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Ndai AM, Allen BR, Wynn TT, Rajasekhar A, Saqr Z, Sandeli I, Vouri SM, Reise R. Rapid recognition and optimal management of hemophilia in the emergency department: A quality improvement project. J Am Coll Emerg Physicians Open 2024; 5:e13168. [PMID: 38699223 PMCID: PMC11065154 DOI: 10.1002/emp2.13168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/05/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024] Open
Abstract
Objectives This study aimed to assess the effectiveness of a continuous quality improvement initiative at the University of Florida Health Physicians practice in reducing the time to administer factor replacement therapy (FRT) for hemophilia patients presenting with bleeding in the emergency department (ED). Methods The study, a quasi-experimental, interventional design, was conducted between January 2020 and January 2023. The intervention, implemented in September 2021, involved training ED physicians, creating a specialized medication order set within the electronic health record (EHR), and a rapid triage system. The effectiveness was measured by comparing the time from ED arrival to factor administration before and after the intervention and benchmarking it against the National Bleeding Disorders Foundation's Medical and Scientific Advisory Council (MASAC)-recommended 1-hour timeline for factor administration. An interrupted time series (ITS) analysis with a generalized least squares model assessed the intervention's impact. Results A total of 43 ED visits (22 pre-intervention and 21 post-intervention) were recorded. Post-intervention, the average time from ED arrival to factor administration decreased from 5.63 to 3.15 hours. There was no significant increase (27% vs. 29%) in the patients receiving factor within 1-hour of ED arrival. The ITS analysis predicted a 20-hour reduction in the average quarterly time to administer factor by the end of the study, an 84% decrease. Conclusions The quality improvement program decreased the time to administer FRT for patients with hemophilia in the ED. However, the majority of patients did not achieve the 1-hour MASAC-recommended timeline for factor administration after ED arrival.
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Affiliation(s)
- Asinamai M. Ndai
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Brandon R. Allen
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Tung T. Wynn
- Division of Pediatric Hematology/OncologyDepartment of PediatricsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Anita Rajasekhar
- Division of Hematology/OncologyDepartment of MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ziad Saqr
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Ina Sandeli
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Scott M. Vouri
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
| | - Rachel Reise
- Department of Pharmaceutical Outcomes and PolicyCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
- University of Florida Health PhysiciansGainesvilleFloridaUSA
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Burnett AE, Barnes GD, Allen AL, Ansell J, Blumenstein M, Connors JM, Dager WE, Kaatz S, May JE, Nemeth R, O'Connor C, Ragheb B, Rajasekhar A, Sardo L, Siegal DM, Van Beek A. Comment on: 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023; 71:3951-3953. [PMID: 37702478 DOI: 10.1111/jgs.18579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/08/2023] [Indexed: 09/14/2023]
Abstract
See the Reply by Semla and Steinman in this issue.
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Affiliation(s)
- Allison E Burnett
- Inpatient Thrombosis & Hemostasis Stewardship Program, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Arthur L Allen
- Veterans Administration Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | | | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William E Dager
- UC Davis Health System, San Diego, CA, USA
- UC San Francisco, San Francisco, CA, USA
- UC Davis, San Diego, CA, USA
| | - Scott Kaatz
- Michigan State University-College of Human Medicine, East Lansing, MI, USA
- Wayne State University-School of Medicine, Detroit, MI, USA
- Henry Ford Hospital, Detroit, MI, USA
| | - Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ronni Nemeth
- Anticoagulation Clinics, Confluence Health, Wenatchee Washington, Wenatchee, WA, USA
| | - Carlee O'Connor
- Mayo Clinic Health System-Eau Claire, Wisconsin, Eau Claire, WI, USA
| | - Bishoy Ragheb
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Laurie Sardo
- St. Joseph's Healthcare, Hamilton, Hamilton, Ontario, Canada
- McMaster School of Nursing, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- University of Ottawa, Ottowa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottowa, Ontario, Canada
- The Ottawa Hospital, Ottowa, Ontario, Canada
| | - Andrea Van Beek
- Visalia Medical Clinic/Adventist Health Physicians Network, Visalia, CA, USA
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Chrisentery-Singleton T, Boggio LN, Carcao MD, Ibrahimi S, Khan O, Mahajerin A, Rajasekhar A, Sharma V, Steele M, Torres M, Rodino FJ, Carpenter SL. Long-term follow-up of patients with congenital thrombotic thrombocytopenia purpura receiving a plasma-derived factor VIII (Koate) that contains ADAMTS13. Haemophilia 2023; 29:1638-1645. [PMID: 37855744 DOI: 10.1111/hae.14891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/05/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Hereditary thrombotic thrombocytopenia purpura (hTTP) is an ultra-rare disorder resulting from an inherited deficiency of ADAMTS13, a von Willebrand factor (VWF)-cleaving metalloprotease. The plasma-derived factor VIII/VWF Koate (FVIII/VWFKoate ) has been shown to contain ADAMTS13, allowing for its use to treat hTTP at home by the patient/caregiver. AIM Based on prior demonstration of safe and effective use of FVIII/VWFKoate in eight patients with hTTP, we conducted a retrospective study to gather additional data regarding the use of FVIII/VWFKoate for hTTP. METHODS This was a multicentre, retrospective, noninterventional chart review of patients who had received FVIII/VWFKoate for the management of hTTP. Data collected included demographics, medical history, relevant family history, past use and tolerability of fresh frozen plasma, and details regarding FVIII/VWFKoate therapy. RESULTS The cohort included 11 patients (seven males, four females) with hTTP, ranging in age at study entry from 2 to 28 years. The average duration of FVIII/VWFKoate therapy was 4.8 years (range, 0.5-6.5 years). Among nine patients using FVIII/VWFKoate as prophylaxis, the normalized annual rate of breakthrough TTP episodes ranged from 0.2 to 1.1 episodes/year. All nine patients who received FVIII/VWFKoate prophylaxis had thrombocytopenia recorded at baseline, while eight (88.9%) did not have thrombocytopenia after using FVIII/VWFKoate . There was one AE (unspecified) attributed to FVIII/VWFKoate . CONCLUSION These data suggest that FVIII/VWFKoate is a safe and well-tolerated source of the missing ADAMTS13 enzyme in patients with hTTP, producing a marked reduction in thrombocytopenia prevalence, low frequency of TTP episodes, and with the added benefit of self- or caregiver-administration.
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Affiliation(s)
| | - Lisa N Boggio
- Rush Hemophilia & Thrombophilia Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Manuel D Carcao
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sami Ibrahimi
- OUHSC/Stephenson Cancer Center, Oklahoma City, Oklahoma, USA
| | - Osman Khan
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Arash Mahajerin
- Children's Hospital of Orange County, Orange, California, USA
| | - Anita Rajasekhar
- University of Florida - Shands Hospital, Gainesville, Florida, USA
| | - Vivek Sharma
- University of Louisville, Louisville, Kentucky, USA
| | | | - Marcela Torres
- Department of Hematology, Cook Children's Medical Center, Fort Worth, Texas, USA
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4
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Fortier JC, Singhal R, Rajasekhar A, Mathew C. Reducing unnecessary premedication prior to parenteral iron therapy: A quality improvement project. Transfusion 2023; 63:1685-1691. [PMID: 37587736 DOI: 10.1111/trf.17502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/02/2023] [Accepted: 07/09/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Intravenous (IV) iron carries risks of mild, self-limiting, tryptase-negative Fishbane and complement activation-related pseudo-allergy reactions, with rare reports of anaphylaxis. Historically, high-molecular-weight iron dextran (HMWID) was associated with a higher incidence of anaphylaxis and empiric premedication with antihistamines/corticosteroids have been used to mitigate this risk. HMWID is no longer available and the risk of hypersensitivity reactions with newer IV iron formulations is low. Therefore, the use of routine prophylactic premedication in all patients is not justified but should be considered in high-risk patients. STUDY DESIGN AND METHODS Our primary aim was to reduce inappropriate premedication before IV iron administration by 50% so that our institution's hematology providers only prescribe premedications to patients at high risk of having a severe reaction. Interventions included a multidisciplinary education initiative to highlight current evidence against universal administration of premedications and revision of the IV iron informed consent form and electronic order set. RESULTS We measured the success of our intervention by comparing data collected during a 6-month pre-intervention period (837 infusions) to a 6-month post-intervention period (947 infusions). Inappropriate administration of premedications decreased from 79% in the pre-intervention period compared to 65% in the post-intervention period. We found no significant difference in the number of Fishbane reactions, severe reactions, and emergency room admissions, despite this reduction in premedication use. DISCUSSION Although we did not reach our goal of a 50% reduction in inappropriate premedication use, opportunities for process improvements were uncovered and are being explored in the next cycle of this quality improvement project.
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Affiliation(s)
- Julia C Fortier
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ruchi Singhal
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Carol Mathew
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA
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5
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Tarantino MD, Hardesty B, Metjian A, Ortel TL, Chen J, Badejo K, Ma A, Cuker A, Rajasekhar A, Friedman KD, Janbain M. Real-world safety and effectiveness of recombinant porcine sequence factor VIII in acquired haemophilia A: A non-interventional, post-authorization safety study. Haemophilia 2023; 29:1259-1268. [PMID: 37584309 DOI: 10.1111/hae.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) is indicated for the treatment of bleeding episodes in adults with acquired haemophilia A (AHA). AIM To provide long-term real-world safety and effectiveness data for rpFVIII in the management of AHA bleeding episodes. METHODS US PASS (NCT02610127) was a multicentre, uncontrolled, open-label, post-marketing safety surveillance study conducted in adults with AHA. Data were collected retrospectively or prospectively for 180 days after rpFVIII treatment. The primary outcome was the incidence of treatment-related serious adverse events (SAEs). Secondary outcomes included haemostatic effectiveness of rpFVIII and rpFVIII utilization. RESULTS Fifty-three patients were enrolled from December 2015 to June 2019 (prospective, n = 30; retrospective, n = 23). Six patients experienced seven treatment-related SAEs (incidence 12.0%). The most common treatment-related SAE was FVIII inhibition (inhibiting antibodies to rpFVIII; incidence 8.0%, 95% CI: 2.2-19.2). Five patients reported seven thromboembolic events; one was an SAE and possibly related to rpFVIII. Of bleeding events treated with rpFVIII, 80.3% (57/71) of bleeds resolved with rpFVIII. The median (range) dose of rpFVIII per infusion was 50 (10-300) units/kg, with a median (range) of 6.0 (1-140) infusions and a median (range) time from bleed onset to bleed resolution of 14.0 (2.0-132.7) days. CONCLUSION In this real-world study of rpFVIII for AHA, no new safety signals were identified compared with previous clinical trial findings. Eighty percent of bleeds resolved with rpFVIII treatment.
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Affiliation(s)
| | - Brandon Hardesty
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Ara Metjian
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Jie Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Kayode Badejo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Alice Ma
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Rajasekhar
- Department of Hematology/Oncology, University of Florida Health, Gainesville, Florida, USA
| | - Kenneth D Friedman
- Medical College of Wisconsin and Versiti/Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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Lee AI, Masselink LE, De Castro LM, Marshall AL, Connell NT, Dent GA, Fritz J, Homer M, Lucas TL, Naik RP, Nelson M, O’Connell CL, Rajasekhar A, Reynolds RJ, Sharma D, Smith M, Weeks LD, Erikson CE. Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support. Blood Adv 2023; 7:3058-3068. [PMID: 35476017 PMCID: PMC10331414 DOI: 10.1182/bloodadvances.2021006140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Burnout is prevalent throughout medicine. Few large-scale studies have examined the impact of physician compensation or clinical support staff on burnout among hematologists and oncologists. In 2019, the American Society of Hematology conducted a practice survey of hematologists and oncologists in the AMA (American Medical Association) Masterfile; burnout was measured using a validated, single-item burnout instrument from the Physician Work-Life Study, while satisfaction was assessed in several domains using a 5-point Likert scale. The overall survey response rate was 25.2% (n = 631). Of 411 respondents with complete responses in the final analysis, 36.7% (n = 151) were from academic practices and 63.3% (n = 260) from community practices; 29.0% (n = 119) were female. Over one-third (36.5%; n = 150) reported burnout, while 12.0% (n = 50) had a high level of burnout. In weighted multivariate logistic regression models incorporating numerous variables, compensation plans based entirely on relative value unit (RVU) generation were significantly associated with high burnout among academic and community physicians, while the combination of RVU + salary compensation showed no significant association. Female gender was associated with high burnout among academic physicians. High advanced practice provider utilization was inversely associated with high burnout among community physicians. Distinct patterns of career dissatisfaction were observed between academic and community physicians. We propose that the implementation of compensation models not based entirely on clinical productivity increased support for women in academic medicine, and expansion of advanced practice provider support in community practices may address burnout among hematologists and oncologists.
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Affiliation(s)
- Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Leah E. Masselink
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Laura M. De Castro
- Division of Hematology/Oncology, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nathan T. Connell
- Hematology Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Georgette A. Dent
- Department of Pathology & Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Josel Fritz
- American Society of Hematology, Washington, DC
| | | | | | - Rakhi P. Naik
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Marquita Nelson
- Division of Hematology/Oncology, University of Tennessee Health Science Center, Memphis, TN
| | - Casey L. O’Connell
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | | | - Deva Sharma
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Melody Smith
- Division of Blood & Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, CA
| | | | - Clese E. Erikson
- Fitzhugh Mullan Institute for Health Workforce Equity, The George Washington University, Washington, DC
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Marin MJ, Mathew CM, Rajasekhar A, Zumberg M, Euliano TY, Winter WE, Pelletier JPR, Pruitt HD, Harris NS. Dysfibrinogenemia: discrepant results following infusion of purified fibrinogen. Blood Coagul Fibrinolysis 2023:00001721-990000000-00085. [PMID: 37395199 DOI: 10.1097/mbc.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Inherited dysfibrinogenemias are molecular disorders of fibrinogen that affect fibrin polymerization. The majority of cases are asymptomatic, but a significant proportion suffer from increased bleeding or thrombosis. We present two unrelated cases of dysfibrinogenemia, both of whom showed a characteristic discrepancy between fibrinogen activity and the immunologic fibrinogen. In one patient, the dysfibrinogenemia was confirmed by molecular analysis; in the other case, the diagnosis was presumptive based upon laboratory studies. Both patients underwent elective surgery. Both received a highly purified fibrinogen concentrate preoperatively and demonstrated a suboptimal laboratory response to the infusion. Three methods for determining fibrinogen concentration (Clauss fibrinogen, prothrombin-derived fibrinogen, and the viscoelastic functional fibrinogen) were utilized in the case of one patient, and these techniques showed discrepant results with the classic Clauss method giving the lowest concentration. Neither patient experienced excessive bleeding during surgery. Although these discrepancies have been previously described in untreated patients, their manifestation after infusion of purified fibrinogen is less well appreciated.
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Affiliation(s)
- Maximo J Marin
- Department of Pathology, Immunology and Laboratory Medicine
| | | | | | - Marc Zumberg
- Division of Hematology-Oncology, Department of Medicine
| | - Tammy Y Euliano
- Department of Anesthesiology
- Department of Obstetrics and Gynecology, University of Florida College of Medicine
| | | | - J Peter R Pelletier
- Department of Pathology, Immunology and Laboratory Medicine
- Department of Anesthesiology
| | - Heather D Pruitt
- Core Laboratory, UFHealth/Shands Hospital, Gainesville, Florida, USA
| | - Neil S Harris
- Department of Pathology, Immunology and Laboratory Medicine
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8
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Fortier J, Pang S, Schutte S, Zumberg MS, Rajasekhar A. Use of cell salvage and HBOC-201 in a pregnant Jehovah’s Witness with sickle beta+thalassaemia undergoing emergency caesarean section. BMJ Case Rep 2022; 15:15/11/e251368. [DOI: 10.1136/bcr-2022-251368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Patients with severe anaemia who refuse or cannot safely receive red cell transfusion present challenges during pregnancy, delivery and the postpartum period. Strategies including HBOC-201 (Hemopure) and intraoperative use of cell salvage have been used in non-pregnant patients to improve oxygen carrying capacity; however, these products pose unique risks in pregnant patients, those with sickle cell disease (SCD) and those undergoing caesarean section (C-section). We describe a case of a pregnant sickle beta+thalasasaemia patient who presented at 27 weeks gestation with pre-eclampsia and severe anaemia. As a Jehovah’s Witness, she declined allogenic blood transfusion. The patient successfully underwent emergent C-section with cell salvage and received HBOC-201 immediately after delivery, during the operative procedure. To our knowledge, this is the first published report documenting a Jehovah’s Witness patient with SCD who successfully received cell salvage and then HBOC-201 immediately postdelivery.
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9
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Ikesaka R, Kaur B, Crowther M, Rajasekhar A. Efficacy and safety of pre-operative insertion of inferior vena cava filter in patients undergoing bariatric surgery: a systematic review. J Thromb Thrombolysis 2022; 54:502-523. [PMID: 35960423 DOI: 10.1007/s11239-022-02689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 10/15/2022]
Abstract
Prophylactic placement of inferior vena cava (IVC) filters prior to performing bariatric surgery is an intervention of unclear safety and efficacy with disagreement between current practice guidelines. To better characterize the risk and benefit of IVC filter insertion prior to bariatric surgery based on the current evidence. A systematic review of the literature of patients with prophylactic IVC filter insertion prior to bariatric surgery was performed and 32 studies were identified for inclusion into the review, of which none were randomized controlled trials. Meta-analysis was performed including the high-quality included studies. Seven high quality studies reported thrombotic events in patients undergoing bariatric surgery who had an IVCF and a control group which allowed for meta-analysis. The pooled odds ratio of venous thrombotic events in the IVC filter population versus the group without IVC filters was 1.57 (95%CI 0.89, 2.76). Among high quality studies 5 reported major bleeding with a rate of 0.76% and 6 reported on IVC filter complications with a rate of 0.67%. Overall no significant reduction in the rate of venous thrombosis was found with prophylactic IVC filter insertion. Use of IVC filters for prophylaxis remains a concern given the lack of clear efficacy in this setting and a small but present complication risk.
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Affiliation(s)
| | - Bhagwanpreet Kaur
- Health Research Methodology, McMaster University, Hamilton, ON, Canada
| | | | - Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
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10
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Barnes GD, Burnett A, Allen A, Ansell J, Blumenstein M, Clark NP, Crowther M, Dager WE, Deitelzweig SB, Ellsworth S, Garcia D, Kaatz S, Raffini L, Rajasekhar A, Beek AV, Minichiello T. Thromboembolic prevention and anticoagulant therapy during the COVID-19 pandemic: updated clinical guidance from the anticoagulation forum. J Thromb Thrombolysis 2022; 54:197-210. [PMID: 35579732 PMCID: PMC9111941 DOI: 10.1007/s11239-022-02643-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 12/11/2022]
Abstract
Thromboembolism is a common and deadly consequence of COVID-19 infection for hospitalized patients. Based on clinical evidence pre-dating the COVID-19 pandemic and early observational reports, expert consensus and guidance documents have strongly encouraged the use of prophylactic anticoagulation for patients hospitalized for COVID-19 infection. More recently, multiple clinical trials and larger observational studies have provided evidence for tailoring the approach to thromboprophylaxis for patients with COVID-19. This document provides updated guidance for the use of anticoagulant therapies in patients with COVID-19 from the Anticoagulation Forum, the leading North American organization of anticoagulation providers. We discuss ambulatory, in-hospital, and post-hospital thromboprophylaxis strategies as well as provide guidance for patients with thrombotic conditions who are considering COVID-19 vaccination.
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Affiliation(s)
- Geoffrey D Barnes
- University of Michigan, 2800 Plymouth Rd, B14 G214, 48109-2800, Ann Arbor, MI, USA.
| | - Allison Burnett
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Arthur Allen
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jack Ansell
- Professor of Medicine, Hofstra/Northwell School of Medicine , New York, USA
| | | | - Nathan P Clark
- Kaiser Permanente Colorado, Colorado University Skaggs School of Pharmacy, Aurora, CO, USA
| | | | | | | | | | | | | | - Leslie Raffini
- University of Pennsylvania Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Andrea Van Beek
- Kaweah Health Medical Group/Visalia Medical Clinic, Visalia, CA, USA
| | - Tracy Minichiello
- University of California, San Francisco San Francisco VA Medical Center, San Francisco, CA, USA
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11
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Fragner M, Imbo B, Hobson J, Roberts JC, Rajasekhar A, Tarantino MD, Morell J, Kelkar AH. Time is Blood: The Impact of Diagnostic Delays on Acquired Hemophilia A. Cureus 2022; 14:e22048. [PMID: 35340501 PMCID: PMC8915674 DOI: 10.7759/cureus.22048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 02/07/2023] Open
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12
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O'Shea RS, Davitkov P, Ko CW, Rajasekhar A, Su GL, Sultan S, Allen AM, Falck-Ytter Y. AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis. Gastroenterology 2021; 161:1615-1627.e1. [PMID: 34579936 DOI: 10.1053/j.gastro.2021.08.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Robert S O'Shea
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Perica Davitkov
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Cynthia W Ko
- Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Grace L Su
- Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yngve Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Bauer ME, Rajasekhar A, Leffert L. In Response. Anesth Analg 2021; 133:e60-e61. [PMID: 34673734 DOI: 10.1213/ane.0000000000005726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Melissa E Bauer
- Department of Anesthesiology, Duke University, Durham, North Carolina,
| | - Anita Rajasekhar
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainsville, Florida
| | - Lisa Leffert
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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Rajasekhar A, Arnaoutakis GJ, Janelle GM, Harris N, Wynn T, Anderson RD, Ashton JN, Mandernach MW. Multidisciplinary Management of a Hemophilia A Patient Requiring Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2021; 36:534-538. [PMID: 34895963 DOI: 10.1053/j.jvca.2021.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/02/2021] [Accepted: 10/18/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Anita Rajasekhar
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL.
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Gregory M Janelle
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Neil Harris
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Tung Wynn
- Division of Hematology & Oncology, Department of Pediatrics, University of Florida, Gainesville, FL
| | - R David Anderson
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL
| | - Jennifer N Ashton
- Department of Pharmacy, University of Florida Health Shands, Gainesville, FL
| | - Molly W Mandernach
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL
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Bauer ME, Arendt K, Beilin Y, Gernsheimer T, Perez Botero J, James AH, Yaghmour E, Toledano RD, Turrentine M, Houle T, MacEachern M, Madden H, Rajasekhar A, Segal S, Wu C, Cooper JP, Landau R, Leffert L. The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia. Anesth Analg 2021; 132:1531-1544. [PMID: 33861047 DOI: 10.1213/ane.0000000000005355] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.
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Affiliation(s)
- Melissa E Bauer
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Katherine Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yaakov Beilin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Terry Gernsheimer
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Juliana Perez Botero
- Department of Medicine, Medical College of Wisconsin and Versiti, Milwaukee, Wisconsin
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Edward Yaghmour
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Roulhac D Toledano
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, New York
| | - Mark Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, Liaison for the American College of Obstetricians and Gynecologists
| | - Timothy Houle
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan Medical School, Ann Arbor, Michigan
| | - Hannah Madden
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anita Rajasekhar
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Scott Segal
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Christopher Wu
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Jason P Cooper
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Morgano GP, Wiercioch W, Anderson DR, Brożek JL, Santesso N, Xie F, Cuker A, Nieuwlaat R, Akl EA, Darzi A, Yepes-Nuñez JJ, Exteandia-Ikobaltzeta I, Rahman M, Rajasekhar A, Rogers F, Tikkinen KAO, Yates AJ, Dahm P, Schünemann HJ. A modeling approach to derive baseline risk estimates for GRADE recommendations:Concepts, development, and results of its application to the American Society of Hematology 2019 guidelines on prevention of venous thromboembolism in surgical hospitalized patients. J Clin Epidemiol 2021; 140:69-78. [PMID: 34284102 DOI: 10.1016/j.jclinepi.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The goal of this study was to develop an approach that can be used where baseline risk estimates that are directly applicable to prioritized patient-important outcomes are not available from published studies. STUDY DESIGN The McMaster University GRADE Centre and the ASH guideline panel for the prevention of VTE in surgical patients developed a modeling approach based on explicit assumptions about the distribution of symptoms, anatomical location, and severity of VTE events. RESULTS We applied the approach to derive modeled estimates of baseline risk. These estimates were used to calculated absolute measures of anticipated effects that informed the discussion of the evidence and the formulation of 30 guideline recommendations. CONCLUSIONS Our approach can assist guideline developers facing a lack of information about baseline risk estimates that directly apply to outcomes of interest. The use of modeled estimates increases transparency in the process and makes the baseline risk used by guideline experts explicit during their decision-making.
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Affiliation(s)
- Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | | | - Jan L Brożek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, USA
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon
| | - Andrea Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Juan José Yepes-Nuñez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; School of Medicine, Universidad de los Andes, Colombia
| | | | - Maryam Rahman
- Lillian S. Wells Department of Neurosurgery, University of Florida, USA
| | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, USA
| | - Frederick Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, USA
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Finland,; Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, USA; Department of Urology, University of Minnesota, USA
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; Department of Medicine, McMaster University, Canada.
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Abstract
BACKGROUND Cytomegalovirus (CMV) infection has been associated with venous thromboembolism (VTE) and acute coronary syndromes (ACS). METHODS A retrospective study was conducted within the OSF HealthCare System in Peoria, IL. The objectives were to determine the incidence of acute VTE and ACS within one year of CMV testing. The "study group" included patients with positive CMV immunoglobulin M (IgM) or positive CMV polymerase chain reaction (PCR). The "seropositive control" group included patients with positive CMV immunoglobulin G (IgG) and negative IgM. The "seronegative control" group included patients with negative CMV IgG and IgM, or negative PCR. RESULTS Within one year of CMV infection, 38 of 379 patients (10.0%) developed VTE in the study group compared to 41 of 1334 patients (3.1%) in the seropositive control and 37 of 1249 (3.0%) in the seronegative control. Adjusting for age and gender, both control groups were less likely to have VTE than the study group within one year (seropositive control: odds ratio (OR) = 0.3, 95% confidence interval (CI) 0.2-0.5, p < 0.0001; seronegative control: OR = 0.4, 95% CI 0.2-0.6, p < 0.0001). ACS was more likely to occur in the study group, with the incidence of 7.7% compared to 4.7% (p < 0.0001) in the seropositive control and 1.9% (p <0.0001) in the seronegative control. Adjusting for age and gender, the seronegative control was less likely to develop ACS than the study group within one year (OR = 0.4, 95% CI 0.2-0.7, p = 0.003). CONCLUSIONS This retrospective study demonstrates that CMV infection may be a significant risk factor for VTE and ACS.
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Affiliation(s)
- Amar H Kelkar
- Division of Hematology & Oncology, University of Florida College of Medicine, Gainesville, USA
| | - Brian L Loc
- Department of Cardiology, OSF Saint Francis Medical Center, Peoria, USA
| | - Michael D Tarantino
- Department of Hematology, Bleeding & Clotting Disorders Institute, Peoria, USA
| | - Anita Rajasekhar
- Division of Hematology & Oncology, University of Florida College of Medicine, Gainesville, USA
| | - Huaping Wang
- Department of Medicine, University of Illinois College of Medicine at Peoria, Peoria, USA
| | - Mona Kelkar
- Department of Biostatistics & Epidemiology, Harvard School of Public Health, Cambridge, USA
| | - John Farrell
- Department of Microbiology & Immunology, OSF System Laboratory, Peoria, USA
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18
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Kelkar AH, Rajasekhar A. Do prophylactic inferior vena cava filters in trauma patients reduce the risk of mortality or pulmonary embolism? Hematology Am Soc Hematol Educ Program 2020; 2020:629-633. [PMID: 33275719 PMCID: PMC7727549 DOI: 10.1182/hematology.2020000169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- Amar H Kelkar
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, University of Florida Health Shands Hospital, Gainesville, FL
| | - Anita Rajasekhar
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, University of Florida Health Shands Hospital, Gainesville, FL
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19
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Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality. Although most patients can be managed safely with anticoagulation, inferior vena cava filters (IVCFs) represent an important alternative to anticoagulation in a small subset of patients. IVCF use has expanded exponentially with the advent of retrievable filters. Indications for IVCFs have liberalized despite limited evidence supporting this practice. Because indiscriminate use of IVCFs can be associated with net patient harm, knowledge of the risks and benefits of these devices is essential to optimal evidence-based practice. Patients with acute VTE and absolute contraindications to anticoagulation or major complications from anticoagulation are universally agreed indications for IVCFs. However, the reliance on IVCFs for primary VTE prophylaxis in high-risk patients is not substantiated by the available literature. This review examines trends in IVCF use, practice-based recommendations on IVCF use in various clinical scenarios, complications associated with indwelling IVCFs, and indications for IVCF retrieval.
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Affiliation(s)
- Amar H Kelkar
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, University of Florida Health Shands Hospital, Gainesville, FL
| | - Anita Rajasekhar
- Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine, University of Florida Health Shands Hospital, Gainesville, FL
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20
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May JE, Irelan PC, Boedeker K, Cahill E, Fein S, Garcia DA, Hicks LK, Lawson J, Lim MY, Morton CT, Rajasekhar A, Shanbhag S, Zumberg MS, Plovnick RM, Connell NT. Systems-based hematology: highlighting successes and next steps. Blood Adv 2020; 4:4574-4583. [PMID: 32960959 PMCID: PMC7509880 DOI: 10.1182/bloodadvances.2020002947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 12/21/2022] Open
Abstract
Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - David A Garcia
- Division of Hematology, University of Washington, Seattle, WA
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Ming Y Lim
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
| | - Colleen T Morton
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Anita Rajasekhar
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | - Satish Shanbhag
- Cancer Specialists of North Florida, Fleming Island, FL; and
| | - Marc S Zumberg
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | | | - Nathan T Connell
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Kaufman JA, Barnes GD, Chaer RA, Cuschieri J, Eberhardt RT, Johnson MS, Kuo WT, Murin S, Patel S, Rajasekhar A, Weinberg I, Gillespie DL. Society of Interventional Radiology Clinical Practice Guideline for Inferior Vena Cava Filters in the Treatment of Patients with Venous Thromboembolic Disease: Developed in collaboration with the American College of Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association, Society for Vascular Surgery, and Society for Vascular Medicine. J Vasc Interv Radiol 2020; 31:1529-1544. [PMID: 32919823 DOI: 10.1016/j.jvir.2020.06.014] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/23/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations on the use of inferior vena cava (IVC) filters in the treatment of patients with or at substantial risk of venous thromboembolic disease. MATERIALS AND METHODS A multidisciplinary expert panel developed key questions to address in the guideline, and a systematic review of the literature was conducted. Evidence was graded based on a standard methodology, which was used to inform the development of recommendations. RESULTS The systematic review identified a total of 34 studies that provided the evidence base for the guideline. The expert panel agreed on 18 recommendations. CONCLUSIONS Although the evidence on the use of IVC filters in patients with or at risk of venous thromboembolic disease varies in strength and quality, the panel provides recommendations for the use of IVC filters in a variety of clinical scenarios. Additional research is needed to optimize care for this patient population.
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Affiliation(s)
- John A Kaufman
- Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon.
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania
| | - Joseph Cuschieri
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Robert T Eberhardt
- Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Matthew S Johnson
- Department of Radiology, Indiana University School of Medicine, Indiana University Health, Indianapolis, Indiana
| | - William T Kuo
- Division of Vascular and Interventional Radiology, Stanford University School of Medicine, Stanford, California
| | - Susan Murin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, California
| | - Sheena Patel
- Society of Interventional Radiology, Fairfax, Virginia
| | - Anita Rajasekhar
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Ido Weinberg
- Cardiology Division, Vascular Medicine Section, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - David L Gillespie
- Southcoast Vascular and Endovascular Surgery, Southcoast Physicians Group, Dartmouth, Massachusetts
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22
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Wiercioch W, Nieuwlaat R, Akl EA, Kunkle R, Alexander KE, Cuker A, Rajasekhar A, Alonso-Coello P, Anderson DR, Bates SM, Cushman M, Dahm P, Guyatt G, Iorio A, Lim W, Lyman GH, Middeldorp S, Monagle P, Mustafa RA, Neumann I, Ortel TL, Rochwerg B, Santesso N, Vesely SK, Witt DM, Schünemann HJ. Methodology for the American Society of Hematology VTE guidelines: current best practice, innovations, and experiences. Blood Adv 2020; 4:2351-2365. [PMID: 32453843 PMCID: PMC7252554 DOI: 10.1182/bloodadvances.2020001768] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Methods for the development of clinical guidelines have advanced dramatically over the past 2 decades to strive for trustworthiness, transparency, user-friendliness, and rigor. The American Society of Hematology (ASH) guidelines on venous thromboembolism (VTE) have followed these advances, together with application of methodological innovations. OBJECTIVE In this article, we describe methods and methodological innovations as a model to inform future guideline enterprises by ASH and others to achieve guideline standards. Methodological innovations introduced in the development of the guidelines aim to address current challenges in guideline development. METHODS We followed ASH policy for guideline development, which is based on the Guideline International Network (GIN)-McMaster Guideline Development Checklist and current best practices. Central coordination, specialist working groups, and expert panels were established for the development of 10 VTE guidelines. Methodological guidance resources were developed to guide the process across guidelines panels. A methods advisory group guided the development and implementation of methodological innovations to address emerging challenges and needs. RESULTS The complete set of VTE guidelines will include >250 recommendations. Methodological innovations include the use of health-outcome descriptors, online voting with guideline development software, modeling of pathways for diagnostic questions, application of expert evidence, and a template manuscript for publication of ASH guidelines. These methods advance guideline development standards and have already informed other ASH guideline projects. CONCLUSIONS The development of the ASH VTE guidelines followed rigorous methods and introduced methodological innovations during guideline development, striving for the highest possible level of trustworthiness, transparency, user-friendliness, and rigor.
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Affiliation(s)
- Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | - Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública), Barcelona, Spain
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Philipp Dahm
- Urology Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thomas L Ortel
- Department of Medicine and
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nancy Santesso
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK; and
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada Centre
- McMaster GRADE Centre, and
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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23
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 266] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Abstract
Central venous access devices are a critical instrument in the treatment and supportive care delivery for oncology patients. Catheter-related thrombosis (CRT) is a common complication of central venous access devices in oncology patients. Risk factors for CRT include patient-, device-, and treatment-related risk factors. Treatment of CRT is indicated to reduce symptoms, prevent catheter malfunction, prevent recurrent DVT or thromboembolic pulmonary embolism, and minimize the risk of post-thrombotic syndrome. Minimal prospective data exist on the prevention and treatment of catheter-related thromboses in cancer patients. As such recommendations largely are derived from data in the lower-extremity DVT and PE studies in cancer and non-cancer patients. Based on the available literature, primary pharmacologic prophylaxis against CRT is not recommended in cancer patients. Treatment options for CRT include catheter removal, anticoagulation, catheter-directed thrombolysis, or surgical thrombectomy. Current evidence-based guidelines recommend LMWH as the anticoagulant of choice. However, recent data showing efficacy and safety of DOACs in cancer-related VTE may be extrapolated to treatment of CRT in cancer patients. In patients with CRT, catheter removal should be pursued if continued vascular access is no longer needed, the catheter is dysfunctional, a catheter-associated infection is present, or if CRT symptoms do not resolve with anticoagulation alone. Catheter-directed thrombolysis is reserved for rare severe cases of CRT. Herein we discuss the pathophysiology, clinical presentation, diagnosis, and general management of CRT in cancer patients.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, PO Box 100278, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD, 21205, USA
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Giordano C, Johnson C, Lawson J, Rajasekhar A, Thomas E. Administering RiaSTAP for Congenital Afibrinogenemia During Liver Transplant. EXP CLIN TRANSPLANT 2018; 19:269-272. [PMID: 29766777 DOI: 10.6002/ect.2017.0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Liver transplant has occasionally been performed in the presence of congenital afibrinogenemia and has been rarely used to treat it. Historically, to safely manage coagulopathy during transplant, these patients have been administered a combination of fresh frozen plasma and cryoprecipitate. In this case report, we discuss the first reported use of recombinant fibrinogen to treat such a patient and the decision-making process considered to balance the thrombotic and hemorrhagic risks.
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Affiliation(s)
- Chris Giordano
- From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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Hicks LK, Rajasekhar A, Bering H, Carson KR, Kleinerman J, Kukreti V, Ma A, Mueller BU, O'Brien SH, Panepinto JA, Pasquini MC, Sarode R, Wood WA. Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology. Am J Hematol 2016; 91:787-92. [PMID: 27152483 DOI: 10.1002/ajh.24412] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/26/2016] [Accepted: 05/03/2016] [Indexed: 01/03/2023]
Abstract
Choosing Wisely (CW) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. In an effort to learn from and leverage the work of others, the American Society of Hematology CW Task Force developed a method to identify and prioritize CW recommendations from other medical societies of high relevance and importance to patients with blood disorders and their physicians. All 380 CW recommendations were reviewed and assessed for relevance and importance. Relevance was assessed using the MORE(TM) relevance scale. Importance was assessed with regard to six guiding principles: harm avoidance, evidence, aggregate cost, relevance, frequency and impact. Harm avoidance was considered the most important principle. Ten highly relevant and important recommendations were identified from a variety of professional societies. Recommendations focused on decreasing unnecessary imaging, blood work, treatments and transfusions, as well as on increasing collaboration across disciplines and considering value when recommending treatments. Many CW recommendations have relevance beyond the society of origin. The methods developed by the ASH CW Task Force could be easily adapted by other Societies to identify additional CW recommendations of relevance and importance to their fields. Am. J. Hematol. 91:787-792, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Lisa K. Hicks
- St. Michael's Hospital; University of Toronto; Toronto Ontario Canada
| | | | - Harriet Bering
- Harvard Vanguard Medical Associates; Beverly Massachusetts
| | | | | | - Vishal Kukreti
- University of Toronto, University Health Network; Toronto Ontario
| | - Alice Ma
- University of North Carolina; Chapel Hill North Carolina
| | | | | | - Julie A. Panepinto
- Medical College of Wisconsin/Children's Hospital of Wisconsin; Milwaukee Wisconsin
| | | | - Ravi Sarode
- UT Southwestern Medical Center; Dallas Texas
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Gondi JT, Gazula S, Rajasekhar A, Usharani G. Excellent response of infantile orofacio-orbital hemangioma to propranolol-pictorial depiction and literature review. Contemp Clin Dent 2016; 7:269-72. [PMID: 27307684 PMCID: PMC4906880 DOI: 10.4103/0976-237x.183060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Infantile hemangiomas (IHs) are common, benign vascular tumors of infancy, with more than half affecting the head and neck region. IHs involving the lips and oral cavity can often present to the oral surgeon and the pedodontist. Till date, several doubts exist among clinicians regarding the use of propranolol to treat infantile hemangiomas in neonates and small infants, appropriate dose, treatment duration, side effects, response, and long-term follow-up. We present a 2-month-old male infant with extensive hemangioma involving the face, orbit, buccal mucosa and palate with feeding difficulties, and risk of life-threatening complications such as airway compromise, aspiration, and visual loss which showed excellent response with high-dose propranolol and had no side effects. We also reviewed literature for the mechanism of action of propranolol and possible minor and serious side effects.
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Affiliation(s)
- Jonathan Theodore Gondi
- Department of Head and Neck Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Suhasini Gazula
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
| | - A Rajasekhar
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
| | - G Usharani
- Department of Pediatric Surgery, Employees State Insurance Corporation, Super Speciality Hospital, Hyderabad, Telangana, India
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Abstract
Venous thromboembolism (VTE) is a common cause of inpatient and outpatient morbidity and mortality. While anticoagulant therapy is considered the primary means of prevention and treatment of VTE, inferior vena cava filters (IVCFs) are often used as an alternative or adjunct to anticoagulation. With the advent of retrievable filters indications have liberalized, to include placement for primary prophylaxis in high-risk patients. However, this practice is based on limited evidence supporting their efficacy in preventing clinically relevant outcomes. Since indiscriminate use of IVCFs can be associated with net patient harm and increased health care costs, knowledge of the literature surrounding IVCF utilization is critical for providers to adopt best practices. In this review, we will provide an overview of the literature as it relates to specific clinical questions that arise when considering IVCF utilization in the prevention and treatment of VTE. Practice-based recommendations will be reviewed to provide the clinician with guidance on challenging clinical scenarios.
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Affiliation(s)
- Anita Rajasekhar
- University of Florida College of Medicine, Health Science Center, PO Box 100278, Gainesville, FL, 32610, USA,
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Mandernach MW, Beyth RJ, Rajasekhar A. Apixaban for the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism: an evidence-based review. Ther Clin Risk Manag 2015; 11:1273-82. [PMID: 26345156 PMCID: PMC4556259 DOI: 10.2147/tcrm.s68010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Venous thromboembolism (VTE) results in significant morbidity and mortality. The prevention and treatment of VTE is managed with anticoagulant therapy, historically parenteral anticoagulants such as unfractionated heparin, low molecular weight heparin, and fondaparinux, and oral vitamin K antagonists such as warfarin. In the last few years, several target-specific oral anticoagulants have been developed, including the direct thrombin inhibitor dabigatran and anti-Xa inhibitors rivaroxaban, apixaban, and edoxaban. The target-specific oral anticoagulants have proven to be noninferior to vitamin K antagonists and heparins in the prevention and treatment of VTE. This review will focus on the pharmacology, clinical trial data, and laboratory assessment of apixaban. Moreover, perioperative management, use in special populations, and management of bleeding complications in patients taking apixaban for the prevention and treatment of VTE will also be discussed.
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Affiliation(s)
- Molly W Mandernach
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Rebecca J Beyth
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
- North Florida/South Georgia Veterans Health System (NF/SGVHS), Geriatric Research, Education and Clinical Center (GRECC), Gainesville, FL, USA
| | - Anita Rajasekhar
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
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Hicks LK, Bering H, Carson KR, Haynes AE, Kleinerman J, Kukreti V, Ma A, Mueller BU, O'Brien SH, Panepinto JA, Pasquini MC, Rajasekhar A, Sarode R, Wood WA. Five hematologic tests and treatments to question. Hematology Am Soc Hematol Educ Program 2014; 2014:599-603. [PMID: 25696917 DOI: 10.1182/asheducation-2014.1.599] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Choosing Wisely® is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. The American Society of Hematology (ASH) released its first Choosing Wisely® list in 2013. Using the same evidence-based methodology as in 2013, ASH has identified 5 additional tests and treatments that should be questioned by clinicians and patients under specific, indicated circumstances. The ASH 2014 Choosing Wisely® recommendations include: (1) do not anticoagulate for more than 3 months in patients experiencing a first venous thromboembolic event in the setting of major, transient risk factors for venous thromboembolism; (2) do not routinely transfuse for chronic anemia or uncomplicated pain crises in patients with sickle cell disease; (3) do not perform baseline or surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia; (4) do not test or treat for heparin-induced thrombocytopenia if the clinical pretest probability of heparin-induced thrombocytopenia is low; and (5) do not treat patients with immune thrombocytopenia unless they are bleeding or have very low platelet counts.
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Affiliation(s)
- Lisa K Hicks
- University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | | | | | - Vishal Kukreti
- University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Alice Ma
- University of North Carolina, Chapel Hill, NC
| | | | | | - Julie A Panepinto
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | | | | | - Ravi Sarode
- University of Texas Southwestern Medical Center, Dallas, TX
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Rajasekhar A, Elmariah H, Lottenberg L, Beyth R, Lottenberg R, Ang D. Inferior Vena Cava Filters in Trauma Patients: A National Practice Patterns Survey of U.S. Trauma Centers. Am Surg 2014. [DOI: 10.1177/000313481408001226] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inferior vena cava filters (IVCFs) for thromboprophylaxis in trauma patients are being increasingly used despite a lack of strong clinical data in support of their efficacy and conflicting clinical practice guidelines. This national survey elucidates practice patterns of IVCF use across U.S. trauma centers. A web-based survey was administered to members of the Eastern Association for the Surgery of Trauma between September 2011 and October 2011. The survey queried: 1) background and professional practice; 2) trauma patient population; 3) IVCF placement; 4) IVCF retrieval and follow-up; and 5) pharmacologic prophylaxis. Two hundred eighty-one of 1059 eligible providers completed the survey (27%). Respondents were from a wide spectrum of training backgrounds and clinical practice settings. IVCFs were used by 98.9 per cent of respondents. IVCFs in patients without known venous thromboembolism were considered by 93.2 per cent of respondents. Indications and timing of IVCF retrieval vary. Follow-up care of patients with IVCFs was not uniform. An IVCF registry was maintained by 38 per cent of trauma programs. Adjunctive pharmacologic prophylaxis was used by 96.8 per cent of respondents. This study elucidates the gaps and variations in contemporary practices of IVCF use in trauma patients. Identification of best practices in IVCF use and retrieval awaits well-designed comparative effectiveness studies.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Hany Elmariah
- Department of Medicine, Duke University, College of Medicine, Durham, NC
| | - Lawrence Lottenberg
- Department of Surgery, University of Florida, College of Medicine, Gainesville, Florida
| | - Rebecca Beyth
- Department of Medicine, University of Florida, College of Medicine and Malcom Randall VA Medical Center, Gainesville, Florida; and
| | - Richard Lottenberg
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida
| | - Darwin Ang
- Ocala Regional Medical Center, Ocala, Florida
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Rajasekhar A, Elmariah H, Lottenberg L, Beyth R, Lottenberg R, Ang D. Inferior vena cava filters in trauma patients: a national practice patterns survey of U.S. Trauma centers. Am Surg 2014; 80:1237-1244. [PMID: 25513923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Inferior vena cava filters (IVCFs) for thromboprophylaxis in trauma patients are being increasingly used despite a lack of strong clinical data in support of their efficacy and conflicting clinical practice guidelines. This national survey elucidates practice patterns of IVCF use across U.S. trauma centers. A web-based survey was administered to members of the Eastern Association for the Surgery of Trauma between September 2011 and October 2011. The survey queried: 1) background and professional practice; 2) trauma patient population; 3) IVCF placement; 4) IVCF retrieval and follow-up; and 5) pharmacologic prophylaxis. Two hundred eighty-one of 1059 eligible providers completed the survey (27%). Respondents were from a wide spectrum of training backgrounds and clinical practice settings. IVCFs were used by 98.9 per cent of respondents. IVCFs in patients without known venous thromboembolism were considered by 93.2 per cent of respondents. Indications and timing of IVCF retrieval vary. Follow-up care of patients with IVCFs was not uniform. An IVCF registry was maintained by 38 per cent of trauma programs. Adjunctive pharmacologic prophylaxis was used by 96.8 per cent of respondents. This study elucidates the gaps and variations in contemporary practices of IVCF use in trauma patients. Identification of best practices in IVCF use and retrieval awaits well-designed comparative effectiveness studies.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, Florida, USA
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Abstract
Critically ill patients are at increased risk for development of thrombosis. In addition, thrombosis is often unrecognized in this population. Furthermore, these patients are particularly susceptible to bleeding complications from anticoagulants. Herein the authors review the pharmacology, data from clinical trials, management of bleeding complications, and perioperative use of these agents in the intensive care unit population. Well-designed clinical trials are needed to improve our understanding of the safety and efficacy of these newer agents in critically ill patients.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL 32610-0278, USA
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Imanirad I, Rajasekhar A, Zumberg M. A case series of atypical presentations of thrombotic thrombocytopenic purpura. J Clin Apher 2012; 27:221-6. [DOI: 10.1002/jca.21216] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 02/15/2012] [Indexed: 01/21/2023]
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Rajasekhar A, Lottenberg R, Lottenberg L, Liu H, Ang D. Pulmonary embolism prophylaxis with inferior vena cava filters in trauma patients: a systematic review using the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. J Thromb Thrombolysis 2011; 32:40-6. [PMID: 21221716 DOI: 10.1007/s11239-010-0544-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Prophylactic inferior vena cava filters (pIVCFs) for the prevention of pulmonary embolism (PE) are controversial. Current practice guidelines (EAST and ACCP) are based on the critical appraisal of observational studies. As a result, their recommendations are conflicting and may account for practice pattern variation. The purpose of this study is to critically review the available literature and ascertain the level of evidence both for and against the use of pIVCFs for PE prophylaxis in trauma patients. We searched PubMed and Web of Science for publications from 1950 until July 2010 that assessed the efficacy of PE prevention with pIVCFs in the trauma population. We followed the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines for design, implementation, and reporting. The Newcastle-Ottawa Score was used for quality and comparability assessment. Seven observational studies met inclusion criteria for this meta-analysis, representing 1,900 patients. Only one study was published in this decade. The rate of PE was statistically lower in the IVCF group compared to a matched control group without IVCFs (OR 0.21, 95% CI 0.09-0.49). There was no significant difference in DVT. Using the MOOSE criteria these results show a decreased likelihood of PE among trauma patients who receive pIVCFs. Although these results could favor the placement of pIVCFs, the lack of contemporary use of pharmacologic prophylaxis across studies does not allow us to make firm conclusions either for or against the routine use of pIVCFs. Prospective randomized trials are needed to determine the role of pIVCFs in high-risk trauma patients.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, College of Medicine, Gainesville, FL, USA.
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Abstract
Group C streptococci (GCS) are common causes of veterinary diseases and may colonize humans. Human diseases due to GCS are uncommon and generally occur in the elderly and persons exposed to animals or animal products. We report a case of Streptococcus equi subsp. zooepidemicus meningitis in a horse trainer and review 36 cases of GCS meningitis reported in the literature. The median age was 48 y and the majority of patients were previously healthy. Thirty-one percent (11/36) of the reported cases followed equine exposure and 19% (7/36) ingestion of dairy products. Sixty-seven percent (24/36) were found to have concomitant bacteraemia. The case fatality rate was 31% (11/36), and 28% (7/25) of survivors were reported to have residual neurological impairments. At least 4 days of antibiotics were typically required before symptoms improved. Isolates were generally susceptible to beta-lactams. In conclusion, it is important to consider GCS in the differential of bacterial meningitis, in particular in elderly patients exposed to horses or dairy products. Beta-lactams are first-line therapy, but outcomes are poor.
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Affiliation(s)
- Anita Rajasekhar
- Department of Medicine, University of Florida, Gainesville, Florida, USA
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Abstract
Placement of inferior vena cava filters (IVCFs) is considered in many patients undergoing bariatric surgery. Their placement is driven by a high rate of pulmonary embolism (PE), uncertainty as to the effectiveness of pharmacologic prophylaxis, and a lack of alternate methods to prevent pulmonary embolism. We performed a systematic review of the literature to evaluate the evidence supporting placement of IVCFs in patients undergoing bariatric surgery. Eleven studies were identified; none were randomized trials. Descriptive analysis suggests that IVCFs reduced PE; however, the strength of this observation is tempered by the lack of use of effective forms of prophylaxis and the failure to account for complications of IVCF placement. We conclude, pending the results of controlled studies, that the use of IVCFs cannot be recommended for routine patients undergoing bariatric surgery.
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Affiliation(s)
- A Rajasekhar
- Department of Medicine, University of Florida, Gainesville, FL, USA
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Rajasekhar A, Crowther MA. ASH evidence-based guidelines: what is the role of inferior vena cava filters in the perioperative prevention of venous thromboembolism in bariatric surgery patients? Hematology Am Soc Hematol Educ Program 2009; 2009:302-304. [PMID: 20008214 DOI: 10.1182/asheducation-2009.1.302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A 38-year-old morbidly obese male (BMI > 50 kg/m(2)) presents for an elective gastric bypass surgery. He has no personal or family history of venous thromboembolism or hypercoaguability. You are asked by his primary team whether he should receive a retrievable inferior vena cava filter preoperatively for venous thromboembolism prophylaxis.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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Abstract
Gemcitabine is a commonly used chemotherapeutic agent for a variety of tumor types. Although this nucleoside analogue antineoplastic agent is similar in structure to cytarabine, central nervous system toxicities have rarely been attributed to gemcitabine. Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare but increasingly identifiable clinicoradiologic process in cancer patients associated with cytotoxic and immunosuppressive agents. The syndrome is characterized by acute to subacute onset of headache, nausea, vomiting, altered mental status, seizures, stupor, and visual disturbances. The pathophysiology of RPLS continues to remain controversial but likely involves loss of cerebrovascular autoregulation leading to arteriole leakage. Radiologically, posterior occipital white matter edema is noted, with characteristic findings on magnetic resonance imaging. Often the syndrome is reversible with treatment of concurrent hypertension or removal of the causative agent; however, failure to quickly recognize the syndrome and discontinue the offending agent may result in profound and permanent central nervous system dysfunction or death. This article describes a case of RPLS attributed to gemcitabine use for pancreatic cancer. Such a descriptive case serves as a platform for the discussion of the syndrome, proposed mechanisms of central nervous system damage, and review of the currently available literature on the topic. With increased awareness of RPLS by oncologists and other medical providers, cancer patient care may be improved and further insight into this complication of therapy through continued research may be gained.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, College of Medicine, University of Florida, Gainesville, Florida, USA
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Abstract
This is the report of a case of fetus-in-fetu diagnosed in a 3-month-old boy and found to be located in the upper retroperitoneum. The entity was distinguished from teratoma by the presence of vertebral axis with limb buds. It corresponded to a diamniotic, monochorionic, monozygotic twin. Complete excision of the mass was performed. Radiological, histopathologic, and DNA fingerprinting studies performed on fetus-in-fetu specimen showed that the fetus was a monozygotic twin.
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Affiliation(s)
- A N Kumar
- Niloufer Hospital for Children and Institute of Child Health, Red Hills, Hyderabad, India
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44
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Naik P, Malati T, Ratnakar KS, Naidu MU, Rajasekhar A. Cardioprotective effect of magnesium chloride in experimental acute myocardial infarction. Indian J Exp Biol 1999; 37:131-7. [PMID: 10641131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Cardioprotective role of intravenous administration of magnesium chloride was evaluated in rabbits by biochemical and histopathological parameters. Myocardial damage was induced by injecting (i.v.) isoprenaline 1, 2.5, 5 and 7.5 mg/kg body weight of animal. There was a dose dependent increase in the activity of cardiac enzyme creatinine kinase CK (C Max). Maximal elevation of CK (C Max) was observed with 2.5 mg isoprenaline. The mean T-max (mean of the time duration in hr at which maximum creatinine kinase activity of individual rabbit was observed in a group) shifted early, significantly with 2.5, 5 and 7.5 mg isoprenaline compared to control group. Histopathologically, myocardial damage was quite significant in 2.5 mg isoprenaline subgroup of animals. A mortality of 29% was observed in animals injected with 5 and 7.5 mg isoprenaline, whereas all animals subjected with 1 and 2.5 mg isoprenaline were alive for 72 hr. Considering the data on serial determination of cardiac enzyme CK and histopathological changes, 2.5 mg isoprenaline was chosen as standard dose to study efficacy of cardioprotection by gold standard verapamil and magnesium chloride. Verapamil (5 microM) injected prior to 2.5 mg isoprenaline administration revealed significant reduction of CK (C Max) activity (P < 0.05) compared to animals infused with isoprenaline alone. T-max value did not show any alteration in both the groups. Histopathological findings showed no areas of necrosis and cellular infiltrates in animals primed with 2.5 mg isoprenaline following verapamil. Highly significant reduction in CK (C-max) activity was observed in animals administered with 40 mg magnesium chloride prior to isoprenaline compared to animals treated with isoprenaline alone (P < 0.001). In addition to this, significant delay in T-max of CK activity was observed in group treated with 40 mg magnesium chloride and isoprenaline compared to group treated with only isoprenaline (P < 0.01). The study clearly highlighted and confirmed the valuable role of magnesium chloride as cardioprotective agent.
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Affiliation(s)
- P Naik
- Department of Biochemistry, Nizam's Institute of Medical Sciences, Hyderabad, India
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Rajasekhar A, Swaroop BN, Raju BS. Myocardial infarction due to embolism of the right coronary ostium from chronic rheumatic mitral valvular disease. Indian Heart J 1996; 48:165-8. [PMID: 8682560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- A Rajasekhar
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad
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46
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Mamidi NV, Rajasekhar A, Prabhakar MC, Krishna DR. Tissue distribution and deposition of clofazimine in rat following subchronic treatment with or without rifampicin. Arzneimittelforschung 1995; 45:1029-1031. [PMID: 7488306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Tissue distribution and deposition characteristics of clofazimine (CAS 2030-63-9), an antileprotic drug in rats have been investigated following controlled sub-chronic administration (p.o.) for a period of 1-2 months. The drug was administered alone at a dose of 20 mg/kg body weight and in combination with rifampicin (CAS 13292-46-1) (20 mg/kg p.o.). Various tissues (liver, lung, spleen, small intestine, brain, heart, kidney, skin, stomach and subcutaneous fat) were analyzed for clofazimine in all the treated groups. High levels (range 0.9-3.6 mg/g of wet tissue) were observed in tissues having reticuloendothelial components. In other tissues the levels were relatively lower (range 3-114 micrograms/g of wet tissue). Histopathological studies revealed that clofazimine is deposited in many tissues in the form of reddish-orange crystals. Concomitant treatment with rifampicin did not significantly alter tissue distribution or deposition profile of clofazimine nor did it influence the histopathology.
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Affiliation(s)
- N V Mamidi
- University College of Pharmaceutical Sciences, Kakatiya University, Warangal, India
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47
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Rajasekhar A, Sundaram C, Chowdhary T, Charanpal M, Ratnakar KS. Diagnostic utility of fine-needle sampling without aspiration: a prospective study. Diagn Cytopathol 1991; 7:473-6. [PMID: 1954824 DOI: 10.1002/dc.2840070507] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Fine-needle sampling without aspiration (FNS) was done in 100 consecutive patients with 109 palpable masses. Its efficiency in obtaining adequate material is compared with conventional fine-needle aspiration cytology (FNAC) and found to be 80% with either method. FNS shows a diagnostic accuracy that correlates well with FNAC and histopathology. Malignant lesions are sampled more easily. Anatomic site has no influence on the yield. Most of the negative cases are small swellings, less than 1.5 cm in diameter. It is more cost effective than FNAC. Trauma to the tissues and the resultant artifacts are less. It is relatively painless and can safely be applied to many areas, including some sensitive sites.
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Affiliation(s)
- A Rajasekhar
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
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48
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Rajasekhar A, Kapila K, Verma K. Value of demonstration of cytokeratin and leukocyte common antigen in poorly differentiated malignant tumors in fine needle aspirates. Acta Cytol 1989; 33:385-9. [PMID: 2471381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Immunoperoxidase staining for cytokeratin and leukocyte common antigen (LCA) was applied to aspirated material from 21 well-differentiated malignant tumors ("control cases," which could be cytologically categorized) and 32 poorly differentiated malignant tumors ("study cases," whose tumor type was not clearly evident from study of the aspirate). Fifteen (48%) of the 32 poorly differentiated malignant tumors were classified as carcinomas (12 cases) or lymphomas (3 cases) by positive staining for cytokeratin or LCA, respectively. Good cytohistopathologic correlation was observed in all 7 control cases and in 11 cases of the study cases for which histologic specimens were available. The addition of staining for desmin helped in categorizing one undifferentiated tumor as a rhabdomyosarcoma. Immunostaining for vimentin was not found to be valuable in the categorization of these tumors.
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Affiliation(s)
- A Rajasekhar
- Department of Pathology, All India Institute of Medical Sciences, New Delhi
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Rajasekhar A, Prasad CS, Miglani DC, Bhaskar PK, Subbiah NV. Evaluation of Healex Spray as a post-operative periodontal dressing and its usefulness in cases of Anug, mixed oral infections, apthus ulceration and acute herpetic gingivo-stomatitis. J Indian Dent Assoc 1976; 48:73-6. [PMID: 800825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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