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Øvrebotten T, Mecinaj A, Stavem K, Ghanima W, Brønstad E, Durheim MT, Lerum TV, Josefsen T, Grimsmo J, Heck SL, Omland T, Ingul CB, Einvik G, Myhre PL. Trajectory of cardiac troponin T following moderate-to-severe COVID-19 and the association with cardiac abnormalities. BMC Cardiovasc Disord 2024; 24:206. [PMID: 38614990 PMCID: PMC11015606 DOI: 10.1186/s12872-024-03854-7] [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: 08/08/2023] [Accepted: 03/21/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND COVID-19 has been associated with cardiac troponin T (cTnT) elevations and changes in cardiac structure and function, but the link between cardiac dysfunction and high-sensitive cardiac troponin T (hs-cTnT) in the acute and convalescent phase is unclear. OBJECTIVE To assess whether hs-cTnT concentrations are associated with cardiac dysfunction and structural abnormalities after hospitalization for COVID-19, and to evaluate the performance of hs-cTnT to rule out cardiac pathology. METHODS Patients hospitalized with COVID-19 had hs-cTnT measured during the index hospitalization and after 3-and 12 months, when they also underwent an echocardiographic study. A subset also underwent cardiovascular magnetic resonance imaging (CMR) after 6 months. Cardiac abnormalities were defined as left ventricular hypertrophy or dysfunction, right ventricular dysfunction, or CMR late gadolinium. RESULTS We included 189 patients with hs-cTnT concentrations measured during hospitalization for COVID-19, and after 3-and 12 months: Geometric mean (95%CI) 13 (11-15) ng/L, 7 (6-8) ng/L and 7 (6-8) ng/L, respectively. Cardiac abnormalities after 3 months were present in 45 (30%) and 3 (8%) of patients with hs-cTnT ≥ and < 5 ng/L at 3 months, respectively (negative predictive value 92.3% [95%CI 88.5-96.1%]). The performance was similar in patients with and without dyspnea. Hs-cTnT decreased from hospitalization to 3 months (more pronounced in intensive care unit-treated patients) and remained unchanged from 3 to 12 months, regardless of the presence of cardiac abnormalities. CONCLUSION Higher hs-cTnT concentrations in the convalescent phase of COVID-19 are associated with the presence of cardiac pathology and low concentrations (< 5 ng/L) may support in ruling out cardiac pathology following the infection.
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Affiliation(s)
- Tarjei Øvrebotten
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Albulena Mecinaj
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut Stavem
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Hemato-oncology, Østfold Hospital Kalnes, Østfold, Norway
| | - Eivind Brønstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Thoracic Department, St. Olavs Hospital, Trondheim, Norway
| | - Michael T Durheim
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Respiratory Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Tøri V Lerum
- Department of Pulmonary Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Tony Josefsen
- Department of Cardiology, Østfold Hospital Kalnes, Østfold, Norway
| | - Jostein Grimsmo
- Department of cardiac and pulmonary rehabilitation, Cathinka Guldberg's Hospital, Lovisenberg Rehabilitation, Jessheim, Norway
| | - Siri L Heck
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charlotte B Ingul
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnar Einvik
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway.
- K.G. Jebsen Center for Cardiac Biomarkers, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
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Kuter DJ, Mayer J, Efraim M, Bogdanov LH, Baker R, Kaplan Z, Garg M, Trněný M, Choi PY, Jansen AJG, McDonald V, Bird R, Gumulec J, Kostal M, Gernsheimer T, Ghanima W, Daak A, Cooper N. Long-term treatment with rilzabrutinib in patients with immune thrombocytopenia. Blood Adv 2024; 8:1715-1724. [PMID: 38386978 PMCID: PMC10997915 DOI: 10.1182/bloodadvances.2023012044] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/09/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
ABSTRACT Immune thrombocytopenia (ITP) is an autoimmune disease associated with autoantibody-mediated platelet destruction and impaired platelet production, resulting in thrombocytopenia and a predisposition to bleeding. The ongoing, global phase 1/2 study showed that rilzabrutinib, a Bruton tyrosine kinase inhibitor specifically developed to treat autoimmune disorders, could be an efficacious and well-tolerated treatment for ITP. Clinical activity, durability of response, and safety were evaluated in 16 responding patients who continued rilzabrutinib 400 mg twice daily in the long-term extension (LTE) study. At LTE entry, the median platelet count was 87 × 109/L in all patients, 68 × 109/L in those who had rilzabrutinib monotherapy (n = 5), and 156 × 109/L in patients who received concomitant ITP medication (thrombopoietin-receptor agonists and/or corticosteroids, n = 11). At a median duration of treatment of 478 days (range, 303-764), 11 of 16 patients (69%) continued to receive rilzabrutinib. A platelet count of ≥50 × 109/L was reported in 93% of patients for more than half of their monthly visits. The median percentage of LTE weeks with platelet counts ≥30 × 109/L and ≥50 × 109/L was 100% and 88%, respectively. Five patients discontinued concomitant ITP therapy and maintained median platelet counts of 106 × 109/L at 3 to 6 months after stopping concomitant ITP therapy. Adverse events related to treatment were grade 1 or 2 and transient, with no bleeding, thrombotic, or serious adverse events. With continued rilzabrutinib treatment in the LTE, platelet responses were durable and stable over time with no new safety signals. This trial is registered at www.clinicaltrials.gov as #NCT03395210 and www.clinicaltrialsregister.eu as EudraCT 2017-004012-19.
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Affiliation(s)
- David J. Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jiri Mayer
- Department of Internal Medicine, Hematology and Oncology, Masaryk University Hospital, Brno, Czech Republic
| | - Merlin Efraim
- University Multiprofile Hospital for Active Treatment “St. Marina” – Varna, Varna, Bulgaria
| | | | - Ross Baker
- Perth Blood Institute, Murdoch University, Perth, Australia
| | | | - Mamta Garg
- Leicester Royal Infirmary, Leicester, United Kingdom
| | - Marek Trněný
- First Department of Medicine – Department of Haematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | | | | | - Vickie McDonald
- Barts Health NHS Trust, The Royal London Hospital, London, United Kingdom
| | - Robert Bird
- Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jaromir Gumulec
- Department of Hemato-Oncology, University Hospital, Ostrava, Czech Republic
- Department of Hemato-Oncology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Milan Kostal
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Terry Gernsheimer
- University of Washington and Fred Hutchinson Cancer Center, Seattle, WA
| | - Waleed Ghanima
- Østfold Hospital Foundation, Gralum, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College, London, United Kingdom
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Grdinic AG, Radovanovic S, Gleditsch J, Jørgensen CT, Asady E, Pettersen HH, Delibasic B, Ghanima W. Developing a machine learning model for bleeding prediction in patients with cancer-associated thrombosis receiving anticoagulation therapy. J Thromb Haemost 2024; 22:1094-1104. [PMID: 38184201 DOI: 10.1016/j.jtha.2023.12.034] [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: 05/23/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Only 1 conventional score is available for assessing bleeding risk in patients with cancer-associated thrombosis (CAT): the CAT-BLEED score. OBJECTIVES Our aim was to develop a machine learning-based risk assessment model for predicting bleeding in CAT and to evaluate its predictive performance in comparison to that of the CAT-BLEED score. METHODS We collected 488 attributes (clinical data, biochemistry, and International Classification of Diseases, 10th Revision, diagnosis) in 1080 unique patients with CAT. We compared CAT-BLEED score, Ridge and Lasso logistic regression, random forest, and Extreme Gradient Boosting (XGBoost) algorithms for predicting major bleeding or clinically relevant nonmajor bleeding occurring 1 to 90 days, 1 to 365 days, and 90 to 455 days after venous thromboembolism (VTE). RESULTS The predictive performances of Lasso logistic regression, random forest, and XGBoost were higher than that of the CAT-BLEED score in the prediction of bleeding occurring 1 to 90 days and 1 to 365 days after VTE. For predicting major bleeding or clinically relevant nonmajor bleeding 1 to 90 days after VTE, the CAT-BLEED score achieved a mean area under the receiver operating characteristic curve (AUROC) of 0.48 ± 0.13, while Lasso logistic regression and XGBoost both achieved AUROCs of 0.64 ± 0.12. For predicting bleeding 1 to 365 days after VTE, the CAT-BLEED score achieved a mean AUROC of 0.47 ± 0.08, while Lasso logistic regression and XGBoost achieved AUROCs of 0.64 ± 0.08 and 0.59 ± 0.08, respectively. CONCLUSION This is the first machine learning-based risk model for bleeding prediction in patients with CAT receiving anticoagulation therapy. Its predictive performance was higher than that of the conventional CAT-BLEED score. With further development, this novel algorithm might enable clinicians to perform personalized anticoagulation strategies with improved clinical outcomes.
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Affiliation(s)
- Aleksandra G Grdinic
- Department of Cardiology, Østfold Hospital, Sarpsborg, Norway; Department of Research, Østfold Hospital, Sarpsborg, Norway.
| | - Sandro Radovanovic
- Faculty of Organizational Sciences, University of Belgrade, Belgrade, Serbia
| | - Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Camilla Tøvik Jørgensen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | - Elia Asady
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Boris Delibasic
- Faculty of Organizational Sciences, University of Belgrade, Belgrade, Serbia
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
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Mannering N, Hansen DL, Moulis G, Ghanima W, Pottegård A, Frederiksen H. Risk of fractures and use of bisphosphonates in adult patients with immune thrombocytopenia-A nationwide population-based study. Br J Haematol 2024; 204:1464-1475. [PMID: 38302094 DOI: 10.1111/bjh.19301] [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: 10/26/2023] [Revised: 12/25/2023] [Accepted: 01/04/2024] [Indexed: 02/03/2024]
Abstract
Corticosteroids remain the first-line treatment of immune thrombocytopenia (ITP), but increase the risk of osteoporosis and fractures. Bisphosphonates are used for the treatment of osteoporosis, but their usage among patients with ITP has not been systemically described. We investigated the risk of fractures and the use of bisphosphonates in adult patients with primary (pITP) and secondary ITP (sITP) compared with matched comparators in a nationwide registry-based cohort study. We identified 4030 patients with pITP (median age 60 years [IQR, 40-74]), 550 with sITP (median age 59 years [IQR, 43-74]) and 182 939 age-sex-matched general population comparators. All individuals were followed for incident fractures. Bisphosphonate use was estimated for calendar-years and in temporal relation to the ITP diagnosis. Adjusted cause-specific hazard ratio (csHR) for any fracture was 1.37 (95% confidence interval [CI] 1.23; 1.54) for pITP and 1.54 (1.17; 2.03) for sITP. The first-year csHR was 1.82 (1.39; 2.40) for pITP and 2.78 (1.58; 4.91) for sITP. Bisphosphonate use over calendar-years and in the early years following ITP diagnosis was higher among patients with ITP diagnosis compared with the general population. In conclusion, the risk of fractures and the use of bisphosphonates are higher in patients with ITP compared with the general population.
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Affiliation(s)
- Nikolaj Mannering
- Department of Haematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Dennis Lund Hansen
- Department of Haematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Guillaume Moulis
- Department of Internal Medicine, University Hospital Centre Toulouse, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS, University Hospital Centre Toulouse, Toulouse, France
| | - Waleed Ghanima
- Østfold Hospital, Oslo, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anton Pottegård
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Henrik Frederiksen
- Department of Haematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Hussaini P, Larsen TL, Ghanima W, Dahm AEA. Risk Factors for Bleeding in Cancer Patients Treated with Conventional Dose Followed by Low-Dose Apixaban for Venous Thromboembolism. Thromb Haemost 2024; 124:351-362. [PMID: 37816388 DOI: 10.1055/a-2188-8773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND Incidence of and risk factors for bleeding in cancer patients with venous thromboembolism (VTE) treated with apixaban are poorly described. METHODS We analyzed data from the prospective CAP study where 298 cancer patients with any type of VTE received 5 mg apixaban twice daily for 6 months, and then 2.5 mg apixaban twice daily for 30 months. For most analyses, major bleedings and clinically relevant nonmajor bleedings were merged to "clinically relevant bleedings." Risk factors were estimated by odds ratios (OR) and 95% confidence intervals (CIs). RESULTS The incidence of clinically relevant bleedings was 38% per person-year during the first 6 months of treatment, 21% per person-year from 7 to 12 months, and between 4 and 8% per person-year from 13 to 36 months. Clinically relevant bleedings were associated with age above 74 years (OR: 2.0, 95% CI: 1.0-4.1), body mass index (BMI) below 21.7 (OR: 2.3, 95% CI: 1.1-4.8), and hemoglobin at baseline below 10.5 for females (OR: 2.8, 95% CI: 1.1-7.3) and 11.1 for males (OR: 3.3, 95% CI: 1.3-8.4) during the first 6 months. Gastrointestinal (GI) or urogenital cancer was not associated with clinically relevant bleedings compared with other cancers. Among patients with luminal GI cancer, nonresected cancer had increased risk of bleeding (OR: 3.4, 95% CI: 1.0-11.6) compared with resected GI cancer. CONCLUSION There were very few bleedings while patients were on low-dose apixaban. Factors associated with bleeding in patients treated with full-dose apixaban were high age, low BMI, and low hemoglobin, and probably nonresected luminal GI cancer.
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Affiliation(s)
- Parwana Hussaini
- The Medical Student Research Program, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Trine-Lise Larsen
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
| | - Anders Erik Astrup Dahm
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Lambert C, Maitland H, Ghanima W. Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP). Eur J Haematol 2024; 112:504-515. [PMID: 38088207 DOI: 10.1111/ejh.14154] [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: 09/27/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 03/19/2024]
Abstract
Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.
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Affiliation(s)
- Catherine Lambert
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, Oslo University, Oslo, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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Haukeland-Parker S, Jervan Ø, Ghanima W, Spruit MA, Holst R, Tavoly M, Gleditsch J, Johannessen HH. Physical activity following pulmonary embolism and clinical correlates in selected patients: a cross-sectional study. Res Pract Thromb Haemost 2024; 8:102366. [PMID: 38562511 PMCID: PMC10982567 DOI: 10.1016/j.rpth.2024.102366] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
Background There is limited knowledge regarding physical activity and clinical correlates among people who have suffered a pulmonary embolism (PE). Objectives To assess physical activity levels after PE and potential clinical correlates. Methods One hundred forty-five individuals free of major comorbidities were recruited at a mean of 23 months (range, 6-72) after PE diagnosis. Physical activity was assessed by steps/day on the Sensewear monitor for 7 consecutive days, exercise capacity with the incremental shuttle walk test, and cardiac function with left ventricular ejection fraction (LVEF). The association between physical activity and other variables was analyzed by a mixed-effects model. Results Participants achieved a mean of 6494 (SD, 3294; range, 1147-18.486) steps/day. The mixed-effects model showed that physical activity was significantly associated with exercise capacity (β-coefficient, 0.04; 95% CI, 0.03-0.05) and LVEF (β-coefficient, -0.81; 95% CI, -1.42 to -0.21). The analysis further showed that men became less physically active with increasing age (β-coefficient, -0.14; 95% CI, -0.24 to -0.04), whereas no change with age could be detected for women. Conclusion In selected post-PE patients, physical activity seems to be associated with exercise capacity and LVEF but not with quality of life, dyspnea, or characteristics of the initial PE. Men appear to become less physically active with increasing age.
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Affiliation(s)
- Stacey Haukeland-Parker
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Jervan
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research, Emergency Medicine and Hematooncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martijn A. Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - René Holst
- Department of Research, Emergency Medicine and Hematooncology, Østfold Hospital Trust, Grålum, Norway
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Research, Emergency Medicine and Hematooncology, Østfold Hospital Trust, Grålum, Norway
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Radiology, Østfold Hospital Trust, Grålum, Norway
| | - Hege Hølmo Johannessen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
- Department of Health, Welfare and Organization, Østfold University College, Fredrikstad, Norway
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Jørgensen CT, Brækkan SK, Førsund E, Pettersen HH, Tjønnfjord E, Ghanima W, Tavoly M. Incidence of venous thromboembolism, recurrence, and bleeding after isolated superficial vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital. J Thromb Haemost 2024; 22:526-533. [PMID: 37913911 DOI: 10.1016/j.jtha.2023.10.017] [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: 08/10/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND There are limited data on the long-term risk of venous thromboembolism (VTE) after high-risk isolated superficial vein thrombosis (iSVT) treated with anticoagulants. OBJECTIVES To determine the short- and long-term risk of VTE and iSVT recurrence after cessation of anticoagulant treatment and to calculate 45-day cumulative bleeding incidence in patients with iSVT. METHODS Between January 2014 and December 2021, 229 patients with high-risk iSVT (ie, thrombus length ≥5cm), without active cancer, with no history of VTE or iSVT, and who had received anticoagulant treatment for the iSVT were identified through the Venous Thrombosis Registry in Østfold Hospital (TROLL registry), Norway. Cumulative incidences of VTE and iSVT recurrence, as well as cumulative incidences of major and clinically relevant nonmajor bleeding events, were assessed. RESULTS Median age was 60 years (IQR, 48-71), and 125 (55%) were women. Most patients were treated with direct oral anticoagulants (74%), and of these, 79% received a dose of rivaroxaban 10 mg daily. Low-molecular-weight heparin was given to 26% of the patients. The 1- and 5-year cumulative incidences of VTE after iSVT were 4.6% (95% CI, 2.5-8.3) and 15.9% (95% CI, 10.8-22.9), respectively. Further, the 1- and 5-year cumulative incidences of iSVT recurrence were 6.5% (95% CI, 3.9-10.7) and 15.9% (95% CI, 10.8-23.1), respectively. The overall 45-day cumulative incidence of major and clinically relevant nonmajor bleeding events was 0.4% (95% CI, 0.06-3.06) and 1.8% (95% CI, 0.7-4.6), respectively. No major bleeding events were observed in patients treated with direct oral anticoagulants. CONCLUSION Despite anticoagulant treatment, the risk of VTE after high-risk iSVT was substantial, while bleeding complications were low.
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Affiliation(s)
- Camilla Tøvik Jørgensen
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Sigrid Kufaas Brækkan
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group, Department of Clinical Medicine, The University of Tromsø-The Arctic University of Norway, Tromsø, Norway
| | - Eli Førsund
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | | | - Eirik Tjønnfjord
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Clinic of Internal Medicine, Østfold Hospital Sarpsborg, Norway; Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Cooper N, Ghanima W, Vianelli N, Valcárcel D, Yavaşoğlu İ, Melikyan A, Ruiz EY, Haenig J, Somenzi O, Lee J, Clark J, Zhang Y, Zaja F. Sustained response off-treatment in eltrombopag-treated adult patients with ITP who are refractory or relapsed after first-line steroids: Primary, final, and ad-hoc analyses of the Phase II TAPER trial. Am J Hematol 2024; 99:57-67. [PMID: 38014779 DOI: 10.1002/ajh.27131] [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: 12/06/2022] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 11/29/2023]
Abstract
Immune thrombocytopenia (ITP) is characterized by reduced platelet count due to increased destruction and is categorized according to the time following diagnosis (newly diagnosed, persistent, chronic). First-line corticosteroid therapy is associated with transient response, high relapse rates, and considerable toxicity. TAPER (NCT03524612) is a Phase II, prospective, single-arm trial investigating whether eltrombopag can induce a sustained response off-treatment (SRoT) in adult patients with ITP after first-line corticosteroid failure. This study defines SRoT as an off-treatment period wherein platelet count remains above 30 × 109 /L in the absence of bleeding or rescue therapy. The primary endpoint was the proportion of patients who achieved SRoT until Month 12, which was 30.5% (n = 32/105; p < .0001 testing hypothesis H1: proportion >15%) following eltrombopag tapering and discontinuation, and median SRoT duration was ~8 months until Month 12. Median platelet count increased within 1 month of treatment and remained elevated until Month 12. Quality of life improved within 3 months and was maintained. Headache (21%) was the most common adverse event. None of the 4 deaths reported were considered treatment-related. In summary, ~one-third of patients achieved SRoT until Month 12 following eltrombopag tapering and discontinuation. An ad-hoc early-use analysis, stratified by ITP duration at baseline, assessed initial hematologic responses and safety. Results suggest that eltrombopag has similar efficacy in newly diagnosed and later stages of ITP. In follow-up until Month 24, a median SRoT duration of ~22 months was observed (n = 20). The safety profile was comparable across analyses and ITP duration groups and aligned with its well-established safety profile.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
| | - Waleed Ghanima
- Department of Haemato-Oncology, Østfold Hospital Trust, Kalnes, Grålum, Norway
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nicola Vianelli
- Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - David Valcárcel
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - İrfan Yavaşoğlu
- Department of Hematology, Adnan Menderes University, Aydın, Turkey
| | | | - Eduardo Yañez Ruiz
- Hematology-Oncology Unit, Department of Internal Medicine, School of Medicine, Universidad de La Frontera, Temuco, Chile
| | | | | | - James Lee
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Yifan Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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10
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Zaboras Z, Jørgensen CT, Stensvold A, Pettersen HH, Grdinic AG, Brækkan SK, Ghanima W, Tavoly M. Real-world Data on Treatment Patterns and Bleeding in Cancer-associated Thrombosis: Data from the TROLL Registry. TH Open 2024; 8:e132-e140. [PMID: 38532938 PMCID: PMC10965301 DOI: 10.1055/s-0044-1782219] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/05/2024] [Indexed: 03/28/2024] Open
Abstract
Background International guidelines are increasingly recommending direct oral anticoagulants (DOACs) as the first-line treatment for cancer-associated thrombosis (CAT). However, data regarding treatment patterns and adherence to guidelines in patients with CAT are scarce. Objectives This study aimed to explore anticoagulant treatment patterns in patients with CAT and to calculate the incidence rates of bleeding events. Methods Patients ≥18 years with active cancer and a first-time venous thromboembolism between 2005 and 2020 were identified through the Venous T hrombosis R egistry in Østf OL d Hospita L . Outcome measures were patterns of anticoagulant treatment during the study period and bleeding events. We calculated overall incidence rates per 100 person-years and 6- and 12-month cumulative incidence of major and clinically relevant nonmajor bleeding (CRNMB) during anticoagulant treatment. Results Median age of 842 CAT patients at the time of thrombosis was 69 years (interquartile range 61-77), and 443 (52.6%) were men. In total, 526 patients (62.5%) had pulmonary embolism and 255 (30.3%) had deep vein thrombosis. Low molecular weight heparin (LMWH) was prescribed to 713 (85.8%) patients, whereas 64 (7.7%) received DOACs and 54 (6.5%) received vitamin K antagonists as the initial anticoagulant treatment. Prescription of DOACs as initial treatment increased from 3.0% in 2013/2014 to 18.0% in 2019/2020. The incidence rate of major bleeding was 6.9 (95% confidence interval [CI] 5.2-9.2) and 10.1 (95% CI 8.0-12.9) in CRNMB. Conclusion Most patients were treated with LMWH. However, a gradual shift in treatment toward DOACs was observed. Overall, bleeding complications were rare and comparable to those reported in randomized trials.
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Affiliation(s)
| | - Camilla Tøvik Jørgensen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | | | | | | | - Sigrid Kufaas Brækkan
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Thrombosis Research Group (TREC), UiT – The Arctic University of Norway, Tromsø, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway
- Clinic of Internal Medicine, Østfold Hospital, Sarpsborg, Norway
- Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Research, Østfold Hospital, Sarpsborg, Norway
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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11
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de Jong CMM, van den Hout WB, van Dijk CE, Heim N, van Dam LF, Dronkers CEA, Gautam G, Ghanima W, Gleditsch J, von Heijne A, Hofstee HMA, Hovens MMC, Huisman MV, Kolman S, Mairuhu ATA, van Mens TE, Nijkeuter M, van de Ree MA, van Rooden CJ, Westerbeek RE, Westerink J, Westerlund E, Kroft LJM, Klok FA. Cost-Effectiveness of Performing Reference Ultrasonography in Patients with Deep Vein Thrombosis. Thromb Haemost 2023. [PMID: 37984402 DOI: 10.1055/a-2213-9230] [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: 11/22/2023]
Abstract
BACKGROUND The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison. OBJECTIVES To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients. METHODS Patient-level data (n = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared. RESULTS All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS. CONCLUSION One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS.
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Affiliation(s)
- Cindy M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences - Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Noor Heim
- National Health Care Institute, The Netherlands
| | - Lisette F van Dam
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Charlotte E A Dronkers
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Gargi Gautam
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Gralum, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Anders von Heijne
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | - Marcel M C Hovens
- Department of Vascular Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stan Kolman
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcel A van de Ree
- Department of Vascular Medicine, Diakonessen Hospital, Utrecht, The Netherlands
| | | | | | - Jan Westerink
- Department of Internal Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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12
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Myklebust-Hansen HJ, Hasvik E, Solyga VM, Ghanima W. The feasibility of self-performing measurements of peripheral oxygen saturation and respiratory exercises in home-isolated COVID-19 patients-a single-arm prospective trial. Pilot Feasibility Stud 2023; 9:195. [PMID: 38042811 PMCID: PMC10693052 DOI: 10.1186/s40814-023-01415-x] [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: 01/23/2023] [Accepted: 10/25/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND COVID-19 is a highly contagious disease where isolation of infected individuals is deemed warranted. If possible, home isolation is preferred over hospitalization. This implies a need for methods of observation that can ensure the safety of these patients. Preventive treatment methods that can both decrease the probability for development of critical disease and hopefully decrease the need for hospitalization would be an added benefit. This was a single-arm prospective pilot study performed to assess the feasibility of performing self-measurements of SpO2 and respiratory exercises in at-home isolated COVID-19 patients. METHOD A total of 40 ambulant SARS-CoV-2-positive individuals in home isolation were followed up for a period of 14 days. At baseline, they were equipped with a pulse oximeter, PEF meter, a project diary to note all measurements, and simple instructions on how to perform respiratory exercises. No other contact was made, but participants were instructed to contact the hospital based on given criteria for blood oxygenation levels and dyspnea severity and to return study equipment and the project diary at the end of study. RESULTS During the follow-up period, 35 participants (87.5%) recorded daily SpO2 measurements, and 12 (30%) adhered to daily respiratory exercises as instructed. Four participants (10%) were admitted to hospital during the follow-up period. Five participants terminated follow-up prematurely. CONCLUSIONS Performing self-measurements of SpO2 during home isolation due to COVID-19 infection is feasible. The feasibility of performing respiratory exercises in ambulant patients is questionable and may require more motivational interventions to increase adherence. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04647747.
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Affiliation(s)
| | - Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, Grålum, Norway
| | - Volker M Solyga
- Department of Acute Medicine, Østfold Hospital Trust, 1714, Grålum, Norway
| | - Waleed Ghanima
- Department of Acute Medicine, Østfold Hospital Trust, 1714, Grålum, Norway
- Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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13
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Tholin B, Ghanima W, Selle ML, Stavem K. Incidence and determinants of venous thromboembolism over 90 days in hospitalized and nonhospitalized patients with COVID-19. J Intern Med 2023; 294:721-729. [PMID: 37518983 DOI: 10.1111/joim.13706] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
INTRODUCTION COVID-19 is associated with an increased risk of venous thromboembolism (VTE), but there is great variation among reported incidence rates. Most previous studies have focused on hospitalized patients with COVID-19, and only a few reports are from population-based registries. METHODS We studied the 90-day incidence of VTE, associated risk factors and all-cause mortality in hospitalized and nonhospitalized patients with COVID-19 in a nationwide cohort. Data on hospitalizations and outpatient visits were extracted from two national registries with mandatory reporting linked by a unique national identification number carried by all Norwegian residents. We performed Cox proportional hazards regression to determine risk factors for VTE after infection with SARS-CoV-2. RESULTS Our study included 30,495 patients with positive SARS-CoV-2 polymerase chain reaction with a mean (SD) age of 41.9 (17.3) years, and 53% were males. Only 2081 (6.8%) were hospitalized. The 90-day incidence of VTE was 0.3% (95% CI: 0.21-0.33) overall and 2.9% (95% CI: 2.3-3.7) in hospitalized patients. Age (hazard ratio [HR] 1.28 per decade, 95% CI: 1.11-1.48, p < 0.05), history of previous VTE (HR 4.69, 95% CI: 2.34-9.40, p < 0.05), and hospitalization for COVID-19 (HR 23.83, 95% CI: 13.48-42.13, p < 0.05) were associated with risk of VTE. CONCLUSIONS The 90-day incidence of VTE in hospitalized and nonhospitalized patients with COVID-19 was in the lower end compared with previous reports, with considerably higher rates in hospitalized than nonhospitalized patients. Risk factors for VTE were consistent with previously reported studies.
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Affiliation(s)
- Birgitte Tholin
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Waleed Ghanima
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Maria Lie Selle
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
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14
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Åkesson A, Bussel JB, Martin M, Blom AM, Klintman J, Ghanima W, Zetterberg E, Garabet L. Complement activation negatively affects the platelet response to thrombopoietin receptor agonists in patients with immune thrombocytopenia: a prospective cohort study. Platelets 2023; 34:2159019. [PMID: 36636835 DOI: 10.1080/09537104.2022.2159019] [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] [Indexed: 01/14/2023]
Abstract
Increased platelet destruction is central in the pathogenesis of immune thrombocytopenia. However, impaired platelet production is also relevant and its significance underlies the rationale for treatment with thrombopoietin receptor agonists (TPO-RAs). Previous studies have associated enhanced complement activation with increased disease severity. Additionally, treatment refractoriness has been demonstrated to resolve by the administration of complement-targeted therapeutics in a subset of patients. The association between complement activation and the platelet response to TPO-RA therapy has previously not been investigated. In this study, blood samples from patients with immune thrombocytopenia (n = 15) were prospectively collected before and two, six and 12 weeks after the initiation of TPO-RA therapy. Plasma levels of complement degradation product C4d and soluble terminal complement complexes were assessed. Patients with significantly elevated baseline levels of terminal complement complexes exhibited more often an inadequate platelet response (p = .04), were exclusively subjected to rescue therapy with intravenous immunoglobulin (p = .02), and did not respond with a significant platelet count increase during the study period. C4d showed a significant (p = .01) ability to distinguish samples with significant terminal complement activation, implying engagement of the classical complement pathway. In conclusion, elevated levels of complement biomarkers were associated with a worse TPO-RA treatment response. Larger studies are needed to confirm these results. Biomarkers of complement activation may prove valuable as a prognostic tool to predict which patients that potentially could benefit from complement-inhibiting therapy in the future.
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Affiliation(s)
- Alexander Åkesson
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - James B Bussel
- New York Presbyterian Hospital, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Myriam Martin
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Anna M Blom
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jenny Klintman
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Waleed Ghanima
- Center for Laboratory Medicine, Østfold Hospital Trust, Kalnes, Norway
| | - Eva Zetterberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Lamya Garabet
- Center for Laboratory Medicine, Østfold Hospital Trust, Kalnes, Norway.,Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Lørenskog, Norway
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15
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Tavoly M, Asady E, Wik HS, Ghanima W. Measuring Quality of Life after Venous Thromboembolism: Who, When, and How? Semin Thromb Hemost 2023; 49:861-866. [PMID: 36055276 DOI: 10.1055/s-0042-1754390] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There is a growing body of evidence revealing that many patients with a history of venous thromboembolism (VTE) suffer from long-lasting sequelae such as post-thrombotic syndrome and post-pulmonary embolism syndrome. These two syndromes are detrimental to patients as they affect their quality of life (QOL). From this perspective, monitoring QOL may play a crucial role to improve quality care in VTE patients. Many studies have explored possible temporal relations between VTE episodes and decreased functional status and/or QOL. However, studies exploring the implementation of QOL and functional status questionnaires in clinical practice are scarce. In this context, we discuss possible perspectives synthetized from available literature regarding in whom, when, and how QOL could be measured in clinical practice.
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Affiliation(s)
- Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Research, Østfold Hospital Trust, Grålum, Norway
| | - Elia Asady
- Department of Research, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Waleed Ghanima
- Department of Research, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Kuter DJ, Bussel JB, Ghanima W, Cooper N, Gernsheimer T, Lambert MP, Liebman HA, Tarantino MD, Lee M, Guo H, Daak A. Rilzabrutinib versus placebo in adults and adolescents with persistent or chronic immune thrombocytopenia: LUNA 3 phase III study. Ther Adv Hematol 2023; 14:20406207231205431. [PMID: 37869360 PMCID: PMC10585997 DOI: 10.1177/20406207231205431] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023] Open
Abstract
Background Immune thrombocytopenia (ITP) is characterized by primarily autoantibody-mediated platelet destruction and impaired platelet production resulting in thrombocytopenia and an increased risk of bleeding. Other manifestations include increased risk of thrombosis and diminished quality of life. Current treatment approaches are directed toward lowering the rate of platelet destruction or stimulating platelet production to prevent bleeding. Rilzabrutinib is an oral, reversible, potent Bruton tyrosine kinase inhibitor that was specifically designed to treat immune-mediated diseases and mediates its therapeutic effect through a dual mechanism of action: (1) inhibiting B-cell activation and (2) interrupting antibody-coated cell phagocytosis by Fc gamma receptor in spleen and liver. A 24-week dose-finding phase I/II study of rilzabrutinib in patients with ITP showed a 40% platelet response (⩾2 consecutive platelet counts of ⩾50 × 109/L and increase from baseline ⩾20 × 109/L without rescue medication use) and a well-tolerated safety profile with only grade 1/2 transient adverse events across dose levels. Objectives Assess the efficacy and safety of oral rilzabrutinib in adult and adolescent patients with persistent or chronic ITP. Design Rilzabrutinib 400 mg BID is being evaluated in the ongoing LUNA 3 multicenter, double-blind, placebo-controlled phase III study. Methods and analysis The primary endpoint is durable platelet response, defined as achieving platelet counts of ⩾50 × 109/L for at least two-thirds of ⩾8 available weekly scheduled platelet measurements during the last 12 weeks (including ⩾2 available measurements within the last 6 weeks) of the 24-week blinded treatment period in the absence of rescue therapy. Ethics Ethical guidelines and informed consent are followed. Discussion The LUNA 3 trial will further investigate rilzabrutinib's safety and efficacy in adult and adolescent patients, with the primary goal of addressing a major objective in treating patients with ITP: durability of platelet response. Trail Registration ClinicalTrials.gov NCT04562766: https://clinicaltrials.gov/ct2/show/NCT04562766; EU Clinical Trials Register EudraCT 2020-002063-60: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2020-002063-60.
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Affiliation(s)
- David J. Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Bartlett Hall 150, 140 Blossom Street, Boston, MA 02114-2603, USA
| | - James B. Bussel
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Waleed Ghanima
- Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Terry Gernsheimer
- University of Washington Medical Center and Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michele P. Lambert
- Department of Pediatrics, Children’s Hospital of Philadelphia Division of Hematology and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Howard A. Liebman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael D. Tarantino
- The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine Peoria, Peoria, IL, USA
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17
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Jervan Ø, Haukeland-Parker S, Gleditsch J, Tavoly M, Klok FA, Steine K, Johannessen HH, Spruit MA, Atar D, Holst R, Astrup Dahm AE, Sirnes PA, Stavem K, Ghanima W. The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial. Chest 2023; 164:981-991. [PMID: 37149257 DOI: 10.1016/j.chest.2023.04.042] [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: 01/22/2023] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited. RESEARCH QUESTION Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea? STUDY DESIGN AND METHODS This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72 months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8 weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire). RESULTS A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95% CI, 17.7-88.3; P = .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95% CI, -0.09 to 0.00; P = .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention. INTERPRETATION In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03405480; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Stacey Haukeland-Parker
- Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Hege Hølmo Johannessen
- Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway; Department of Health and Welfare, Østfold University College, Fredrikstad, Norway
| | - Martijn A Spruit
- Department of Research and Development, Ciro, Horn, The Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - René Holst
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hematology, Akershus University Hospital, Lørenskog, Norway
| | | | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Clinic of Internal Medicine, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
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Jørgensen CT, Tavoly M, Førsund E, Pettersen HH, Tjønnfjord E, Ghanima W, Brækkan SK. Incidence of bleeding and recurrence in isolated distal deep vein thrombosis: findings from the Venous Thrombosis Registry in Østfold Hospital. J Thromb Haemost 2023; 21:2824-2832. [PMID: 37394122 DOI: 10.1016/j.jtha.2023.06.028] [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: 01/30/2023] [Revised: 06/05/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Isolated distal deep vein thrombosis (IDDVT) is a common presentation of deep vein thrombosis. There are limited data on the long-term risk of recurrence after IDDVT. OBJECTIVES We aimed to determine the short- and long-term incidence of venous thrombosis (VTE) recurrence after cessation of anticoagulation and the 3-month incidence of bleeding during anticoagulant treatment in patients with IDDVT. METHODS Between January 2005 and May 2020, 475 patients with IDDVT and without active cancer were identified from the Venous Thrombosis Registry in Østfold Hospital, which is an ongoing registry of consecutive patients with VTE at Østfold Hospital, Norway. Major and clinically relevant, nonmajor bleeding as well as recurrent VTE were registered, and the cumulative incidences of these events were assessed. RESULTS The median age of the patients was 59 years (IQR, 48-72 years), 243 (51%) patients were women, and 175 events (36.8%) were classified as unprovoked. The 1-, 5-, and 10-year cumulative incidences of recurrent VTE were 5.6% (95% CI, 3.7-8.4), 14.7% (95% CI, 11.1-19.4), and 27.2% (95% CI, 21.1-34.5), respectively. The recurrence rates were higher for unprovoked IDDVT than for provoked IDDVT. Among the recurrent events, 18 (29%) were pulmonary embolisms and 21 (33%) were proximal deep vein thromboses. The 3-month cumulative incidence of major bleeding was 1.5% (95% CI, 0.7-3.1) overall and 0.8% (95% CI, 0.2-3.1) when restricted to patients treated with direct oral anticoagulants. CONCLUSION Despite initial treatment, the long-term risk of VTE recurrence after first-time IDDVT is high. The bleeding rates during anticoagulation, particularly with direct oral anticoagulants, were acceptably low.
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Affiliation(s)
- Camilla Tøvik Jørgensen
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mazdak Tavoly
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eli Førsund
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | | | - Eirik Tjønnfjord
- Department of Emergency Medicine, Østfold Hospital, Sarpsborg, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Sarpsborg, Norway; Clinic of Internal Medicine, Østfold Hospital Sarpsborg, Sarpsborg, Norway; Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sigrid Kufaas Brækkan
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Center, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Arnold DM, Clerici B, Ilicheva E, Ghanima W. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol 2023; 203:23-27. [PMID: 37642211 DOI: 10.1111/bjh.19075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune haematological disorder characterized by immune-mediated thrombocytopenia and a variable risk of bleeding. Despite the availability of multiple treatment options, some patients are considered refractory since they do not achieve a platelet count response to multiple treatments and are at risk of bleeding. The term 'refractory' has been used to identify this patient group; however, with the advent of multiple lines of treatment, its meaning has become ambiguous. To address this issue, we reviewed previous definitions of refractory ITP, solicited the views of ITP experts and collected data from registries to inform a definition. Twenty ITP experts who attended the 7th Expert Meeting of the Intercontinental Cooperative ITP Study Group in September 2022 answered a web-based survey: 95% felt that there was a need for a new definition of refractory ITP for clinical and research purposes. The use of the term refractory, accompanied by a clear indication of the type and timing of failed treatments, was supported by 85% of respondents. Preliminary data on the frequency of refractory patients from the McMaster and Norwegian ITP Registries demonstrated that the proportion of adult ITP patients who had failed first-line therapy, rituximab, thrombopoietin receptor agonists, any immune suppressant medication and splenectomy ranged from 0.4% to 3.8%. We propose a definition of refractory ITP that could be evaluated in future studies.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Bianca Clerici
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Dipartimento di Scienze della Salute, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy
| | | | - Waleed Ghanima
- Department of Research, Østfol Hospital, Sarpsborg, Norway
- Department of Hemato-Oncolology, Østfol Hospital, Sarpsborg, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
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20
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Jervan Ø, Dhayyat A, Gleditsch J, Haukeland-Parker S, Tavoly M, Klok FA, Rashid D, Stavem K, Ghanima W, Steine K. Demographic, clinical, and echocardiographic factors associated with residual perfusion defects beyond six months after pulmonary embolism. Thromb Res 2023; 229:7-14. [PMID: 37356172 DOI: 10.1016/j.thromres.2023.06.004] [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: 03/03/2023] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Residual perfusion defects (RPD) after pulmonary embolism (PE) are common. PRIMARY AIM This study aimed to determine the prevalence of RPD in a cohort diagnosed with PE 6-72 months earlier, and to determine demographic, clinical, and echocardiographic variables associated with RPD. METHODS Patients aged 18-75 years with prior PE, confirmed by computed tomography pulmonary angiography 6-72 months earlier, were included. Participants (N = 286) completed a diagnostic work-up consisting of transthoracic echocardiography and ventilation/perfusion scintigraphy. Demographic, clinical, and echocardiographic characteristics between participants with RPD and those without RPD were explored in univariate analyses using t-test or Mann-Whitney U test. Multiple logistic regression analysis was used to assess the association between selected variables and RPD. RESULTS RPD were detected in 72/286 patients (25.2 %, 95 % CI:20.5 %-30.5 %). Greater tricuspid annular plane systolic excursion (TAPSE) (adjusted odds ratio (aOR) 1.10, 95 % CI:1.00-1.21, p = 0.048) at echocardiographic follow-up, greater thrombotic burden at diagnosis, as assessed by mean bilateral proximal extension of the clot (MBPEC) score 3-4 (aOR 2.08, 95 % CI:1.06-4.06, p = 0.032), and unprovoked PE (aOR 2.25, 95 % CI:1.13-4.48, p = 0.021) were independently associated with increased risk of RPD, whereas increased pulmonary artery acceleration time was associated with a lower risk of RPD (aOR 0.72, 95 % CI:0.62-0.83, p < 0.001, per 10 ms). Dyspnoea was not associated with RPD. CONCLUSION RPD were common after PE. Reduced pulmonary artery acceleration time and greater TAPSE on echocardiography at follow-up, greater thrombotic burden at diagnosis, and unprovoked PE were associated with RPD.
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Affiliation(s)
- Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Adam Dhayyat
- Department of Cardiology, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Stacey Haukeland-Parker
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Physical Medicine and Rehabilitation, Østfold Hospital, Kalnes, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Diyar Rashid
- Department of Radiology, Østfold Hospital, Kalnes, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway; Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Medicine, Østfold Hospital, Kalnes, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Kjetil Steine
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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21
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van Es N, Takada T, Kraaijpoel N, Klok FA, Stals MAM, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, Wells PS, de Wit K, van Smeden M, Geersing GJ. Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis. Eur Heart J 2023; 44:3073-3081. [PMID: 37452732 PMCID: PMC10917087 DOI: 10.1093/eurheartj/ehad417] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/25/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. METHODS AND RESULTS An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). CONCLUSION The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. REGISTRATION PROSPERO ID 89366.
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Affiliation(s)
- Nick van Es
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1247, Japan
| | - Noémie Kraaijpoel
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Milou A M Stals
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Harry R Büller
- Amsterdam University Medical Center, Department of Vascular Medicine, University of Amsterdam, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Yonathan Freund
- Emergency Department, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Bd de l'Hôpital, 75013 Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, C. de Arturo Soria, 270, 28033 Madrid, Spain
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold hospital, Kalnesveien 300, 1714 Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds vei 3, 0372 Oslo, Oslo, Norway
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, Zuid-Holland, The Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 4820, USA
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, & Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
- Department of Oncology, McMaster University, Juravinski Cancer Centre, 699 Concession St. Suite 4-204, Hamilton, Ontario, Canada
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Rue Michel-Servet 1, 1206 Genève, Switzerland
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, UNIV Angers, 4 Rue Larrey, 49100 Angers, Maine-et-Loire, France
| | - Phil S Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, ON K1Y 4E9, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, 76 Stuart Street, Kingston ON K7L 2V7, Canada
- Department of Medicine, McMaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, L8N 3Z5 Ontario, Canada
- Department of Health Evidence and Impact, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
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Larsen TL, Svalastoga M, Brekke J, Enden T, Frøen H, Garresori H, Jacobsen EM, Paulsen PQ, Porojnicu AC, Ree AH, Torfoss D, Velle EO, Wik HS, Ghanima W, Sandset PM, Dahm AEA. Arterial events in cancer patients treated with apixaban for venous thrombosis. Thromb Res 2023; 228:128-133. [PMID: 37327527 DOI: 10.1016/j.thromres.2023.05.017] [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: 03/13/2023] [Revised: 04/20/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION In a recent interventional study of cancer patients with newly diagnosed venous thrombosis (VT), we found a high risk of arterial thrombotic events (AT) during treatment with therapeutic doses of apixaban. METHODS Total 298 cancer patients with VT received apixaban as treatment and secondary prophylaxis for up to 36 months. AT was registered as a serious adverse event, and this is a post hoc analysis of risk factors for AT. Clinical risk factors and concomitant medication were assessed through odds ratios (OR) with 95 % confidence interval using multivariate logistic regression. Biomarkers were assessed by non-parametric testing. RESULTS AT occurred in 16/298 patients (5.4 %, 95 % confidence interval (CI) 3.1-8.6 %). Median leucocyte count at baseline was higher in patients with AT compared with patients without AT (11 vs. 6.8·109/L, p < 0.01). Clinical factors associated with AT were pancreatic cancer (OR 13.7, 95 % CI 4.3-43.1), ovarian cancer (OR 19.3, 95 % CI 2.3-164.4), BMI <25 percentile (OR 3.1, 95 % CI 1.1-8.8) and previous VT (OR 4.4, 95 % CI 1.4-13.7). Pancreatic cancer had a cumulative incidence of AT of 36 % compared with 0.8 % for all other cancers at 6 months (p < 0.01). Non-steroidal anti-inflammatory drugs (OR 4.9, 95 % CI 1.0-26) and antiplatelet treatment (OR 3.8, 95 % CI 1.2-12.2) were associated with AT. CONCLUSION In cancer patients with apixaban treated VT, pancreatic cancer was strongly associated with AT. In addition, ovarian cancer, BMI < 25 percentile, previous VT, antiplatelet treatment, non-steroidal anti-inflammatory drug use and high leucocyte count at baseline were associated with AT. The CAP study is registered with the unique identifier NCT02581176 in ClinicalTrials.gov.
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Affiliation(s)
- Trine-Lise Larsen
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway; Department of Hematology, Akershus University Hospital, P.O. BOX 1000, N-1478 Lørenskog, Norway.
| | - Marte Svalastoga
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway.
| | - Jorunn Brekke
- Department of Oncology, Haukeland University Hospital, P.O. BOX 1400, N-5021 Bergen, Norway.
| | - Tone Enden
- Tidsskriftet, den norske legeforening, Postboks 1152, Sentrum, 0107 Oslo, Norway.
| | - Hege Frøen
- Department of Haematology, Oslo University Hospital, P.O. BOX 4950, Nydalen, N-0424 Oslo, Norway
| | - Herish Garresori
- Department of Oncology, Stavanger University Hospital, P.O. BOX 8100, N-4068 Stavanger, Norway.
| | - Eva Marie Jacobsen
- Department of Haematology, Oslo University Hospital, P.O. BOX 4950, Nydalen, N-0424 Oslo, Norway.
| | - Petter Quist Paulsen
- Department of Hematology, St. Olav's University Hospital, P.O. BOX 3250, Torgarden, N-7006 Trondheim, Norway.
| | - Alina Carmen Porojnicu
- Department of Oncology, Drammen Hospital, Vestre Viken Hospital Trust, P.O. BOX 800, N-3004 Drammen, Norway.
| | - Anne Hansen Ree
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway; Department of Oncology, Akershus University Hospital, P.O. BOX 1000, N-1478 Lørenskog, Norway.
| | - Dag Torfoss
- Department of Oncology, Oslo University Hospital, P.O. BOX 4950 Nydalen, N-0424 Oslo, Norway
| | - Elin Osvik Velle
- Department of Medicine, Volda Hospital, Møre and Romsdal Hospital, P.O. BOX b 113, 6101 Volda, Norway.
| | - Hilde Skuterud Wik
- Department of Haematology, Oslo University Hospital, P.O. BOX 4950, Nydalen, N-0424 Oslo, Norway.
| | - Waleed Ghanima
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway; Clinic of Internal Medicine, Østfold Hospital, P.O. BOX 300, N-1714 Grålum, Norway.
| | - Per Morten Sandset
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway; Department of Haematology, Oslo University Hospital, P.O. BOX 4950, Nydalen, N-0424 Oslo, Norway.
| | - Anders Erik Astrup Dahm
- Faculty of Medicine, University of Oslo, Postboks 1078, Blindern, 0316 Oslo, Norway; Department of Hematology, Akershus University Hospital, P.O. BOX 1000, N-1478 Lørenskog, Norway
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Rinde FB, Jørgensen CT, Pettersen HH, Hansen JB, Ghanima W, Braekkan SK. Low D-dimer levels at diagnosis of venous thromboembolism are associated with reduced risk of recurrence: data from the TROLL registry. J Thromb Haemost 2023; 21:1861-1868. [PMID: 37004791 DOI: 10.1016/j.jtha.2023.03.026] [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: 01/02/2023] [Revised: 03/14/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a frequent disease with a high risk of recurrence. It has been suggested that the D-dimer level at the time of VTE diagnosis can be used to identify patients at a low risk of recurrence. OBJECTIVES We aimed to investigate the impact of D-dimer levels measured at the time of VTE diagnosis on the risk of recurrence in a large cohort of patients with a first-time VTE. METHODS The study included 2585 patients with first symptomatic non-cancer-associated VTE from the Venous Thrombosis Registry in Østfold Hospital (TROLL) (2005-2020). All recurrent events during the follow-up were recorded, and cumulative incidences of recurrence were estimated according to D-dimer levels of ≤1900 ng/mL (≤25th percentile) and >1900 ng/mL. RESULTS During a median follow-up of 3.3 years, 395 patients experienced a recurrent VTE. The 1- and 5-year cumulative incidences of recurrence were 2.9% (95% CI: 1.8-4.6) and 11.4% (95% CI: 8.7-14.8), respectively, in those with a D-dimer concentration of ≤1900 ng/mL and 5.0% (95% CI, 4.0-6.1) and 18.3% (95% CI: 16.2-20.6), respectively, in those with a D-dimer concentration of >1900 ng/mL, respectively. In patients with unprovoked VTE, the 5-year cumulative incidence was 14.3% (95% CI: 10.3-19.7) in the ≤1900-ng/mL category, and 20.2% (95% CI: 17.3-23.5) in the >1900-ng/mL category. CONCLUSIONS D-dimer levels within the lowest quartile, measured at the time of VTE diagnosis, were associated with lower recurrence risk. Our findings imply that D-dimer levels measured at the time of diagnosis may be used to identify patients with VTE at a low risk of recurrent VTE.
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Affiliation(s)
- Fridtjof B Rinde
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.
| | - Camilla T Jørgensen
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway; Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Sigrid K Braekkan
- Thrombosis Research Center (TREC), Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway; Thrombosis Research Group (TREC), Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
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Gleditsch J, Jervan Ø, Klok F, Holst R, Hopp E, Tavoly M, Ghanima W. Does the clot burden as assessed by the Mean Bilateral Proximal Extension of the Clot score reflect mortality and adverse outcome after pulmonary embolism? Acta Radiol Open 2023; 12:20584601231187094. [PMID: 37426515 PMCID: PMC10328056 DOI: 10.1177/20584601231187094] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/24/2023] [Indexed: 07/11/2023] Open
Abstract
Background Rapid diagnosis and risk stratification are important to reduce the risk of adverse clinical events and mortality in acute pulmonary embolism (PE). Although clot burden has not been consistently shown to correlate with disease outcomes, proximally located PE is generally perceived as more severe. Purpose To explore the ability of the Mean Bilateral Proximal Extension of the Clot (MBPEC) score to predict mortality and adverse outcome. Methods This was a single center retrospective cohort study. 1743 patients with computed tomography pulmonary arteriography (CTPA) verified PE diagnosed between 2005 and 2020 were included. Patients with active malignancy were excluded. The PE clot burden was assessed with MBPEC score: The most proximal extension of PE was scored in each lung from 1 = sub-segmental to 4 = central. The MBPEC score is the score from each lung divided by two and rounded up to nearest integer. Results We found inconsistent associations between higher and lower MBPEC scores versus mortality. The all-cause 30-day mortality of 3.9% (95% CI: 3.0-4.9). The PE-related mortality was 2.4% (95% CI: 1.7-3.3). Patients with MBPEC score 1 had higher all-cause mortality compared to patients with MBPEC score 4: Crude Hazard Ratio (cHR) was 2.02 (95% CI: 1.09-3.72). PE-related mortality was lower in patients with MBPEC score 3 compared to score 4: cHR 0.22 (95% CI: 0.05-0.93). Patients with MBPEC score 4 did more often receive systemic thrombolysis compared to patients with MBPEC score 1-3: 3.2% vs. 0.6% (p < .001). Patients with MBPEC score 4 where more often admitted to the intensive care unit: 13% vs. 4.7% (p < .001). Conclusion We found no consistent association between the MBPEC score and mortality. Our results therefore indicate that peripheral PE does not necessarily entail a lower morality risk than proximal PE.
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Affiliation(s)
- Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
| | - Øyvind Jervan
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
- Department of Cardiology, Østfold Hospital, Kalnes, Norway
| | - Frederikus Klok
- Department of Medicine – Thrombosis
and Hemostasis, Leiden University Medical
Center, Leiden, The Netherlands
| | - René Holst
- Oslo Centre for Biostatistics and
Epidemiology, University of Oslo and Oslo
University Hospital, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear
Medicine, Oslo University
Hospital, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University
Hospital, Gothenburg, Sweden
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway
- Department of Hematology, Oslo
University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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25
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Kanagaratnam P, Francis DP, Chamie D, Coyle C, Marynina A, Katritsis G, Paiva P, Szigeti M, Cole G, de Andrade Nunes D, Howard J, Esper R, Khan M, More R, Barreto G, Meneguz-Moreno R, Arnold A, Nowbar A, Kaura A, Mariveles M, March K, Shah J, Nijjer S, Lip GY, Mills N, Camm AJ, Cooke GS, Corbett SJ, Llewelyn MJ, Ghanima W, Toshner M, Peters N, Petraco R, Al-Lamee R, Boshoff ASM, Durkina M, Malik I, Ruparelia N, Cornelius V, Shun-Shin M. A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE USE OF ACUTE CORONARY SYNDROME THERAPY IN PATIENTS HOSPITALISED WITH COVID-19: THE C19-ACS TRIAL. J Thromb Haemost 2023:S1538-7836(23)00428-2. [PMID: 37230416 DOI: 10.1016/j.jtha.2023.04.045] [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] [Received: 11/14/2022] [Revised: 04/11/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Patients hospitalised with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. OBJECTIVES To investigate efficacy of an acute coronary syndrome regimen in patients hospitalised with COVID-19 and coronary disease risk factors. PATIENTS/METHODS A randomised controlled open-label trial across acute hospitals (UK and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28-days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, death). RESULTS 320 patients from 9 centres were randomised. The trial terminated early due to low recruitment. At 30 days there was no significant difference in mortality (intervention: 11.5% vs control: 15%, unadjusted OR 0.73, 95%CI 0.38 to 1.41, p=0.355). Significant bleeds were infrequent and not significantly different between the arms (intervention: 1.9% vs control 1.9%, p>0.999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR 1.46, 95% CrI 0.88 to 2.37, Pr(Beta>0)=93%; adjusted OR 1.50, 95% CrI 0.91 to 2.45, Pr(Beta>0)=95%) and median time to discharge home was two days shorter (95% CrI -4 to 0, 2% probability that it was worse). CONCLUSIONS Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.
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Affiliation(s)
- Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK.
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Daniel Chamie
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Clare Coyle
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Patricia Paiva
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Matyas Szigeti
- Imperial College, London, UK; Physiological Controls Research Centre, Obuda University, Budapest, Hungary
| | - Graham Cole
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - James Howard
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Ranjit More
- Blackpool Teaching Hospitals NHS Foundation Trust, UK
| | | | - Rafael Meneguz-Moreno
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Centro de Ensino e Pesquisa da Rede Primavera, Aracaju, Brazil; Universidade Federal de Sergipe, Lagarto, Brazil
| | - Ahran Arnold
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Amit Kaura
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Jaymin Shah
- London North West University Healthcare NHS Trust, UK
| | | | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicholas Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A John Camm
- St George's University of London, London, UK
| | - Graham S Cooke
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Waleed Ghanima
- Østfold Hospital: Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Mark Toshner
- Heart and Lung Research Institute, Dept of Medicine, University of Cambridge
| | - Nicholas Peters
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Ricardo Petraco
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Rasha Al-Lamee
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Margarita Durkina
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Iqbal Malik
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Neil Ruparelia
- Imperial College Healthcare NHS Trust, London, UK; Royal Berkshire Hospital NHS Trust, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Matthew Shun-Shin
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
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26
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Ghanima W, Hill QA, Kuter DJ. ITP definitions: Time for an update. Br J Haematol 2023; 201:1005-1006. [PMID: 37004991 DOI: 10.1111/bjh.18791] [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] [Received: 03/04/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Waleed Ghanima
- Departments of Research and Haemato-oncology, Østfold Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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27
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Pradier M, Rodger MA, Ghanima W, Kovacs MJ, Shivakumar S, Kahn SR, Sandset PM, Kearon C, Mallick R, Delluc A. Performance and Head-to-Head Comparison of Three Clinical Models to Predict Occurrence of Postthrombotic Syndrome: A Validation Study. Thromb Haemost 2023. [PMID: 36809776 DOI: 10.1055/a-2039-3388] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The SOX-PTS, Amin, and Méan models are three different clinical prediction scores stratifying the risk for postthrombotic syndrome (PTS) development in patients with acute deep vein thrombosis (DVT) of the lower limbs. Herein, we aimed to assess and compare these scores in the same cohort of patients. METHODS We retrospectively applied the three scores in a cohort of 181 patients (196 limbs) who participated in the SAVER pilot trial for an acute DVT. Patients were stratified into PTS risk groups using positivity thresholds for high-risk patients as proposed in the derivation studies. All patients were assessed for PTS 6 months after index DVT using the Villalta scale. We calculated the predictive accuracy for PTS and area under receiver operating characteristic (AUROC) curve for each model. RESULTS The Méan model was the most sensitive (sensitivity 87.7%; 95% confidence interval [CI]: 77.2-94.5) with the highest negative predictive value (87.5%; 95% CI: 76.8-94.4) for PTS. The SOX-PTS was the most specific score (specificity 97.5%; 95% CI: 92.7-99.5) with the highest positive predictive value (72.7%; 95% CI: 39.0-94.0). The SOX-PTS and Méan models performed well for PTS prediction (AUROC: 0.72; 95% CI: 0.65-0.80 and 0.74; 95% CI: 0.67-0.82), whereas the Amin model did not (AUROC: 0.58; 95% CI: 0.49-0.67). CONCLUSION Our data support that the SOX-PTS and Méan models have good accuracy to stratify the risk for PTS.
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Affiliation(s)
- Michelle Pradier
- Department of Medicine (Division of Hematology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc A Rodger
- Department of Medicine, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Waleed Ghanima
- Department of Research, Ostfold Hospital Trust, Norway
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sudeep Shivakumar
- Division of Hematology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan R Kahn
- Department of Medicine, McGill University and Division of Clinical Epidemiology, Lady Davis Institute, Montreal, Quebec, Canada
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Clive Kearon
- Department of Medicine (Division of Hematology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ranjeeta Mallick
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Aurélien Delluc
- Department of Medicine (Division of Hematology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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28
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Larsen TL, Ghanima W, Sandset PM, Frøen H, Jacobsen EM, Torfoss D, Dahm AEA. Faktor Xa-hemmere til forebygging og behandling av venøs tromboembolisme ved kreft. Tidsskr Nor Laegeforen 2023; 142:22-0228. [PMID: 36655971 DOI: 10.4045/tidsskr.22.0228] [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: 01/21/2023] Open
Abstract
Venous thromboembolism is a common complication of cancer. The prevalence varies according to cancer type and increases proportionally with the stage of cancer. In the past 15-20 years, low molecular weight heparin has been recommended as the first-line treatment. New international guidelines now allow for use of direct factor Xa inhibitors both as prophylaxis and treatment for venous thromboembolism. Prophylaxis should as a general rule only be initiated in patients with moderate to high risk. Bleeding risk assessment is important before starting anticoagulation. Both thrombosis and bleeding risk can change and should therefore be assessed on an ongoing basis. In this clinical review, use of anticoagulation therapy in cancer patients is discussed with particular emphasis on the use of direct factor Xa inhibitors.
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Affiliation(s)
- Trine-Lise Larsen
- Avdeling for blodsykdommer, Akershus universitetssykehus, og, Universitetet i Oslo
| | - Waleed Ghanima
- Avdeling for blodsykdommer, Sykehuset Østfold Kalnes, og, Institutt for klinisk medisin, Universitetet i Oslo
| | | | - Hege Frøen
- Avdeling for blodsykdommer, Oslo universitetssykehus, Rikshospitalet
| | | | | | - Anders Erik Astrup Dahm
- Avdeling for blodsykdommer, Akershus universitetssykehus, og, Institutt for klinisk medisin, Universitetet i Oslo
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29
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Garabet L, Eriksson A, Tjønnfjord E, Cui XY, Olsen MK, Jacobsen HK, Jørgensen CT, Mathisen ÅB, Mowinckel MC, Ahlen MT, Sørvoll IH, Horvei KD, Ernstsen SL, Lægreid IJ, Stavik B, Holst R, Sandset PM, Ghanima W. SARS-CoV-2 vaccines are not associated with hypercoagulability in apparently healthy people. Res Pract Thromb Haemost 2023; 7:100002. [PMID: 36448024 PMCID: PMC9691277 DOI: 10.1016/j.rpth.2022.100002] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/18/2022] [Accepted: 10/23/2022] [Indexed: 01/31/2023] Open
Abstract
Background SARS-CoV-2 adenoviral vector DNA vaccines have been linked to the rare but serious thrombotic postvaccine complication vaccine-induced immune thrombotic thrombocytopenia. This has raised concerns regarding the possibility of increased thrombotic risk after any SARS-CoV-2 vaccines. Objectives To investigate whether SARS-CoV-2 vaccines cause coagulation activation leading to a hypercoagulable state. Methods This observational study included 567 health care personnel; 521 were recruited after the first dose of adenoviral vector ChAdOx1-S (Vaxzevria, AstraZeneca) vaccine and 46 were recruited prospectively before vaccination with a messenger RNA (mRNA) vaccine, either Spikevax (Moderna, n = 38) or Comirnaty (Pfizer-BioNTech, n = 8). In the mRNA group, samples were acquired before and 1 to 2 weeks after vaccination. In addition to the prevaccination samples, 56 unvaccinated blood donors were recruited as controls (total n = 102). Thrombin generation, D-dimer levels, and free tissue factor pathway inhibitor (TFPI) levels were analyzed. Results No participant experienced thrombosis, vaccine-induced immune thrombotic thrombocytopenia, or thrombocytopenia (platelet count <100 × 109/L) 1 week to 1 month postvaccination. There was no increase in thrombin generation, D-dimer level, or TFPI level in the ChAdOx1-S vaccine group compared with controls or after the mRNA vaccines compared with baseline values. Eleven of 513 (2.1%) participants vaccinated with ChAdOx1-S had anti-PF4/polyanion antibodies without a concomitant increase in thrombin generation. Conclusion In this study, SARS-CoV-2 vaccines were not associated with thrombosis, thrombocytopenia, increased thrombin generation, D-dimer levels, or TFPI levels compared with baseline or unvaccinated controls. These findings argue against the subclinical activation of coagulation post-COVID-19 vaccination.
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Affiliation(s)
- Lamya Garabet
- Center for Laboratory Medicine, Østfold Hospital, Grålum, Norway.,Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Nordbyhagen, Norway
| | - Anna Eriksson
- Department of Research, Østfold Hospital, Grålum, Norway
| | | | - Xue-Yan Cui
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | | | | | | | - Marie-Christine Mowinckel
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Maria Therese Ahlen
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Ingvild Hausberg Sørvoll
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kjersti Daae Horvei
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.,Department of Medical Biology, University of Tromsø, Tromsø, Norway
| | - Siw Leiknes Ernstsen
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Ingvild Jenssen Lægreid
- Norwegian National Unit for Platelet Immunology, Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Benedicte Stavik
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - René Holst
- Department of Research, Østfold Hospital, Grålum, Norway
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Waleed Ghanima
- Department of Research, Østfold Hospital, Grålum, Norway.,Department of Medicine, Østfold Hospital, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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30
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Cooper N, Ghanima W, Hill QA, Nicolson PLR, Markovtsov V, Kessler C. Recent advances in understanding spleen tyrosine kinase (SYK) in human biology and disease, with a focus on fostamatinib. Platelets 2022; 34:2131751. [DOI: 10.1080/09537104.2022.2131751] [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: 11/06/2022]
Affiliation(s)
- Nichola Cooper
- Clinical Reader in Immune Haematology and Honorary Consultant, Faculty of Medicine, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Waleed Ghanima
- Head of Research and Consultant Haematologist, Department of Hemato-oncology, Østfold Hospital, and Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Quentin A Hill
- Consultant Haematologist, Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Phillip LR Nicolson
- Clinical Lecturer in Haematology, Institute of Cardiovascular Sciences, University of Birmingham, and Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vadim Markovtsov
- Translational Biology, Rigel Pharmaceuticals, South San Francisco, CA, USA
| | - Craig Kessler
- Medicine and Pathology, Director, Division of Coagulation, Director, Cellular and Therapeutic Apheresis and Cellular Collection, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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31
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Dhayyat A, Mykland Hilde J, Jervan O, Stavem K, Ghanima W, Melsom MN, Steine K. Exercise-induced pulmonary hypertension assessed by echocardiography in patients with chronic thromboembolic pulmonary disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1895] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Many patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension (PH) at rest suffer from exercise intolerance. Exercise echocardiography, which is a noninvasive examination, may have potential to discover exercise-induced PH in these patients, however, its role is scarcely explored in this population.
Purpose
To determine the occurrence of abnormal pulmonary pressure during rest and by exercise echocardiography in patients with CTEPD.
Methods
In total, 24 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography with dynamic supine leg exercise using a cycle ergometer. In addition, all participants underwent a modified incremental shuttle walk test (mISWT), pulmonary function tests and measurement of NT pro-BNP. Systolic pulmonary arterial pressure (sPAP) >50 mmHg by echocardiography during exercise was chosen as cutoff to define exercise-induced pulmonary hypertension (EIPH). Left ventricular diastolic dysfunction during stress was defined according to the American Society of Cardiology guidelines from 2016. Mean pulmonary artery pressure was estimated by sPAP measurements using the Chemla formula (0.61 x sPAP + 2 mmHg), and pulmonary vascular resistance (PVR) by the Doppler method (5.19 x TRV2/TVI RVOT − 0.4) proposed by Abbas et al. [1]. Subjects with heart failure with reduced or preserved ejection fraction, significant valvular heart disease, chronic pulmonary disease and chronic thromboembolic pulmonary hypertension were excluded.
Results
11 (46%) of the patients had EIPH at peak exercise (range 50 to 89 mmHg). PVR at peak exercise ranged from 2.6 to 5.9 WU, whereas 10 had PVR >3.0 WU. None had unmasked left ventricular diastolic dysfunction during exercise, resting tricuspid regurgitation peak velocity (TR V max) >3.4m/s, or a high probability of PH at rest. Three patients had TR V max between 2.9 and 3.4m/s or intermediate probability of PH. All patients had normal biventricular systolic function at rest and during exercise (Table 2).
Conclusion
Patients with CTEPD had normal pulmonary pressures at rest. However, approximately half of the patients showed abnormal rise in pulmonary pressure during exercise, which may explain or contribute to the exercise intolerance in these patients.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust
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Affiliation(s)
- A Dhayyat
- Sykehuset Ostfold Kalnes, Department of Cardiology , Sarpsborg , Norway
| | - J Mykland Hilde
- Akershus University Hospital, Department of Cardiology , Akershus , Norway
| | - O Jervan
- Sykehuset Ostfold Kalnes, Department of Cardiology , Sarpsborg , Norway
| | - K Stavem
- Akershus University Hospital, Department of Pulmonary Medicine , Akershus , Norway
| | - W Ghanima
- Akershus University Hospital, Department of Hematology , Akershus , Norway
| | - M N Melsom
- Baerum Hospital Vestre Viken Trust, Department of Pulmonary Medicine , Gjettum , Norway
| | - K Steine
- Akershus University Hospital, Department of Cardiology , Akershus , Norway
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32
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Dhayyat A, Mykland Hilde J, Jervan O, Stavem K, Ghanima W, Melsom MN, Steine K. Exercise hemodynamics by echocardiography and right heart catheterization in patients with chronic thromboembolic pulmonary disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1897] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Chronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of pulmonary hypertension (PH). A subclinical form of PH is referred to as exercise-induced pulmonary hypertension (EIPH), and its prevalence in patients with chronic thromboembolic pulmonary disease (CTEPD) without pulmonary hypertension at rest is unknown.
Purpose
To explore the occurrence of exercise-induced pulmonary hypertension (PH) in patients with CTEPD and compare exercise echocardiography with right heart catheterization (RHC).
Methods
In total, 16 patients with CTEPD, all diagnosed after pulmonary embolism, underwent exercise echocardiography and exercise RHC with dynamic supine leg exercise using a cycle ergometer. CTEPH at rest was defined as mean pulmonary artery pressure (mPAP) >20 mmHg and pulmonary vascular resistance (PVR) ≥3WU. EIPH by RHC was defined as mPAP >30 mmHg with total pulmonary resistance (TPR) ≥3 WU. Based on these criteria, our patients with CTEPD are presented by a flow chart (Figure 1). Systolic pulmonary artery pressure by echocardiography was calculated by tricuspid regurgitation peak velocity (TR V max) and the Bernoulli formula: 4 × (TR V)2. The RHC examination followed the exercise echocardiography within 2 hours. Groups were compared with independent sample t-test.
Results
Four patients (25%) were diagnosed with EIPH by exercise RHC. Patients with EIPH had a mean mPAP at peak exercise of 40.5 mmHg (range 38 to 43mmHg) and TPR of 3.7 WU (range 3.0 to 4.3 WU). The same patients also had a higher TR V max at peak exercise during exercise echocardiography compared to the patients without EIPH (Table 2). None of the patients had signs of elevated left-sided filling pressure during exercise by RHC, and none had left ventricular diastolic dysfunction during exercise by echocardiography.
Conclusion
In total, 4 of 16 patients with CTEPD were diagnosed with EIPH. The same four patients also had abnormal pulmonary artery pressure rise during exercise echocardiography and invasive RHC. These findings suggest that exercise echocardiography may be useful for screening patients with CTEPD and suspected EIPH.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Ostfold Hospital Trust
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Affiliation(s)
| | - J Mykland Hilde
- Akershus University Hospital, Department of Cardiology , Akershus , Norway
| | - O Jervan
- Sykehuset Ostfold Kalnes, Department of Cardiology , Sarpsborg , Norway
| | - K Stavem
- Akershus University Hospital, Department of Pulmonary Medicine , Akershus , Norway
| | - W Ghanima
- Akershus University Hospital, Department of Hematology , Akershus , Norway
| | - M N Melsom
- Baerum Hospital Vestre Viken Trust, Department of Pulmonary Medicine , Gjettum , Norway
| | - K Steine
- Akershus University Hospital, Department of Cardiology , Akershus , Norway
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Mohamad H, Fronas SG, Jørgensen CT, Tavoly M, Garabet L, Ghanima W. The effect of rivaroxaban on the diagnostic value of D-dimer in patients with suspected deep vein thrombosis. Thromb Res 2022; 216:22-24. [DOI: 10.1016/j.thromres.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/15/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022]
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Larsen TL, Garresori H, Brekke J, Enden T, Frøen H, Jacobsen EM, Quist-Paulsen P, Porojnicu AC, Ree AH, Torfoss D, Velle EO, Wik HS, Ghanima W, Sandset PM, Dahm AEA. "Low dose apixaban as secondary prophylaxis of venous thromboembolism in cancer patients - 30 months follow-up": Reply. J Thromb Haemost 2022; 20:1937-1939. [PMID: 35859282 DOI: 10.1111/jth.15774] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Trine-Lise Larsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
| | - Herish Garresori
- Department of Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Jorunn Brekke
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Tone Enden
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Hege Frøen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | | | | | | | - Anne Hansen Ree
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Dag Torfoss
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Elin Osvik Velle
- Department of Medicine, Volda Hospital, Møre and Romsdal Hospital Trust Volda, Ålesund, Norway
| | | | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
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Bistervels IM, Bavalia R, Beyer‐Westendorf J, ten Cate‐Hoek AJ, Schellong SM, Kovacs MJ, Falvo N, Meijer K, Stephan D, Boersma WG, ten Wolde M, Couturaud F, Verhamme P, Brisot D, Kahn SR, Ghanima W, Montaclair K, Hugman A, Carroll P, Pernod G, Sanchez O, Ferrari E, Roy P, Sevestre‐Pietri M, Birocchi S, Wik HS, Hutten BA, Coppens M, Naue C, Grosso MA, Shi M, Lin Y, Quéré I, Middeldorp S. Postthrombotic syndrome and quality of life after deep vein thrombosis in patients treated with edoxaban versus warfarin. Res Pract Thromb Haemost 2022; 6:e12748. [PMID: 35992565 PMCID: PMC9248314 DOI: 10.1002/rth2.12748] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 04/18/2022] [Accepted: 04/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background Postthrombotic syndrome (PTS) is a long-term complication after deep vein thrombosis (DVT) and can affect quality of life (QoL). Pathogenesis is not fully understood but inadequate anticoagulant therapy with vitamin K antagonists is a known risk factor for the development of PTS. Objectives To compare the prevalence of PTS after acute DVT and the long-term QoL following DVT between patients treated with edoxaban or warfarin. Methods We performed a long-term follow-up study in a subset of patients with DVT who participated in the Hokusai-VTE trial between 2010 and 2012 (NCT00986154). Primary outcome was the prevalence of PTS, defined by the Villalta score. The secondary outcome was QoL, assessed by validated disease-specific (VEINES-QOL) and generic health-related (SF-36) questionnaires. Results Between 2017 and 2020, 316 patients were enrolled in 26 centers in eight countries, of which 168 (53%) patients had been assigned to edoxaban and 148 (47%) to warfarin during the Hokusai-VTE trial. Clinical, demographic, and thrombus-specific characteristics were comparable for both groups. Mean (SD) time since randomization in the Hokusai-VTE trial was 7.0 (1.0) years. PTS was diagnosed in 85 (51%) patients treated with edoxaban and 62 (42%) patients treated with warfarin (adjusted odds ratio 1.6, 95% CI 1.0-2.6). Mean differences in QoL scores between treatment groups were not clinically relevant. Conclusion Contrary to our hypothesis, the prevalence of PTS tended to be higher in patients treated with edoxaban compared with warfarin. No differences in QoL were observed. Further research is warranted to unravel the role of anticoagulant therapy on development of PTS.
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Affiliation(s)
- Ingrid M. Bistervels
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
- Department of Internal Medicine Flevo Hospital Almere The Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Jan Beyer‐Westendorf
- Department of Medicine I, Division of Hematology and Hemostasis, Thrombosis Research University Hospital "Carl Gustav Carus" Dresden Dresden Germany
| | - Arina J. ten Cate‐Hoek
- Thrombosis Expertise Centre, Heart+Vascular Center Maastricht University Medical Centre Maastricht The Netherlands
| | | | - Michael J. Kovacs
- Department of Hematology and Thrombosis London Health Sciences Centre,Victoria Hospital London Ontario Canada
| | - Nicolas Falvo
- Department of Internal Medicine and Immunology Centre Hospitalier Regionale Universitaire Dijon Dijon France
| | - Karina Meijer
- Department of Hematology University Medical Centre Groningen Groningen The Netherlands
| | - Dominique Stephan
- Department of Hypertension, Vascular Disease and Clinical Pharmacology Regional University Hospital Strasbourg France
| | - Wim G. Boersma
- Department of Pulmonology Noordwest Ziekenhuisgroep Alkmaar The Netherlands
| | - Marije ten Wolde
- Department of Internal Medicine Flevo Hospital Almere The Netherlands
| | - Francis Couturaud
- Department of Pulmonology Centre Hospitalier Regionale Universitaire Brest Brest France
| | - Peter Verhamme
- Department of Vascular Medicine and Hemostasis University Hospital Leuven Leuven Belgium
| | - Dominique Brisot
- Department of Vascular Medicine Clinique du Parc Castelnau le Lez France
| | - Susan R. Kahn
- Department of Medicine McGill University Montreal Canada
| | - Waleed Ghanima
- Department of Research, Østfold Hospital and Institute of Clinical Medicine University of Oslo Oslo Norway
| | | | - Amanda Hugman
- Department of Haematology St George Hospital Sydney New South Wales Australia
| | - Patrick Carroll
- Department of Vascular Medicine Redcliffe Hospital Queensland Australia
| | - Gilles Pernod
- Department of Medicine Centre Hospitalier Regionale Universitaire de Grenoble‐Alpes Grenoble France
| | - Olivier Sanchez
- Department of Pulmonology Hôpital Européen Georges‐Pompidou Paris France
| | - Emile Ferrari
- Department of Cardiology Centre Hospitalier Universitaire de Nice Nice France
| | - Pierre‐Marie Roy
- Department of Emergency Medicine Centra Hospitalier Universitaire d'Angers Angers France
| | | | - Simone Birocchi
- Department of Hematology and Thrombosis SanPaolo Hospital Milan Italy
| | - Hilde S. Wik
- Department of Haematology Oslo University Hospital Oslo Norway
| | - Barbara A. Hutten
- Department of Epidemiology and Data Science, Amsterdam Cardiovascular Sciences Amsterdam UMC, University of Amsterdam Amsterdam The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Christiane Naue
- Department of Medicine I, Division of Hematology and Hemostasis, Thrombosis Research University Hospital "Carl Gustav Carus" Dresden Dresden Germany
| | | | - Minggao Shi
- Daiichi Sankyo Pharma Development Basking Ridge New Jersey USA
| | - Yong Lin
- Daiichi Sankyo Pharma Development Basking Ridge New Jersey USA
| | - Isabelle Quéré
- Department of Vascular Medicine IDESP Inserm‐Montpellier University, InnoVTE Network, CHU Montpellier Montpellier France
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS)Radboud University Medical Center Nijmegen The Netherlands
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Jørgensen CT, Tavoly M, Pettersen HH, Førsund E, Roaldsnes C, Olsen MK, Tjønnfjord E, Gleditsch J, Galovic AG, Vikum SF, Brækkan SK, Ghanima W. The venous thrombosis registry in Østfold Hospital (TROLL registry) - design and cohort description. Res Pract Thromb Haemost 2022; 6:S2475-0379(22)00161-3. [PMID: 35949883 PMCID: PMC9351429 DOI: 10.1002/rth2.12770] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 03/09/2022] [Revised: 05/31/2022] [Accepted: 06/14/2022] [Indexed: 11/09/2022] Open
Abstract
Purpose The incidence of venous thromboembolism (VTE) is expected to increase over the next decades, further increasing its substantial impact on patients and health care resources. Registries have the benefit of reporting real‐world data without excluding clinically important subgroups. Our aim was to describe a Norwegian VTE registry and to provide descriptive data on the population and management. Registry Population The Venous Thrombosis Registry in Østfold Hospital (TROLL) is an ongoing registry of consecutive patients diagnosed with, treated, and/or followed up for VTE at Østfold Hospital, Norway, since 2005. Baseline and follow‐up data, including demographics, clinical features, risk factors, diagnostic procedures, classification of VTE, and treatment were collected during hospitalization, and at scheduled outpatient visits. Findings to Date From January 2005 to June 2021, 5037 patients were eligible for research in TROLL. Median age was 67 years (interquartile range, 55–77), and 2622 (52.1%) were male. Of these, 2736 (54.3%) had pulmonary embolism (PE), 2034 (40.4%) had deep vein thrombosis (DVT), and 265 (5.3%) had upper‐extremity DVT or splanchnic or cerebral sinus vein thrombosis. In total, 2330 (46.3%) were classified as unprovoked VTE, and 1131 (22.5%) had cancer. Direct oral anticoagulants were the most frequent therapeutic agents (39.3%) followed by low‐molecular‐weight heparins (30.4%) and vitamin K antagonists (30.3%). Outpatient treatment for PE increased from 4% in 2005 to 23% in 2019. Future Plans TROLL is a population‐based ongoing registry that represents a valuable source of real‐world data that will be used for future research on the management and outcomes of VTE.
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Affiliation(s)
- Camilla Tøvik Jørgensen
- Department of Emergency Medicine Østfold Hospital Sarpsborg Norway.,Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Mazdak Tavoly
- Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | | | - Eli Førsund
- Department of Emergency Medicine Østfold Hospital Sarpsborg Norway
| | | | | | - Eirik Tjønnfjord
- Department of Emergency Medicine Østfold Hospital Sarpsborg Norway
| | - Jostein Gleditsch
- Institute of Clinical Medicine University of Oslo Oslo Norway.,Department of Radiology Østfold Hospital Sarpsborg Norway
| | | | | | - Sigrid Kufaas Brækkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT The Arctic University of Norway Tromsø Norway.,Division of Internal Medicine University Hospital of North Norway Tromsø Norway
| | - Waleed Ghanima
- Department of Research Østfold Hospital Sarpsborg Norway.,Clinic of Internal Medicine Østfold Hospital Sarpsborg Norway.,Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine University of Oslo Oslo Norway
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Larsen TL, Garresori H, Brekke J, Enden T, Frøen H, Jacobsen EM, Quist-Paulsen P, Porojnicu AC, Ree AH, Torfoss D, Osvik Velle E, Skuterud Wik H, Ghanima W, Sandset PM, Dahm AEA. Low dose apixaban as secondary prophylaxis of venous thromboembolism in cancer patients - 30 months follow-up. J Thromb Haemost 2022; 20:1166-1181. [PMID: 35114046 DOI: 10.1111/jth.15666] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 12/02/2021] [Revised: 01/20/2022] [Accepted: 01/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND There are no data on the effect of low-dose anticoagulation as secondary prophylaxis for venous thromboembolism (VTE) in cancer patients. We assessed the efficacy and safety of low-dose apixaban for 30 months, after initial 6 months of full-dose treatment. METHODS We included 298 patients with cancer and any type of VTE in a single arm interventional clinical trial. All patients were treated with full-dose apixaban (5 mg twice daily) for 6 months. Total 196 patients with active cancer after 6 months treatment continued with apixaban 2.5 mg twice daily for another 30 months. The main endpoints were recurrent VTE, major bleeding and clinically relevant non-major bleeding. RESULTS During the 30 months of treatment with low-dose apixaban 14 (7.6%; 95% confidence interval (CI) 4.0%-11.7%) patients experienced recurrent VTE, six (3.1%; 95% CI 1.1%-6.5%) experienced major bleeding and 16 (8.1%, 95% CI: 4.7%-12.8%) experienced clinically relevant non-major bleeding. The incidence rate per person month of recurrent VTE was 0.8% (95% CI 0.41-1.6) at 2-6 months with full-dose apixaban, and 1.0% (95% CI 0.5-1.9) at 7-12 months with low-dose apixaban. The incidence rate of major bleeding was 1.1% (95% CI 0.6-2.0) at 2-6 months, and 0.3% (95% CI 0.1-1.0) at 7-12 months. Between 12 and 36 months the incidence rate of recurrent VTE and major bleedings remained low. CONCLUSION Dose reduction of apixaban to 2.5 mg twice daily seems safe after 6 months of full-dose treatment. After 12 months the incidence rate of recurrent VTE and major bleeding remained low.
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Affiliation(s)
- Trine-Lise Larsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
| | - Herish Garresori
- Department of Oncology, Stavanger University Hospital, Stavanger, Norway
| | - Jorunn Brekke
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - Tone Enden
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Hege Frøen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | | | | | | | - Anne Hansen Ree
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Dag Torfoss
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Elin Osvik Velle
- Department of Medicine, Volda Hospital, Møre and Romsdal Hospital Trust Volda, Ålesund, Norway
| | | | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Clinic of Internal Medicine, Østfold Hospital, Grålum, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Hematology, Akershus University Hospital, Lørenskog, Norway
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Kuter DJ, Efraim M, Mayer J, Trněný M, McDonald V, Bird R, Regenbogen T, Garg M, Kaplan Z, Tzvetkov N, Choi PY, Jansen AJG, Kostal M, Baker R, Gumulec J, Lee EJ, Cunningham I, Goncalves I, Warner M, Boccia R, Gernsheimer T, Ghanima W, Bandman O, Burns R, Neale A, Thomas D, Arora P, Zheng B, Cooper N. Rilzabrutinib, an Oral BTK Inhibitor, in Immune Thrombocytopenia. N Engl J Med 2022; 386:1421-1431. [PMID: 35417637 DOI: 10.1056/nejmoa2110297] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Rilzabrutinib, an oral, reversible covalent inhibitor of Bruton's tyrosine kinase, may increase platelet counts in patients with immune thrombocytopenia by means of dual mechanisms of action: decreased macrophage (Fcγ receptor)-mediated platelet destruction and reduced production of pathogenic autoantibodies. METHODS In an international, adaptive, open-label, dose-finding, phase 1-2 clinical trial, we evaluated rilzabrutinib therapy in previously treated patients with immune thrombocytopenia. We used intrapatient dose escalation of oral rilzabrutinib over a period of 24 weeks; the lowest starting dose was 200 mg once daily, with higher starting doses of 400 mg once daily, 300 mg twice daily, and 400 mg twice daily. The primary end points were safety and platelet response (defined as at least two consecutive platelet counts of ≥50×103 per cubic millimeter and an increase from baseline of ≥20×103 per cubic millimeter without the use of rescue medication). RESULTS Sixty patients were enrolled. At baseline, the median platelet count was 15×103 per cubic millimeter, the median duration of disease was 6.3 years, and patients had received a median of four different immune thrombocytopenia therapies previously. All the treatment-related adverse events were of grade 1 or 2 and transient. There were no treatment-related bleeding or thrombotic events of grade 2 or higher. At a median of 167.5 days (range, 4 to 293) of treatment, 24 of 60 patients (40%) overall and 18 of the 45 patients (40%) who had started rilzabrutinib treatment at the highest dose met the primary end point of platelet response. The median time to the first platelet count of at least 50×103 per cubic millimeter was 11.5 days. Among patients with a primary platelet response, the mean percentage of weeks with a platelet count of at least 50×103 per cubic millimeter was 65%. CONCLUSIONS Rilzabrutinib was active and associated with only low-level toxic effects at all dose levels. The dose of 400 mg twice daily was identified as the dose for further testing. Overall, rilzabrutinib showed a rapid and durable clinical activity that improved with length of treatment. (Funded by Sanofi; ClinicalTrials.gov number, NCT03395210; EudraCT number, 2017-004012-19.).
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Affiliation(s)
- David J Kuter
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Merlin Efraim
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Jiri Mayer
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Marek Trněný
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Vickie McDonald
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Robert Bird
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Thomas Regenbogen
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Mamta Garg
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Zane Kaplan
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Nikolay Tzvetkov
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Philip Y Choi
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - A J Gerard Jansen
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Milan Kostal
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Ross Baker
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Jaromir Gumulec
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Eun-Ju Lee
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Ilona Cunningham
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Isaac Goncalves
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Margaret Warner
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Ralph Boccia
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Terry Gernsheimer
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Waleed Ghanima
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Olga Bandman
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Regan Burns
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Ann Neale
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Dolca Thomas
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Puneet Arora
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Beiyao Zheng
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
| | - Nichola Cooper
- From the Hematology Division, Massachusetts General Hospital, and Harvard Medical School - both in Boston (D.J.K.); the Multiprofile Hospital for Active Treatment Sveta Marina EAD, Varna (M.E.), and the Clinic of Hematology, University Multiprofile Hospital for Active Treatment "Dr. Georgi Stranski" EAD, Pleven (N.T.) - both in Bulgaria; the Department of Internal Medicine, Hematology, and Oncology, Masaryk University Hospital, Brno (J.M.), the First Department of Medicine and the Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague (M.T.), the Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove (M.K.), and the Department of Hemato-oncology, University Hospital Ostrava, and the Faculty of Medicine, University of Ostrava, Ostrava (J.G.) - all in the Czech Republic; Barts Health NHS Trust, the Royal London Hospital (V.M.), and the Department of Immunology and Inflammation, Imperial College London (N.C.), London, and Leicester Royal Infirmary, Leicester (M.G.) - all in the United Kingdom; Princess Alexandra Hospital, Woolloongabba, QLD (R. Bird), Monash Medical Centre, Clayton, VIC (Z.K.), Canberra Hospital, Garran, ACT (P.Y.C.), Perth Blood Institute, Murdoch University, Perth, WA (R. Baker), Concord Repatriation General Hospital, Concord, NSW (I.C.), and Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, VIC (I.G.) - all in Australia; MidMichigan Health, Midland, MI (T.R.); Erasmus MC-University Medical Center, Rotterdam, the Netherlands (A.J.G.J.); NewYork-Presbyterian Hospital and Weill Cornell Medical Center, New York (E.-J.L.); McGill University Health Centre, Montreal (M.W.); the Center for Cancer and Blood Disorders, Bethesda, MD (R. Boccia); the University of Washington Medical Center, Seattle (T.G.); Ostfold Hospital Foundation, Gralum, and the Institute of Clinical Medicine, University of Oslo, Oslo - both in Norway (W.G.); and Principia Biopharma (a Sanofi company), South San Francisco, CA (O.B., R. Burns, A.N., D.T., P.A., B.Z.)
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Tsykunova G, Ghanima W. Avatrombopag for the Treatment of Adult Patients with Chronic Immune Thrombocytopenia (cITP): Focus on Patient Selection and Perspectives. Ther Clin Risk Manag 2022; 18:273-286. [PMID: 35386180 PMCID: PMC8977771 DOI: 10.2147/tcrm.s251672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 12/03/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a reduced number of circulating platelets due to immune-mediated destruction and decreased platelet production in the bone marrow. Thrombopoietin receptor agonists (TPO-RAs) are highly effective and widely used in the treatment of patients with steroid treatment failure or dependency. Avatrombopag represents a new supplement to the TPO-RAs family. It was originally approved for the treatment of thrombocytopenia in patients with chronic liver disease who are scheduled to undergo an invasive procedure. However, labeled indications for avatrombopag have been relatively recently expanded to include treatment of chronic ITP in adults with insufficient response to the previous treatments. In this article, we provide an overview of pharmacodynamics and pharmacokinetics of avatrombopag as well as results of the clinical trials related to safety and efficacy of avatrombopag with a perspective on current clinical use. Available data so far suggests that avatrombopag can be effectively used in ITP patients and has a favorable safety profile. Though further studies are needed to affirm the efficacy and safety, avatrombopag has the potential to become a TPO agonist of choice for many patients with ITP.
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Affiliation(s)
- Galina Tsykunova
- Department of Hematology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hemato-Oncology, Østfold Hospital, Grålum, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hemato-Oncology, Østfold Hospital, Grålum, Norway.,Department of hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Moulis G, Cooper N, Ghanima W, González-López T, Kühne T, Lozano ML, Michel M, Provan D, Zaja F, Aladjidi N, Christiansen CF, Frederiksen H, Grainger J, McDonald V, Robinson S, Schifferli A, Rodeghiero F. Registries in immune thrombocytopenia (ITP) in Europe: the European Research Consortium on ITP (ERCI) network. Br J Haematol 2022; 197:633-638. [PMID: 35303315 DOI: 10.1111/bjh.18111] [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] [Received: 12/20/2021] [Revised: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France.,CIC 1436, Team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, Imperial College London, London, UK
| | - Waleed Ghanima
- Department of Hematooncology, Østfol Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Thomas Kühne
- Oncology/Hematology, University Children's Hospital Basel, Basel, Switzerland
| | - Maria L Lozano
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, Spain
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
| | - Drew Provan
- Department of Haematology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Nathalie Aladjidi
- Pediatric Hematology, University Hospital Centre, d'Investigation Clinique Plurithématique CICP, INSERM, Bordeaux.,Centre de Référence National des Cytopénies Auto-Immunes de l'Enfant (CEREVANCE), Bordeaux, France
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Frederiksen
- Department of Haematology and Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - John Grainger
- Department of Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK.,Department of Medical Sciences, University of Manchester, Manchester, UK
| | - Vickie McDonald
- Department of Clinical Haematology, Royal London Hospital, Barts Health, London, UK
| | - Susan Robinson
- Department of Clinical Haematology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | | | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Hematology Department of the San Bortolo Hospital, Vicenza, Italy
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Chakrabarti P, George B, Shanmukhaiah C, Sharma LM, Udupi S, Ghanima W. How do patients and physicians perceive immune thrombocytopenia (ITP) as a disease? Results from Indian analysis of ITP World Impact Survey (I-WISh). J Patient Rep Outcomes 2022; 6:24. [PMID: 35303181 PMCID: PMC8933602 DOI: 10.1186/s41687-022-00429-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Received: 09/09/2021] [Accepted: 02/28/2022] [Indexed: 11/12/2022] Open
Abstract
Purpose Immune thrombocytopenia (ITP) is primarily considered a bleeding disorder; its impact on patients’ health-related quality of life (HRQoL) is under-recognized. We aimed to assess how aligned patient and physician perceptions are regarding ITP-associated symptoms, HRQoL, and disease management in India. Methods Patients and physicians (hematologists/hemato-oncologists) from India who participated in the global ITP World Impact Survey (I-WISh) were included in this subgroup analysis (survey). Physicians were recruited via a local, third party recruiter in India. In addition to completing a survey themselves, physicians were asked to invite consulting patients on a consecutive basis to complete a survey. All surveys were completely independently by the respondents online in English. The respondents took 30 min to complete the questionnaire. Patients also completed the newly developed ITP Life Quality Index (ILQI) that included 10 questions on the impact of ITP on the following: work or studies, time taken off work or education, ability to concentrate, social life, sex life, energy levels, ability to undertake daily tasks, ability to provide support, hobbies, and capacity to exercise. Results A total of 65 patients and 21 physicians were included in this study. Average disease duration from diagnosis-to-survey-completion was 5.3 years. The most severe symptoms reported by patients at diagnosis were menorrhagia (15 of 19 patients [79%]), anxiety surrounding unstable platelet counts (17 of 28 patients [61%]), and fatigue (27 of 46 patients [59%]); these were also the key symptoms they wanted to be resolved. In contrast, physicians perceived petechiae (19 of 21 patients [90%]), bleeding-from-gums (8 of 21 patients [86%]), and purpura (16 of 21 patients [76%]) as the most common symptoms. While the important treatment goals for patients were healthy blood counts (42 of 65 patients [65%]), improved QoL (35 of 65 patients [54%]), and prevention of worsening of ITP (33 of 65 patients [51%]), physicians’ goals were reduction in spontaneous bleeding (17 of 21 physicians [81%]), better QoL (14 of 21 physicians [67%]), and symptom improvement (9 of 21 physicians [43%]). More than half the patients reported that ITP affected their work life/studies, social life, and energy levels, thereby negatively impacting their QoL. Patients were almost entirely dependent on family and friends for support. Conclusions This survey highlights the substantial discrepancy in patients’ and physicians’ perceptions regarding ITP-associated symptoms and treatment goals in India. Based on the identified gaps, educating physicians on aspects of ITP beyond bleeding, and highlighting patients’ under-recognized symptoms/needs through support-systems should be prioritized in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00429-y.
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Affiliation(s)
- Prantar Chakrabarti
- Department of Hematology, Vivekananda Institute of Medical Sciences, Machan, L 16 Panchasayar, Kolkata, West Bengal, 700094, India
| | - Biju George
- Department of Hematology, CMC Vellore, Vellore, Tamil Nadu, 632004, India
| | - Chandrakala Shanmukhaiah
- Department of Clinical Hematology, KEM Hospital, 1902, 19th floor UG PG hostel, KEM Hospital Campus, Parel, Mumbai, Maharashtra, 400012, India
| | - Lalit Mohan Sharma
- Department of Medical Oncology, MG Medical College, 67/166, Sector 6, Pratap Nagar, Jaipur, Rajasthan, India
| | - Shashank Udupi
- Medical Affairs, Oncology (Hematology), Novartis Healthcare Private Limited, Inspire BKC, Part of 601 & 701, 7th Floor, Bandra Kurla Complex, Bandra (East), Mumbai, Maharashtra, 400051, India
| | - Waleed Ghanima
- Departments of Research and Hemato-Oncology, Østfold Hospital, Østfold Hospital, PB 300, 1714, Grålum, Norway.
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42
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Tholin B, Fiskvik H, Tveita A, Tsykonova G, Opperud H, Busterud K, Mpinganzima C, Garabet L, Ahmed J, Stavem K, Ghanima W. Thromboembolic complications during and after hospitalization for COVID-19: Incidence, risk factors and thromboprophylaxis. Thromb Update 2022; 6:100096. [PMID: 38620916 PMCID: PMC8720677 DOI: 10.1016/j.tru.2021.100096] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 11/02/2022] Open
Abstract
Introduction The incidence of thromboembolism during COVID-19 and the use of thromboprophylaxis vary greatly between studies. Only a few studies have investigated the rate of thromboembolism post-discharge. This study determined the 90-day incidence of venous and arterial thromboembolic complications, risk factors for venous thromboembolic events and characterized the use of thromboprophylaxis during and after hospitalization. Materials and methods We retrospectively reviewed medical records for adult patients hospitalized for >24 h for COVID-19 before May 15, 2020, in ten Norwegian hospitals. We extracted data on demographics, thromboembolic complications, thromboembolic risk factors, and the use of thromboprophylaxis. Cox proportional hazards regression was used to determine risk factors for VTE. Results 550 patients were included. The 90-day incidence of arterial and venous thromboembolism in hospitalized patients was 6.9% (95% CI: 5.1-9.3) overall and 13.8% in the ICU. Male sex (hazard ratio (HR) 7.44, 95% CI 1.73-32.02, p = 0.007) and previous VTE (HR 6.11, 95% CI: 1.74-21.39, p = 0.005) were associated with risk of VTE in multivariable analysis. Thromboprophylaxis was started in 334 patients (61%) with a median duration of 7 days (25th-75th percentile 3-13); in the VTE population 10/23 (43%) started thromboprophylaxis prior to diagnosis. After discharge 20/223 patients received extended thromboprophylaxis and 2/223 (0.7%, 95% CI: 0.3-1.9) had a thromboembolism. Conclusions The 90-day incidence of thromboembolism in COVID-19 patients was 7%, but <1% after discharge. Risk factors were male sex and previous VTE. Most patients received thromboprophylaxis during hospitalization, but only <10% after discharge.
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Affiliation(s)
- Birgitte Tholin
- Clinic of Internal Medicine, Østfold Hospital, Norway
- Department of Internal Medicine, Molde Hospital, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
| | - Hilde Fiskvik
- Department of Haematology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Anders Tveita
- Department of Internal Medicine, Bærum Hospital, Norway
| | - Galina Tsykonova
- Clinic of Internal Medicine, Østfold Hospital, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
- Department of Haematology, Haukeland University Hospital, Haukeland, Norway
| | | | - Kari Busterud
- Department of Haematology, Akershus University Hospital, Lørenskog, Norway
| | | | - Lamya Garabet
- Department of Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital, Norway
| | - Jamal Ahmed
- Clinic of Internal Medicine, Østfold Hospital, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Norway
- Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Waleed Ghanima
- Clinic of Internal Medicine, Østfold Hospital, Norway
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Norway
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Stals MAM, Takada T, Kraaijpoel N, van Es N, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Huisman MV, Kline JA, Moons KGM, Parpia S, Perrier A, Righini M, Robert-Ebadi H, Roy PM, van Smeden M, Wells PS, de Wit K, Geersing GJ, Klok FA. Safety and Efficiency of Diagnostic Strategies for Ruling Out Pulmonary Embolism in Clinically Relevant Patient Subgroups : A Systematic Review and Individual-Patient Data Meta-analysis. Ann Intern Med 2022; 175:244-255. [PMID: 34904857 DOI: 10.7326/m21-2625] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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: 11/22/2022] Open
Abstract
BACKGROUND How diagnostic strategies for suspected pulmonary embolism (PE) perform in relevant patient subgroups defined by sex, age, cancer, and previous venous thromboembolism (VTE) is unknown. PURPOSE To evaluate the safety and efficiency of the Wells and revised Geneva scores combined with fixed and adapted D-dimer thresholds, as well as the YEARS algorithm, for ruling out acute PE in these subgroups. DATA SOURCES MEDLINE from 1 January 1995 until 1 January 2021. STUDY SELECTION 16 studies assessing at least 1 diagnostic strategy. DATA EXTRACTION Individual-patient data from 20 553 patients. DATA SYNTHESIS Safety was defined as the diagnostic failure rate (the predicted 3-month VTE incidence after exclusion of PE without imaging at baseline). Efficiency was defined as the proportion of individuals classified by the strategy as "PE considered excluded" without imaging tests. Across all strategies, efficiency was highest in patients younger than 40 years (47% to 68%) and lowest in patients aged 80 years or older (6.0% to 23%) or patients with cancer (9.6% to 26%). However, efficiency improved considerably in these subgroups when pretest probability-dependent D-dimer thresholds were applied. Predicted failure rates were highest for strategies with adapted D-dimer thresholds, with failure rates varying between 2% and 4% in the predefined patient subgroups. LIMITATIONS Between-study differences in scoring predictor items and D-dimer assays, as well as the presence of differential verification bias, in particular for classifying fatal events and subsegmental PE cases, all of which may have led to an overestimation of the predicted failure rates of adapted D-dimer thresholds. CONCLUSION Overall, all strategies showed acceptable safety, with pretest probability-dependent D-dimer thresholds having not only the highest efficiency but also the highest predicted failure rate. From an efficiency perspective, this individual-patient data meta-analysis supports application of adapted D-dimer thresholds. PRIMARY FUNDING SOURCE Dutch Research Council. (PROSPERO: CRD42018089366).
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Affiliation(s)
- Milou A M Stals
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands, and Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Fukushima, Japan (T.T.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, location AMC, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (N.K., N.v.E., H.R.B.)
| | - D Mark Courtney
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas (D.M.C.)
| | - Yonathan Freund
- Department of Emergency Medicine, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France (Y.F.)
| | - Javier Galipienzo
- Service of Anesthesiology, Hospital MD Anderson Cancer Center, Madrid, Spain (J.G.)
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust and Institute of Clinical Medicine, University of Oslo, Oslo, Norway (W.G.)
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana (J.A.K.)
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland (A.P., M.R., H.R.E.)
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University of Angers, Angers, France (P.M.R.)
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Phil S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Ontario, Canada (G.L.G., P.S.W.)
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, and Departments of Medicine and Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada (K.d.W.)
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M.M., M.v.S., G.J.G.)
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands (M.A.M.S., M.V.H., F.A.K.)
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Ng S, Rodger MA, Ghanima W, Kovacs MJ, Shivakumar S, Kahn SR, Sandset PM, Kearon C, Mallick R, Delluc A. External validation of the patient reported Villalta scale for the diagnosis of post-thrombotic syndrome. Thromb Haemost 2022; 122:1379-1383. [PMID: 35021257 DOI: 10.1055/a-1738-1313] [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: 10/19/2022]
Affiliation(s)
- Sara Ng
- Liverpool Hospital, Liverpool, Australia
| | | | | | | | | | | | - Per-Morten Sandset
- Haemotology, Oslo universitetssykehus Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Universitetet i Oslo Institutt for klinisk medisin, Oslo, Norway
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Gleditsch J, Jervan Ø, Tavoly M, Geier O, Holst R, Klok FA, Ghanima W, Hopp E. Association between myocardial fibrosis, as assessed with cardiac magnetic resonance T1 mapping, and persistent dyspnea after pulmonary embolism. Int J Cardiol Heart Vasc 2022; 38:100935. [PMID: 35005213 PMCID: PMC8717259 DOI: 10.1016/j.ijcha.2021.100935] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/25/2022]
Abstract
Background Persistent dyspnea is a common symptom after pulmonary embolism (PE). However, the pathophysiology of persistent dyspnea is not fully clarified. This study aimed to explore possible associations between diffuse myocardial fibrosis, as assessed by cardiac magnetic resonance (CMR) T1 mapping, and persistent dyspnea in patients with a history of PE. Methods CMR with T1 mapping and extracellular volume fraction (ECV) calculations were performed after PE in 51 patients with persistent dyspnea and in 50 non-dyspneic patients. Patients with known pulmonary disease, heart disease and CTEPH were excluded. Results Native T1 was higher in the interventricular septum in dyspneic patients compared to non-dyspneic patients; difference 13 ms (95% CI: 2–23 ms). ECV was also significantly higher in patients with dyspnea; difference 0.9 percent points (95% CI: 0.04–1.8 pp). There was no difference in native T1 or ECV in the left ventricular lateral wall. Native T1 in the interventricular septum had an adjusted Odds Ratio of 1.18 per 10 ms increase (95% CI: 0.99–1.42) in predicting dyspnea, and an adjusted Odds Ratio of 1.47 per 10 ms increase (95% CI: 1.10–1.96) in predicting Incremental Shuttle Walk Test (ISWT) score < 1020 m. Conclusion Septal native T1 and ECV values were higher in patients with dyspnea after PE compared with those who were fully recovered suggesting a possible pathological role of myocardial fibrosis in the development of dyspnea after PE. Further studies are needed to validate our findings and to explore their pathophysiological role and clinical significance.
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Affiliation(s)
- Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Jervan
- Department of Cardiology, Østfold Hospital, Kalnes, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oliver Geier
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - René Holst
- Department of Research, Østfold Hospital, Kalnes, Norway.,Oslo Centre for Biostatistics and Epidemiology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Waleed Ghanima
- Internal medicine clinic, Østfold Hospital, Kalnes, Norway.,Department of hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
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Geersing GJ, Takada T, Klok FA, Büller HR, Courtney DM, Freund Y, Galipienzo J, Le Gal G, Ghanima W, Kline JA, Huisman MV, Moons KGM, Perrier A, Parpia S, Robert-Ebadi H, Righini M, Roy PM, van Smeden M, Stals MAM, Wells PS, de Wit K, Kraaijpoel N, van Es N. Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis. PLoS Med 2022; 19:e1003905. [PMID: 35077453 PMCID: PMC8824365 DOI: 10.1371/journal.pmed.1003905] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/08/2022] [Accepted: 01/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. METHODS AND FINDINGS We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the "failure rate" of each strategy-i.e., the proportion of missed PE among patients categorized as "PE excluded" and "efficiency"-defined as the proportion of patients categorized as "PE excluded" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. CONCLUSIONS The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.
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Affiliation(s)
- Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- * E-mail:
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Frederikus A. Klok
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Harry R. Büller
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Yonathan Freund
- Sorbonne University, Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Javier Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center Madrid, Madrid, Spain
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust, Norway and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State School of Medicine, Detroit, Michigan, United States of America
| | - Menno V. Huisman
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arnaud Perrier
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Marie Roy
- UNIV Angers, UMR (CNRS 6015—INSERM 1083) and CHU Angers, Department of Emergency Medicine, F-CRIN InnoVTE, Angers, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Milou A. M. Stals
- Department of Medicine, Thrombosis and Haemostasis, Dutch Thrombosis Network, Leiden University Medical Center, Leiden, the Netherlands
| | - Philip S. Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kerstin de Wit
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Emergency Medicine, Queen’s University, Kingston, Canada
| | - Noémie Kraaijpoel
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nick van Es
- Department of Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Delluc A, Ghanima W, Kovacs MJ, Shivakumar S, Kahn SR, Sandset PM, Kearon C, Mallick R, Rodger MA. Statins for venous event reduction in patients with venous thromboembolism: A multicenter randomized controlled pilot trial assessing feasibility. J Thromb Haemost 2022; 20:126-132. [PMID: 34564938 DOI: 10.1111/jth.15537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 06/08/2021] [Revised: 09/07/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Statins may reduce the risk for recurrent venous thromboembolism (VTE); however, no randomized trials have explored this hypothesis. We performed a pilot randomized trial to determine feasibility of recruitment for a larger trial of secondary VTE prevention with rosuvastatin. METHODS Patients with a newly diagnosed symptomatic proximal deep vein thrombosis and/or pulmonary embolism, receiving standard anticoagulation, were randomly allocated to adjuvant rosuvastatin 20 mg once daily for 180 days or no rosuvastatin for 6 months. RESULTS Between November 2016 and December 2019, 3391 patients were assessed for eligibility in six centers. Of these patients, 1347 (39.7%) were eligible and approached for participation in the trial and 312 (23.1%) were randomized. The mean rate of randomization was 8.2 ± 4.3 patients per month. During follow-up, five recurrent VTE events were observed, three (1.9%) in the rosuvastatin group (two pulmonary embolism, one deep vein thrombosis), and two (1.3%) in the control group (two pulmonary embolism; P = 0.68). One major arterial event occurred in the rosuvastatin arm and none in the control arm (0.6% vs. 0%, P = 0.50). CONCLUSION This pilot trial supports the feasibility of a larger scale randomized controlled trial to determine the efficacy of adjuvant rosuvastatin for the secondary prevention of VTE.
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Affiliation(s)
- Aurélien Delluc
- Department of Medicine (Division of Hematology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Waleed Ghanima
- Department of Research, Ostfold Hospital Trust, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sudeep Shivakumar
- Division of Hematology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan R Kahn
- Division of Clinical Epidemiology, Department of Medicine, Lady Davis Institute, McGill University, Montreal, Quebec, Canada
| | - Per Morten Sandset
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Ranjeeta Mallick
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc A Rodger
- Department of Medicine, Faculty of Medicine, McGill University, Montréal, Quebec, Canada
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Viana R, D'Alessio D, Grant L, Cooper N, Arnold D, Morgan M, Provan D, Cuker A, Hill QA, Tomiyama Y, Ghanima W. Psychometric Evaluation of ITP Life Quality Index (ILQI) in a Global Survey of Patients with Immune Thrombocytopenia. Adv Ther 2021; 38:5791-5808. [PMID: 34704193 PMCID: PMC8572218 DOI: 10.1007/s12325-021-01934-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune disorder caused by immunologic destruction of otherwise normal platelets. Patients and physicians differ in their views pertaining to the limitations imposed on patients' daily lives by ITP and its treatment. Poor understanding of ITP symptoms can result in misdiagnosis and complex treatment patterns, and affect patient health-related quality of life (HRQoL). The ITP Life Quality Index (ILQI) is a 10-item patient-reported outcome measure developed for clinical practice to aid discussions between patients and physicians. This research aimed to validate the psychometric properties of the ILQI using data collected in the ITP World Impact Survey (I-WISh). METHODS I-WISh data containing responses to the ILQI from 1507 patients with ITP across 13 countries worldwide was subject to psychometric analysis to evaluate the structure, reliability and validity of the ILQI and assess scoring cut-offs. RESULTS The ILQI has an overarching unidimensional structure, supporting a total score including all 10 items. Reliability was supported (Cronbach's alpha = 0.90). ILQI scores monotonically increased with ITP severity. ILQI scores correlated with measures of fatigue and emotional well-being, supporting construct validity. Differential item functioning (DIF) analyses showed that ILQI item responses were interpreted similarly between the USA and other Western countries. It was suggested that previous clinical cut-off score of 20 for "impaired HRQoL" was reduced to 17 and a cut-off of 23-25 (rather than 30) was suggested to assess "significantly impaired HRQoL". CONCLUSION The validity and reliability of the ILQI to assess HRQoL of patients with ITP is supported. The revised cut-off scores for the ILQI will aid patient-centric decision-making.
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Affiliation(s)
| | | | - Laura Grant
- Adelphi Values Ltd, Adelphi Mill, Grimshaw Lane, Bollington, Cheshire, SK10 5JB, UK.
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, Imperial College London, London, UK
| | - Donald Arnold
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | | | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The School of Medicine and Dentistry, London, UK
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Quentin A Hill
- Leeds Teaching Hospital NHS Trust, St James' University Hospital, Leeds, UK
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
| | - Waleed Ghanima
- Ostfold Hospital Trust, Gralum, Norway
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Michel M, Ghanima W, Mcdonald V, Jain S, Carpenedo M, Oliva E, Hultberg A, Gandini D, Hofman E, Bragt T, Parys W, Hoorick B, Godar M, Miyakawa Y, Broome C. La modélisation pharmacocinétique-pharmacodynamique supporte la sélection de la dose d’efgartigimod à administrer par voie sous-cutanée dans un essai clinique de phase 3 chez des patients atteints de purpura thrombopénique immunologique. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tavoly M, Gleditsch J, Ghanima JP, Bremtun F, Schintzkewitz M, Thrane KJ, Jervan O, Ghanima W. The mean bilateral proximal extension of the clot is associated with pulmonary embolism severity parameters and management-associated outcomes. Acta Radiol 2021; 62:1309-1316. [PMID: 33100028 DOI: 10.1177/0284185120966724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The value of the proximal extension of the clot in risk stratification of pulmonary embolism (PE) has not been established. The mean bilateral proximal extension of the clot (MBPEC) is a computed tomography (CT) radiological score, where initial evaluation showed promising results considering its ability in predicting the severity of PE. PURPOSE To explore the possible associations between MBPEC and PE-severity parameters, short- and long-term outcomes of PE, and inter-observer agreement. MATERIAL AND METHODS Patients diagnosed with PE at Østfold Hospital, Norway during 2003-2011 were identified. MBPEC was calculated by calculating the mean of a score in the range of 1-4 assigned for the most proximal extension of the clot in each lung: sub-segmental; segmental; lobar; and main pulmonary arteries. Medical records were reviewed to capture clinical, biochemical, and management-associated data (thrombolysis, admission to ICU). RESULTS The mean age of 245 included patients was 55 ± 16 years; 42% were women. Patients with higher MBPEC scores had a significantly higher pulse rate and lower oxygen saturation. MBPEC score <4 predicted a negative troponin value with a negative predictive value of 90% (95% confidence interval [CI] 81-95). Patients with MBPEC 4 were 5.3 times more likely to have elevated troponin (odds ratio [OR] 5.3, 95% CI 2.0-14.3). MBPEC score of 4 was independently associated with admission to ICU (OR 3.8, 95% CI 1.8-7.9). The inter-observer agreement was excellent; weighted kappa 0.82. CONCLUSION MBPEC is associated with PE-severity parameters and can predict short-term adverse outcomes.
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Affiliation(s)
- Mazdak Tavoly
- Medical Division, Østfold Hospital, Sarpsborg, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | | | | | | | - Oyvind Jervan
- Medical Division, Østfold Hospital, Sarpsborg, Norway
| | - Waleed Ghanima
- Medical Division, Østfold Hospital, Sarpsborg, Norway
- Department of Haematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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