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Kammath V, Gupta A, Bald A, Hope G, Kansal N, Al Samaraee A, Bhattacharya V. A Three-year Retrospective Study Looking at Preventing Hospital Acquired Thrombosis. Cardiovasc Hematol Agents Med Chem 2024; 22:212-222. [PMID: 38288832 DOI: 10.2174/0118715257269027231228114930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/13/2023] [Accepted: 12/06/2023] [Indexed: 07/09/2024]
Abstract
BACKGROUND Hospital-acquired venous thromboembolism (HA-VTE) is defined as cases of venous thromboembolism (VTE) that occur in a hospital and within ninety days of a hospital admission. Deep vein thromboses (DVTs) most commonly occur within the deep veins of the pelvis and legs. If the thrombus dislodges and travels to the lungs, it can result in a pulmonary embolus (PE). VTE is associated with significant morbidity and mortality, accounting for almost 10% of all hospital deaths. If risk factors are correctly identified and VTE prophylaxis is prescribed, VTE can be a preventable condition. In 2010, NHS England launched The National Venous Thromboembolism Prevention Programme. This included NICE guidance, and a VTE risk assessment tool, which must be completed for at least 95% of patients on admission. The National Thrombosis Survey, published by Thrombosis UK, studied how this program was implemented locally, and audited HA-VTE prevention strategies nationally. OBJECTIVES Using the Thrombosis Survey and NICE guidance as an aide, this study collects data about hospital-acquired DVT (HA-DVT) at the Queen Elizabeth Hospital in Gateshead (QEH) and aims to: 1. Identify cases of HA-DVT and understand the clinical circumstances surrounding these cases 2. Assess the quality of VTE preventative measures at QEH 3. Outline potential improvement in reducing the incidence of HA-VTE at this hospital Methods: This retrospective cohort study used electronic records to identify all cases of DVT between April 2019 and April 2022 at QEH. Cases of HA-DVT were defined as: a positive ultrasound doppler report and either the case occurring in the 90 days following an inpatient stay, or beyond two days into an admission. For these cases of HA-DVT, we recorded the: reason for admission; admitting specialty; presence of an underlying active cancer and deaths occurring within 90 days of diagnosis. We assessed the quality of VTE preventative measures, by recording the: completion of VTE risk assessments; prescription of weight-adjusted pharmacological VTE prophylaxis and provision of VTE prophylaxis on discharge. For HA-DVT cases occurring within 90 days of an inpatient stay, the preventative measures were assessed on the original admission. Electronic records were used to record the completion rate of the National VTE risk assessment tool for all inpatients during this time frame. RESULTS The VTE risk assessment tool was completed for 98.5% of all admissions. One hundred and thirty-five cases of HA-DVT were identified between April 2019 and April 2022. Sixteen patients with HA-DVT did not have VTE prophylaxis prescribed on admission. Eleven of these patients had a clearly documented reason why anticoagulation was avoided. In HA-DVT cases where pharmacological VTE prophylaxis was prescribed, 23% were prescribed an inappropriate dose for their weight. If anticoagulation was required on discharge, this was prescribed appropriately in 94% of cases. About 31% of the patients with HA-DVT had an underlying active malignancy. Thirty-nine patients died within 90 days of the DVT being diagnosed; in only 1 case was VTE thought to be a contributing factor to death. CONCLUSION The hospital exceeded the national standard of VTE risk assessment completion on admission (greater than 95%). For almost a quarter of patients with HA-DVT, the dose of thromboprophylaxis prescribed was not appropriate for weight. In five cases of HA-DVT, thromboprophylaxis was omitted with no clear justification. HA-DVT often affects the most clinically vulnerable patients and is associated with a high mortality.
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Affiliation(s)
- Vipin Kammath
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
| | - Anuj Gupta
- Newcastle University Medical School, Newcastle, UK
| | - Alexander Bald
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
| | - Gavin Hope
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
| | - Nisheeth Kansal
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
| | - Ahmad Al Samaraee
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
| | - Vish Bhattacharya
- Department of Surgery, Queen Elizabeth Hospital NHS Foundation Trust, Gateshead, UK
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Kumar S, Azadi N, Emerson D, Santoso J. Randomized Trial of Sequential Compression Versus Ankle-Calf Movement to Increase Femoral Venous Velocity. Cureus 2023; 15:e48070. [PMID: 37927740 PMCID: PMC10620617 DOI: 10.7759/cureus.48070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/07/2023] Open
Abstract
Objective In postoperative patients with a high risk of bleeding, sequential compression devices (SCD) and ambulation are effective methods to reduce venous thromboembolic (VTE) risks. High leg venous flow decreases VTE risk. We postulated that ankle flexion and extension (AFE) while in bed increased leg venous flow velocity as well. We wished to compare the effectiveness of SCD versus AFE in increasing leg venous velocity. Methods Thirty-two healthy volunteers were recruited into the study. Each subject had two legs that were randomized into SCD or AFE. After 15 minutes of rest, SCD or AFE was applied, followed by 15 minutes of rest, and then an alternate treatment was given to the second leg. The sequence of leg and methodology was then reversed so the second treatment was applied to the first leg, and the first treatment to the second leg, and measurements were obtained. All treatments were separated by a rest period of 15 minutes. The venous velocity on each leg was measured by Doppler ultrasound at the superficial femoral vein. Venous velocity was measured initially (first cycle peak venous velocity) and during subsequent cycles. The alternate treatments on both legs with both treatments allowed for analysis in a manner where each subject could act as its control. Results Relative to baseline bed rest, SCD increased peak venous flow velocity by 112%, while AFE increased peak venous flow velocity by 161%. AFE resulted in 43% higher venous velocity on average than did SCDs (p<0.05). Conclusions AFE leads to significantly higher venous flow in the femoral veins of healthy subjects.
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Affiliation(s)
- Saurabh Kumar
- Obstetrics and Gynecology, University of California, Riverside, USA
| | - Negin Azadi
- Obstetrics and Gynecology, Meharry Medical College, Nashville, USA
| | - Donald Emerson
- Radiology, Methodist Le Bonheur Healthcare, Memphis, USA
| | - Joseph Santoso
- Obstetrics and Gynecology, Gynecologic Oncology, Baptist Medical Group, Memphis, USA
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Kemp M, Chan AHY, Harrison J, Rogers H, Zhao A, Kaur H, Tang G, Yang E, Beyene K. Formal and informal venous thromboembolism risk assessment and impact on prescribing of thromboprophylaxis: a retrospective cohort study. Int J Clin Pharm 2023; 45:864-874. [PMID: 37074512 PMCID: PMC10366250 DOI: 10.1007/s11096-023-01578-w] [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: 11/22/2022] [Accepted: 03/13/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Hospital-acquired thrombosis (HAT) is a leading cause of preventable death and disability worldwide. HAT includes any venous thromboembolic (VTE) event occurring in-hospital or within 90-days of hospitalisation. Despite availability of evidence-based guidelines for HAT risk assessment and prophylaxis, guidelines are still underutilised. AIM To determine the proportion of patients who developed HAT that could have been potentially prevented with appropriate VTE risk assessment and prophylaxis at a large public hospital in New Zealand. Additionally, the predictors of VTE risk assessment and thromboprophylaxis were examined. METHOD VTE patients admitted under general medicine, reablement, general surgery, or orthopaedic surgery service were identified using ICD-10-AM codes. Data were collected on patient characteristics, VTE risk factors, and the thromboprophylaxis regimen prescribed. The hospital VTE guidelines were used to determine rates of VTE risk assessment and the appropriateness of thromboprophylaxis. RESULTS Of 1302 VTE patients, 213 HATs were identified. Of these, 116 (54%) received VTE risk assessment, and 98 (46%) received thromboprophylaxis. Patients who received VTE risk assessment were 15 times more likely to receive thromboprophylaxis (odds ratio [OR] = 15.4; 95% CI 7.65-30.98) and 2.8 times more likely to receive appropriate thromboprophylaxis (OR = 2.79; 95% CI 1.59-4.89). CONCLUSION A large proportion of high-risk patients who were admitted to medical, general surgery and reablement services and who developed HAT did not receive VTE risk assessment and thromboprophylaxis during their index admission, demonstrating a significant gap between guideline recommendations and clinical practice. Implementing mandatory VTE risk assessment and adherence to guidelines to improve thromboprophylaxis prescription in hospitalised patients may help reduce the burden of HAT.
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Affiliation(s)
- Megan Kemp
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Pharmacy Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Amy Hai Yan Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Jeff Harrison
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Hannah Rogers
- Pharmacy Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Adele Zhao
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Harleen Kaur
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Genevieve Tang
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Esther Yang
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Kebede Beyene
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
- Department of Pharmaceutical and Administrative Sciences, St Louis College of Pharmacy, University of Health Sciences and Pharmacy in St. Louis, 1 Pharmacy Place, St. Louis, MO, 63110, USA.
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Muacevic A, Adler JR. Perioperative Challenges in a Septic Shock Patient With Extensive Splanchnic and Extra-Splanchnic Vein Thrombosis Up to the Right Atrium. Cureus 2022; 14:e32935. [PMID: 36712719 PMCID: PMC9873450 DOI: 10.7759/cureus.32935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 12/27/2022] Open
Abstract
Venous thromboembolism (VTE) has a significant disease burden worldwide and comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT most commonly occurs in the lower extremities, very rarely it can present in the splanchnic venous circulation or inferior vena cava or both. We report an unusual presentation of a 68-year-old woman with septic shock secondary to ischemic bowel, complicated by non-tumor related, extensive right hepatic vein thrombosis extending up to the inferior vena cava (IVC) and right atrium. She underwent bowel resection surgery emergently and was started on systemic anticoagulation in the perioperative period after an extensive evaluation and resuscitation. She was managed by a multidisciplinary team during her admission and was discharged after four weeks. This case poses an interesting therapeutic challenge to the team as there is little literature to guide treatment in a critically ill patient with ischemic bowel, septic shock with extensive splanchnic and IVC thrombosis who also had likely pseudo-heparin resistance with artifactual activated partial thromboplastin time (aPTT) values. This case report seeks to share our experience of a multidisciplinary and patient-centric approach in this rare presentation of a disease spectrum.
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Trihan JE, Adam M, Jidal S, Aichoun I, Coudray S, Laurent J, Chaussavoine L, Chausserie S, Guillaumat J, Lanéelle D, Perez-Martin A. Performance of the Wells score in predicting deep vein thrombosis in medical and surgical hospitalized patients with or without thromboprophylaxis: The R-WITT study. Vasc Med 2021; 26:288-296. [PMID: 33749393 DOI: 10.1177/1358863x21994672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Wells score had shown weak performance to determine pre-test probability of deep vein thrombosis (DVT) for inpatients. So, we evaluated the impact of thromboprophylaxis on the utility of the Wells score for risk stratification of inpatients with suspected DVT. This bicentric cross-sectional study from February 1, 2018 to January 31, 2019 included consecutive medical and surgical inpatients who underwent lower limb ultrasound study for suspected DVT. Wells score clinical predictors were assessed by both ordering and vascular physicians within 24 h after clinical suspicion of DVT. Primary outcome was the Wells score's accuracy for pre-test risk stratification of suspected DVT, accounting for anticoagulation (AC) treatment (thromboprophylaxis for ⩾ 72 hours or long-term anticoagulation). We compared prevalence of proximal DVT among the low, moderate and high pre-test probability groups. The discrimination accuracy was defined as area under the receiver operating characteristics (ROC) curve. Of the 415 included patients, 30 (7.2%) had proximal DVT. Prevalence of proximal DVT was lower than expected in all pre-test probability groups. The prevalence in low, moderate and high pre-test probability groups was 0.0%, 3.1% and 8.2% (p = 0.22) and 1.7%, 4.2% and 25.8% (p < 0.001) for inpatients with or without AC, respectively. Area under ROC curves for discriminatory accuracy of the Wells score, for risk of proximal DVT with or without AC, was 0.72 and 0.88, respectively. The Wells score performed poorly for discrimination of risk for proximal DVT in hospitalized patients with AC but performed reasonably well among patients without AC; and showed low inter-rater reliability between physicians. ClinicalTrials.gov Identifier: NCT03784937.
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Affiliation(s)
- Jean-Eudes Trihan
- Vascular Medicine Department, University Hospital Poitiers, Poitiers, France
| | - Michael Adam
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Sara Jidal
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Isabelle Aichoun
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Sarah Coudray
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Jeremy Laurent
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
| | - Laurent Chaussavoine
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Sebastien Chausserie
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Jerome Guillaumat
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Damien Lanéelle
- Vascular Medicine Department, University Hospital Caen, Caen, Basse-Normandie, France
| | - Antonia Perez-Martin
- Vascular Medicine Department, University Hospital Nîmes, Nîmes, Languedoc-Roussillon, France
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Post-Discharge Prophylaxis With Rivaroxaban Reduces Fatal and Major Thromboembolic Events in Medically Ill Patients. J Am Coll Cardiol 2021; 75:3140-3147. [PMID: 32586587 PMCID: PMC7308003 DOI: 10.1016/j.jacc.2020.04.071] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/17/2022]
Abstract
Background Hospitalized acutely ill medical patients are at risk for fatal and major thromboembolic events. Whether use of extended-duration primary thromboprophylaxis can prevent such events is unknown. Objectives The purpose of this study was to evaluate whether extended-duration rivaroxaban reduces the risk of venous and arterial fatal and major thromboembolic events without significantly increasing major bleeding in acutely ill medical patients after discharge. Methods MARINER (A Study of Rivaroxaban [JNJ-39039039] on the Venous Thromboembolic Risk in Post-Hospital Discharge Patients) studied acutely ill medical patients with additional risk factors for venous thromboembolism (VTE). Medically ill patients with a baseline creatinine clearance ≥50 ml/min were randomized in a double-blind fashion to rivaroxaban 10 mg or placebo daily at hospital discharge for 45 days. Exploratory efficacy analyses were performed with the intent-to-treat population including all data through day 45. Time-to-event curves were calculated using the Kaplan-Meier method. A blinded independent committee adjudicated all clinical events. Results In total, 4,909 patients were assigned to rivaroxaban and 4,913 patients to placebo. The mean age was 67.8 years, 55.5% were men, mean baseline creatinine clearance was 87.8 ml/min, and mean duration of hospitalization was 6.7 days. The pre-specified composite efficacy endpoint (symptomatic VTE, myocardial infarction, nonhemorrhagic stroke, and cardiovascular death) occurred in 1.28% and 1.77% of patients in the rivaroxaban and placebo groups, respectively (hazard ratio: 0.72; 95% confidence interval: 0.52 to 1.00; p = 0.049), whereas major bleeding occurred in 0.27% and 0.18% of patients in the rivaroxaban and placebo groups, respectively (hazard ratio: 1.44; 95% confidence interval: 0.62 to 3.37; p = 0.398). Conclusions Extended-duration rivaroxaban in hospitalized medically ill patients resulted in a 28% reduction in fatal and major thromboembolic events without a significant increase in major bleeding. (A Study of Rivaroxaban [JNJ-39039039] on the Venous Thromboembolic Risk in Post-Hospital Discharge Patients [MARINER]; NCT02111564)
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Uppuluri EM, Shapiro NL. Development of pulmonary embolism in a nonhospitalized patient with COVID-19 who did not receive venous thromboembolism prophylaxis. Am J Health Syst Pharm 2020; 77:1957-1960. [PMID: 32780839 PMCID: PMC7454312 DOI: 10.1093/ajhp/zxaa286] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Coronavirus disease 2019 (COVID-19) has been associated with thrombotic complications such as stroke and venous thromboembolism (VTE), and VTE prophylaxis for hospitalized patients with COVID-19 is recommended. However, extended postdischarge VTE prophylaxis and VTE prophylaxis for nonhospitalized patients with COVID-19 are not routinely recommended due to uncertain benefit in these populations. SUMMARY Here we report development of a pulmonary embolism (PE) in a young patient without other VTE risk factors who was treated for COVID-19 in an emergency department (ED) and discharged home without VTE prophylaxis, which was consistent with current recommendations. The patient presented to the ED 12 days later with complaints of chest pain for 1 day and was found to have a PE within the segmental and subsegmental branches of the left lower lobe. CONCLUSION This case suggests that nonhospitalized patients with COVID-19 may be at higher risk for VTE than patients with other medical illnesses and warrants further research into the risk of VTE in outpatients with COVID-19.
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Affiliation(s)
- Ellen M Uppuluri
- University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Nancy L Shapiro
- University of Illinois at Chicago College of Pharmacy, Chicago, IL
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Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative. Am J Med 2020; 133 Suppl 1:1-27. [PMID: 32362349 DOI: 10.1016/j.amjmed.2019.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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Abstract
Venous thromboembolism (VTE) remains highly prevalent in medically ill patients, and often leads to increased mortality and cost burden during hospitalization and post-discharge. Nearly half of all VTEs occur during or after hospitalization, with pulmonary embolism accounting for 10% of inpatient mortality. Appropriate prophylaxis in high-risk medically ill patients has been shown to reduce risk of VTE and related mortality. Despite current evidence-based guidelines, VTE prophylaxis has been under-used. This owes greatly to ambiguity and concerns related to appropriate patient and prophylactic agent selection, and duration of prophylaxis. Because many acutely ill medical patients have multiple comorbidities, the risk of major bleeding must be considered when choosing to implement pharmacological VTE prophylaxis. Multiple risk assessment models have been developed and validated to help estimate VTE and bleeding risks in this population. While studies have shown that the risk for VTE often extends far beyond hospital discharge, there is no evidence to support extending prophylaxis after hospital discharge. The appropriate selection of VTE prophylaxis requires consideration for cost, availability, patient preference, compliance, and underlying comorbidities. Our paper reviews the current evidence and reasoning for appropriate selection of VTE prophylaxis in acutely medical ill patients, and highlights our own approach and recommendations.
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Affiliation(s)
- Nedaa Skeik
- Associate Professor of Medicine, Section Head of Vascular Medicine, Medical Director of Anticoagulation and Thrombophilia Clinic, Medical Director of Vascular Lab and Hyperbaric Oxygen Center, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minnesota, Minneapolis, USA
| | - Emily Westergard
- Internal Medicine Resident, Abbott Northwestern Hospital, Minnesota, Minneapolis, USA
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Laskier V, Guy H, Fisher M, Neuman WR, Bucior I, Cohen AT, Ren S. Effectiveness and safety of betrixaban extended prophylaxis for venous thromboembolism compared with standard-duration prophylaxis intervention in acute medically ill patients: a systematic literature review and network meta-analysis. J Med Econ 2019; 22:1063-1072. [PMID: 31314619 DOI: 10.1080/13696998.2019.1645679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aims: To determine the clinical effectiveness and safety of venous thromboembolism (VTE) prophylaxis using US- and Europe-approved anticoagulants relative to extended-duration VTE prophylaxis with betrixaban. Low molecular weight heparins (LMWHs), unfractionated heparin (UFH), fondaparinux sodium and placebo were each compared to betrixaban, as standard-duration VTE prophylaxis for hospitalized, non-surgical patients with acute medical illness at risk of VTE. Materials and methods: A systematic literature review was conducted up to June 2019 to identify randomized controlled trials (RCTs) of VTE prophylaxis in hospitalized, non-surgical patients with acute medical illness at risk of VTE. Studies that reported the occurrence of VTE events (including death) and, where possible, major bleeding, from treatment initiation to 20-50 days thereafter were retrieved and extracted. A Bayesian fixed effect network meta-analysis was used to estimate efficacy and safety of betrixaban compared with standard-duration VTE prophylaxis. Results: Seven RCTs were analyzed which compared betrixaban, LMWHs, UFH, fondaparinux sodium, or placebo. There were significantly higher odds (median odds [95% credible interval]) of VTE with LMWHs (1.38 [1.12-1.70]), UFH (1.60 [1.05-2.46]), and placebo (2.37 [1.55-3.66]) compared with betrixaban. There were significantly higher odds of VTE-related death with placebo (7.76 [2.14-34.40]) compared with betrixaban. No significant differences were observed for the odds of major bleeding with all comparators, VTE-related death with any active standard-duration VTE prophylaxis, or of VTE with fondaparinux sodium, compared with betrixaban. Limitations and conclusions: In this indirect comparison, betrixaban was shown to be an effective regimen with relative benefits compared with LMWHs and UFH. This indicates that betrixaban could reduce the burden of VTE in at-risk hospitalized patients with acute medical illness who need extended prophylaxis, though without direct comparative evidence, stronger conclusions cannot be drawn.
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Affiliation(s)
| | - Holly Guy
- Health Economics, FIECON Ltd , St Albans , UK
| | - Mark Fisher
- Health Economics, FIECON Ltd , St Albans , UK
| | - W Richey Neuman
- Medical Affairs, Portola Pharmaceuticals, Inc , South San Francisco , CA , USA
| | - Iwona Bucior
- Medical Affairs, Portola Pharmaceuticals, Inc , South San Francisco , CA , USA
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St. Thomas' Hospitals, King's College London , London , UK
| | - Shijie Ren
- HEDS, ScHARR, The University of Sheffield , Sheffield , UK
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D'Ambola M, Fiengo L, Chini MG, Cotugno R, Bader A, Bifulco G, Braca A, De Tommasi N, Dal Piaz F. Fusicoccane Diterpenes from Hypoestes forsskaolii as Heat Shock Protein 90 (Hsp90) Modulators. JOURNAL OF NATURAL PRODUCTS 2019; 82:539-549. [PMID: 30839211 DOI: 10.1021/acs.jnatprod.8b00924] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Ten new (1-10) and six known (11-16) fusicoccane diterpenes were isolated from the roots of Hypoestes forsskaolii. The structural characterization of 1-10 was performed by spectroscopic analysis, including 1D and 2D NMR, ECD, and HRESIMS experiments. From a perspective of obtaining potential Hsp90α inhibitors, the isolates were screened by surface plasmon resonance measurements and their cytotoxic activity was assayed using Jurkat and HeLa cancer cells. Compound 6, 18-hydroxyhypoestenone, was shown to be the most active compound against Hsp90, and its interactions were studied also by biochemical and cellular assays and by molecular docking.
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Affiliation(s)
- Massimiliano D'Ambola
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Lorenzo Fiengo
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Maria Giovanna Chini
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Roberta Cotugno
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Ammar Bader
- Department of Pharmacognosy, Faculty of Pharmacy , Umm Al-Qura University , 21955 Makkah , Saudi Arabia
| | - Giuseppe Bifulco
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Alessandra Braca
- Dipartimento di Farmacia , Università di Pisa , Via Bonanno 33 , 56126 Pisa , Italy
- Centro Interdipartimentale di Ricerca "Nutraceutica e Alimentazione per la Salute" , Università di Pisa , Via del Borghetto 80 , 56124 Pisa , Italy
| | - Nunziatina De Tommasi
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Fabrizio Dal Piaz
- Dipartimento di Farmacia , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
- Dipartimento di Medicina, Chirurgia e Odontoiatria "Scuola Medica Salernitana" , Università degli Studi di Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
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Hospital length of stay in patients initiated on direct oral anticoagulants versus warfarin for venous thromboembolism: a real-world single-center study. J Thromb Thrombolysis 2018; 46:16-21. [PMID: 29626281 DOI: 10.1007/s11239-018-1661-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This study was conducted to describe the real-world hospital length of stay in patients treated with all of the U.S. Food and Drug Administration approved direct oral anticoagulants (DOACs) versus warfarin for new-onset venous thromboembolism (VTE) at a large, tertiary, academic medical center. A retrospective cohort analysis of all adult patients diagnosed with acute onset VTE was conducted. Of the 441 patients included, 261 (57%) patients received DOACs versus 180 (41%) patients received warfarin. In the DOAC group, a total of 92 (35%) patients received rivaroxaban, followed by 83 (32%) patients received apixaban, 50 (19%) patients received dabigatran, and 36 (14%) patients received edoxaban. Patients initiated on DOACs had a statistically significant shorter hospital length of stay compared to patients initiated on warfarin (median 3 days, [IQR 0-5] vs. 8 days [IQR 5-11], P < 0.05). Despite the shorter hospital length of stay in patients receiving DOACs, the overall reported differences between the DOACs group and the warfarin group in terms of recurrent VTE, major bleeding, intracranial bleeding, and gastrointestinal bleeding at 3 and 6 months were deemed to be statistically insignificant.
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Khalfaoui A, Chini MG, Bouheroum M, Belaabed S, Lauro G, Terracciano S, Vaccaro MC, Bruno I, Benayache S, Mancini I, Bifulco G. Glucopyranosylbianthrones from the Algerian Asphodelus tenuifolius: Structural Insights and Biological Evaluation on Melanoma Cancer Cells. JOURNAL OF NATURAL PRODUCTS 2018; 81:1786-1794. [PMID: 30063349 DOI: 10.1021/acs.jnatprod.8b00234] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Two new glucopyranosylbianthrones (1 and 2) were isolated from the aerial part of the plant Asphodelus tenuifolius, collected in Southwest Algeria. The 2D structures of 1 and 2 were defined by NMR analysis, HRESIMS data, and comparison with literature data. The comparison of experimental and calculated electronic circular dichroism and NMR data led to characterization of the ( M) and ( P) atropisomeric forms of the glucopyranosylbianthrones, asphodelins (1) and (2), respectively. The in vitro activities of these two metabolites were evaluated in human melanoma A375 cells, and both the compounds inhibited cell proliferation in a concentration-dependent manner, with IC50 values of 20.6 ± 0.8 and 23.2 ± 1.1 μM, respectively. Considering their biological profile, an inverse virtual screening approach was employed to identify and suggest putative anticancer interacting targets.
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Affiliation(s)
- Ayoub Khalfaoui
- Department of Chemistry, Research Unit, Development of Natural Resources, Bioactive Molecules, Physicochemical and Biological Analysis , University Mentouri Constantine , Route Ain ElBey , 25000 , Constantine , Algeria
| | - Maria G Chini
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Mohamed Bouheroum
- Department of Chemistry, Research Unit, Development of Natural Resources, Bioactive Molecules, Physicochemical and Biological Analysis , University Mentouri Constantine , Route Ain ElBey , 25000 , Constantine , Algeria
| | - Soumia Belaabed
- Department of Chemistry, Research Unit, Development of Natural Resources, Bioactive Molecules, Physicochemical and Biological Analysis , University Mentouri Constantine , Route Ain ElBey , 25000 , Constantine , Algeria
| | - Gianluigi Lauro
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Stefania Terracciano
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Maria C Vaccaro
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Ines Bruno
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
| | - Samir Benayache
- Department of Chemistry, Research Unit, Development of Natural Resources, Bioactive Molecules, Physicochemical and Biological Analysis , University Mentouri Constantine , Route Ain ElBey , 25000 , Constantine , Algeria
| | - Ines Mancini
- Department of Physics , University of Trento , Via Sommarive 14 , I-38123 Povo-Trento , Italy
| | - Giuseppe Bifulco
- Department of Pharmacy , University of Salerno , Via Giovanni Paolo II 132 , 84084 Fisciano ( SA ), Italy
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Highlights: burden of venous thromboembolism and role of extended-duration thromboprophylaxis in acute medically ill patients. Eur Heart J Suppl 2018; 20:E3-E5. [PMID: 29977162 PMCID: PMC6016711 DOI: 10.1093/eurheartj/suy018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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15
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Ageno W, Hunt BJ. Reducing the burden of venous thromboembolism in the acute medically ill population with extended-duration thromboprophylaxis. Eur Heart J Suppl 2018; 20:E6-E11. [PMID: 29977163 PMCID: PMC6016713 DOI: 10.1093/eurheartj/suy015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hospitalized acute medically ill patients are vulnerable to venous thromboembolism (VTE), known as hospital-acquired thrombosis (HAT). The elevated risk of HAT is usually due to a combination of factors, with immobility and a prothrombotic state due to acute illness being the most frequent. The HAT risk persists well after hospital discharge, with more than half of events occurring after patient release. These HAT events may be fatal, and patients who survive the initial event may be subject to VTE recurrence, chronic discomfort from post-thrombotic syndrome and, although rare, may develop chronic thrombo-embolic pulmonary hypertension, which is often debilitating. The risk of HAT can be reduced with effective thromboprophylaxis. Current guidelines recommend thromboprophylaxis with subcutaneous heparin, low molecular weight heparin (LMWH) or fondaparinux for at-risk acute medically ill patients, but reports of real-world practice indicated that some patients do not receive protection in the short-term as outlined by the guidelines. Previous studies that have assessed extended thromboprophylaxis for 4-5 weeks with LMWH or direct oral anticoagulants in medically ill patients found they did not offer a net clinical benefit; any demonstrated efficacy was outweighed by the significantly increased risk of major haemorrhage. Therefore, there is an ongoing need for improved VTE prevention without increasing the risk of bleeding. In the APEX trial, conducted in an acute medically ill population, betrixaban provided a significant reduction in VTE events after 35 to 42 days of treatment compared with short-term enoxaparin without an increase in major bleeding.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
| | - Beverley J Hunt
- Department of Thrombosis & Haemostasis, King's College & Consultant, Guy's & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
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Morrone D, Morrone V. Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean Circ J 2018; 48:365-381. [PMID: 29737640 PMCID: PMC5940642 DOI: 10.4070/kcj.2017.0314] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/27/2018] [Accepted: 04/11/2018] [Indexed: 12/29/2022] Open
Abstract
Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.
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Affiliation(s)
- Doralisa Morrone
- Department of Surgery, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy.
| | - Vincenzo Morrone
- Department of Cardiology, SS. Annunziata Hospital, Taranto, Italy
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Cimminiello C, Prandoni P, Agnelli G, Di Minno G, Polo Friz H, Scaglione F, Boracchi P, Marano G, Harenberg J. Thromboprophylaxis with enoxaparin and direct oral anticoagulants in major orthopedic surgery and acutely ill medical patients: a meta-analysis. Intern Emerg Med 2017; 12:1291-1305. [PMID: 28756546 DOI: 10.1007/s11739-017-1714-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022]
Abstract
Subjects undergoing major orthopedic surgery and acutely ill hospitalized medical patients represent a population at medium-high risk for venous thromboembolism (VTE). They are treated with low molecular weight heparin (LMWH) and direct oral anticoagulants [DOACs] for VTE prevention. We conducted a meta-analysis of phase III randomized clinical trials evaluating LMWH enoxaparin versus DOACs for prophylaxis of VTE by combining studies including patients undergoing elective total hip and knee replacement surgery, and acutely ill hospitalized medical subjects. Studies were searched using PubMed, MEDLINE, and EMBASE databases until December 2016. Differences in clinical outcomes for efficacy and safety endpoints between treatment groups were expressed as risk differences with 95% confidence intervals (95% CI), using random effects regression models. Fourteen RCTs were considered (60,467 subjects). Overall mortality, symptomatic deep venous thrombosis, non-fatal pulmonary embolism (PE) major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) are not different between treatment regimens. Treatment with LMWH enoxaparin is associated with a lower risk of fatal PE plus VTE-related death compared therapy with DOACs (RD = 0.040%, 95% CI 0.001-0.080%, p = 0.0434). Subgroup analysis shows an incidence of MB (RD = 0.181%, 95% CI 0.029-0.332%, p = 0.0033) and CRNMB (RD = 0.546%, 95% CI 0.009-1.082%, p = 0.0462) in patients treated with 40 mg OD enoxaparin compared to DOACs. In major orthopedic surgery and acutely ill hospitalized medical patients, DOACs do not offer clear advantages in terms of clinical efficacy compared to enoxaparin. The advantage of the latter in terms of major and CRNMB, when used at a dose of 40 mg, is statistically significant, but small in terms of clinical relevance.
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Affiliation(s)
- Claudio Cimminiello
- Studies and Research Center of the Italian Society of Angiology and Vascular Patholog (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), via Gorizia 22, 20144, Milan, Italy
| | - Paolo Prandoni
- Vascular Medicine Unit, Department of Cardiothoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Piazzale Menghini 1, 06100, Perugia, Italy
| | - Giovanni Di Minno
- Department of Clinical and Experimental Medicine, Federico II, University Hospital, Via S. Pansini 5, Naples, Italy
| | - Hernan Polo Friz
- Department of Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, Italy.
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Via Vanvitelli 32, 20129, Milan, Italy
| | - Patrizia Boracchi
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Giuseppe Marano
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Job Harenberg
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Goldhaber S, Lessard D, Goldberg R, Emery C, Spencer F, Piazza G. Venous thromboembolism in patients with symptomatic atherosclerosis. Thromb Haemost 2017; 106:1095-102. [DOI: 10.1160/th11-07-0469] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 09/23/2011] [Indexed: 11/05/2022]
Abstract
SummaryPatients with atherosclerosis have an increased risk of venous thromboembolism (VTE). We studied patients in the population-based Worcester VTE Study of 1,822 consecutive patients with validated VTE to compare clinical characteristics, prophylaxis, treatment, and outcomes of VTE in patients with and without symptomatic atherosclerotic cardiovascular disease, defined as history of ischaemic heart disease, history of positive cardiac catheterisation, percutaneous coronary intervention, or coronary artery bypass graft surgery, or history of peripheral artery disease. Of the 1,818 patients with VTE, 473 (26%) had a history of symptomatic atherosclerosis. Patients with atherosclerosis were significantly older (mean age 71.9 years vs. 61.6 years) and were more likely to have immobility (57.2% vs. 46.7%), prior heart failure (36.9% vs. 10.7%), chronic lung disease (26.4% vs. 15.5%), cerebrovascular disease (18.1% vs. 9.8%), and chronic kidney disease (4.9% vs. 1.9%) (all p<0.001) compared with non-atherosclerosis patients. Thromboprophylaxis was omitted in more than one-third of atherosclerosis patients who had been hospitalised for non-VTE-related illness or had undergone major surgery within the three months prior to VTE. Patients with atherosclerosis were significantly more likely to suffer in-hospital major bleeding (7.6% vs. 3.8%, p=0.0008). In conclusion, patients with atherosclerosis and VTE are more likely to suffer a complicated hospital course. Despite a high frequency of comorbid conditions contributing to the risk of VTE, we observed a low rate of thromboprophylaxis in patients with symptomatic atherosclerosis.
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Imberti D, Ageno W, Dentali F, Manfredini R, Gallerani M. Higher mortality rate in patients hospitalised for acute pulmonary embolism during weekends. Thromb Haemost 2017; 106:83-9. [DOI: 10.1160/th11-02-0068] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 03/25/2011] [Indexed: 11/05/2022]
Abstract
SummaryThe management of acute pulmonary embolism (PE) is often challenging and requires specific medical expertise, diagnostic techniques and therapeutic options that may not be available in all hospitals throughout the entire week. The aim of our study was to evaluate whether or not an association exists between weekday or weekend admission and mortality for patients hospitalised with acute PE. Using routinely collected hospital administrative data, we examined patients discharged with a diagnosis of PE from the hospitals of the Emilia- Romagna Region in Italy (January 1999-December 2009). The risk of inhospital death was calculated for admissions at the weekend and compared to weekday admissions. Of a total of 26,560 PEs, 6,788 (25.6%) had been admitted during weekends. PE admissions were most frequent on Mondays (15.8%) and less frequent on Saturdays and Sun- days/holidays (12.8%) (p<0.001). Weekend admissions were associated with significantly higher rates of in-hospital mortality than weekday admissions (28% vs. 24.8%) (p<0.001). The risk of weekend admission and in-hospital mortality was higher after adjusting for sender, hospital characteristics, and the Charlson co-morbidity index. In conclusion, hospitalisation for PE on weekends seems to be associated with a significantly higher mortality rate than on weekdays. Further research is needed to investigate the reasons for this observed difference in mortality in order to try and implement future strategies that ensure an adequate level of care throughout the entire week.
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Badreldin HA, Rimsans J, Connors JM, Wiviott SD. Use of systemic bivalirudin with catheter-directed thrombolysis in a patient with heparin-induced thrombocytopenia: A case report. Catheter Cardiovasc Interv 2017; 91:E17-E20. [PMID: 29068112 DOI: 10.1002/ccd.27368] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/12/2017] [Accepted: 09/17/2017] [Indexed: 11/07/2022]
Abstract
In patients with submassive pulmonary embolism, the use of catheter-directed thrombolysis (CDT), using low-dose alteplase is associated with improvement in overall hemodynamics. The data for use of CDT in patients with heparin-induced thrombocytopenia are limited. We report a case of CDT in a patient with HIT using bivalirudin anticoagulation. Data of the use of bivalirudin and argatroban for systemic anticoagulation with CDT are limited.
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Affiliation(s)
- Hisham A Badreldin
- Division of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jessica Rimsans
- Division of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Gombert A, Barbati ME, Grommes J, Kurstjens RL, deWolf MA, Wittens CH, Jalaie H. Wound complications after common femoral vein endophlebectomy: Influence on outcome. Phlebology 2017; 33:407-417. [PMID: 28595505 DOI: 10.1177/0268355517714712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Venous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome. Material and methods A retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates. Results This study includes 96 patients, thereof 58 females with a mean age of 44.1 years. The mean procedure time was 344 ± 140 min (range 124-663). Median follow-up time was 12.5 months (2-33 months). Primary patency was 62.5% and secondary patency was 90%. Re-intervention due to early occlusion within the first 30 post-intervention days was necessary in 37.5% of all cases. Besides bleeding complications, wound complications, mainly classified as Szilagyi I, occurred in 33% of all patients. A multivariate analysis showed a significant impact of wound complications on primary as well as secondary patency rate ( p = 0.032, respectively 0.015). Conclusion Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome. As wound complications are a common and associated with a significant impact on patency rate, further attempts to improve the procedure are crucial.
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Affiliation(s)
- Alexander Gombert
- 1 European Venous Center Aachen-Maastricht, University Hospital Aachen, Aachen, Germany
| | - Mohammad E Barbati
- 1 European Venous Center Aachen-Maastricht, University Hospital Aachen, Aachen, Germany
| | - Jochen Grommes
- 1 European Venous Center Aachen-Maastricht, University Hospital Aachen, Aachen, Germany
| | - Ralph Lm Kurstjens
- 2 Department of Obstetrics and Gynaecology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Mark Af deWolf
- 3 European Venous Center Aachen-Maastricht, Maastricht University Hospital, Maastricht, the Netherlands.,4 Department of Radiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Cees Ha Wittens
- 1 European Venous Center Aachen-Maastricht, University Hospital Aachen, Aachen, Germany.,3 European Venous Center Aachen-Maastricht, Maastricht University Hospital, Maastricht, the Netherlands
| | - Houman Jalaie
- 1 European Venous Center Aachen-Maastricht, University Hospital Aachen, Aachen, Germany
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Assareh H, Chen J, Ou L, Hillman K, Flabouris A. Incidences and variations of hospital acquired venous thromboembolism in Australian hospitals: a population-based study. BMC Health Serv Res 2016; 16:511. [PMID: 27659903 PMCID: PMC5034410 DOI: 10.1186/s12913-016-1766-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/16/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Data on hospital-acquired venous thromboembolism (HA-VTE) incidence, case fatality rate and variation amongst patient groups and health providers is lacking. We aim to explore HA-VTE incidences, associated mortality, trends and variations across all acute hospitals in New South Wales (NSW)-Australia. METHODS A population-based study using all admitted patients (aged 18-90 with a length of stay of at least two days and not transferred to another acute care facility) in 104 NSW acute public and private hospitals during 2002-2009. Poisson mixed models were used to derive adjusted rate ratios (IRR) in presence of patient and hospital characteristics. RESULTS Amongst, 3,331,677 patients, the incidence of HA-VTE was 11.45 per 1000 patients and one in ten who developed HA-VTE died in hospital. HA-VTE incidence, initially rose, but subsequently declined, whereas case fatality rate consistently declined by 22 % over the study period. Surgical patients were 128 % (IRR = 2.28, 95 % CI: 2.19-2.38) more likely to develop HA-VTE, but had similar case fatality rates compared to medical patients. Private hospitals, in comparison to public hospitals had a higher incidence of HA-VTE (IRR = 1.76; 95 % CI: 1.42-2.18) for medical patients. However, they had a similar incidence (IRR = 0.91; 95 % CI: 0.75-1.11), but a lower mortality (IRR = 0.59; 95 % CI: 0.47-0.75) amongst surgical patients. Smaller public hospitals had a lower HA-VTE incidence rate compared to larger hospitals (IRR < 0.68) but a higher case fatality rate (IRR > 1.71). Hospitals with a lower reported HA-VTE incidence tended to have a higher HA-VTE case fatality rate. CONCLUSION Despite the decline in HA-VTE incidence and case fatality, there were large variations in incidents between medical and surgical patients, public and private hospitals, and different hospital groups. The causes of such differences warrant further investigation and may provide potential for targeted interventions and quality improvement initiatives.
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Affiliation(s)
- Hassan Assareh
- Epidemiology and Health Analytics, Western Sydney Local Health Districts, Gungurra Building 68, Cumberland Hospital, 5 Fleet Street, North Parramatta, 2151 NSW Australia
- Simpson Centre for Health Services Research-South Western Sydney Clinical School Faculty of Medicine, University of New South Wales, and Ingham Institute, Sydney, Australia
| | - Jack Chen
- Simpson Centre for Health Services Research-South Western Sydney Clinical School Faculty of Medicine, University of New South Wales, and Ingham Institute, Sydney, Australia
| | - Lixin Ou
- Simpson Centre for Health Services Research-South Western Sydney Clinical School Faculty of Medicine, University of New South Wales, and Ingham Institute, Sydney, Australia
| | - Ken Hillman
- Simpson Centre for Health Services Research-South Western Sydney Clinical School Faculty of Medicine, University of New South Wales, and Ingham Institute, Sydney, Australia
| | - Arthas Flabouris
- Intensive Care Unit, Royal Adelaide Hospital and School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia Australia
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Ikama S, Nkoua M, Gombet T, Makani J, Mongo-Ngamami S, Ondze-Kafata L, Ellenga-Mbolla B, Kimbally-Kaky G. Évaluation du risque de maladie thromboembolique veineuse et de sa prévention chez des patients hospitalisés à Brazzaville. ACTA ACUST UNITED AC 2016; 41:182-7. [DOI: 10.1016/j.jmv.2016.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
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Mahan CE, Liu Y, Turpie AG, Vu JT, Heddle N, Cook RJ, Dairkee U, Spyropoulos AC. External validation of a risk assessment model for venous thromboembolism in the hospitalised acutely-ill medical patient (VTE-VALOURR). Thromb Haemost 2014; 112:692-9. [PMID: 24990708 DOI: 10.1160/th14-03-0239] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/30/2014] [Indexed: 11/05/2022]
Abstract
Venous thromboembolic (VTE) risk assessment remains an important issue in hospitalised, acutely-ill medical patients, and several VTE risk assessment models (RAM) have been proposed. The purpose of this large retrospective cohort study was to externally validate the IMPROVE RAM using a large database of three acute care hospitals. We studied 41,486 hospitalisations (28,744 unique patients) with 1,240 VTE hospitalisations (1,135 unique patients) in the VTE cohort and 40,246 VTE-free hospitalisations (27,609 unique patients) in the control cohort. After chart review, 139 unique VTE patients were identified and 278 randomly-selected matched patients in the control cohort. Seven independent VTE risk factors as part of the RAM in the derivation cohort were identified. In the validation cohort, the incidence of VTE was 0.20%; 95% confidence interval (CI) 0.18-0.22, 1.04%; 95%CI 0.88-1.25, and 4.15%; 95%CI 2.79-8.12 in the low, moderate, and high VTE risk groups, respectively, which compared to rates of 0.45%, 1.3%, and 4.74% in the three risk categories of the derivation cohort. For the derivation and validation cohorts, the total percentage of patients in low, moderate and high VTE risk occurred in 68.6% vs 63.3%, 24.8% vs 31.1%, and 6.5% vs 5.5%, respectively. Overall, the area under the receiver-operator characteristics curve for the validation cohort was 0.7731. In conclusion, the IMPROVE RAM can accurately identify medical patients at low, moderate, and high VTE risk. This will tailor future thromboprophylactic strategies in this population as well as identify particularly high VTE risk patients in whom multimodal or more intensive prophylaxis may be beneficial.
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Affiliation(s)
| | | | | | | | | | | | | | - Alex C Spyropoulos
- Alex C Spyropoulos, MD, FACP, FCCP, FRCPC, Director - Anticoagulation Services and Clinical Thrombosis, North Shore-LIJ Health System at Lenox Hill Hospital, Professor of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York, USA, Tel.: +1 212 434 6776, Fax: +1 212 434 6781, E-mail:
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Takemoto CM, Sohi S, Desai K, Bharaj R, Khanna A, McFarland S, Klaus S, Irshad A, Goldenberg NA, Strouse JJ, Streiff MB. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr 2014; 164:332-8. [PMID: 24332452 DOI: 10.1016/j.jpeds.2013.10.025] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/09/2013] [Accepted: 10/09/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine incidence and clinical characteristics of hospital-associated venous thromboembolism (VTE) in pediatric patients. STUDY DESIGN A retrospective analysis of patients with hospital-associated VTE at the Johns Hopkins Hospital from 1994 to 2009 was performed. Clinical characteristics of patients aged 21 years and younger who developed VTE symptoms after 2 days of hospitalization or <90 days after hospital discharge were examined. International Classification of Diseases, Ninth Revision codes were used to categorize patients with complex chronic medical conditions and trauma. RESULTS There were 270 episodes of hospital-associated VTE in 90,485 admissions (rate 30 per 10,000 admissions). Young adults (18-21 years) and adolescents (14-17 years) had significantly increased rates of VTE compared with children (2-9 years) (incidence rate ratio [IRR] 7.7, 95% CI 5.1-12.0; IRR 4.3, 95% CI 2.7-6.8, respectively). A central venous catheter (CVC) was present in 50% of patients, and a surgical procedure was performed in 45% of patients before VTE diagnosis. For patients without a CVC, trauma was the most common admitting diagnosis. CVC-related VTE was diagnosed most frequently in infants (<1 year old) and in patients with malignancy. Renal and cardiac diseases were associated with the highest rates of VTE (51 and 48 per 10,000, respectively). Rates were significantly higher among those with ≥ 4 medical conditions compared with those with 1 medical condition (IRR 4.0, 95% CI 1.4-8.9). CONCLUSION Older age and multiple medical conditions were associated with increased rates of hospital-associated VTE. These data can contribute to the design of future clinical trials to prevent hospital-associated VTE in high-risk children.
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Affiliation(s)
| | - Sajeet Sohi
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Kruti Desai
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Raman Bharaj
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Anuj Khanna
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD
| | - Susan McFarland
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Sybil Klaus
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Alia Irshad
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Neil A Goldenberg
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD; Pediatric Thrombosis Program, All Children's Hospital-Johns Hopkins Medicine, St. Petersburg, FL
| | - John J Strouse
- Division of Pediatric Hematology, Johns Hopkins University, Baltimore, MD; Division of Adult Hematology, The Johns Hopkins Hospital, Baltimore, MD
| | - Michael B Streiff
- Division of Adult Hematology, The Johns Hopkins Hospital, Baltimore, MD
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Socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time follow-up. J Thromb Thrombolysis 2014; 36:58-64. [PMID: 23247894 DOI: 10.1007/s11239-012-0858-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
While the risk for arterial vascular disease has been shown to be influenced by socioeconomic status (SES), there is limited information whether SES also influences the risk for venous thromboembolism (VTE). To evaluate whether there is an association between SES and VTE incidence. In 1990, all 730,050 inhabitants (379,465 women and 350,585 men) above 25 years of age in the County of Skåne in Sweden were evaluated with regard to age, household income, marital status, country of birth, number of years of residence in Sweden, educational level, and concomitant diseases. The cohort was hereafter prospectively investigated regarding diagnosis of, or death from VTE (deep venous thrombosis or pulmonary embolism ), during 1991-2003. The association between socioeconomic data and concomitant diseases at the baseline investigation 1990 and incidence of VTE during follow-up was examined by Cox proportional hazard models. During the 13 years prospective follow-up, 10,212 women and 7,922 men were diagnosed with VTE. In both genders, age above 40 years at baseline, low income, single status, and a lower level of education were associated with an increased risk of VTE. However, both men and women born outside of Sweden have a lower risk for VTE during follow-up, however. Age above 40 years, low income, single marital status, and lower level of education were independently related to an increased risk of VTE diagnosis during 13 years of prospective follow-up.
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Imberti D, Benedetti R, Ageno W. Prevention of venous thromboembolism in acutely ill medical patients after the results of recent trials with the new oral anticoagulants. Intern Emerg Med 2013; 8:667-72. [PMID: 23857035 DOI: 10.1007/s11739-013-0979-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 07/05/2013] [Indexed: 01/02/2023]
Abstract
Venous thromboembolism (VTE) is a common potentially life-threatening complication in acutely ill medical patients; over 70 % of the fatal episodes of pulmonary embolism during hospitalization occur in non-surgical patients. In the absence of thromboprophylaxis, the incidence of venographically detected deep vein thrombosis is about 15 % in medical patients. Several trials and meta-analyses have clearly demonstrated the prophylactic role of unfractionated heparin, low molecular weight heparin and fondaparinux. Although over the past few years the knowledge of epidemiology, clinical features and prophylaxis in medical patients has significantly improved, there remain a number of controversial areas that require further investigation. Newer VTE risk assessment models have been proposed to select high risk hospitalized medical patients, but they still require external validation; scarce data are available to stratify patients to identify their individual bleeding risk. The optimal duration of thromboprophylaxis in medical patients is still a matter of debate; currently, extended prophylaxis after discharge is not recommended, but it may be required for subgroup of patients with persistently high VTE risk and a negligible risk of bleeding. Based on the results of recent studies, the new oral anticoagulants appear to have a very limited role, if any. However, a better risk stratification of patients who have a persistently increased risk of VTE is warranted to improve the risk to benefit profile of any anticoagulant drug to be used in this setting.
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Affiliation(s)
- Davide Imberti
- Internal Medicine Department, Haemostasis and Thrombosis Center, Piacenza Hospital, Via Taverna 49, 29121, Piacenza, Italy,
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Mahan CE, Fisher MD, Mills RM, Fields LE, Stephenson JJ, Fu AC, Spyropoulos AC. Thromboprophylaxis patterns, risk factors, and outcomes of care in the medically ill patient population. Thromb Res 2013; 132:520-6. [DOI: 10.1016/j.thromres.2013.08.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/19/2022]
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Albertsen IE, Larsen TB, Rasmussen LH, Overvad TF, Lip GYH. Prevention of venous thromboembolism with new oral anticoagulants versus standard pharmacological treatment in acute medically ill patients: a systematic review and meta-analysis. Drugs 2013; 72:1755-64. [PMID: 22876779 DOI: 10.2165/11635630-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common and potentially avoidable cause of morbidity and mortality in patients hospitalized for acute medical illness. OBJECTIVE Our objective was to conduct a systematic review of studies that assessed the efficacy and safety of new oral anticoagulant (OAC) drugs versus standard pharmacological drugs and/or placebo in prevention of VTE in acute medically ill patients. METHODS PubMed.org and ClinicalTrials.gov databases were searched to identify studies that evaluated the efficacy and safety of a new OAC versus the standard pharmacological treatment and/or placebo in the prevention of VTE in medically ill patients. Relative risks (RR), weighted means and 95% CIs were calculated. Statistical heterogeneity was evaluated using Chi2 and I2 statistics. Two studies were included in the meta-analysis. The primary outcome in both studies was the composite of VTE-related death, symptomatic non-fatal pulmonary embolism (PE), symptomatic deep venous thrombosis (DVT) and asymptomatic proximal DVT. Both studies compared a factor (F)Xa inhibitor with enoxaparin in standard short-term thromboprophylaxis followed by a period where the FXa inhibitor was compared with placebo as prolonged thromboprophylaxis in medically ill patients. The primary major safety outcome in both studies was a composite of treatment-related major bleeding and clinically relevant non-major bleeding. A total of 14 629 patients were randomized. RESULTS Compared with subjects treated with enoxaparin followed by placebo, the RR of the primary outcome during the prolonged treatment period was 0.79 (95% CI 0.66, 0.94), the RR for the primary outcome during the first short-term treatment period was 1.03 (95% CI 0.81, 1.31). For major bleeding during the prolonged treatment period, the RR was 2.69 (95% CI 1.65, 4.39) for patients treated with an FXa inhibitor compared with enoxaparin/placebo. For major bleeding during the shorter treatment period, the RR was 2.01 (95% CI 1.10, 3.65) in favour of enoxaparin. CONCLUSION In acute medically ill patients, prolonged thromboprophylaxis with an oral FXa inhibitor is more protective than regular short-term treatment with enoxaparin. However, treatment with FXa inhibitors is significantly associated with major bleeding, both in long- and short-term treatment compared with enoxaparin.
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Affiliation(s)
- Ida Ehlers Albertsen
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Abstract
Pulmonary embolism is the third most common cardiovascular disease after myocardial infarction and stroke. The death rate from pulmonary embolism exceeds the death rate from myocardial infarction, because myocardial infarction is much easier to detect and to treat. Among survivors of pulmonary embolism, chronic thromboembolic pulmonary hypertension occurs in 2-4 of every 100 patients. Post-thrombotic syndrome of the legs, characterized by chronic venous insufficiency, occurs in up to half of patients who suffer deep vein thrombosis or pulmonary embolism. We have effective pharmacological regimens using fixed low dose unfractionated or low molecular weight heparin to prevent venous thromboembolism among hospitalized patients. There remains the problem of low rates of utilization of pharmacological prophylaxis. The biggest change in our understanding of the epidemiology of venous thromboembolism is that we now believe that deep vein thrombosis and pulmonary embolism share similar risk factors and pathophysiology with atherothrombosis and coronary artery disease.
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Patient education program for venous thromboembolism prevention in hospitalized patients. Am J Med 2012; 125:258-64. [PMID: 22340923 DOI: 10.1016/j.amjmed.2011.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 09/01/2011] [Accepted: 09/01/2011] [Indexed: 11/22/2022]
Abstract
PURPOSE Up to 15% of clinician-ordered doses of injectable pharmacological prophylaxis to prevent venous thromboembolism are not administered. Patient refusal accounts for nearly 50% of these omitted doses. We conducted a prospective cohort study to determine whether a patient education program would improve medication adherence to clinician-ordered injectable prophylactic anticoagulation. METHODS We identified 528 hospitalized patients ordered to receive injectable pharmacological venous thromboembolism prophylaxis. We evaluated the impact of pharmacist-led patient education sessions on medication adherence (defined as the ratio of doses administered to doses scheduled) compared with our historical cohort. RESULTS Individualized patient education sessions were conducted within 24 hours of the initial order for prophylactic anticoagulation in 99% of patients. Adherence to clinician-ordered pharmacological venous thromboembolism prophylaxis was higher after the patient education program than in our historical cohort (94.4% vs 89.9%, P <.0001). The proportion of patients receiving 100% of scheduled doses of injectable pharmacological venous thromboembolism prophylaxis was higher after our novel patient education program than in our historical cohort (73.7% vs 62.4%, P=.001). Patient refusal as a reason for omitted doses was less frequent after the patient education program (29.3% vs 43.7%, P=.001). CONCLUSION Pharmacist-led individualized patient education sessions were associated with higher medication adherence to clinician-ordered injectable pharmacological venous thromboembolism prophylaxis and a reduction in patient refusal as a reason for omitted doses. A randomized controlled trial to evaluate the impact of a patient education program on medication adherence to pharmacological venous thromboembolism prophylaxis is warranted.
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Restenosis and therapy. Int J Vasc Med 2012; 2012:406236. [PMID: 22489270 PMCID: PMC3303576 DOI: 10.1155/2012/406236] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 11/11/2011] [Accepted: 12/05/2011] [Indexed: 01/03/2023] Open
Abstract
The vascular disease involves imbalanced function of the blood vessels. Risk factors playing a role in development of impaired vessel functions will be briefly discussed. In ischemia/reperfusion (I/R), ischemic hypoxia is one of the cardinal risk factors of restenosis. Various insults are shown to initiate the phenotype switch of VSMCs. The pathological process, leading to activated inflammatory process, complement activation, and release of growth factors, initiate the proliferation of VSMCs in the media and cause luminal narrowing and impaired vascular function. The review summarizes the alteration process and demonstrates some of the clinical genetic background showing the role of complement and the genotypes of mannose-binding lectin (MBL2). Those could be useful markers of carotid restenosis after stent implantation. Gene therapy and therapeutic angiogenesis is proposed for therapy in restenosis. We suggest a drug candidate (iroxanadine), which ensures a noninvasive treatment by reverse regulation of the highly proliferating VSMCs and the disturbed function of ECs.
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Lecumberri R, Panizo E, Gomez-Guiu A, Varea S, García-Quetglas E, Serrano M, García-Mouriz A, Marqués M, Gómez-Outes A, Páramo JA. Economic impact of an electronic alert system to prevent venous thromboembolism in hospitalised patients. J Thromb Haemost 2011; 9:1108-15. [PMID: 21481177 DOI: 10.1111/j.1538-7836.2011.04282.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The prevention of venous thromboembolism (VTE) is a priority for improved safety in hospitalised patients. Worldwide, there is growing concern over the undersuse of appropriate thromboprophylaxis. Computerised decision support improves the implementation of thromboprophylaxis and reduces inpatient VTE. However, an economic assessment of this approach has not yet been performed. OBJECTIVES To evaluate the economic impact of an electronic alert (e-alert) system to prevent VTE in hospitalised patients over a 4year period. PATIENTS/METHODS All hospitalised patients at a single institution during the first semesters of 2005-2009 (n=32280) were included. All cases of VTE developed during hospitalisation were followed and direct costs of diagnosis and management collected. RESULTS E-alerts achieved a sustained reduction of the incidence of in-hospital VTE, OR 0.50 (95% CI, 0.29-0.84), the impact being especially significant in medical patients, OR 0.44 (95% CI, 0.22-0.86). No increase in prophylaxis-related bleeding was observed. In our setting, the mean direct cost (during hospitalisation and after discharge) of an in-hospital VTE episode is €7058. Direct costs per single hospitalised patient were reduced after e-alerts from €21.6 to €11.8, while the increased use of thromboprophylaxis and the development of e-alerts meant €3 and €0.35 per patient, respectively. Thus, the implementation of e-alerts led to a net cost saving of €6.5 per hospitalised patient. Should all hospitalised patients in Spain be considered, total yearly savings would approach €30million. CONCLUSIONS E-alerts are useful and cost-effective tools for thromboprophylaxis strategy in hospitalised patients. Fewer thromboembolic complications and lower costs are achieved by its implementation.
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Affiliation(s)
- R Lecumberri
- Hematology Service Clinical Pharmacology Service Clinical Pharmacy Service Informatics Service Documentation Service, University Clinic of Navarra, Pamplona, Spain.
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1500] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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Venous thromboembolism in heart failure: preventable deaths during and after hospitalization. Am J Med 2011; 124:252-9. [PMID: 21396509 DOI: 10.1016/j.amjmed.2010.10.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/17/2010] [Accepted: 10/12/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Our aim was to compare the clinical characteristics, prophylaxis, treatment, and outcomes of patients with venous thromboembolism with and without heart failure. METHODS We studied patients with heart failure in the population-based Worcester Venous Thromboembolism Study of 1822 consecutive patients with validated venous thromboembolism. RESULTS Of the 1822 patients with venous thromboembolism, 319 (17.5%) had a history of clinical heart failure and 1503 (82.5%) did not. Patients with heart failure were older (mean age 75 vs 62 years, P<.0001) and more likely to have been immobilized (65.2% vs 46.1%, P<.0001). Thromboprophylaxis was omitted in approximately one third of patients with heart failure who had been hospitalized for non-venous thromboembolism-related illness or had undergone major surgery within the 3 months before diagnosis. Patients with heart failure had a higher frequency of in-hospital death (9.7% vs 3.3%, P<.0001) and death within 30 days of venous thromboembolism diagnosis (15.6% vs 6.4%, P<.0001). Heart failure (adjusted odds ratio [OR] 2.04; 95% confidence interval [CI], 1.15-3.62) and immobility (adjusted OR 4.37; 95% CI, 2.42-7.9) were associated with an increased risk of in-hospital death. Heart failure (adjusted OR 1.57; 95% CI, 1.01-2.43) and immobility (adjusted OR 3.05; 95% CI, 2.01-4.62) also were independent predictors of death within 30 days of venous thromboembolism diagnosis. CONCLUSION High mortality was observed among patients with heart failure and venous thromboembolism both during and after hospitalization. Heart failure and immobility are potent risk factors for in-hospital death and death within 30 days in patients with venous thromboembolism.
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Affiliation(s)
- Gregory Piazza
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Taute BM, Melnyk H, Podhaisky H. Alternative sonographische Diagnosen bei klinischem Thromboseverdacht. ACTA ACUST UNITED AC 2010; 105:619-26. [DOI: 10.1007/s00063-010-1101-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Accepted: 07/05/2010] [Indexed: 11/30/2022]
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Wilbur K, Lynd LD, Sadatsafavi M. Low-molecular-weight heparin versus unfractionated heparin for prophylaxis of venous thromboembolism in medicine patients--a pharmacoeconomic analysis. Clin Appl Thromb Hemost 2010; 17:454-65. [PMID: 20699258 DOI: 10.1177/1076029610376935] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prevention of in-hospital venous thromboembolism (VTE) is identified internationally as a priority to improve patient safety. Advocated alternatives include low-dose unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Although LMWHs are as effective as UFH, less frequent administration and potentially safer adverse effect profile associated with LMWHs might off-set greater drug acquisition costs. The objective of this study was to determine the most cost-effective thromboprophylaxis strategy for hospitalized medicine patients and specific subgroups in Canada. METHODS A decision-analytic model assessed costs and outcomes of LMWH compared to UFH for thromboprophylaxis in at-risk hospitalized medicine patients from an institutional perspective. The outcome of interest was the incremental cost-effectiveness ratio (ICER) for preventing deep vein thrombosis (DVT) and combined untoward events (pulmonary embolism [PE], major bleed, and death). The time horizon of the model was the hospital stay. RESULTS In the base-case analysis, LMWH thromboprophylaxis resulted in higher costs ($7.40), but 3.6 and 1.1 fewer DVT and untoward events per 1000 patients, respectively, with associated ICERs of $2042 and $6832. Results remained predominantly stable when alternative assumptions were evaluated in the sensitivity analysis. Low-molecular-weight heparin had the most favorable economic profile in patients with a history of DVT. In the probabilistic sensitivity analysis, in 33% of simulations LMWH was less costly and more effective, whereas the reverse was true for UFH only in 13% of simulations. CONCLUSIONS Low-molecular-weight heparin administration is a cost-effective alternative for thromboprophylaxis strategy in Canadian hospitalized medicine patients.
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Affiliation(s)
- Kerry Wilbur
- College of Pharmacy, Qatar University, Doha, Qatar.
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Affiliation(s)
- Gregory Piazza
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z. Goldhaber
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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