Literature. Int J Gen Med 2021; 14:4479-4483. [PMID: 34413675 PMCID: PMC8370587 DOI: 10.2147/ijgm.s323146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/22/2021] [Indexed: 01/06/2023] Open
Abstract
Objective To provide a reference for the diagnosis and treatment of patients with immune thrombocytopenia (ITP) complicated with pulmonary thromboembolism (PTE) by analyzing the clinical characteristics of five such patients. Methods This paper summarizes the clinical manifestations and hematological indexes of five patients with ITP complicated with pulmonary embolism. Results In this study, the incidence of ITP complicated with PTE was 2.75%. All five cases were elderly patients with nonspecific clinical manifestations. Platelet counts were different when PTE occurred. The time from the diagnosis of ITP to the occurrence of PTE was from 5 to 24 months, with an average of 12.8 months. There was no significant change in hemoglobin, white blood cell levels, prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen levels, or the international normalized ratio. Four patients had significantly increased D-dimer levels, while D-dimer was only slightly increased in one patient. Antithrombin (AT) was significantly decreased in four cases (less than 70%), and C-reactive protein (CRP) was increased in all five cases. Conclusion PTE may be related to AT and CRP in patients with ITP, which is of great clinical significance to the diagnosis and treatment of ITP complicated with PTE.
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Affiliation(s)
- Yong Tan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Min Yan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Zhen Cheng
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
| | - Xiangtao Pan
- Department of Haematology, The Taicang Hospital Affiliated of Soochow University, Taicang, 215400, Jiangsu, People's Republic of China
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12
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Risk of recurrent venous thromboembolism and bleeding in patients with interstitial lung disease: a cohort study. J Thromb Thrombolysis 2021; 53:67-73. [PMID: 34232453 DOI: 10.1007/s11239-021-02518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
Interstitial lung disease (ILD) encompasses various parenchymal lung disorders, which has the potential to increase the risk of venous thromboembolism (VTE). To evaluate, in patients with ILD and VTE, the risk of recurrent VTE during follow-up after stopping anticoagulation. This was a cohort of patients with a first VTE recruited between 1997 and 2015. The primary outcome was adjudicated fatal or nonfatal recurrent VTE after stopping anticoagulation. Main secondary outcomes were major or clinically relevant non-major bleeding under anticoagulation. Among 4314 patients with VTE, 50 had ILD diagnosed before VTE. Of these, anticoagulation was stopped in 30 patients after a median duration of 180 days and continued indefinitely in 20 patients. During a median follow-up of 27.8 months after anticoagulation discontinuation, recurrent VTE occurred in 15 on 30 patients (annual incidence of 19.2 events per 100-person-years [95%CI 12.0-29.3], case-fatality rate of 6.7% [95%CI 1.21-29.8]). The risk of recurrence was threefold higher when VTE was unprovoked and case-fatality rate of recurrence was increased by 3 when VTE index was PE. During the anticoagulant period, (median duration of 8.6 months), 6 patients had a major or clinically relevant bleeding (annual incidence of 7.3 events per 100-person-years [95%CI 3.4-15.1], case-fatality rate of 16.7% [95%CI 3.0-56.4]). In patients with ILD, the risk of recurrent VTE after stopping anticoagulation and the risk of bleeding under anticoagulation were very high. Our results suggest that anticoagulation should not be prolonged beyond 3-6 months of anticoagulation in most of cases.
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13
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Abstract
BACKGROUND Pilonidal sinus is a hole in the natal cleft which may cause severe pain and become infected. The evidence base for management of pilonidal sinus is said to be poor quality, poorly focused and rapidly proliferating. We undertook a systematic mapping review to provide a broad overview of the field and support the identification of research priorities. METHODS We searched MEDLINE, CINAHL, and EMBASE from inception to 22nd Nov 2020 for primary research studies focused on the management of pilonidal sinus. We extracted data on study design and categorised studies under five major headings ('non-surgical treatment', 'surgical treatment', 'aftercare' and 'other'), producing frequency counts for different study designs. Gaps in research were identified from published systematic reviews and tabulated. RESULTS We identified 983 eligible studies, of which 36 were systematic reviews and/or meta-analyses; 121 were randomised controlled trials), and 826 observational studies of various design. The majority of studies evaluated surgical techniques (n = 665), or adjuvant medical interventions (n = 98). The literature on wound care has developed most recently, and the evidence base includes 30% randomised controlled trials. Gaps analysis highlighted comparison of surgical techniques including flaps, laser depilation, and wound care interventions as potential areas for randomised controlled trials. CONCLUSIONS This mapping review summarises eight decades of research on the management of pilonidal sinus. Further research is needed to identify front-running interventions, understand variation in practice and patient values, and to prioritise future research.
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14
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van Dam LF, Kroft LJM, Huisman MV, Ninaber MK, Klok FA. Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism. TH OPEN 2021; 5:e66-e72. [PMID: 33585787 PMCID: PMC7875679 DOI: 10.1055/s-0041-1723782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background
Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE.
Patients and Methods
This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death.
Results
We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (
n
= 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (
n
= 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19,
p
= 0.02).
Conclusion
CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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15
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Tritschler T, Langlois N, Hutton B, Shea BJ, Shorr R, Ng S, Dubois S, West C, Iorio A, Tugwell P, Le Gal G. Protocol for a scoping review of outcomes in clinical studies of interventions for venous thromboembolism in adults. BMJ Open 2020; 10:e040122. [PMID: 33293309 PMCID: PMC7722803 DOI: 10.1136/bmjopen-2020-040122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common, potentially fatal yet treatable disease. Several advances in treatment of VTE have been made over the past decades, but definition and reporting of outcomes across those studies are inconsistent. Development of an international core outcome set for clinical studies of interventions for VTE addresses this lack of standardisation. The first step in the development of a core outcome set is to conduct a scoping review which aims to generate an inclusive list of unique outcomes that have been reported in previous studies. METHODS AND ANALYSIS MEDLINE, Embase and the Cochrane Central Register of Controlled Trials will be searched with no language restriction for prospective studies reporting on interventions for treatment of VTE in patients who are adult and non-pregnant. Records will be sorted in reverse chronological order. Study screening and data extraction will be independently performed by two authors in blocks based on date of publication, starting with 2015 to 2020 and subsequent 1-year periods, until no new outcome measures are identified from the set of included studies. After homogenising spelling and combining outcomes with the same meaning, a list of unique outcomes will be determined. Those outcomes will be grouped into outcome domains. Qualitative analysis and descriptive statistics will be used to report results. ETHICS AND DISSEMINATION Ethical approval is not required for this study. The results of this scoping review will be presented at scientific conferences, published in a peer-reviewed journal, and they will provide candidate outcome domains to be considered in subsequent steps in the development of a core outcome set for clinical studies of interventions for VTE. PROTOCOL REGISTRATION DETAILS: http://hdl.handle.net/10393/40459.
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Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Beverley J Shea
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sara Ng
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Suzanne Dubois
- Canadian Venous Thromboembolism Research Network (CanVECTOR), Patient Partner Platform, Ottawa, Ontario, Canada
| | - Carol West
- Canadian Venous Thromboembolism Research Network (CanVECTOR), Patient Partner Platform, Ottawa, Ontario, Canada
| | - Alfonso Iorio
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tugwell
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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16
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Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000-18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database. THE LANCET RESPIRATORY MEDICINE 2020; 9:33-42. [PMID: 33058771 PMCID: PMC7550106 DOI: 10.1016/s2213-2600(20)30417-3] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pulmonary embolism (PE)-related mortality is decreasing in Europe. However, time trends in the USA and Canada remain uncertain because the most recent analyses of PE-related mortality were published in the early 2000s. METHODS For this retrospective epidemiological study, we accessed medically certified vital registration data from the WHO Mortality Database (USA and Canada, 2000-17) and the Multiple Cause of Death database produced by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2000-18). We investigated contemporary time trends in PE-related mortality in the USA and Canada and the prevalence of conditions contributing to PE-related mortality reported on the death certificates. We also estimated PE-related mortality by age group and sex. A subgroup analysis by race was performed for the USA. FINDINGS In the USA, the age-standardised annual mortality rate (PE as the underlying cause) decreased from 6·0 deaths per 100 000 population (95% CI 5·9-6·1) in 2000 to 4·4 deaths per 100 000 population (4·3-4·5) in 2006. Thereafter, it continued to decrease to 4·1 deaths per 100 000 population (4·0-4·2) in women in 2017 and plateaued at 4·5 deaths per 100 000 population (4·4-4·7) in men in 2017. Among adults aged 25-64 years, it increased after 2006. The median age at death from PE decreased from 73 years to 68 years (2000-18). The prevalence of cancer, respiratory diseases, and infections as a contributing cause of PE-related death increased in all age categories from 2000 to 2018. The annual age-standardised PE-related mortality was consistently higher by up to 50% in Black individuals than in White individuals; these rates were approximately 50% higher in White individuals than in those of other races. In Canada, the annual age-standardised mortality rate from PE as the underlying cause of death decreased from 4·7 deaths per 100 000 population (4·4-5·0) in 2000 to 2·6 deaths per 100 000 population (2·4-2·8) in 2017; this decline slowed after 2006 across age groups and sexes. INTERPRETATION After 2006, the initially decreasing PE-related mortality rates in North America progressively reached a plateau in Canada, while a rebound increase was observed among young and middle-aged adults in the USA. These findings parallel recent upward trends in mortality from other cardiovascular diseases and might reflect increasing inequalities in the exposure to risk factors and access to health care. FUNDING None.
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17
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Direct oral anticoagulants for cancer-associated venous thromboembolism: a systematic review and meta-analysis. Blood 2020; 136:1433-1441. [DOI: 10.1182/blood.2020005819] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
Abstract
Direct oral anticoagulants (DOACs) are an emerging treatment option for patients with cancer and acute venous thromboembolism (VTE), but studies have reported inconsistent results. This systematic review and meta-analysis compared the efficacy and safety of DOACs and low-molecular-weight heparins (LMWHs) in these patients. MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and conference proceedings were searched to identify relevant randomized controlled trials. Additional data were obtained from the original authors to homogenize definitions for all study outcomes. The primary efficacy and safety outcomes were recurrent VTE and major bleeding, respectively. Other outcomes included the composite of recurrent VTE and major bleeding, clinically relevant nonmajor bleeding (CRNMB), and all-cause mortality. Summary relative risks (RRs) were calculated in a random effects meta-analysis. In the primary analysis comprising 2607 patients, the risk of recurrent VTE was nonsignificantly lower with DOACs than with LMWHs (RR, 0.68; 95% CI, 0.39-1.17). Conversely, the risks of major bleeding (RR, 1.36; 95% CI, 0.55-3.35) and CRNMB (RR, 1.63; 95% CI, 0.73-3.64) were nonsignificantly higher. The risk of the composite of recurrent VTE or major bleeding was nonsignificantly lower with DOACs than with LMWHs (RR, 0.86; 95% CI, 0.60-1.23). Mortality was comparable in both groups (RR, 0.96; 95% CI, 0.68-1.36). Findings were consistent during the on-treatment period and in those with incidental VTE. In conclusion, DOACs are an effective treatment option for patients with cancer and acute VTE, although caution is needed in patients at high risk of bleeding.
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18
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Abstract
Given the broad treatment options, risk stratification of pulmonary embolism is a highly desirable component of management. The ideal tool identifies patients at risk of death from the original or recurrent pulmonary embolism. Using all-cause death in the first 30-days after pulmonary embolism diagnosis as a surrogate, clinical parameters, biomarkers, and radiologic evidence of right ventricular dysfunction and strain are predictive. However, no study has demonstrated improved mortality rates after implementation of a risk stratification strategy to guide treatment. Further research should use better methodology to study prognosis and test new management strategies in patients at high risk for death.
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Affiliation(s)
- Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Angers, 4 rue Larrey, 49100 Angers, France; MITOVASC Institute, UMR CNRS 6015 UMR INSERM 1083, Angers University, 28, rue Roger-Amsler, 49045 Angers, France; University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Road, Suite M1857, PO Box 206, Ottawa, Ontario K1H 8L6, Canada.
| | - Sebastien Miranda
- University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada; Department of Internal Medicine, Vascular and Thrombosis Unit, Rouen University Hospital, 37 Boulevard Gambetta, 76000 Rouen, France; Normandie University, UNIROUEN, INSERM U1096, 22 Boulevard Gambetta, 76000 Rouen, France
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19
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Tritschler T, Kraaijpoel N, Girard P, Büller HR, Langlois N, Righini M, Schulman S, Segers A, Le Gal G. Definition of pulmonary embolism-related death and classification of the cause of death in venous thromboembolism studies: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:1495-1500. [PMID: 32496023 DOI: 10.1111/jth.14769] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 01/18/2023]
Abstract
Pulmonary embolism (PE)-related death is often a component of the primary outcome in venous thromboembolism (VTE) clinical studies. Definitions for PE-related death vary widely, which may lead to biased risk estimates of clinical outcomes, thereby affecting both internal and external validity of study results. We here provide a standardized definition of PE-related death and propose guidance for classification and reporting of the cause of death for clinical studies in VTE. The proposal was developed in a four-step process, including a systematic review of definitions used for PE-related death in previous studies, two subsequent surveys with VTE experts, and meetings held within the Scientific and Standardization Committee (SSC) working group until consensus on the proposal was reached. The proposed classification comprises three categories: Category A: PE-related death, category B: undetermined cause of death, and category C: cause of death other than PE. Category A includes A1: autopsy-confirmed PE in the absence of another more likely cause of death; A2: objectively confirmed PE before death in the absence of another more likely cause of death; and A3: PE is not objectively confirmed, but is most likely the main cause of death. Category B includes B1: cause of death is undetermined, despite available information; and B2: insufficient clinical information available to determine the cause of death. The use of the proposed definition will hopefully improve the accuracy of study outcomes, between-study comparisons, meta-analyses, and validity of future clinical VTE studies.
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Affiliation(s)
- Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Paris, France
- Institut Mutualiste Montsouris, Paris, France
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Annelise Segers
- ITREAS, Academic Research Organization, Amsterdam, the Netherlands
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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20
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Tritschler T, Kraaijpoel N, Langlois N, Girard P, Schulman S, Büller HR, Segers A, Righini M, Le Gal G. Development of a standardized definition of pulmonary embolism-related death: A cross-sectional survey of international thrombosis experts. J Thromb Haemost 2020; 18:1415-1420. [PMID: 32073218 DOI: 10.1111/jth.14775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE)-related death is often part of the primary outcome in venous thromboembolism (VTE) studies. The Scientific and Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis developed a definition for PE-related death and classification of the cause of death. The present survey evaluated a preliminary version of this definition and classification. METHODS Sixty-nine VTE experts from nine countries were invited for a cross-sectional online survey on January 15, 2019, including multiple-choice and open-ended questions on a seven-subcategory classification of the cause of death. Descriptive statistics were used to describe the results; qualitative comments were summarized. RESULTS Forty of 69 (58%) invitees completed the survey. All respondents agreed that guidance on classification of the cause of death in VTE studies is required. There was high agreement on the proposal (median overall score, 6; interquartile range, 6-7; scale from 1 [poor] to 7 [excellent]). All respondents approved the wording and content of the seven subcategories, except for one disagreeing vote for two subcategories (A3: "PE is not objectively confirmed, but is most likely the main cause of death" and C1: "Another cause of death is more likely than PE but has not been objectively confirmed"). Suggestions for improvement mainly concerned the extensiveness of the criteria and clinical situations described to define the cause of death. CONCLUSION Acceptance of the proposal was excellent. Suggestions for improvement were incorporated in the SSC communication on the definition of PE-related death and classification of the cause of death in VTE studies.
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Affiliation(s)
- Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Annelise Segers
- ITREAS, Academic Research Organization, Amsterdam, the Netherlands
| | - Marc Righini
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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21
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Barco S, Sebastian T. Death from, with, and without pulmonary embolism. Eur J Intern Med 2020; 73:25-26. [PMID: 32051093 DOI: 10.1016/j.ejim.2020.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Rämistrasse 100, RAE C 04, 8091 Zurich, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.
| | - Tim Sebastian
- Clinic of Angiology, University Hospital Zurich, Rämistrasse 100, RAE C 04, 8091 Zurich, Switzerland
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22
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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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23
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Home treatment of patients with cancer-associated venous thromboembolism - An evaluation of daily practice. Thromb Res 2019; 184:122-128. [PMID: 31731069 DOI: 10.1016/j.thromres.2019.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Home treatment of cancer-associated venous thromboembolism (VTE) is challenging due to the high risk of adverse events. While home treatment is quite agreeable to cancer patients, studies evaluating the safety of VTE home treatment in this setting are largely unavailable. METHODS This was an observational study in patients with cancer-associated VTE. The main outcomes were the proportion of patients treated at home (hospital discharge <24 h after diagnosis) and the 3-month incidence of VTE-related adverse events (major bleeding, recurrent VTE and/or suspected VTE-related mortality) in patients managed in hospital versus at home. RESULTS A total of 183 outpatients were diagnosed with cancer-associated VTE: 69 had deep vein thrombosis (DVT) and 114 had pulmonary embolism (PE ± DVT). Of those, 120 (66%) were treated at home; this was 83% for patients with DVT and 55% for patients with PE (±DVT). The 3-month incidence of any VTE-related adverse event was 13% in those treated at home versus 19% in the hospitalized patients (HR 0.48; 95%CI 0.22-1.1), independent of initial presentation as PE or DVT. All-cause 3-month mortality occurred in 33 patients treated as inpatient (54%) compared to 29 patients treated at home (24%; crude HR 3.1 95%CI 1.9-5.0). CONCLUSIONS Two-third of patients with cancer-associated VTE - including PE - were selected to start anticoagulant treatment at home. Cancer-associated VTE is associated with high rates of VTE-related adverse events independent of initial in hospital or home treatment. However, home treatment may be a good option for selected patients with cancer-associated DVT or PE.
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