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Rehman A, Bahk J, Baloch HNU, Salman S, Sharma V, Singh A, Steiger DJ. Association of Different Anticoagulation Strategies With Outcomes in Patients Hospitalized With Acute Pulmonary Embolism. Cureus 2024; 16:e61545. [PMID: 38962644 PMCID: PMC11219246 DOI: 10.7759/cureus.61545] [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: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
Background Therapeutic anticoagulation is the cornerstone of treatment for pulmonary embolism (PE), but the impact of different anticoagulation strategies on patient outcomes remains unclear. In this study, we assessed the association of different anticoagulation strategies with the outcomes of patients with acute PE. Methods A retrospective chart review of 207 patients with acute PE who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (in New York City) from January 2020 to September 2022 was performed. Demographic, clinical, and radiographic data were recorded for all patients. Multivariate regression analyses were performed to assess the association of different outcomes with the approach of therapeutic anticoagulation used. Results The median age of the included patients was 65 years, and 50.2% were women. The most common approach (n = 153, 73.9%) to therapeutic anticoagulation was initial treatment with unfractionated or low molecular weight heparin followed by a direct-acting oral anticoagulant (DOAC), while heparin alone (either unfractionated or low molecular weight heparin) was used in 37 (17.9%) patients, and another 17 (8.2%) patients were treated with heparin followed by bridging to warfarin. Hospital length of stay was longer for patients in the "heparin to warfarin" group (risk-adjusted incidence rate ratio of 2.52). The rates of in-hospital bleeding, all-cause 30-day mortality, and all-cause 30-day re-admissions did not have any significant association with the therapeutic anticoagulation approach used. Conclusion Patients with acute PE who were initially treated with heparin and subsequently bridged to warfarin had a longer hospital stay. Rates of in-hospital bleeding, 30-day mortality, and 30-day re-admission were not associated with the strategy of therapeutic anticoagulation employed.
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Affiliation(s)
- Abdul Rehman
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Jeeyune Bahk
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | | | - Sidra Salman
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | - Venus Sharma
- Internal Medicine, Mount Sinai Hospital, New York City, USA
| | - Avinash Singh
- Pulmonary and Critical Care Medicine, Mount Sinai Hospital, New York City, USA
| | - David J Steiger
- Pulmonary and Critical Care Medicine, Mount Sinai Hospital, New York City, USA
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2
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Balmforth C, Whittington B, Tzolos E, Bing R, Williams MC, Clark L, Corral CA, Tavares A, Dweck MR, Newby DE. Translational molecular imaging: Thrombosis imaging with positron emission tomography. J Nucl Cardiol 2024:101848. [PMID: 38499227 DOI: 10.1016/j.nuclcard.2024.101848] [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: 12/29/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Abstract
A key focus of cardiovascular medicine is the detection, treatment, and prevention of disease, with a move towards more personalized and patient-centred treatments. To achieve this goal, novel imaging approaches that allow for early and accurate detection of disease and risk stratification are needed. At present, the diagnosis, monitoring, and prognostication of thrombotic cardiovascular diseases are based on imaging techniques that measure changes in structural anatomy and biological function. Molecular imaging is emerging as a new tool for the non-invasive detection of biological processes, such as thrombosis, that can improve identification of these events above and beyond current imaging modalities. At the forefront of these evolving techniques is the use of high-sensitivity radiotracers in conjunction with positron emission tomography imaging that could revolutionise current diagnostic paradigms by improving our understanding of the role and origin of thrombosis in a range of cardiovascular diseases.
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Affiliation(s)
- Craig Balmforth
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Beth Whittington
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Evangelos Tzolos
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Laura Clark
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Carlos Alcaide Corral
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Adriana Tavares
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Marc Richard Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David Ernest Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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3
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Cohen AT, Sah J, Dhamane AD, Hines DM, Lee T, Rosenblatt L, Emir B, Keshishian A, Yuce H, Luo X. Effectiveness and Safety of Apixaban vs Warfarin in Patients with Venous Thromboembolism with Risk Factors for Bleeding or for Recurrences. Adv Ther 2023; 40:1705-1735. [PMID: 36811795 PMCID: PMC10070226 DOI: 10.1007/s12325-023-02440-1] [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: 08/19/2022] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Patients at increased risk of bleeding and recurrent VTE who develop venous thromboembolism (VTE) present challenges for clinical management. This study evaluated the effectiveness and safety of apixaban vs warfarin in patients with VTE who have risk factors for bleeding or recurrences. METHODS Adult patients with VTE initiating apixaban or warfarin were identified from five claims databases. Stabilized inverse probability treatment weighting (IPTW) was used to balance characteristics between cohorts for the main analysis. Subgroup interaction analyses were conducted to evaluate treatment effects among patients with and without each of the conditions that increased the risk of bleeding (thrombocytopenia and history of bleed) or recurrent VTE (thrombophilia, chronic liver disease, and immune-mediated disorders). RESULTS A total of 94,333 warfarin and 60,786 apixaban patients with VTE met selection criteria. After IPTW, all patient characteristics were balanced between cohorts. Apixaban (vs warfarin) patients were at lower risk of recurrent VTE (HR [95% confidence interval (CI) 0.72 [0.67-0.78]), major bleeding (MB) (HR [95% CI] 0.70 [0.64-0.76]), and clinically relevant non-major (CRNM) bleeding (HR [95% CI] 0.83 [0.80-0.86]). Subgroup analyses showed generally consistent findings with the overall analysis. For most subgroup analyses, there were no significant interactions between treatment and subgroup strata on VTE, MB and CRNM bleeding. CONCLUSION Patients with prescription fills for apixaban had lower risk of recurrent VTE, MB, and CRNM bleeding compared with warfarin patients. Treatment effects of apixaban vs warfarin were generally consistent across subgroups of patients at increased risk of bleeding/recurrences.
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Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, UK.
| | | | | | | | | | | | | | | | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, NY, USA
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Jiménez D, Rodríguez C, Pintado B, Pérez A, Jara-Palomares L, López-Reyes R, Ruiz-Artacho P, García-Ortega A, Bikdeli B, Lobo JL. Effect of Prognostic Guided Management of Patients With Acute Pulmonary Embolism According to the European Society of Cardiology Risk Stratification Model. Front Cardiovasc Med 2022; 9:872115. [PMID: 35497990 PMCID: PMC9039515 DOI: 10.3389/fcvm.2022.872115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background A recent trial showed that management driven by prognostic assessment was effective in reducing the length of stay (LOS) for acute stable pulmonary embolism (PE). The efficacy and safety of this strategy in each subgroup of risk stratification remains unknown. Methods We conducted a post-hoc analysis of the randomized IPEP study to evaluate the effect of a management strategy guided by early use of a prognostic pathway in the low- and intermediate-high risk subgroups defined by the European Society of Cardiology (ESC) model. These subgroups were retrospectively identified in the control arm. The primary outcome was LOS. The secondary outcomes were 30-day clinical outcomes. Results Of 249 patients assigned to the intervention group, 60 (24%) were classified as low-, and 30 (12%) as intermediate-high risk. Among 249 patients assigned to the control group, 66 (27%) were low-, and 13 (5%) intermediate-high risk. In the low-risk group, the mean LOS was 2.1 (±0.9) days in the intervention group and 5.3 (±2.9) days in the control group (P < 0.001). In this group, no significant differences were observed in 30-day readmissions (0% vs. 3.0%, respectively), all-cause (0% vs. 0%) and PE-related mortality rates (0% vs. 0%), or severe adverse events (0% vs. 1.5%). In the intermediate-high risk group, the mean LOS was 5.3 (±1.8) days in the intervention group and 6.5 (±2.5) days in the control group (P = 0.08). In this group, no significant differences were observed in 30-day readmissions (3.3% vs. 3.0%, respectively), all-cause (6.7% vs. 7.7%) and PE-related mortality rates (6.7% vs. 7.7%), or severe adverse events (16.7% vs. 15.4%). Conclusion The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE without comprising safety across subgroups of risk stratification. Clinical Trial Registration [ClinicalTrials.gov], Identifier [NCT02733198].
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Department of Medicine, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: David Jiménez,
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Beatriz Pintado
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Andrea Pérez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital, Instituto de Biomedicina, Seville, Spain
| | | | - Pedro Ruiz-Artacho
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain
- Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Universidad de Navarra, Madrid, Spain
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
- Cardiovascular Research Foundation, New York, NY, United States
| | - José Luis Lobo
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Respiratory Department, Hospital Araba, Vitoria-Gasteiz, Spain
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Ruben-Castillo C, Cuen-Ojeda C, Lopez-Peña G, Anaya-Ayala JE, Hinojosa CA. Surgical Intervention for Phlegmasia Cerulea Dolens in a 61-Year-Old Cancer Patient. Tex Heart Inst J 2022; 49:477163. [DOI: 10.14503/thij-20-7400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Phlegmasia cerulea dolens, a rare and potentially fatal complication of acute deep vein thrombosis, is characterized by substantial edema, intense pain, and cyanosis. Phlegmasia cerulea dolens may compromise limb perfusion and lead to acute ischemia, gangrene, amputation, and death. We present the case of a 61-year-old woman with a history of breast cancer who had signs and symptoms of phlegmasia cerulea dolens in her left leg. She was treated promptly with open surgical thrombectomy and sequential distal compression with use of an Esmarch bandage to ensure complete thrombus extraction. These techniques restored venous flow and saved her leg. Open surgical thrombectomy should be considered in the presence of limb-threatening acute deep vein thrombosis presenting as phlegmasia cerulea dolens.
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Affiliation(s)
- Christopher Ruben-Castillo
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Cesar Cuen-Ojeda
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriel Lopez-Peña
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier E. Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A. Hinojosa
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Arasappa A, Kumar N, Anto M, Manoharan GV, Selvanathan D. Cost-effective treatment for deep-vein thrombosis in rural tertiary care hospital. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.4103/ijves.ijves_23_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Nikvarz N, Seyedi Z. Improved utilisation of venous thromboembolism prophylaxis in renal-impaired patients following a clinical pharmacist intervention. Eur J Hosp Pharm 2022; 29:40-43. [PMID: 34930793 PMCID: PMC8717764 DOI: 10.1136/ejhpharm-2019-002030] [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: 07/02/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To evaluate the role of the clinical pharmacist in improving venous thromboembolism (VTE) prophylaxis prescription in patients with renal impairment (RI). METHODS This was an interventional cross-sectional study conducted in a nephrology ward. Patients' risk scores for VTE and bleeding during hospitalisation (evaluated by the Caprini Risk Assessment Model (RAM), Padua Prediction Score and IMPROVE Bleeding Risk Score, respectively), and the rate of VTE prophylaxis administration to patients, were evaluated before and after a clinical pharmacist's intervention. RESULTS In the pre-intervention phase, 34.8% of high-VTE-risk patients, of whom 12.5% were also at high risk of bleeding, received pharmacological prophylaxis. Moreover, 22.2% of low-VTE-risk patients received prophylaxis. In the intervention phase, prophylaxis was administered to all high-risk patients (mechanical prophylaxis in 7% of patients with a high risk of both VTE and bleeding, and heparin in the remainder) and to 3.3% of those at low risk of VTE. CONCLUSIONS The clinical pharmacist's intervention using RAMs can improve the rate of thrombosis prophylaxis prescription in patients with RI who have a high risk of VTE.
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Affiliation(s)
- Naemeh Nikvarz
- Herbal and Traditional Medicines Research Center and Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kerman University of Medical Sciences, Kerman, Iran (the Islamic Republic of)
| | - Zahra Seyedi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences, Kerman University of Medical Sciences, Kerman, Iran (the Islamic Republic of)
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Bui A, Lashkari N, Formanek B, Wang JC, Buser Z, Liu JC. Incidence and Risk Factors for Postoperative Venous Thromboembolic Events in Patients Undergoing Cervical Spine Surgery. Clin Spine Surg 2021; 34:E458-E465. [PMID: 33605609 DOI: 10.1097/bsd.0000000000001140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective database study. OBJECTIVE The objective of this study was to investigate preoperative risk factors and incidence of venous thromboembolic events (VTEs) after cervical spine surgery. SUMMARY OF BACKGROUND DATA VTEs are preventable complications that may occur after spinal procedures. Globally, VTEs account for a major cause of morbidity and mortality. Preoperative risks factors associated with increased VTE incidence after cervical spine surgery have not been well-characterized. MATERIALS AND METHODS Patients undergoing anterior cervical discectomy and fusion (ACDF); posterior cervical fusion (PCF); discectomy; and decompression from 2007 to 2017 were identified using the PearlDiver Database. International Classification of Diseases (ICD) Ninth and 10th Revision codes were used to identify VTEs at 1 week, 1 month, and 3 months postoperative as well as preoperative risk factors. RESULTS Risk factors with the highest incidence of VTE at 3 months were primary coagulation disorder [ACDF=7.82%, odds ratio (OR)=3.96; decompression=11.24%, OR=3.03], central venous line (ACDF=5.68%, OR=2.11; PCF=12.58%, OR=2.27; decompression=10.17%, OR=2.80) and extremity paralysis (ACDF=6.59%, OR=2.73; PCF=18.80%, OR=2.99; decompression=11.86, OR=3.74). VTE incidence at 3 months for populations with these risks was significant for all surgery types (P<0.001) with the exception of patients with primary coagulation disorder who underwent PCF. Tobacco use had the lowest VTE incidence for all surgery types. CONCLUSIONS The total cumulative incidence of VTEs at 3-month follow-up was 3.10%, with the highest incidence of VTEs occurring within the first postoperative week (0.65% at 1 wk, 0.61% at 1 mo, 0.53% at 3 mo for ACDF; 2.56% at 1 wk, 1.93% at 1 mo, 1.45% at 3 mo for PCF; 1.37% at 1 wk, 0.93% at 1 mo, 0.91% at 3 mo for decompression). Several preoperative risk factors were found to be significant predictors for postoperative VTEs and can be used to suggest those at increased risk as well as decrease the incidence of preventable VTEs after cervical spine surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | | | | | - John C Liu
- Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Jiménez D, Rodríguez C, León F, Jara-Palomares L, López-Reyes R, Ruiz-Artacho P, Elías T, Otero R, García-Ortega A, Rivas-Guerrero A, Abelaira J, Jiménez S, Muriel A, Morillo R, Barrios D, Le Mao R, Yusen RD, Bikdeli B, Monreal M, Lobo JL. Randomised controlled trial of a prognostic assessment and management pathway to reduce the length of hospital stay in normotensive patients with acute pulmonary embolism. Eur Respir J 2021; 59:13993003.00412-2021. [PMID: 34385269 DOI: 10.1183/13993003.00412-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/18/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The length of hospital stay (LOS) for acute pulmonary embolism (PE) varies considerably. Whether the upfront use of a PE prognostic assessment and management pathway is effective in reducing the LOS remains unknown. METHODS We conducted a randomised, controlled trial of adults hospitalised for acute PE: patients were assigned to a prognostic assessment and management pathway involving risk stratification, followed by predefined criteria for mobilisation and discharge (intervention group), or usual care (control group). The primary end point was LOS. The secondary end points were the cost of prognostic tests and of hospitalisation, and 30-day clinical outcomes. RESULTS Of 500 patients who underwent randomisation, 498 were included in the modified intention-to-treat analysis. The median LOS was 4.0 days (interquartile range [IQR], 3.7 to 4.2 days) in the intervention group and 6.1 days (IQR, 5.7 to 6.5 days) in the control group (p<0.001). The mean total cost of prognostic tests was €174.76 in the intervention group, as compared with €233.12 in the control group (mean difference, €-58.37; 95% confidence interval [CI], €-84.34 to €-32.40). The mean total hospitalisation cost per patient was €2085.66 in the intervention group, compared with €3232.97 in the control group (mean difference, €-1147.31; 95% CI, €-1414.97 to €-879.65). No significant differences were observed in 30-day readmissions (4.0% versus 4.8%, respectively), or all-cause (2.4% versus 2.0%) and PE-related mortality rates (0.8% versus 1.2%). CONCLUSIONS The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain .,Medicine Department, Universidad de Alcalá, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Francisco León
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | | | - Pedro Ruiz-Artacho
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Department of Internal Medicine, Clinica Universidad de Navarra, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Universidad de Navarra, Madrid, Spain
| | - Teresa Elías
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Remedios Otero
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | | | | | - Jaime Abelaira
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Sonia Jiménez
- Emergency Department, Hospital Clinic, Grupo UPP, Área 1 IDIBAPS, Barcelona, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raphael Le Mao
- EA3878, Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Université Européenne de Bretagne, Brest, France
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA.,Cardiovascular Research Foundation, New York, USA
| | - Manuel Monreal
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.,Universidad Católica de Murcia, Murcia, Spain
| | - José Luis Lobo
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Salas E, Farm M, Pich S, Onelöv L, Guillen K, Ortega I, Antovic JP, Soria JM. Predictive Ability of a Clinical-Genetic Risk Score for Venous Thromboembolism in Northern and Southern European Populations. TH OPEN 2021; 5:e303-e311. [PMID: 34263111 PMCID: PMC8266419 DOI: 10.1055/s-0041-1729626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/01/2021] [Indexed: 11/01/2022] Open
Abstract
Venous thromboembolism (VTE) is a complex, multifactorial problem, the development of which depends on a combination of genetic and acqfiguired risk factors. In a Spanish population, the Thrombo inCode score (or TiC score), which combines clinical and genetic risk components, was recently proven better at determining the risk of VTE than the commonly used model involving the analysis of two genetic variants associated with thrombophilia: the Factor V Leiden (F5 rs6025) and the G20210A prothrombin (F2 rs1799963). The aim of the present case-control study was to validate the VTE risk predictive capacity of the TiC score in a Northern European population (from Sweden). The study included 173 subjects with VTE and 196 controls. All were analyzed for the genetic risk variants included in the TiC gene panel. Standard measures -receiver operating characteristic (ROC) area under the curve (AUC), sensitivity, specificity, and odds ratio (OR)-were calculated. The TiC score returned an AUC value of 0.673, a sensitivity of 72.25%, a specificity of 60.62%, and an OR of 4.11. These AUC, sensitivity, and OR values are all greater than those associated with the currently used combination of genetic variants. A TiC version adjusted for the allelic frequencies of the Swedish population significantly improved its AUC value (0.783). In summary, the TiC score returned more reliable risk estimates for the studied Northern European population than did the analysis of the Factor V Leiden and the G20210A genetic variations in combination. Thus, the TiC score can be reliably used with European populations, despite differences in allelic frequencies.
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Affiliation(s)
- Eduardo Salas
- Scientific Department, Gendiag, c/ Lepant, 141-4-1, 08013 Barcelona, Spain
| | - Maria Farm
- Institute for Molecular Medicine and Surgery and Department of Clinical Chemistry, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Sara Pich
- Scientific Department, Gendiag, c/ Lepant, 141-4-1, 08013 Barcelona, Spain
| | - Liselotte Onelöv
- Institute for Molecular Medicine and Surgery and Department of Clinical Chemistry, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Kevin Guillen
- Scientific Department, Gendiag, c/ Lepant, 141-4-1, 08013 Barcelona, Spain
| | - Israel Ortega
- Scientific Department, Gendiag, c/ Lepant, 141-4-1, 08013 Barcelona, Spain
| | - Jovan P Antovic
- Institute for Molecular Medicine and Surgery and Department of Clinical Chemistry, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Jose Manuel Soria
- Genomic of Complex Diseases, Institut d'Investigació Sant Pau (IIB-Sant Pau), Barcelona, Spain
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Veeranki SP, Xiao Z, Levorsen A, Sinha M, Shah BR. Real-World Comparative Effectiveness and Cost Comparison of Thromboprophylactic Use of Enoxaparin versus Unfractionated Heparin in 376,858 Medically Ill Hospitalized US Patients. Am J Cardiovasc Drugs 2021; 21:443-452. [PMID: 33313988 PMCID: PMC8263404 DOI: 10.1007/s40256-020-00456-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication in medically ill inpatients. Enoxaparin or unfractionated heparin (UFH) thromboprophylaxis has been shown to reduce VTE in clinical trials; however, comparative effectiveness and differences in hospital costs are unknown in US hospital practice. OBJECTIVE This study compared clinical and economic outcomes between enoxaparin and UFH thromboprophylaxis in medically ill inpatients. METHODS A retrospective cohort study was conducted using the Premier Healthcare Database between 1 January 2010 and 30 September 2016. Inpatients aged ≥ 18 years with a ≥ 6-day hospital stay for serious medical conditions were included. Two patient groups receiving thromboprophylaxis were identified during hospitalization: one receiving enoxaparin and other receiving UFH. Regression models were constructed to compare VTE events, in-hospital mortality, pulmonary embolism (PE)-related mortality, major bleeding, and total hospital costs during both the index hospitalization and the 90-day readmission period between the two groups. RESULTS A total of 242,474 and 134,384 inpatients received enoxaparin or UFH for thromboprophylaxis, respectively. Compared with UFH prophylaxis, enoxaparin was significantly associated with 15%, 9%, 33%, and 41% reduced odds of VTE, in-hospital mortality, PE-related mortality, and major bleeding, respectively, during index hospitalization, and 10% and 19% reduced odds of VTE and bleeding, respectively, during the readmission period. Mean total hospital costs were significantly lower in patients receiving enoxaparin prophylaxis than in those given UFH. CONCLUSIONS Thromboprophylaxis with enoxaparin was associated with significantly reduced in-hospital VTE events, death, and major bleeding and lower hospital costs compared with UFH in hospitalized medically ill patients.
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Affiliation(s)
- S. Phani Veeranki
- Premier Applied Sciences, Premier Inc., Charlotte, NC USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX USA
- Precision HEOR, 11100 Santa Monica Blvd., Suite 500, Los Angeles, CA USA
| | - Zhimin Xiao
- Sanofi, Cambridge, MA USA
- 650 E Kendall St, Cambridge, MA 02138 USA
| | - Andrée Levorsen
- Global Health Economics and Value Assessment, Sanofi, Professor Kohtsvei 5-17, Lysaker, 1366 Oslo, Norway
| | - Meenal Sinha
- Premier Applied Sciences, Premier Inc., Charlotte, NC USA
| | - Bimal R. Shah
- Livongo Health, Mountain View, CA USA
- Department of Medicine, Duke University, Durham, NC USA
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Pharmacologic venous thromboembolism prophylaxis is not associated with post sphincterotomy bleeding after endoscopic retrograde cholangiopancreatography. Dig Liver Dis 2021; 53:766-771. [PMID: 33896749 DOI: 10.1016/j.dld.2021.03.033] [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] [Received: 02/11/2021] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Endoscopic sphincterotomy is considered high risk for post-procedure bleeding. Sphincterotomy in patients on therapeutic anticoagulation is avoided given increased bleeding risk. There is minimal data on the risk of post-sphincterotomy bleeding (PSB) among those on prophylactic anticoagulation for venous thromboembolism (VTE) prophylaxis. METHODS We performed a retrospective case control study of all inpatient endoscopic retrograde cholangiopancreatographies (ERCPs) with a sphincterotomy at our institution between July 2016 to February 2020. Cases were divided into two groups based on administration of peri‑procedural pharmacologic VTE prophylaxis. The outcomes were the rates of PSB and VTE within 30-days of the ERCP. RESULTS A total of 369 inpatient ERCPs with a sphincterotomy were identified. 151 cases received peri‑procedural pharmacologic VTE prophylaxis and 218 did not. The mean Padua score and American Society of Anesthesiologists physical status classification were significantly greater in the prophylaxis group. PSB was statistically similar between both groups (3.3% vs. 5.5%, p=.32). VTE was statistically similar (0.7% vs. 0.5%, p=.79). Multivariate analysis did not reveal an association between PSB and peri‑procedural pharmacologic VTE prophylaxis. CONCLUSION Peri-procedural pharmacologic VTE prophylaxis is not associated with increased rates of PSB. These findings suggest that pharmacologic VTE prophylaxis can be safely continued in those undergoing an endoscopic sphincterotomy.
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Nopp S, Ay C. Bleeding Risk Assessment in Patients with Venous Thromboembolism. Hamostaseologie 2021; 41:267-274. [PMID: 33626580 DOI: 10.1055/a-1339-9987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The recommended treatment for patients with venous thromboembolism (VTE) is anticoagulation for at least 3 months. However, anticoagulant treatment increases the risk of bleeding, and patients at high risk for major bleeding might benefit from treatment discontinuation. In this review, we discuss strategies for assessing bleeding risk and compare different bleeding risk tools. Bleeding risk assessment is best viewed as a continuous approach with varying challenges throughout the acute and chronic phase. At diagnosis, bleeding risk factors must be identified and reversible risk factors treated or modified. After initial treatment, repeated bleeding risk assessment is crucial for the decision on extended/long-term anticoagulation. Current clinical prediction models (e.g., HAS-BLED, RIETE, or VTE-BLEED scores) are externally validated tools with relevant differences in specificity and sensitivity, which can aid in clinical decision-making. Unfortunately, none of the current bleeding risk assessment tools has been investigated in clinical trials and provides evidence to withhold anticoagulation treatment based on the score. Nevertheless, the HAS-BLED or RIETE score can be used to identify patients at high risk for major bleeding during the initial treatment phase, while the VTE-BLEED score might be used to identify patients at low risk for bleeding and, therefore, to safely administer extended/long-term anticoagulation for secondary thromboprophylaxis. As clinical prediction scores still lack predictive value, future research should focus on developing biomarker-based risk assessment models.
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Affiliation(s)
- Stephan Nopp
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Khorana AA, Kuderer NM, McCrae K, Milentijevic D, Germain G, Laliberté F, MacKnight SD, Lefebvre P, Lyman GH, Streiff MB. Healthcare costs of patients with cancer stratified by Khorana score risk levels. J Med Econ 2021; 24:866-873. [PMID: 34181497 DOI: 10.1080/13696998.2021.1948681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS Patients with cancer are at high risk of venous thromboembolism (VTE), which entails a high economic burden. The risk of cancer-associated VTE can be assessed using the Khorana score (KS), a validated VTE risk prediction algorithm. This study compared healthcare costs associated with different KS in a population of patients newly diagnosed with cancer. METHODS The Optum Clinformatics DataMart database (01/01/2012-09/30/2017) was used to select adult patients with ≥1 hospitalization or ≥2 outpatient claims with a cancer diagnosis (index date) initiated on systemic therapy or radiation therapy. Patients were classified in mutually exclusive cohorts based on KS (i.e. KS = 0, 1, 2 or ≥3). The observation period spanned from index to the earliest among the end of data availability, death, end of insurance coverage, or 12 months. RESULTS In total 6,194 patients (KS = 0: 2,488; KS = 1: 2,125; KS = 2: 1,074; KS ≥ 3: 507) were included. On average, patients were aged 68 years, 48-52% were female, and the Quan-Charlson comorbidity index ranged between 1.1 and 1.4. Over the observation period, all-cause total healthcare costs per patient per month (PPPM) were $8,826 (KS = 0), $11,598 (KS = 1), $14,028 (KS = 2), and $16,211 (KS ≥ 3). Using the KS = 0 cohort as a reference, adjusted PPPM costs were $2,506, $4,775, and $6,452 higher in the KS = 1, KS = 2, and KS ≥ 3 cohorts, respectively. Hospitalization and outpatient costs were the main drivers of these differences. Similar results were found for VTE-related costs, which represented 4-11% of the total all-cause cost difference between KS cohorts. LIMITATIONS Residual confounders; results may not be generalized to patients with other insurance plans or those who received treatments other than systemic therapy or radiation therapy. CONCLUSIONS This real-world analysis found that cancer patients at higher risk of VTE (based on KS) incurred significantly greater all-cause and VTE-related healthcare costs compared with cancer patients at lower risk of VTE.
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Affiliation(s)
- Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | - Keith McCrae
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | | | | | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, WA, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, USA
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Shapiro JA, Stillwagon MR, Padovano AG, Moll S, Lim MR. An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery. Int J Spine Surg 2020; 14:599-606. [PMID: 32986584 DOI: 10.14444/7080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although venous thromboembolism (VTE) is a potentially serious and life-threatening complication, there is no widely accepted protocol to guide VTE prophylaxis in adult degenerative spinal surgery, and pharmacologic overtreatment may result in hemorrhagic complications. Previously, we published the VTE Prophylaxis Risk/Benefit Score, an evidence-based algorithm that balances the risk and consequences of thrombotic versus hemorrhagic complications by taking consideration of patient-related risks, procedure-related risks, and the risk of neurological compromise to guide VTE prophylaxis. To objective of this study was to validate the VTE Prophylaxis Risk/Benefit Score. METHODS From January 1, 2016, to December 31, 2017, VTE Prophylaxis Risk/Benefit Scores and corresponding prophylaxes were prospectively assigned. When indicated, chemoprophylaxis was dosed 24 to 36 hours postoperatively to allow for adequate surgical hemostasis. Patients were retrospectively evaluated for immediate and short-term complications. The Fisher exact test compared incidence of complications by VTE prophylaxis. Multinomial logistic regression modeled the probability of complication by prophylaxis type, demographics, and comorbidities. Significance was set at P < .05. RESULTS Of the 266 patients who met inclusion criteria, 79.3% were given mechanical prophylaxis alone and 20.7% were given combined mechanical and chemical prophylaxis. Complications including VTE (0.38%), delayed wound healing or infection (2.26%), and hematoma (0.75%) were observed at rates similar to or lower than previously published studies with increased utilization of chemoprophylaxis. Use of chemoprophylaxis and continuation of perioperative aspirin were significantly associated with the development of a hemorrhagic complication. No patient developed persistent neurologic deficit from hematoma or pulmonary embolism. CONCLUSIONS The VTE Prophylaxis Risk/Benefit Score comprehensively considers the risk of thrombotic, wound, and bleeding complications and is an effective tool for determining appropriate thromboprophylaxis in adult degenerative spinal surgery. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Joshua A Shapiro
- University of North Carolina, Department of Orthopaedics, Chapel Hill, North Carolina
| | - Matthew R Stillwagon
- University of North Carolina, Department of Orthopaedics, Chapel Hill, North Carolina
| | - Alexander G Padovano
- University of North Carolina, Department of Orthopaedics, Chapel Hill, North Carolina
| | - Stephan Moll
- University of North Carolina, Department of Medicine, Division of Hematology/Oncology, Chapel Hill, North Carolina
| | - Moe R Lim
- University of North Carolina, Department of Orthopaedics, Chapel Hill, North Carolina
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Caron A, Depas N, Chazard E, Yelnik C, Jeanpierre E, Paris C, Beuscart JB, Ficheur G. Risk of Pulmonary Embolism More Than 6 Weeks After Surgery Among Cancer-Free Middle-aged Patients. JAMA Surg 2020; 154:1126-1132. [PMID: 31596449 DOI: 10.1001/jamasurg.2019.3742] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance The risk of postoperative pulmonary embolism has been reported to be highest during the first 5 weeks after surgery. However, how long the excess risk of postoperative pulmonary embolism persists remains unknown. Objective To assess the duration and magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery. Design, Setting, and Participants Case-crossover analysis to compute the respective risks of pulmonary embolism after 6 types of surgery using data from a French national inpatient database, which covers a total of 203 million inpatient stays over an 8-year period between 2007 and 2014. Participants were cancer-free middle-aged adult patients (aged 45 to 64) with a diagnosis of a first pulmonary embolism. Exposures Hospital admission for surgery. Surgical procedures were classified into 6 types: (1) vascular surgery, (2) gynecological surgery, (3) gastrointestinal surgery, (4) hip or knee replacement, (5) fractures, and (6) other orthopedic operations. Main Outcomes and Measures Diagnosis of a first pulmonary embolism. Results A total of 60 703 patients were included (35 766 [58.9%] male; mean [SD] age, 56.6 [6.0] years). The risk of postoperative pulmonary embolism was elevated for at least 12 weeks after all types of surgery and was highest during the immediate postoperative period (1 to 6 weeks). The excess risk of postoperative pulmonary embolism ranged from odds ratio (OR), 5.24 (95% CI, 3.91-7.01) for vascular surgery to OR, 8.34 (95% CI, 6.07-11.45) for surgery for fractures. The risk remained elevated from 7 to 12 weeks, with the OR ranging from 2.26 (95% CI, 1.81-2.82) for gastrointestinal operations to 4.23 (95% CI, 3.01-5.92) for surgery for fractures. The risk was not clinically significant beyond 18 weeks postsurgery for all types of procedures. Conclusions and Relevance The risk of postoperative pulmonary embolism is elevated beyond 6 weeks postsurgery regardless of the type of procedure. The persistence of this excess risk suggests that further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define the optimal duration of treatment with regard to both the thrombotic and bleeding risks.
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Affiliation(s)
- Alexandre Caron
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Nicolas Depas
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Emmanuel Chazard
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Cécile Yelnik
- University Lille, Inserm, CHU Lille, U995, Lille Inflammation Research International Center, Lille, France
| | - Emmanuelle Jeanpierre
- University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011, EGID, Lille, France
| | - Camille Paris
- University Lille, CHU Lille, Hematology Transfusion Institute, Lille, France
| | - Jean-Baptiste Beuscart
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Grégoire Ficheur
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
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Sadri L, Rogers A, Sharma D, Tunis J, Sullivan T, Pineda DM. A survey of patients lost to follow-up after inferior vena cava filter placement. J Vasc Surg Venous Lymphat Disord 2020; 8:365-370. [DOI: 10.1016/j.jvsv.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
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Sartori M, Gabrielli F, Favaretto E, Filippini M, Migliaccio L, Cosmi B. Proximal and isolated distal deep vein thrombosis and Wells score accuracy in hospitalized patients. Intern Emerg Med 2019; 14:941-947. [PMID: 30864093 DOI: 10.1007/s11739-019-02066-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/04/2019] [Indexed: 01/08/2023]
Abstract
Deep vein thrombosis (DVT) is an important cause of morbidity and mortality in hospitalized patients. The Wells score for DVT pretest probability (PTP) was validated in outpatients, but its utility for inpatients is unclear. The aim of this study was to establish the prevalence of inpatient proximal and distal DVT and the Wells score performance in inpatients. A single-center cross-sectional study was conducted in a university hospital. During 183 days, all inpatients with suspected lower-extremity DVT were evaluated with the Wells score and whole-leg ultrasound. Among 634 inpatients (age 77.5 ± 13.8 years, males 39.3%), 507 (80.0%) were from medical wards and 127 (20.0%) from surgical wards. During the study period, there were 11,662 hospital admissions in the surgical/medical services. Whole-leg ultrasound detected 128 DVTs (20.2%); 51 (39.8%) were proximal and 77 (60.1%) were isolated distal DVTs. Estimated DVT prevalence in hospital setting was 1.09% (95% CI 0.93-1.31), and isolated distal DVT prevalence was 0.66% (95% CI 0.53-0.82). DVT frequency in low-, moderate-, and high-PTP groups was 9.8%, 24.3%, and 41.5%, respectively (p = 0.001). The area under the receiver operating characteristic curve for the Wells score was 0.67 ± 0.03 for all DVTs and 0.75 ± 0.04 for only proximal DVTs. A high PTP had a sensitivity of 24% (95% CI 14-37%) and a specificity of 93% (95% CI 91-95%) for proximal DVT diagnosis. In hospitalized patients, isolated distal DVT has a higher incidence than expected, and the Wells score accuracy for proximal DVT is similar to that found in outpatients.
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Affiliation(s)
- Michelangelo Sartori
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy.
| | - Filippo Gabrielli
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy
| | - Elisabetta Favaretto
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy
| | - Massimo Filippini
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy
| | - Ludovica Migliaccio
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy
| | - Benilde Cosmi
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, via Albertoni, 15, 40138, Bologna, Italy
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Sargin M, Erdogan SB, Bastopcu M, Arslanhan G, Tasdemir MM, Orhan G. Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center. Value Health Reg Issues 2019; 19:81-86. [PMID: 31254969 DOI: 10.1016/j.vhri.2019.03.007] [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: 11/23/2017] [Revised: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. METHODS Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. RESULTS Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. CONCLUSIONS Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Arslanhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Effects of Perioperative Venous Thromboembolism on Outcomes in Soft Tissue Reconstruction of Traumatic Lower Extremity Injuries. Ann Plast Surg 2019; 82:S345-S349. [DOI: 10.1097/sap.0000000000001871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Betrixaban: Safely Reducing Venous Thromboembolic Events with Extended Prophylaxis. Am J Med 2019; 132:307-311. [PMID: 30201249 DOI: 10.1016/j.amjmed.2018.08.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 11/23/2022]
Abstract
Although venous thromboembolism prophylaxis of acute medically ill patients is commonly employed, a percentage of high-risk patients still have venous thromboembolic events within 30 days of discharge. Research over the last several years has attempted to identify characteristics of these high-risk patients to facilitate provision of extended prophylaxis and venous thromboembolic event reduction; however, extended prophylaxis has been associated with a significant increase in the risk for major bleeding until recently. Betrixaban, a new oral direct Xa inhibitor with once-daily dosing and limited renal elimination, significantly reduces the risk of venous thromboembolism without increasing the risk for major bleeding. Consequently, betrixaban is the only anticoagulant approved by the Food and Drug Administration for preventing venous thromboembolism with extended prophylaxis in acute medically ill patients.
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Lower Extremity Duplex Ultrasound Screening Protocol for Moderate- and High-Risk Trauma Patients. J Surg Res 2019; 235:280-287. [DOI: 10.1016/j.jss.2018.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/26/2018] [Accepted: 10/02/2018] [Indexed: 11/17/2022]
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23
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Holleck JL, Gunderson CG. Things We Do for No Reason: Intermittent Pneumatic Compression for Medical Ward Patients? J Hosp Med 2019; 14:47-50. [PMID: 30667410 DOI: 10.12788/jhm.3114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jürgen L Holleck
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.
| | - Craig G Gunderson
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
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Ruff SM, Weber KT, Khader A, Conte C, Kadison A, Sullivan J, Wang J, Zaidi R, Deutsch GB. Venous thromboembolism in patients with cancer undergoing surgical exploration. J Thromb Thrombolysis 2018; 47:316-323. [DOI: 10.1007/s11239-018-1774-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Venous thromboembolism laboratory testing (factor V Leiden and
factor II c.*97G>A), 2018 update: a technical standard of the American College of
Medical Genetics and Genomics (ACMG). Genet Med 2018; 20:1489-1498. [DOI: 10.1038/s41436-018-0322-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023] Open
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Predicting inferior vena cava (IVC) filter retrievability using positional parameters: A comparative study of various filter types. Diagn Interv Imaging 2018; 99:615-624. [DOI: 10.1016/j.diii.2018.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 11/17/2022]
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Saad M, Shaikh DH, Mantri N, Alemam A, Zhang A, Adrish M. Fever is associated with higher morbidity and clot burden in patients with acute pulmonary embolism. BMJ Open Respir Res 2018; 5:e000327. [PMID: 30271608 PMCID: PMC6157512 DOI: 10.1136/bmjresp-2018-000327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Fever is considered as a presenting symptom of pulmonary embolism (PE). We aim to evaluate the association between PE and fever, its clinical characteristics, outcomes and role in prognosis. METHODS A retrospective chart review of patients who were hospitalised with the diagnosis of acute PE was conducted. Patients in whom underlying fever could also be attributable to an underlying infection were also excluded. RESULTS A total of 241 patients met the study criteria. 63 patients (25.7%) had fever within 1 week of diagnosis of PE of which four patients had fever that could be due to underlying infection and were excluded. Patients in PE with fever group were younger compared with PE without fever group (52.52 vs 58.68, p=0.012) and had higher incidence of smoking (44.1% vs 20.9%, p<0.001). Patients in PE with fever group were more likely to require intensive care admission (69.5% vs 35.7%, p<0.001), had a longer hospital length of stay (19.80 vs 12.20, p<0.001) and higher requirement of mechanical ventilation (30.5% vs 6.6%, p<0.001) compared with those without fever. PE with fever group were more likely to have massive and submassive PE (55.9% vs 36.8%, p=0.015) and had higher incidence of deep vein thrombosis (33.3% vs 17.4%, p=0.0347) compared with PE without fever. In a univariate model, there was higher likelihood of in-hospital mortality in PE with fever group compared with PE without fever (22.0% vs 10.4%, p=0.039). CONCLUSION Patients with acute PE and fever have higher morbidity and clot burden.
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Affiliation(s)
- Muhammad Saad
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
| | - Danial H Shaikh
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
| | - Nikhitha Mantri
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
| | - Ahmed Alemam
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
| | - Aiyi Zhang
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
| | - Muhammad Adrish
- Department of Internal Medicine, BronxCare Health System, Bronx, New York, USA
- Department of Medicine, Affiliated with Icahn School of Medicine at Mt Sinai, New York, USA
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Hood JE, Yesudasan S, Averett RD. Glucose Concentration Affects Fibrin Clot Structure and Morphology as Evidenced by Fluorescence Imaging and Molecular Simulations. Clin Appl Thromb Hemost 2018; 24:104S-116S. [PMID: 30114949 PMCID: PMC6714860 DOI: 10.1177/1076029618792304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Although in vivo studies have been conducted in the past to determine hyperglycemic effects and influence on clotting risk in patients with diabetes, the true extent of hyperglycemia on unstable and spontaneous clot formation remains highly debated. Factors such as increased glycation, elevated fibrinogen concentration, elevated prothrombin levels, and decreased plasminogen are known to influence fibrin conversion, clot morphology, and thrombus formation in these individuals. In this regard, the isolated effects of hyperglycemia on irregular fibrin clot formation were investigated in a controlled fibrinogen system. In this study, fibrin clot characteristic differences at 3 glucose concentrations were analyzed to determine the effects of glucose concentration on fibrinogen glycation and fibrin clot morphology using confocal microscopy, glycation quantification, molecular simulations, and image processing methods. Algorithms coupled with statistical analysis support in vivo findings that hyperglycemia increases fibrinogen glycation, with ensuing altered fibrin clot structure characteristics. Our experimental and molecular simulation results consistently show an increased glucose adsorption by fibrinogen with increased glucose concentration. Significant differences in clot structure characteristics were observed, and the results of this work can be used to further develop diagnostic tools for evaluating clotting risk in individuals with hypercoagulable and hyperglycemic conditions.
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Affiliation(s)
- Jacob E Hood
- School of Chemical, Materials, and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Sumith Yesudasan
- School of Chemical, Materials, and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Rodney D Averett
- School of Chemical, Materials, and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
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Gourzoulidis G, Kourlaba G, Kakisis J, Matsagkas M, Giannakoulas G, Gourgoulianis KI, Vassilakopoulos T, Maniadakis N. Cost-Effectiveness Analysis of Rivaroxaban for Treatment of Deep Vein Thrombosis and Pulmonary Embolism in Greece. Clin Drug Investig 2018; 37:833-844. [PMID: 28608312 DOI: 10.1007/s40261-017-0540-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Venous thromboembolism (VTE), comprising deep-vein thrombosis (DVT) and pulmonary embolism (PE), is a major healthcare concern that results in substantial morbidity and mortality with great economic burden for healthcare systems. Hence, the need for effective and efficient treatment of patients with VTE is important for both clinical and economic reasons. The objective of this study was to evaluate the cost effectiveness of rivaroxaban compared to standard of care (SoC) with enoxaparin followed by dose-adjusted vitamin-K antagonists for the treatment of DVT and PE in Greece. METHODS An existing Markov model was locally adapted from a third-party payer perspective to reflect the management and complications of DVT and PE in the course of 3-month cycles, up to death. The clinical inputs and utility values were extracted from published studies. Direct medical costs, obtained from local resources, were incorporated in the model and refer to year 2017. Both costs and outcomes were discounted at 3.5%. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained was calculated. Probabilistic sensitivity analysis (PSA) was carried out to deal with uncertainty. RESULTS The base-case analysis showed that rivaroxaban in 3- and 6-month treatment duration for DVT and PE, respectively, as this is the common clinical practice in Greece, was associated with a 0.02 and 0.01 increment in QALYs compared to SoC, respectively. Rivaroxaban was associated with a reduced total cost in DVT (€85) but with an additional total cost in PE (€2) compared to SoC. Therefore, rivaroxaban was a dominant (less costly, more effective) and cost-effective (ICER: €177) alternative over SoC for the management of DVT and PE, respectively. PSA revealed that the probability of rivaroxaban being cost effective at a threshold of €34,000 per QALY gained was 99% and 81% for DVT and PE, respectively. CONCLUSION Rivaroxaban may represent a cost-effective option relative to SoC for the management of DVT and PE in Greece.
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Affiliation(s)
- George Gourzoulidis
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
| | - Georgia Kourlaba
- The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John Kakisis
- Department of Vascular Surgery, Attikon Hospital, Athens University Medical School, Athens, Greece
| | - Mitiadis Matsagkas
- Department of Surgery - Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | | | - Theodoros Vassilakopoulos
- Department of Critical Care and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece
| | - Nikos Maniadakis
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece
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Sobh AH, Koueiter DM, Mells A, Siljander MP, Karadsheh MS. The Role of Aspirin and Unfractionated Heparin Combination Therapy Immediately After Total Hip and Knee Arthroplasty. Orthopedics 2018; 41:171-176. [PMID: 29570760 DOI: 10.3928/01477447-20180320-08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/24/2018] [Indexed: 02/03/2023]
Abstract
Aspirin and unfractionated heparin (UH) are accepted options for venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA). The use of aspirin in addition to UH in preventing VTE after TJA has yet to be studied. The primary objective of this study was to determine VTE rates in patients receiving aspirin monotherapy and those receiving aspirin and UH combination therapy immediately following TJA. A TJA database from a single hospital system was retrospectively reviewed to identify all patients who underwent primary hip or knee arthroplasty from 2013 to 2016. Patients were divided into 3 groups based on postoperative VTE chemoprophylaxis: aspirin only, aspirin with 1 dose of UH, and aspirin with multiple doses of UH. There were 5350 patients included: 1024 aspirin only, 1695 aspirin plus 1 dose of UH, and 2631 aspirin plus multiple doses of UH. Deep venous thrombosis and pulmonary embolus rates did not vary significantly between groups (deep venous thrombosis: 1.1%, 0.9%, and 1.2%, respectively, P=.701; pulmonary embolus: 0.3%, 0.3%, and 0.2%, respectively, P=.894). Transfusion rates were significantly greater with 1 dose of UH (1.8%) and multiple doses of UH (4.3%) compared with aspirin only (0.9%) (P<.001). Additionally, the postoperative hemoglobin decreased significantly more postoperatively with the use of UH (P<.001). Aspirin and UH combination therapy did not decrease VTE incidence compared with aspirin monotherapy. Additionally, there was greater perioperative blood loss and an increased rate of blood transfusion in patients receiving UH. On the basis of these findings, the authors do not recommend UH as an additional mode of VTE prophylaxis when prescribing aspirin after elective TJA. [Orthopedics. 2018; 41(3):171-176.].
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Hong Y, Mansour S, Alotaibi G, Wu C, McMurtry MS. Effect of anticoagulants on admission rates and length of hospital stay for acute venous thromboembolism: A systematic review of randomized control trials. Crit Rev Oncol Hematol 2018; 125:12-18. [PMID: 29650271 DOI: 10.1016/j.critrevonc.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/05/2018] [Accepted: 02/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is a paucity of data available on hospitalization and length of stay (LOS) for different anticoagulant therapies. We sought to compare and summarize admission rates and LOS, and describe the frequency of reporting these two outcomes in randomized control trials (RCTs) comparing different anticoagulant therapies for venous thromboembolism (VTE). METHODS A literature search was conducted from inception to August 15, 2016 on RCTs of anticoagulant therapy for patients with VTE. Study selection, data extraction and risk of bias analysis were done by two reviewers independently. Meta-analyses were conducted for admission rates and LOS. RESULTS A total of 4064 articles were identified. There were 74 articles of 70 studies included in the analysis. Hospitalization rates and LOS were reported in 13 (18.6%) and 12 (17.1%) of the 70 included studies, respectively. Low-molecular-weight heparin (LMWH)-treated patients were 33.0% less likely to be admitted to hospitals compared to unfractionated heparin (UFH) (RR = 0.67, 95% CI [0.58, 0.78]). The mean difference in LOS between LMWH and UFH was 2.54 days in favor of LMWH (95% CI [-4.94, -0.14]). Compared to parenteral therapy, using rivaroxaban was associated with a lower admission rate for a difference of 1.4-5.1% in VTE, 2.5% in DVT and 0.2% in PE. The LOS of patients receiving rivaroxaban was significant shorter than the LOS in parenteral therapy group for a difference of 1-5 days in VTE, 3 days in DVT and 1 day in PE. CONCLUSION Admission rates were lower and LOS was shorter using LMWH compared to UFH and oral therapy compared to parenteral therapy for acute VTE treatment in RCTs, based on limited eligible RCTs. These crucial clinically relevant outcomes are underreported in the existing VTE clinical trials.
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Affiliation(s)
- Yongzhe Hong
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Sola Mansour
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ghazi Alotaibi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Cave B, Hough A, Dobesh PP. Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients. Pharmacotherapy 2018. [PMID: 29543384 DOI: 10.1002/phar.2102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Brandon Cave
- Fort Loudoun Medical Center; Lenoir City Tennessee
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center; West Palm Beach Florida
| | - Paul P. Dobesh
- College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
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Aboagye JK, Hayanga JW, Lau BD, Bush EL, Shaffer DL, Hobson DB, Kraus PS, Streiff MB, Haut ER, D’Cunha J. Venous Thromboembolism in Patients Hospitalized for Lung Transplantation. Ann Thorac Surg 2018; 105:1071-1076. [DOI: 10.1016/j.athoracsur.2017.10.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/05/2017] [Accepted: 10/11/2017] [Indexed: 12/01/2022]
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Ruhe AM, Hebbard A, Hayes G. Assessment of venous thromboembolism risk and initiation of appropriate prophylaxis in psychiatric patients. Ment Health Clin 2018; 8:68-72. [PMID: 29955548 PMCID: PMC6007734 DOI: 10.9740/mhc.2018.03.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) prophylaxis is not included among the measures for the Inpatient Psychiatric Facilities Quality Reporting Program. Evidence suggests that antipsychotic agents may be an independent risk factor for the development of VTE; therefore, development of a VTE risk stratification tool would improve the quality and safety of care for the psychiatric inpatient population. This study aims to develop clinically relevant criteria to assess VTE risk upon admission to an inpatient psychiatric hospital. Methods This retrospective, single-center cohort study enrolled patients in 2 cohorts from an inpatient psychiatric hospital. Patients in cohort I with new-onset VTE diagnosis during admission were identified through international classification of diseases 9 and 10 coding. Cohort II consisted of a random sample of 100 patients in a 3-month period. The percentage meeting criteria for prophylaxis in each cohort was assessed utilizing both the Padua Prediction Score and a modified score. Results In cohorts I and II, 66.7% and 14% of patients, respectively, met criteria for VTE prophylaxis utilizing the modified Padua Prediction Score. One patient received VTE prophylaxis in each cohort, and the median time to VTE diagnosis in cohort I was 42 days. In cohort I, the rate of VTE was 0.08% based on estimated discharges in the 26-month period. This is less than the annual rate of 1% to 2.4% for nursing homes or postacute rehabilitation facilities. Discussion We recommend the implementation of clinical decision support to prompt individualized reassessment of VTE risk when length of stay exceeds 30 days.
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Affiliation(s)
- Ann Marie Ruhe
- Clinical Pharmacy Specialist in Psychiatry, Sheppard Pratt Health System, Baltimore, Maryland; Previously: Medical University of South Carolina (MUSC), Charleston, South Carolina,
| | - Amy Hebbard
- Clinical Specialist, Psychiatry, MUSC Medical Center/South Carolina College of Pharmacy Residency Program, Medical University of South Carolina (MUSC), Charleston, South Carolina
| | - Genevieve Hayes
- Clinical Specialist, Outcomes Management, MUSC Medical Center/South Carolina College of Pharmacy Residency Program, Medical University of South Carolina (MUSC), Charleston, South Carolina
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Cohen A, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost 2017; 107:1035-43. [DOI: 10.1160/th11-12-0859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 02/04/2012] [Indexed: 12/22/2022]
Abstract
SummaryVenous thromboembolism (VTE) is a major healthcare concern and affects more than 1.6 million individuals each year worldwide. Long-term complications include recurrent VTE, chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Rivaroxaban is an oral, direct factor Xa inhibitor that has advantages over traditional VTE therapies, including minimal drug and food interactions and no requirement for routine coagulation monitoring. It is currently approved for VTE prevention in adult patients undergoing elective hip or knee replacement surgery. This review evaluates the potential clinical implications of the multicentre, randomised EINSTEIN studies (EINSTEIN DVT and EINSTEIN EXT), which investigated rivaroxaban for the treatment and prevention of recurrent VTE. In EINSTEIN DVT, rivaroxaban was non-inferior to the standard of care (enoxaparin plus a vitamin K antagonist) for recurrent VTE in patients with acute deep-vein thrombosis (DVT) without pulmonary embolism (PE). In EINSTEIN EXT, extended-duration rivaroxaban had superior efficacy to placebo in patients with confirmed DVT or PE who had received 6–12 months of prior VTE treatment. Rivaroxaban was associated with an acceptable safety profile in both studies. The net clinical benefit (efficacy and safety end-points combined) of rivaroxaban was significantly greater than its comparators. The EINSTEIN studies are the first demonstration that a single drug - rivaroxaban - can be effective for both the initial treatment of DVT and prevention of recurrent VTE. Moreover, the simple, once-daily oral administration of rivaroxaban could potentially improve adherence to extended-duration VTE treatment compared with the current standard of care in individuals with confirmed DVT or PE.
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Abstract
The development of new methods to image the onset and progression of thrombosis is an unmet need. Non-invasive molecular imaging techniques targeting specific key structures involved in the formation of thrombosis have demonstrated the ability to detect thrombus in different disease state models and in patients. Due to its high concentration in the thrombus and its essential role in thrombus formation, the detection of fibrin is an attractive strategy for identification of thrombosis. Herein we provide an overview of recent and selected fibrin-targeted probes for molecular imaging of thrombosis by magnetic resonance imaging (MRI), positron emission tomography (PET), single photon emission computed tomography (SPECT), and optical techniques. Emphasis is placed on work that our lab has explored over the last 15 years that has resulted in the progression of the fibrin-binding PET probe [64Cu]FBP8 from preclinical studies into human trials.
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Affiliation(s)
- Bruno L Oliveira
- Department of Chemistry, University of Cambridge, Lensfield Road, CB2 1EW, Cambridge, UK.
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Mou E, Kwang H, Hom J, Shieh L, Kumar A, Richman I, Berube C. Magnitude of Potentially Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting. J Hosp Med 2017; 12:735-738. [PMID: 28914278 DOI: 10.12788/jhm.2819] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Laboratory costs of thrombophilia testing exceed an estimated $650 million (in US dollars) annually. Quantifying the prevalence and financial impact of potentially inappropriate testing in the inpatient hospital setting represents an integral component of the effort to reduce healthcare expenditures. We conducted a retrospective analysis of our electronic medical record to evaluate 2 years' worth of inpatient thrombophilia testing measured against preformulated appropriateness criteria. Cost data were obtained from the Centers for Medicare and Medicaid Services 2016 Clinical Laboratory Fee Schedule. Of the 1817 orders analyzed, 777 (42.7%) were potentially inappropriate, with an associated cost of $40,422. The tests most frequently inappropriately ordered were Factor V Leiden, prothrombin gene mutation, protein C and S activity levels, antithrombin activity levels, and the lupus anticoagulant. Potentially inappropriate thrombophilia testing is common and costly. These data demonstrate a need for institution-wide changes in order to reduce unnecessary expenditures and improve patient care.
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Affiliation(s)
- Eric Mou
- Department of Medicine, Stanford University, Stanford, California, USA.
| | - Henry Kwang
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Jason Hom
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Andre Kumar
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Ilana Richman
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Caroline Berube
- Division of Hematology, Stanford University, Stanford, California, USA
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Parisi TJ, Konopka JF, Bedair HS. What is the Long-term Economic Societal Effect of Periprosthetic Infections After THA? A Markov Analysis. Clin Orthop Relat Res 2017; 475:1891-1900. [PMID: 28389865 PMCID: PMC5449335 DOI: 10.1007/s11999-017-5333-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/22/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Current estimates for the direct costs of a single episode of care for periprosthetic joint infection (PJI) after THA are approximately USD 100,000. These estimates do not account for the costs of failed treatments and do not include indirect costs such as lost wages. QUESTIONS/PURPOSES The goal of this study was to estimate the long-term economic effect to society (direct and indirect costs) of a PJI after THA treated with contemporary standards of care in a hypothetical patient of working age (three scenarios, age 55, 60, and 65 years). METHODS We created a state-transition Markov model with health states defined by surgical treatment options including irrigation and débridement with modular exchange, single-stage revision, and two-stage revision. Reoperation rates attributable to septic and aseptic failure modes and indirect and direct costs were calculated estimates garnered via multiple systematic reviews of peer-reviewed orthopaedic and infectious disease journals and Medicare reimbursement data. We conducted an analysis over a hypothetical patient's lifetime from the societal perspective with costs discounted by 3% annually. We conducted sensitivity analysis to delineate the effects of uncertainty attributable to input variables. RESULTS The model found a base case cost of USD 390,806 per 65-year-old patient with an infected THA. One-way sensitivity analysis gives a range of USD 389,307 (65-year-old with a 3% reinfection rate) and USD 474,004 (55-year-old with a 12% reinfection rate). Indirect costs such as lost wages make up a considerable portion of the costs and increase considerably as age at the time of infection decreases. CONCLUSIONS The results of this study show that the overall treatment of a periprosthetic infection after a THA is markedly more expensive to society than previously estimated when accounting for the considerable failure rates of current treatment options and including indirect costs. These overall costs, combined with a large projected increase in THAs and a steady state of septic failures, should be taken into account when considering the total cost of THA. Further research is needed to adequately compare the clinical and economic effectiveness of alternative treatment pathways. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Thomas J. Parisi
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Joseph F. Konopka
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
| | - Hany S. Bedair
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building 3B, Boston, MA 02114 USA
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How long should we fear? Long-term risk of venous thromboembolism in patients with traumatic brain injury. J Trauma Acute Care Surg 2017; 81:71-8. [PMID: 27015575 DOI: 10.1097/ta.0000000000001046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although patients with traumatic brain injury (TBI) are known to be at high risk for venous thromboembolism (VTE), it is not clear how long this risk persists after injury. We aimed to determine the risk of VTE in patients with TBI during one year after injury and to identify associated factors. METHODS Patients 18 years and older with International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses of isolated TBI (head Abbreviated Injury Scale [AIS] ≥3 and AIS <3 for all other body regions) were identified in the California State Inpatient Database (2007-2011). Patient and admission (injury severity score, length of stay, and discharge disposition) characteristics were assessed. Hospital factors (teaching status, trauma center verification, and bed size) were extracted from the American Hospital Association database. Patients who developed VTE during the index admission and at different time points after discharge were determined. Multivariate logistic regression models were used to assess the associated risk factors for VTE after discharge. RESULTS There were 38,984 patients with isolated TBI identified. The incidence of VTE was 1.31% during the index admission and the cumulative incidence of VTE involving hospitalization within one year of injury was 2.83%. The major risk factors for VTE one year after injury (not including the index admission) were discharge to extended care facilities versus home [adjusted odds ratio, 2.69 (95% confidence interval, 2.14-3.37)], age older than 64 years versus 18 to 44 years [2.62 (1.80-3.81)], having an operation during the index admission [1.65 (1.36-2.01)], and hospital length of stay of more than 7 days versus 3 days or less [1.64 (1.27-2.11)]. CONCLUSION The risk of VTE persists long after discharge in a significant proportion of patients with TBI. Demographic and admission characteristics of patients play significant roles in the risk of VTE after discharge. These results highlight the need for sustained surveillance and preventive measures among patients with TBI at increased risk for long-term VTE. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Evaluation of venous thromboembolism prophylaxis in a major hospital in a developing country. Int J Clin Pharm 2017. [DOI: 10.1007/s11096-017-0494-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Klevanets J, Starodubtsev V, Ignatenko P, Voroshilina O, Ruzankin P, Karpenko A. Systemic Thrombolytic Therapy and Catheter-Directed Fragmentation with Local Thrombolytic Therapy in Patients with Pulmonary Embolism. Ann Vasc Surg 2017; 45:98-105. [PMID: 28501664 DOI: 10.1016/j.avsg.2017.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective was to compare immediate and long-term results of systemic thrombolytic therapy (STT) and catheter-directed fragmentation (CDF) with local thrombolytic therapy (LTT) in patients with massive pulmonary embolism (PE). METHODS About 209 patients with massive PE (the high risk of early death) were included in our study. From 2008 till 2010 in the first group (n = 102), STT was performed. From 2011 till 2013 in the second group (n = 107), CDF with LTT was carried out. Echocardiography and pulmonary arteriography were performed in all patients on admission to hospital and in 5 days after treatment. The patients of both groups were re-examined in 6 months, 1, 2, and 3 years after the operation. RESULTS In the first group, there were 5 (4.9%) cases of in-hospital 30-day mortality. In the second group, there was 1 (0.9%) case of in-hospital 30-day mortality (P = 0.08). In the first group, a clinically significant bleeding was noted in 4 (3.9%) cases, but it caused mortality only in 1 case. In the second group, the clinically significant bleeding was not found (P = 0.038). Persistent postembolic pulmonary hypertension (PPPH) in 9.8% cases of patients in the first group and 2.9% cases of patients in the second group was determined (P = 0.048). CONCLUSIONS CDF combined with LTT is an effective minimal invasive treatment (helped us to reduce significantly the number of bleeding and PPPH cases), at least in the midterm, in patients with massive PE.
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Affiliation(s)
- Julia Klevanets
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Vladimir Starodubtsev
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation.
| | - Pavel Ignatenko
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Olga Voroshilina
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Pavel Ruzankin
- The Sobolev Institute of Mathematics SB RAS, Novosibirsk State University, Novosibirsk, Russian Federation
| | - Andrey Karpenko
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
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Yuksel A, Tuydes O. Midterm Outcomes of Pharmacomechanical Thrombectomy in the Treatment of Lower Extremity Deep Vein Thrombosis With a Rotational Thrombectomy Device. Vasc Endovascular Surg 2017; 51:301-306. [DOI: 10.1177/1538574417708726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The purpose of this study was to assess the safety and efficacy with midterm outcomes of pharmacomechanical thrombectomy (PMT) performed by using a relatively new thrombectomy device in the treatment of lower extremity deep vein thrombosis (DVT). Methods: Between February 2014 and February 2016, a total of 46 patients with lower extremity DVT were treated with PMT by using Cleaner rotational thrombectomy system. Preprocedural, intraprocedural, postprocedural, and follow-up records of patients were collected and retrospectively analyzed. Results: Mean age of patients was 50.5 (14.8) years, and 58.7% of them were female. Technical success rate of procedure was 91.3%. Mean procedure time was 81.8 (40.3) minutes. Early clinical improvement was observed in all patients with successful treatment. No serious adverse event related to procedure and mortality was observed. Mean follow-up time was 16.0 (7.9) months. Reocclusion was observed in 7 (17.5%) patients during the follow-up period. Venous patency rates of patients at 1-, 3-, 6-, and 12-month follow-up visits were 95%, 92.5%, 89.7%, and 79.5%, respectively. Mild, moderate, and severe postthrombotic syndrome were observed in 8 (20%) patients, 4 (10%) patients, and 1 (2.5%) patient, respectively. Postthrombotic syndrome–free survival rate was 67.5%. Conclusion: Cleaner rotational thrombectomy system appears to be safe and effective in the treatment of lower extremity DVT. Further larger randomized studies are needed to determine the long-term outcomes of this treatment modality.
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Affiliation(s)
- Ahmet Yuksel
- Department of Cardiovascular Surgery, Bursa State Hospital, Bursa, Turkey
| | - Oktay Tuydes
- Department of Cardiovascular Surgery, Bingol State Hospital, Bingol, Turkey
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Whitworth MM, Haase KK, Fike DS, Bharadwaj RM, Young RB, MacLaughlin EJ. Utilization and prescribing patterns of direct oral anticoagulants. Int J Gen Med 2017; 10:87-94. [PMID: 28331354 PMCID: PMC5354547 DOI: 10.2147/ijgm.s129235] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Scant literature exists evaluating utilization patterns for direct oral anticoagulants (DOACs). OBJECTIVES The primary objective was to assess DOAC prescribing in patients with venous thromboembolism (VTE) and nonvalvular atrial fibrillation (NVAF) in outpatient clinics. Secondary objectives were to compare utilization between family medicine (FM) and internal medicine (IM) clinics, characterize potentially inappropriate use, and identify factors associated with adverse events (AEs). METHODS This was a retrospective cohort study of adults with NVAF or VTE who received a DOAC at FM or IM clinics between 10/19/2010 and 10/23/2014. Descriptive statistics were utilized for the primary aim. Fisher's exact test was used to evaluate differences in prescribing using an adapted medication appropriateness index. Logistic regression evaluated factors associated with inappropriate use and AEs. RESULTS One-hundred twenty patients were evaluated. At least 1 inappropriate criterion was met in 72 patients (60.0%). The most frequent inappropriate criteria were dosage (33.0%), duration of therapy (18.4%), and correct administration (18.0%). Apixaban was dosed inappropriately most frequently. There was no difference in dosing appropriateness between FM and IM clinics. The odds of inappropriate choice were lower with apixaban compared to other DOACs (odds ratio [OR]=0.088; 95% confidence interval [CI] 0.008-0.964; p=0.047). Twenty-seven patients (22.5%) experienced an AE while on a DOAC, and the odds of bleeding doubled with each inappropriate criterion met (OR=1.949; 95% CI 1.190-3.190; p=0.008). CONCLUSION Potentially inappropriate prescribing of DOACs is frequent with the most common errors being dosing, administration, and duration of therapy. These results underscore the importance of prescriber education regarding the appropriate use and management of DOACs.
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Affiliation(s)
- Maegan M Whitworth
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy
| | - Krystal K Haase
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy
| | - David S Fike
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy
| | | | | | - Eric J MacLaughlin
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center (TTUHSC) School of Pharmacy; Departments of Family Medicine and Internal Medicine, TTUHSC School of Medicine, Amarillo, TX, USA
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44
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Failure of chemical thromboprophylaxis in critically ill medical and surgical patients with sepsis. J Crit Care 2017; 37:206-210. [DOI: 10.1016/j.jcrc.2016.10.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/31/2016] [Accepted: 10/05/2016] [Indexed: 01/19/2023]
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Gharaibeh L, Younes N, Albsoul-Younes A. Role of the clinical pharmacist in improving the appropriateness of venous thromboembolism prophylaxis in hospitalised patients in Jordan. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lubna Gharaibeh
- Faculty of Pharmacy; Department of Biopharmaceutics and Clinical Pharmacy; University of Jordan; Amman Jordan
| | - Nidal Younes
- Faculty of Medicine; Department of General Surgery; University of Jordan; Amman Jordan
| | - Abla Albsoul-Younes
- Faculty of Pharmacy; Department of Biopharmaceutics and Clinical Pharmacy; University of Jordan; Amman Jordan
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Jenkins IH, White RH, Amin AN, Afsarmanesh N, Auerbach AD, Khanna R, Maynard GA. Reducing the incidence of hospital-associated venous thromboembolism within a network of academic hospitals: Findings from five University of California medical centers. J Hosp Med 2016; 11 Suppl 2:S22-S28. [PMID: 27925421 DOI: 10.1002/jhm.2658] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/02/2016] [Accepted: 09/11/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Almost 700 patients suffered from hospital-associated venous thromboembolism (HA-VTE) across 5 University of California hospitals in calendar year 2011. OBJECTIVE Optimize venous thromboembolism (VTE) prophylaxis (VTEP) in adult medical/surgical inpatients and reduce HA-VTE by at least 20% within 3 years. DESIGN Prospective, unblinded, open-intervention study with historical controls. SETTING Five independent but cooperating academic hospitals. PATIENTS All adult medical and surgical inpatients with stays ≥3 days. The baseline year was 2011, 2012 to 2014 were intervention years, and year 2014 was the mature comparison period. VTEP adequacy was assessed with structured chart review of 45 patients per month at each site via random selection beginning partway through the study. HA-VTE was identified by discharge coding, capturing patients readmitted within 30 days of prior VTE-free admit and VTE occurring during index admission. Cases were stratified medical versus surgical and cancer or noncancer. INTERVENTIONS Interventions included structured order sets with "3-bucket" risk-assessment, measure-vention, techniques to improve reliable administration of VTEP, and education. RESULTS Adequate prophylaxis reached 89% by early 2014. The rate of HA-VTE fell from 0.90% in 2011 to 0.69% in 2014 (24% relative risk [RR] reduction; RR: 0.76, 95% confidence interval: 0.68-0.852), equivalent to averting 81 pulmonary emboli and 89 deep venous thrombi. VTE rates were highest in cancer and surgical patients. CONCLUSIONS Hospital systems can reduce HA-VTE by implementing a bundle of active interventions including structured VTEP orders with embedded risk assessment and measure-vention. Journal of Hospital Medicine 2016;11:S22-S28. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Ian H Jenkins
- Department of Medicine, University of California San Diego Health System, San Diego, California
| | - Richard H White
- Department of Medicine, University of California Davis, Davis, California
| | - Alpesh N Amin
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Nasim Afsarmanesh
- Department of Medicine, University of California Los Angeles Health, Los Angeles, California
| | - Andrew D Auerbach
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Raman Khanna
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Erzinger FL, Carneiro MB. Prevenção de tromboembolismo venoso em hospital com perfil oncológico: como melhorá-la? J Vasc Bras 2016; 15:189-196. [PMID: 29930589 PMCID: PMC5829755 DOI: 10.1590/1677-5449.003216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Contexto Complicações do tromboembolismo venoso são encontradas frequentemente em pacientes internados, tanto em condições clínicas quanto em pós-operatórios. Objetivo Verificar a quimioprofilaxia utilizada para tromboembolismo venoso em pacientes oncológicos internados, antes e após a realização de um programa de esclarecimento da sua importância. Métodos Estudo de corte transversal realizado em três momentos distintos: inicialmente antes do programa de conscientização da importância da profilaxia do tromboembolismo venoso, durante o período em que foi realizada e um ano após a etapa anterior. Para fins estatísticos, os pacientes foram divididos em alto risco e baixo risco, e estratificados quanto a erro na quimioprofilaxia em: precisavam, mas não fizeram profilaxia; não precisavam, mas fizeram profilaxia; fizeram profilaxia não padronizada; e não podiam, mas fizeram profilaxia. Resultados Foram avaliados 399 pacientes internados, sendo 56 pacientes antes do início do programa de conscientização, 255 durante o programa e 88 após um ano. Antes da realização da semana de conscientização, apenas 35,7% dos pacientes estavam recebendo a quimioprofilaxia adequada; após a semana de conscientização, houve um aumento do número de prescrições corretas, que passou para 63,9% (p < 0,001). Após um ano sem as aulas de conscientização, a manutenção da quimioprofilaxia não foi tão eficaz, com uma tendência ao aumento do número de profilaxias incorretas (p = 0,081). Conclusão A quimioprofilaxia é utilizada em uma porcentagem muito pequena nos pacientes internados, sendo necessários programas de esclarecimento de sua importância na prevenção do tromboembolismo venoso e a realização de monitoramento contínuo para auxiliar na sua prescrição.
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Zuin M, Picariello C, Badin A, Rinuncini M, Rigatelli G, Zonzin P, Roncon L. Economic burden of venous thromboembolism: Are novel oral anticaoagulants the possible solution? Int J Cardiol 2016; 220:551-2. [PMID: 27390985 DOI: 10.1016/j.ijcard.2016.06.312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marco Zuin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy; Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Claudio Picariello
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Badin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Massimo Rinuncini
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy.
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Cohen AT, Hamilton M, Bird A, Mitchell SA, Li S, Horblyuk R, Batson S. Comparison of the Non-VKA Oral Anticoagulants Apixaban, Dabigatran, and Rivaroxaban in the Extended Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis. PLoS One 2016; 11:e0160064. [PMID: 27487187 PMCID: PMC4972314 DOI: 10.1371/journal.pone.0160064] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/11/2016] [Indexed: 01/12/2023] Open
Abstract
Background Historically, warfarin or aspirin have been the recommended therapeutic options for the extended treatment (>3 months) of VTE. Data from Phase III randomised controlled trials (RCTs) are now available for non-VKA oral anticoagulants (NOACs) in this indication. The current systematic review and network meta-analysis (NMA) were conducted to compare the efficacy and safety of anticoagulants for the extended treatment of VTE. Methods Electronic databases (accessed July 2014 and updated April 2016) were systematically searched to identify RCTs evaluating apixaban, aspirin, dabigatran, edoxaban, rivaroxaban, and warfarin for the extended treatment of VTE. Eligible studies included adults with an objectively confirmed deep vein thrombosis, pulmonary embolism or both. A fixed-effect Bayesian NMA was conducted, and results were presented as relative risks (RRs). Sensitivity analyses examining (i) the dataset employed according to the time frame for outcome assessment (ii) the model used for the NMA were conducted. Results Eleven Phase III RCTs (examining apixaban, aspirin, dabigatran, rivaroxaban, warfarin and placebo) were included. The risk of the composite efficacy outcome (VTE and VTE-related death) was statistically significantly lower with the NOACs and warfarin INR 2.0–3.0 compared with aspirin, with no significant differences between the NOACs. Treatment with apixaban (RR 0.23, 95% CrI 0.10, 0.55) or dabigatran (RR 0.55, 95% Crl 0.43, 0.71) was associated with a statistically significantly reduced risk of ‘major or clinically relevant non-major bleed’ compared with warfarin INR 2.0–3.0. Apixaban also showed a significantly reduced risk compared with dabigatran (RR 0.42, 95% Crl 0.18, 0.97) and rivaroxaban (RR 0.23, 95% Crl 0.09, 0.59). Sensitivity analyses indicate that results were dependent on the dataset, but not on the type of NMA model employed. Conclusions Results from the NMA indicate that NOACs are an effective treatment for prevention of VTE or VTE-related death) in the extended treatment setting. However, bleeding risk differs between potential treatments, with apixaban reporting the most favourable profile compared with other NOACs, warfarin INR 2.0–3.0, and aspirin.
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Affiliation(s)
- A. T. Cohen
- Guy’s and St Thomas’ Hospitals, King’s College, London, United Kingdom
| | | | - A. Bird
- Pfizer, Walton Oaks, United Kingdom
| | | | - S. Li
- BMS, Princeton, United States of America
| | | | - S. Batson
- Abacus International, Bicester, United Kingdom
- * E-mail:
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50
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Khalafallah AA, Kirkby BE, Wong S, Foong YC, Ranjan N, Luttrell J, Mathew R, Chilvers CM, Mauldon E, Sharp C, Hannan T. Venous thromboembolism in medical patients during hospitalisation and 3 months after hospitalisation: a prospective observational study. BMJ Open 2016; 6:e012346. [PMID: 27489158 PMCID: PMC4985867 DOI: 10.1136/bmjopen-2016-012346] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This study was conducted to assess the incidence and risk factors for venous thromboembolism (VTE) in a cohort of medical patients both during the period of hospitalisation and following discharge. DESIGN This was a prospective observational study to document the risk profile and incidence of VTE posthospitalisation among all medical patients admitted to our institution during the trial period. SETTINGS Primary healthcare. Single tertiary referral centre, Tasmania, Australia. PARTICIPANTS A total of 986 patients admitted to the medical ward between January 2012 and September 2012 were included in the study with male to female ratio of 497:489. The mean age of patients was 68 years (range 17-112, SD 16). RESULTS Overall, 54/986 patients (5.5%) had a VTE during the study period. Of these, 40/54 (74.1%) occurred during hospitalisation and 14/54 (25.9%) occurred following discharge. VTE risk factors revealed in multivariate analysis to be associated with a previous diagnosis of VTE (p<0.001, OR=6.63, 95% CI 3.3 to 13.36), the occurrence of surgery within the past 30 days (p<0.001, OR=2.52, 95% CI 1.33 to 4.79) and an admission diagnosis of pulmonary disease (p<0.01, OR 3.61, 95% CI 1.49 to 8.76). Mobility within 24 hours of admission was not associated with an increased risk. There was risk of VTE when the length of stay prolonged (p=0.046, OR=1.01, 95% CI 1.00 to 1.03), however it was not sustained with multivariate modelling. VTE-specific prophylaxis was used in 53% of the studied patients. Anticoagulation including antiplatelet agents were administered in 63% of patients who developed VTE. CONCLUSIONS This prospective observational study found that 5.5% of the studied patients developed VTE. Among those, 25.9% (14/54) of patients had a detected VTE posthospitalisation with this risk being increased if there was a history of VTE, recent surgery and pulmonary conditions. Thromboprophylaxis may be worth considering in these cohorts. Further study to confirm these findings are warranted. TRIAL REGISTRATION NUMBER ACTRN12611001255976.
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Affiliation(s)
- Alhossain A Khalafallah
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia School of Health Sciences and School of Medicine, University of Tasmania, Launceston, Tasmania, Australia Menzies Institute for Medical Research, University of Tasmania, Australia
| | - Brooke E Kirkby
- Pathology Department, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Sophia Wong
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Yi Chao Foong
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Nishant Ranjan
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - James Luttrell
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Ronnie Mathew
- School of Health Sciences and School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Charles M Chilvers
- School of Health Sciences and School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Emily Mauldon
- School of Health Sciences and School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Colin Sharp
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Terry Hannan
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia Menzies Institute for Medical Research, University of Tasmania, Australia
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