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Abdel-Qadir H, Austin PC, Pang A, Fang J, Udell JA, Geerts WH, McNaughton CD, Jackevicius CA, Kwong JC, Yeh CH, Cox JL, Lee DS, Ko DT, Atzema CL. The association between anticoagulation and adverse outcomes after a positive SARS-CoV-2 test among older outpatients: A population-based cohort study. Thromb Res 2022; 211:114-122. [PMID: 35149396 PMCID: PMC8667561 DOI: 10.1016/j.thromres.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/24/2021] [Accepted: 12/09/2021] [Indexed: 01/08/2023]
Abstract
Introduction Anticoagulation may improve outcomes in patients with COVID-19 when started early in the course of illness. Materials and methods This was a population-based cohort study using linked administrative datasets of outpatients aged ≥65 years old testing positive for SARS-CoV-2 between January 1 and December 31, 2020 in Ontario, Canada. The key exposure was anticoagulation with warfarin or direct oral anticoagulants before COVID-19 diagnosis. We calculated propensity scores and used matching weights (MWs) to reduce baseline differences between anticoagulated and non-anticoagulated patients. The primary outcome was a composite of death or hospitalization within 60 days of a positive SARS-CoV-2 test. We used the Kaplan-Meier method and cumulative incidence functions to estimate risk of the primary and component outcomes at 60 days. Results We studied 23,159 outpatients (mean age 78.5 years; 13,474 [58.2%] female), among whom 3200 (13.8%) deaths and 3183 (13.7%) hospitalizations occurred within 60 days of the SARS-CoV-2 test. After application of MWs, the 60-day risk of death or hospitalization was 29.2% (95% CI 27.4%–31.2%) for anticoagulated individuals and 32.1% (95% CI 30.7%–33.5%) without anticoagulation (absolute risk difference [ARD], −2.9%; p = 0.005). Anticoagulation was also associated with a lower risk of death: 18.6% (95% CI 17.0%–20.2%) with anticoagulation and 20.9% (95% CI 19.7%–22.2%) in non-anticoagulated patients (ARD -2.3%; p = 0.005). Conclusions Among outpatients aged ≥65 years, oral anticoagulation at the time of a positive SARS-CoV-2 test was associated with a lower risk of a composite of death or hospitalization within 60 days.
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Affiliation(s)
- Husam Abdel-Qadir
- Women's College Hospital, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Peter C Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrea Pang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Jacob A Udell
- Women's College Hospital, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - William H Geerts
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Candace D McNaughton
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- University Health Network, Toronto, ON, Canada; ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Western University of Health Sciences, Pomona, CA, United States of America
| | - Jeffrey C Kwong
- University Health Network, Toronto, ON, Canada; ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Calvin H Yeh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, Division of Emergency Medicine, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Jafna L Cox
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Douglas S Lee
- University Health Network, Toronto, ON, Canada; ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dennis T Ko
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Clare L Atzema
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Geerts JM, Kinnair D, Taheri P, Abraham A, Ahn J, Atun R, Barberia L, Best NJ, Dandona R, Dhahri AA, Emilsson L, Free JR, Gardam M, Geerts WH, Ihekweazu C, Johnson S, Kooijman A, Lafontaine AT, Leshem E, Lidstone-Jones C, Loh E, Lyons O, Neel KAF, Nyasulu PS, Razum O, Sabourin H, Schleifer Taylor J, Sharifi H, Stergiopoulos V, Sutton B, Wu Z, Bilodeau M. Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement. JAMA Netw Open 2021; 4:e2120295. [PMID: 34236416 DOI: 10.1001/jamanetworkopen.2021.20295] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. OBJECTIVE To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. EVIDENCE REVIEW A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. FINDINGS The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. CONCLUSIONS AND RELEVANCE Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.
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Affiliation(s)
- Jaason M Geerts
- Research and Leadership Development, Canadian College of Health Leaders, Ottawa, Ontario, Canada
- Bayes Business School, University of London, London, United Kingdom
| | - Donna Kinnair
- Royal College of Nursing, Marylebone, London, United Kingdom
| | - Paul Taheri
- Yale School of Medicine, New Haven, Connecticut
| | - Ajit Abraham
- Barts Health NHS Trust, Royal Hospital, London, United Kingdom
- Staff College: Leadership in Healthcare, London, United Kingdom
| | - Joonmo Ahn
- Department of Public Administration, Korea University, Seoul, Republic of Korea
| | - Rifat Atun
- Global Health Systems, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Lorena Barberia
- Department of Political Science, University of São Paulo, São Paulo, Brazil
- Solidarity Research Network for Public Policies and Society, Observatorio COVID-19 Brazil
| | - Nigel J Best
- United Nations Mission in South Sudan, UN House, Juba, South Sudan
| | - Rakhi Dandona
- Public Health Foundation of India, Gurugram, India
- Department of Health Metrics Sciences, Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Louise Emilsson
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
- Vårdcentralen Värmlands Nysäter and Centre for Clinical Research, County Council of Värmland, Värmland, Sweden
- Medicine and Health, Örebro University, Örebro, Sweden
| | - Julian R Free
- University of Lincoln, Brayford Pool, Lincoln, United Kingdom
| | - Michael Gardam
- Chief Executive Officer, Health PEI, Charlottetown, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - William H Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Shanthi Johnson
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Allison Kooijman
- World Health Organization Patients for Patient Safety, Geneva, Switzerland
- Patients for Patient Safety Canada, Edmonton, Alberta, Canada
| | - Alika T Lafontaine
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
- Canadian Medical Association, First Nations Health Authority, Indigenous Physicians Association of Canada, West Vancouver, British Columbia, Canada
| | - Eyal Leshem
- Institute for Travel and Tropical Medicine, Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Erwin Loh
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
- St Vincent's Health Australia, East Melbourne, Australia
| | - Oscar Lyons
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, John Radcliffe Hospital, Headington, Oxford, United Kingdom
| | | | - Peter S Nyasulu
- Division of Epidemiology & Biostatistics, Department of Global Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Oliver Razum
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Hélène Sabourin
- Canadian Association of Occupational Therapists, Nepean, Ontario, Canada
- Organizations for Health Action, Ottawa, Ontario, Canada
| | - Jackie Schleifer Taylor
- London Health Sciences Centre, London, Ontario, Canada
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center and WHO Collaborating Center for HIV Surveillance, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brett Sutton
- Department of Health, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| | - Zunyou Wu
- China Center for Disease Control and Prevention, Beijing, China
- Division of HIV Prevention, National Center for AIDS/STD Control and Prevention, Beijing, China
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles
| | - Marc Bilodeau
- Surgeon General, Canadian Armed Forces, Ottawa, Ontario, Canada
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Leclerc JR, Geerts WH, Desjardins L, Jobin F, Laroche F, Delorme F, Haviernick S, Atkinson S, Bourgouine J. Prevention of Deep Vein Thrombosis after Major Knee Surgery - A Randomized, Double-Blind Trial Comparing a Low Molecular Weight Heparin Fragment (Enoxaparin) to Placebo. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648463] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryConsecutive patients undergoing knee arthroplasty or tibial osteotomy at four participating hospitals received either enoxaparin, 30 mg subcutaneously every 12 h (n = 66) or an identicalappearing placebo (n = 65). All study medications started the morning after the operation and were continued up to a maximum of 14 days. Patients underwent surveillance with 125I-fibrinogen leg scanning and impedance plethysmography. Bilateral contrast venography was performed routinely at Day 14 or at time of discharge, if sooner. Deep vein thrombosis was detected by venography in 35 of 54 patients (65%) in the placebo group and in 8 of 41 patients in the enoxaparin group (19%), a risk reduction of 71%, P <0.0001. For the entire study group, deep vein thrombosis was detected by either venography of non-invasive tests in 37 of 64 patients (58%) in the placebo group and in 11 of 65 patients (17%) in the enoxaparin group, a risk reduction of 71%, P <0.0001. Proximal vein thrombosis was found in 19% of the placebo patients and in none of the enoxaparin patients, a risk reduction of 100%, P <0.001. Bleeding complications occurred in 5 of 65 patients (8%) in the placebo group and in 4 of 66 patients (6%) in the enoxaparin group, P = 0.71. There were no differences in the amount of blood loss, minimum hemoglobin levels and number of units of packed red cells given between the two treatment groups. We conclude that a fixed dose regimen of enoxaparin, started post-operatively, is an effective and safe regimen for reducing the frequency of deep vein thrombosis after major knee surgery.
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Affiliation(s)
- Jacques R Leclerc
- The Department of Medicine and Clinical Epidemiology Unit, Montreal General Hospital, McGill University, Montreal, Canada
| | - William H Geerts
- Department of Medicine and Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada
| | - Louis Desjardins
- Division of Hematology, Centre Hospitalier de I’Université Laval, Université Laval, Quebec, Canada
| | - François Jobin
- Division of Hematology, Hopital du St-Sacrement, Université Laval, Quebec, Canada
| | - François Laroche
- Division of Radiology, Hôpital du St-Sacrement, Universite Laval, Quebec, Canada
| | - Fernand Delorme
- Department of Pathology, Universite de Montréal, Montreal, Canada
| | - Sylvie Haviernick
- Division of Clinical Research, Rhône-Poulenc Rorer, Montreal, Canada
| | - Susan Atkinson
- Division of Hematology, Montreal General Hôspital, Me Gill University, Montreal, Canada
| | - Jean Bourgouine
- Division of Pharmacology, Universite de Montreal, Montreal, Canada
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Diamantouros A, Marchesano R, Geerts WH, Pennefather P, Zwarenstein M, Austin Z. Development and evaluation of a continuing pharmacy education (CPE) program in thrombosis management. Curr Pharm Teach Learn 2017; 9:911-917. [PMID: 29233324 DOI: 10.1016/j.cptl.2017.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 01/16/2017] [Accepted: 05/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND PURPOSE A continuing education (CE) course in thrombosis management for pharmacists was developed through the Office of Continuing Professional Development (CPD) at the University of Toronto to address pharmacists' needs for the knowledge and skills to provide care to patients receiving anticoagulants. This article describes the development of the course as well as the evaluation designed to assess its impact on pharmacists' knowledge, attitudes, and changes in practice. EDUCATIONAL ACTIVITY AND SETTING A three-day course was developed. Outcomes were evaluated using a feedback questionnaire, pre- and post-session quizzes and semi-structured interviews conducted six months after course completion. Participant satisfaction, knowledge acquisition and perceived change in knowledge, skills and practice were evaluated. FINDINGS Thirty-seven pharmacists enrolled in the program, 21 of whom participated in a semi-structured interview. More than 90% reported that the program exceeded their expectations. Pharmacists' knowledge in thrombosis care improved significantly after each day of the course. Participants felt the greatest benefits of the program were increases in knowledge and confidence and the opportunity to network. The case-based discussions and practical tips gained from experts and peers were highly ranked. Participants strongly agreed that they were applying what they learned in the course to clinical practice, and they provided numerous examples of how their practice changed because of the program. DISCUSSION AND SUMMARY The development of this CE course demonstrates application of best practices in continuing education. The evaluation of the program suggests that a CE course in thrombosis improves pharmacist knowledge, confidence and ability to incorporate what was learned into practice. This course design and evaluation can serve as a model for other CE courses for pharmacists as this field continues to grow and encourages thoughtful use of theoretical principles and well-designed evaluation for continual improvement of CE.
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Affiliation(s)
- Artemis Diamantouros
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, Canada M5S 3M2.
| | - Romina Marchesano
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5.
| | - William H Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5.
| | - Peter Pennefather
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, Canada M5S 3M2.
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, 2nd Floor, London, ON, Canada, N6A 3K7.
| | - Zubin Austin
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, Canada M5S 3M2.
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Diamantouros A, Kiss A, Papastavros T, U. D, Zwarenstein M, Geerts WH. The TOronto ThromboProphylaxis Patient Safety Initiative (TOPPS): A cluster randomised trial. Res Social Adm Pharm 2017; 13:997-1003. [DOI: 10.1016/j.sapharm.2017.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 11/25/2022]
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Kahn SR, Hirsch AM, Akaberi A, Hernandez P, Anderson DR, Wells PS, Rodger MA, Solymoss S, Kovacs MJ, Rudski L, Shimony A, Dennie C, Rush C, Geerts WH, Aaron SD, Granton JT. Functional and Exercise Limitations After a First Episode of Pulmonary Embolism. Chest 2017; 151:1058-1068. [DOI: 10.1016/j.chest.2016.11.030] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/18/2016] [Accepted: 11/18/2016] [Indexed: 11/24/2022] Open
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Aloia TA, Geerts WH, Clary BM, Day RW, Hemming AW, D'Albuquerque LC, Vollmer CM, Vauthey JN, Toogood GJ. Venous Thromboembolism Prophylaxis in Liver Surgery. J Gastrointest Surg 2016; 20:221-9. [PMID: 26489742 DOI: 10.1007/s11605-015-2902-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND At a recently concluded Americas Hepato-Pancreato-Biliary Association Annual Meeting, a Clinical Practice Guidelines Conference Series was convened with the topic focusing on Venous Thromboembolism (VTE) Prophylaxis in Liver Surgery. The symposium brought together hepatobiliary surgeons from three continents as well as medical experts in hematology and coagulation. METHODS The content of the discussion included literature reviews, evaluation of multi-institutional VTE outcome data, and examination of practice patterns at multiple high-volume centers. RESULTS Literature review demonstrated that, within gastrointestinal surgery, liver resection patients are at particularly high-risk for VTE. Recent evidence clearly indicates a direct relationship between the magnitude of hepatectomy and postoperative VTE rates, however, the PT/INR does not accurately reflect the coagulation status of the post-hepatectomy patient. Evaluation of available data and practice patterns regarding the utilization and timing of anticoagulant VTE prophylaxis led to recommendations regarding preoperative and postoperative thromboprophylaxis for liver surgery patients. CONCLUSIONS This conference was effective in consolidating our knowledge of coagulation abnormalities after liver resection. Based on the expert review of the available data and practice patterns, a number of recommendations were developed.
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Gladstone DJ, Geerts WH, Douketis J, Ivers N, Healey JS, Leblanc K. How to Monitor Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Practice Tool Endorsed by Thrombosis Canada, the Canadian Stroke Consortium, the Canadian Cardiovascular Pharmacists Network, and the Canadian Cardiovascular Society. Ann Intern Med 2015; 163:382-5. [PMID: 26121536 DOI: 10.7326/m15-0143] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David J. Gladstone
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
| | - William H. Geerts
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
| | - James Douketis
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
| | - Noah Ivers
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
| | - Jeff S. Healey
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
| | - Kori Leblanc
- From the University of Toronto Department of Medicine; Sunnybrook Regional Stroke Prevention Clinic, Hurvitz Brain Sciences Program, Dr. Thomas and Harriet Black Rapid TIA Clinic, and Anticoagulant Management Clinic and Thromboembolism Service, Sunnybrook Health Sciences Centre; University of Toronto Stroke Program; Family Practice Health Centre, Women's College Research Institute, and Institute for Health Systems Solutions and Virtual Care, Women's College Hospital
- and University Health Network and OpenLab, University Health Network, Toronto, Ontario, Canada, and McMaster University, Population Health Research Institute, and Canadian Stroke Prevention Intervention Network, Hamilton, Ontario, Canada
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Fowler RA, Mittmann N, Geerts WH, Heels-Ansdell D, Gould MK, Guyatt G, Krahn M, Finfer S, Pinto R, Chan B, Ormanidhi O, Arabi Y, Qushmaq I, Rocha MG, Dodek P, McIntyre L, Hall R, Ferguson ND, Mehta S, Marshall JC, Doig CJ, Muscedere J, Jacka MJ, Klinger JR, Vlahakis N, Orford N, Seppelt I, Skrobik YK, Sud S, Cade JF, Cooper J, Cook D. Economic evaluation of the prophylaxis for thromboembolism in critical care trial (E-PROTECT): study protocol for a randomized controlled trial. Trials 2014; 15:502. [PMID: 25528663 PMCID: PMC4413997 DOI: 10.1186/1745-6215-15-502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 01/14/2014] [Accepted: 11/25/2014] [Indexed: 11/22/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a common complication of critical illness with important clinical consequences. The Prophylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) is a multicenter, blinded, randomized controlled trial comparing the effectiveness of the two most common pharmocoprevention strategies, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) dalteparin, in medical-surgical patients in the intensive care unit (ICU). E-PROTECT is a prospective and concurrent economic evaluation of the PROTECT trial. Methods/Design The primary objective of E-PROTECT is to identify and quantify the total (direct and indirect, variable and fixed) costs associated with the management of critically ill patients participating in the PROTECT trial, and, to combine costs and outcome results to determine the incremental cost-effectiveness of LMWH versus UFH, from the acute healthcare system perspective, over a data-rich time horizon of ICU admission and hospital admission. We derive baseline characteristics and probabilities of in-ICU and in-hospital events from all enrolled patients. Total costs are derived from centers, proportional to the numbers of patients enrolled in each country. Direct costs include medication, physician and other personnel costs, diagnostic radiology and laboratory testing, operative and non-operative procedures, costs associated with bleeding, transfusions and treatment-related complications. Indirect costs include ICU and hospital ward overhead costs. Outcomes are the ratio of incremental costs per incremental effects of LMWH versus UFH during hospitalization; incremental cost to prevent a thrombosis at any site (primary outcome); incremental cost to prevent a pulmonary embolism, deep vein thrombosis, major bleeding event or episode of heparin-induced thrombocytopenia (secondary outcomes) and incremental cost per life-year gained (tertiary outcome). Pre-specified subgroups and sensitivity analyses will be performed and confidence intervals for the estimates of incremental cost-effectiveness will be obtained using bootstrapping. Discussion This economic evaluation employs a prospective costing methodology concurrent with a randomized controlled blinded clinical trial, with a pre-specified analytic plan, outcome measures, subgroup and sensitivity analyses. This economic evaluation has received only peer-reviewed funding and funders will not play a role in the generation, analysis or decision to submit the manuscripts for publication. Trial registration Clinicaltrials.gov Identifier: NCT00182143. Date of registration: 10 September 2005. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-502) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert A Fowler
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Department of Pharmacology, University of Toronto, 2075 Bayview Avenue, E240, Toronto, ON, M4N 3M5, Canada.
| | - William H Geerts
- Department of Medicine, Room D674, Sunnybrook Health Sciences Centre, Room D674, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSC-2C12, Hamilton, ON, L8S 4K1, Canada.
| | - Michael K Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, Pasadena, CA, 91101, USA.
| | - Gordon Guyatt
- Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, HSC-2C12, Hamilton, ON, L8S 4K1, Canada.
| | - Murray Krahn
- Department of Medicine, 144 College Street, Room 600, Toronto, ON, M5S 3M2, Canada.
| | - Simon Finfer
- The George Institute for Global Health, Royal North Shore Hospital, University of Sydney, Pacific Highway, St Leonards, NSW, 2065, Australia.
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | - Brian Chan
- Institute of Health Policy, Management and Evaluation University of Toronto Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Orges Ormanidhi
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 144 College Street, 6th Floor, Toronto, ON, M5S 3M2, Canada.
| | - Yaseen Arabi
- Intensive Care Department, Medical Director, Respiratory Services, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, ICU 1425, PO Box 22490, Riyadh, 11426, Kingdom of Saudi Arabia.
| | - Ismael Qushmaq
- Department of Medicine, King Faisal Specialist Hospital & Research Centre-Gen. Org, PO Box 40047, Jeddah, 21499 MBC# J-46, Saudi Arabia.
| | - Marcelo G Rocha
- Department of Intensive Care, Hospitalar Santa Casa, Rua Professor Annes Dias, 295 - Centro Histórico, Porto Alegre, RS, 90020-200, Brazil.
| | - Peter Dodek
- Division of Critical Care Medicine, Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of British Columbia, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Center for Health Evaluation and Outcome Sciences, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), Ottawa Hospital, Ottawa Hospital Research Institute, Centre for Transfusion and Critical Care Research, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Richard Hall
- Departments of Anesthesiology, Medicine, Pharmacology and Surgery, Dalhousie University and the Capital District Health Authority, Halifax NS, Room 5452-Halifax Infirmary, 1796 Summer St, Halifax, NS, B3H 3A7, Canada.
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine and Departments of Medicine & Physiology, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada. .,Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - John C Marshall
- Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, 4-007 Bond Wing, St Michael's Hospital, 30 Bond Street, Toronto, M5B 1W8, Canada.
| | - Christopher James Doig
- Department of Community Health Sciences, Departments of Critical Care Medicine, Attending Physician, Foothills Medical Centre Multisystem Intensive Care Unit, Alberta Health Services, University of Calgary, Room 3D39, Teaching Research and Wellness Building, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
| | - John Muscedere
- Department of Medicine, Angada 4 Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Michael J Jacka
- Department of Anesthesiology and Critical Care, University of Alberta Hospital, 8440-112 St, Edmonton, AB, T6G 2B7, Canada.
| | - James R Klinger
- Division of Pulmonary, Sleep and Critical Care Medicine, Rhode Island Hospital, Professor of Medicine, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02903, USA.
| | - Nicholas Vlahakis
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
| | - Neil Orford
- Intensive Care Barwon Health, Australian and New Zealand Intensive Care Research Centre, Monash University School of Medicine, 99 Commercial Road, Geelong, VIC, 3004, Australia. .,Intensive Care Barwon Health, Australian and New Zealand Intensive Care Research Centre, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia.
| | - Ian Seppelt
- Critical Care Medicine, Nepean Hospital, Derby Street, Penrith, NSW, 2747, Australia.
| | - Yoanna K Skrobik
- Critical Care Medicine, Hôpital Maisonneuve-Rosemont, 5415 Blvd. De l'Assomption, Montreal, QC, H1T 2M4, Canada.
| | - Sachin Sud
- Department of Medicine, University Trillium Hospital, 100 Queensway West, Toronto, ON, L5B 1B8, Canada.
| | - John F Cade
- Intensive Care Unit, Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3050, Australia.
| | - Jamie Cooper
- ANZIC-RC Department of Epidemiology and Preventive Medicine Monash University, The Alfred Centre Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
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10
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Selby R, Geerts WH, Kreder HJ, Crowther MA, Kaus L, Sealey F. Symptomatic venous thromboembolism uncommon without thromboprophylaxis after isolated lower-limb fracture: the knee-to-ankle fracture (KAF) cohort study. J Bone Joint Surg Am 2014; 96:e83. [PMID: 24875035 DOI: 10.2106/jbjs.m.00236] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 02/01/2023]
Abstract
BACKGROUND The prevalence of deep vein thrombosis as demonstrated by routine venography in patients with distal lower-extremity injury requiring cast immobilization or surgery is 10% to 40%. These deep vein thromboses are usually asymptomatic and distal, and the need for thromboprophylaxis in these patients is not known. METHODS We conducted a multicenter prospective cohort study to define the prevalence of symptomatic venous thromboembolism in patients with a tibial, fibular, or ankle fracture (treated nonoperatively) or a patellar or foot fracture (treated operatively or conservatively). Consecutive patients were enrolled at five Ontario, Canada, hospitals within ninety-six hours after injury, and they were followed with a telephone interview at two, six, and twelve weeks. Thromboprophylaxis was not allowed. Suspected venous thromboembolism was investigated in a standardized manner. RESULTS From August 2002 to June 2005, 1200 patients were enrolled, and a three-month follow-up was completed for 98% of them. Eighty-two percent of the patients were treated with cast or splint immobilization for an average (and standard deviation) of 42 ± 32 days. Overall, seven patients (0.6%; 95% confidence interval [CI] = 0.2% to 1.2%) had symptomatic, objectively confirmed venous thromboembolism. Two of them had proximal deep vein thrombosis; three, calf deep vein thrombosis; and two, pulmonary embolism. There were no fatal pulmonary emboli. CONCLUSIONS Symptomatic venous thromboembolism is an infrequent complication after fractures of the distal part of the lower limb requiring cast immobilization and managed without thromboprophylaxis. Given these estimates of symptomatic venous thromboembolism, the risk-benefit ratio and cost-effectiveness of routine anticoagulant prophylaxis are unlikely to be favorable for these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Rita Selby
- Departments of Medicine (R.S., W.H.G., L.K., and F.S.), Clinical Pathology (R.S.), and Surgery (H.J.K.), Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for R. Selby: rita.selby@su
| | - William H Geerts
- Departments of Medicine (R.S., W.H.G., L.K., and F.S.), Clinical Pathology (R.S.), and Surgery (H.J.K.), Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for R. Selby: rita.selby@su
| | - Hans J Kreder
- Departments of Medicine (R.S., W.H.G., L.K., and F.S.), Clinical Pathology (R.S.), and Surgery (H.J.K.), Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for R. Selby: rita.selby@su
| | - Mark A Crowther
- Department of Medicine, St. Joseph's Healthcare, 50 Charlton Avenue East, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Lisa Kaus
- Departments of Medicine (R.S., W.H.G., L.K., and F.S.), Clinical Pathology (R.S.), and Surgery (H.J.K.), Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for R. Selby: rita.selby@su
| | - Faith Sealey
- Departments of Medicine (R.S., W.H.G., L.K., and F.S.), Clinical Pathology (R.S.), and Surgery (H.J.K.), Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail address for R. Selby: rita.selby@su
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11
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Gandhi R, Salonen D, Geerts WH, Khanna M, McSweeney S, Mahomed NN. A pilot study of computed tomography-detected asymptomatic pulmonary filling defects after hip and knee arthroplasties. J Arthroplasty 2012; 27:730-5. [PMID: 22177790 DOI: 10.1016/j.arth.2011.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [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] [Received: 07/11/2011] [Accepted: 10/17/2011] [Indexed: 02/01/2023] Open
Abstract
We asked what the incidence of asymptomatic filling defects is on routine multidetector computed tomography (MDCT) in primary hip (total hip arthroplasty [THA]) and knee arthroplasties (TKA) patients. We prospectively performed MDCT scans on the first postoperative day for THA (n = 21)/TKA (n = 27). Patients underwent routine postoperative care, and data were collected for symptoms such as tachycardia or shortness of breath. More patients undergoing TKA had positive computed tomography scans than those undergoing THA: 11 (41%) vs 1 (5%), respectively. All patients diagnosed with a filling defect were discharged from the hospital without treatment of symptomatic pulmonary embolism. Our study demonstrates a high rate of abnormal MDCT early after lower extremity arthroplasty, the clinical importance of which may be benign.
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Affiliation(s)
- Rajiv Gandhi
- Toronto Western Hospital, Toronto, Ontario, Canada
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12
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Thirugnanam S, Pinto R, Cook DJ, Geerts WH, Fowler RA. Economic analyses of venous thromboembolism prevention strategies in hospitalized patients: a systematic review. Crit Care 2012; 16:R43. [PMID: 25927574 PMCID: PMC3964799 DOI: 10.1186/cc11241] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 10/11/2011] [Accepted: 03/09/2012] [Indexed: 11/14/2022]
Abstract
Introduction Despite evidence-based guidelines for venous thromboembolism prevention, substantial variability is found in practice. Many economic evaluations of new drugs for thromboembolism prevention do not occur prospectively with efficacy studies and are sponsored by the manufacturers, raising the possibility of bias. We performed a systematic review of economic analyses of venous thromboembolism prevention in hospitalized patients to inform clinicians and policy makers about cost-effectiveness and the potential influence of sponsorship. Methods We searched MEDLINE, EMBASE, Cochrane Databases, ACP Journal Club, and Database of Abstracts of Reviews of Effects, from 1946 to September 2011. We extracted data on study characteristics, quality, costs, and efficacy. Results From 5,180 identified studies, 39 met eligibility and quality criteria. Each addressed pharmacologic prevention: low-molecular-weight heparins versus placebo (five), unfractionated heparin (12), warfarin (eight), one or another agents (five); fondaparinux versus enoxaparin (11); and rivaroxaban and dabigatran versus enoxaparin (two). Low-molecular-weight heparins were most economically attractive among most medical and surgical patients, whereas fondaparinux was favored for orthopedic patients. Fondaparinux was associated with increased bleeding events. Newer agents rivaroxaban and dabigatran may offer additional value. Of all economic evaluations, 64% were supported by manufacturers of a "new" agent. The new agent had a favorable outcome in 38 (97.4%) of 39 evaluations [95% confidence interval [CI] (86.5 to 99.9)]. Among studies supported by a pharmaceutical company, the sponsored medication was economically attractive in 24 (96.0%) of 25 [95% CI, 80.0 to 99.9)]. We could not detect a consistent bias in outcome based on sponsorship; however, only a minority of studies were unsponsored. Conclusion Low-molecular-weight heparins and fondaparinux are the most economically attractive drugs for venous thromboembolism prevention in hospitalized patients. Approximately two thirds of evaluations were supported by the manufacturer of the new agent; such drugs were likely to be reported as economically favorable.
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Affiliation(s)
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Deborah J Cook
- Department of Medicine, St. Joseph's Hospital and McMaster University, Hamilton, Ontario, Canada.
| | - William H Geerts
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Robert A Fowler
- Department of Medicine, St. Joseph's Hospital and McMaster University, Hamilton, Ontario, Canada. .,Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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13
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Bucci C, Geerts WH, Sinclair A, Fremes SE. Comparison of the effectiveness and safety of low-molecular weight heparin versus unfractionated heparin anticoagulation after heart valve surgery. Am J Cardiol 2011; 107:591-4. [PMID: 21184996 DOI: 10.1016/j.amjcard.2010.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 10/11/2010] [Accepted: 10/11/2010] [Indexed: 11/26/2022]
Abstract
Although unfractionated heparin (UFH) is used routinely after heart valve surgery at many institutions, cardiovascular surgery patients have a particularly high risk for developing heparin-induced thrombocytopenia (HIT). The aim of this study was to compare the efficacy and safety of low-molecular-weight heparin (LMWH) or UFH after heart valve surgery by conducting a retrospective evaluation of consecutive cardiovascular surgery patients in whom the LMWH dalteparin (n = 100) was used as the postoperative anticoagulant. This group was compared to an earlier group of patients who received UFH (n = 103). The main outcomes included the efficacy of the anticoagulant regimens (determined by the incidence of valve thrombosis, arterial thromboembolic events, and venous thromboembolic events) and the safety (determined by major bleeding, HIT, thrombotic events in HIT-positive cases, and death). Overall, there were for fewer thrombotic events in the LMWH-treated group (4% vs 11%, p = 0.11). There was a higher rate of bleeding events in the UFH-treated group (10% vs 3%, p = 0.08). Six patients in the UFH-treated group developed HIT, 4 of whom had thrombotic events (HIT with thrombosis). In the LMWH-treated group, 3 patients developed HIT, 1 of whom had HIT with thrombosis. In conclusion, in this study, an LMWH regimen after heart valve surgery was effective and safe, with fewer thrombotic, bleeding, HIT, and HIT with thrombosis events.
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14
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Affiliation(s)
- William H Geerts
- From Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Graham F Pineo
- Foothills Hospital, University of Calgary, Calgary, AB, Canada
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15
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Crowther MA, Cook DJ, Meade MO, Griffith LE, Guyatt GH, Arnold DM, Rabbat CG, Geerts WH, Warkentin TE. Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors. J Crit Care 2006; 20:348-53. [PMID: 16310606 DOI: 10.1016/j.jcrc.2005.09.008] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 09/02/2005] [Accepted: 09/08/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study is to describe the prevalence, to analyze the incidence and independent risk factors for thrombocytopenia, and to examine the impact of thrombocytopenia developing in the intensive care unit (ICU) on patient outcome in a well-defined cohort of critically ill patients in a medical-surgical ICU. MATERIALS AND METHODS As part of a prospective cohort study examining the frequency and clinical importance of venous thromboembolism in the ICU, we enrolled consecutive patients older than 18 years expected to be in the ICU for more than 72 hours. Exclusion criteria were an admitting diagnosis of trauma, orthopedic surgery or cardiac surgery, pregnancy, and life support withdrawal. Patients had platelet counts performed as directed by clinical need. We defined thrombocytopenia as a platelet count of less than 150 x 10(9)/L and severe thrombocytopenia as a platelet count of less than 50 x 10(9)/L. Protocol-directed care included routine thromboprophylaxis and twice weekly screening ultrasonography of the legs. Patients were followed to hospital discharge. RESULTS Of the 261 enrolled patients, 121 (46%, 95% confidence interval [CI], 40%-53%) had thrombocytopenia (62 on ICU admission and 59 acquired during their ICU stay). Patients who developed a platelet count less than 150 x 10(9)/L during their ICU stay had higher ICU and hospital mortality (P = .03 and .005, respectively), required longer mechanical ventilation (P = .05), and were more likely to receive platelets (P < .001), fresh frozen plasma (P = .005), and red blood cell transfusions (P = .004) than patients who did not develop thrombocytopenia. The only independent risk factors for thrombocytopenia developing during the ICU stay were administration of nonsteroidal anti-inflammatory drugs before ICU admission (hazard ratio, 2.8; 95% CI, 1.3-6.0) and dialysis during the ICU stay (hazard ratio, 3.1; 95% CI, 1.2-7.8). Of the 33 patients who underwent 36 tests for heparin-induced thrombocytopenia, none tested positive. CONCLUSIONS We found that about 50% of the patients admitted to the ICU had at least one platelet count of less than 150 x 10(9)/L during their ICU stay. Patients who developed thrombocytopenia were more likely to die, required longer duration of mechanical ventilation, and were more likely to require blood product transfusion. Heparin-induced thrombocytopenia was frequently suspected but did not develop in these critically ill patients.
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Affiliation(s)
- Mark A Crowther
- Department of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8N 3Z5
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16
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Colwell CW, Lassen MR, Bergqvist D, Geerts WH, Pineo GF, Heit JA, Ray JG. Prophylaxis for the thromboembolic disease--recommendations from the American College of Chest Physicians--are they appropriate for orthopaedic surgery? J Arthroplasty 2006; 21:148-9; author reply 149. [PMID: 16446202 DOI: 10.1016/j.arth.2005.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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17
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Abstract
Abstract
The prevention of venous thromboembolism (VTE) in patients recovering from major trauma, spinal cord injury (SCI), or other critical illness is often challenging. These patient groups share a high risk for VTE, they often have at least a temporary high bleeding risk, and there are relatively few thromboprophylaxis trials specific to these populations. A systematic literature review has been conducted to summarize the risks and prevention of VTE in these three groups. It is concluded that routine thromboprophylaxis should be provided to major trauma, SCI and critical care patients based on an individual assessment of their thrombosis and bleeding risks. For patients at high risk for VTE, including those recovering from major trauma and SCI, prophylaxis with a low molecular weight heparin (LMWH) should commence as soon as hemostasis has been demonstrated. For critical care patients at lower thrombosis risk, either LMWH or low-dose heparin is recommended. For those with a very high risk of bleeding, mechanical prophylaxis should be instituted as early as possible and continued until pharmacologic prophylaxis can be initiated. The use of prophylactic inferior vena caval filters is strongly discouraged because their potential benefit has not been shown to outweigh the risks or substantial costs. Implementation of thromboprophylaxis in these patients requires a local commitment to this important patient safety priority as well as a highly functional delivery system, based on the use of pre-printed orders, computer prompts, regular audit and feedback, and ongoing quality improvement efforts.
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Affiliation(s)
- William H Geerts
- Thromboembolism Program, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, ON, Canada.
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18
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Cook DJ, Crowther MA, Geerts WH. On the need for a workshop on venous thromboembolism in critical care. J Crit Care 2005; 20:306-8. [PMID: 16310599 DOI: 10.1016/j.jcrc.2005.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Revised: 08/29/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
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Cook DJ, Crowther MA, Douketis J, Meade MO, Rocker GM, Martin CM, Geerts WH. Research agenda: venous thromboembolism in medical-surgical critically ill patients. J Crit Care 2005; 20:330-3. [PMID: 16404823 DOI: 10.1016/j.jcrc.2005.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Deborah J Cook
- Deparment of Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5.
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20
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Crowther MA, Cook DJ, Griffith LE, Devereaux PJ, Rabbat CC, Clarke FJ, Hoad N, McDonald E, Meade MO, Guyatt GH, Geerts WH, Wells PS. Deep venous thrombosis: clinically silent in the intensive care unit. J Crit Care 2005; 20:334-40. [PMID: 16310604 DOI: 10.1016/j.jcrc.2005.09.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 09/02/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE The reliability of clinical signs and the physical examination in the evaluation of deep venous thrombosis (DVT) in the critically ill is unknown. The purpose of this study was to determine the diagnostic properties of clinical examination for signs of DVT in a cohort of medical-surgical intensive care unit (ICU) patients using screening compression ultrasonography as a reference standard. MATERIALS AND METHODS We prospectively included patients older than 18 years with an expected length of ICU stay of more than 72 hours. Patients underwent bilateral lower limb screening compression ultrasound twice weekly and structured physical examination twice weekly by 2 independent trained research coordinators blinded to the ultrasonography results. We classified patients according to 2 methods: method 1, a DVT Risk Stratification System of 3 categories and method 2, a DVT Risk Score, both of which use the history and physical examination to stratify patients for their risk of DVT. RESULTS We included 239 patients in our study, 32 of whom had DVT based on the results of their compression ultrasound. We excluded 7 patients with DVT on ICU admission and 2 who did not undergo any structured examinations. We matched controls with cases (9:1) based on duration of ICU stay. Cases and controls were then allocated to low, moderate, and high risk strata for DVT. Using method 1, the area under the receiver operating characteristic curve (AUC) was 0.57 (95% CI, 0.33-0.78, P = .01). Using method 2, the AUC was 0.59 (95% CI, 0.42-0.75, P = .02). An AUC of 1.0 indicates an ideal test, and AUC of 0.50 indicates a test with no diagnostic utility. CONCLUSIONS The history and physical examination for DVT are not useful in detecting lower limb DVT in the ICU.
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Affiliation(s)
- Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5
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21
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Abstract
OBJECTIVE To explore the association between giant cell arteritis (GCA) and subsequent cardiovascular disease in older adults. DESIGN Population based retrospective cohort study. SETTING The entire province of Ontario, Canada. PARTICIPANTS Patients aged 66 years and older with newly diagnosed GCA (n = 1141), osteoarthritis (n = 172,953), or neither (n = 200,000). Patients with neither were randomly selected from the general population and formed the control group. MAIN OUTCOME MEASURES The primary composite outcome was based on a subsequent diagnosis or surgical treatment for coronary artery disease, stroke, peripheral arterial disease, or aneurysm or dissection of the aorta. RESULTS The composite end point was more common in seniors with GCA (12.1/1000 person-years) than in patients with osteoarthritis (7.3/1000 person-years) or neither condition (5.3/1000 person-years). The adjusted hazard ratio for cardiovascular disease was 1.6 (95% confidence interval (CI) 1.1 to 2.2) in patients with GCA versus patients with osteoarthritis, and 2.1 (95% CI 1.5 to 3.0) in patients with GCA versus unaffected controls. CONCLUSIONS Older adults with GCA appear to be at increased risk for developing cardiovascular disease. Whether an aggressive approach to cardiovascular risk factor modification is particularly beneficial in these patients remains to be determined.
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Affiliation(s)
- J G Ray
- Department of Medicine, Inner City Health, St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8.
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22
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Abstract
Patients with renal failure have an increased risk of both thrombotic and bleeding complications. A number of antithrombotic drugs undergo renal clearance. Therefore, estimation of renal function is necessary when prescribing these drugs to patients with renal dysfunction. Pharmacokinetic and clinical data in patients with chronic renal impairment are limited for several anticoagulants, and adequate administration information is often absent. Dose adjustment of anticoagulants may be indicated when the creatinine clearance falls below 30 mL/min. Unfractionated heparin, argatroban, and vitamin K antagonists generally do not require dose adjustment with renal dysfunction. However, smaller doses of warfarin may be required to achieve a particular target international normalized ratio. Close monitoring of anticoagulation is recommended when argatroban or high doses of unfractionated heparin are administered in patients with severe chronic renal impairment. Low-molecular weight heparins, danaparoid sodium, hirudins, and bivalirudin all undergo renal clearance. Lower doses and closer anticoagulation monitoring may be advisable when these agents are used in patients with chronic renal failure. We recommend that fondaparinux sodium and ximelagatran (not yet licensed) be avoided in the presence of severe renal impairment and be used with caution in patients with moderate renal dysfunction. While acknowledging the lack of pharmacokinetic data, this review provides specific recommendations for the use of anticoagulants in patients with chronic renal impairment.
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Affiliation(s)
- Anne Grand'Maison
- The Department of Medicine, Hematology and Thrombosis Program, University Health Network, Toronto General Site, University of Toronto, Toronto, Ontario, Canada.
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Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:338S-400S. [PMID: 15383478 DOI: 10.1378/chest.126.3_suppl.338s] [Citation(s) in RCA: 1923] [Impact Index Per Article: 96.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).
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Affiliation(s)
- William H Geerts
- Thromboembolism Program, Sunnybrook & Women's College Health Sciences Centre, Room D674, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5
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Moltyaner Y, Geerts WH, Chamberlain DW, Heyworth PG, Noack D, Rae J, Doyle JJ, Downey GP. Underlying chronic granulomatous disease in a patient with bronchocentric granulomatosis. Thorax 2004; 58:1096-8. [PMID: 14645984 PMCID: PMC1746555 DOI: 10.1136/thorax.58.12.1096] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We present a case of bronchocentric granulomatosis in a woman with no history of asthma who was colonised with Aspergillusfumigatus. A family history of chronic granulomatous disease prompted further testing that demonstrated severely depressed neutrophil oxidant production and gp91(phox) deficiency compatible with the X linked carrier state of chronic granulomatous disease. Only one report of the association of these two rare diseases has previously appeared in the literature. We postulate that an ineffective immune response led to the prolonged colonisation of Afumigatus resulting in a hypersensitivity reaction that was manifest clinically as bronchocentric granulomatosis.
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Affiliation(s)
- Y Moltyaner
- Division of Respirology, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND Our objective was to systematically review the incidence of deep vein thrombosis (DVT) and the efficacy of thromboprophylaxis in critically ill adults, including patients admitted to intensive care units and following trauma, neurosurgery, or spinal cord injury. METHODS Two authors independently searched MEDLINE, EMBASE, abstract databases, and the Cochrane database. Data were extracted independently in triplicate. RESULTS Ten percent to 30% of medical and surgical intensive care unit patients develop DVT within the first week of intensive care unit admission. The use of subcutaneous low-dose heparin reduced the rate by 50% compared with no prophylaxis. Approximately 60% of trauma patients developed DVT within the first 2 weeks of admission. Use of unfractionated heparin appears to decrease the incidence of DVT by only 20%, whereas low-molecular-weight heparin decreases the incidence by a further 30%. The estimated prevalence of DVT in neurosurgical patients not given prophylaxis is 22% to 35%. Mechanical prophylaxis is efficacious, with a pooled odds ratio in 5 randomized trials of 0.28. Use of low-molecular-weight heparin has been investigated as an adjunct to mechanical prophylaxis with a pooled odds ratio of 0.59 compared with graduated compression stockings alone. The incidence of DVT without prophylaxis in acute spinal cord injury patients is likely in excess of 50% to 80%. Studies of prophylaxis in these patients are too sparse to come to any definitive conclusion. CONCLUSIONS Critically ill patients commonly develop DVT, with rates that vary from 22% to almost 80%, depending on patient characteristics. Methods of prophylaxis proven in one group do not necessarily generalize to other critically ill patient groups. More potent prophylactic regimens other than unfractionated or low-molecular-weight heparins alone may be needed with higher-risk groups.
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Affiliation(s)
- J Attia
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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McLeod RS, Geerts WH, Sniderman KW, Greenwood C, Gregoire RC, Taylor BM, Silverman RE, Atkinson KG, Burnstein M, Marshall JC, Burul CJ, Anderson DR, Ross T, Wilson SR, Barton P. Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial. Ann Surg 2001; 233:438-44. [PMID: 11224634 PMCID: PMC1421263 DOI: 10.1097/00000658-200103000-00020] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery. METHODS In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected. RESULTS Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different. CONCLUSIONS Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.
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Affiliation(s)
- R S McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Affiliation(s)
- W H Geerts
- Thromboembolism Program, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON, Canada
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Abstract
BACKGROUND Venous thromboembolism (VTE) frequently complicates the course of patients with cancer, and there is evidence to suggest that patients with brain tumors are at particularly high risk. The objective of this methodology-based literature review was to quantify the rate of incidence of VTE in patients with malignant glioma and to determine the factors that predict an increased risk of this complication. METHODS Studies meeting predefined inclusion criteria were evaluated independently on an eight-item methodology index by three raters. Authors were contacted to resolve ambiguities. The results of the studies were summarized and the incidence rate of VTE within the early postoperative phase and during extended follow-up were reported separately. RESULTS Within 6 weeks after surgery the incidence rate of deep venous thrombosis (DVT) ranged from 3% to 60%, varying with the prophylaxis regimen used, the method of diagnosis, and the study design. Beyond 6 weeks postoperatively, the rates of DVT ranged from 0.013 to 0.023 per patient-month of follow-up. The single study with no significant methodologic deficiencies found a 24% rate of incidence of symptomatic DVT over the 17 months of follow-up beyond the first 6 postoperative weeks. In 6 studies the presence of leg paresis, histologic diagnosis of glioblastoma multiform, age >/= 60 years, large tumor size, use of chemotherapy, and length of surgery > 4 hours were identified as possible risk factors. CONCLUSIONS The incidence of VTE is high throughout the course of malignant glioma. A randomized, controlled trial is needed to clarify whether the benefits of long term anticoagulant prophylaxis outweigh the risks and costs of such therapy.
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Affiliation(s)
- L C Marras
- Department of Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Chang H, Hall GA, Geerts WH, Greenwood C, McLeod RS, Sher GD. Allogeneic red blood cell transfusion is an independent risk factor for the development of postoperative bacterial infection. Vox Sang 2000; 78:13-8. [PMID: 10729806 DOI: 10.1159/000031143] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Allogeneic red blood cell transfusions may exert immunomodulatory effects in recipients including an increased rate of postoperative bacterial infection. It is controversial whether allogeneic transfusion is an independent predictor for the development of postoperative bacterial infection. METHODS We analysed a prospectively collected database of 1,349 patients undergoing colorectal surgery in 11 centres across Canada. The primary outcome was the development of either a postoperative wound infection or intra-abdominal sepsis in transfused and nontransfused patients. The effect of allogeneic transfusion on postoperative infection was evaluated with adjustment for all the confounding factors in a multiple regression analysis. RESULTS The 282 patients who received a total of 832 allogeneic units had a significantly higher frequency of wound infections and intra-abdominal sepsis than the patients who were not transfused (25. 9 vs. 14.2%, p = 0.001). A significant dose-response relationship between transfusion and infection rate was demonstrated. Multiple regression analysis identified allogeneic transfusion as a statistically significant independent predictor for postoperative bacterial infection (OR 1.18, 95% CI 1.05-1.33, p = 0.007). Other independent predictors were anastomotic leak, repeat operation, patient age and preoperative haemoglobin level. The mortality rate was also significantly higher in the transfused group. CONCLUSION These data support the hypothesis that allogeneic red cell transfusion is an independent risk factor for the development of postoperative bacterial infection in patients undergoing colorectal surgery. This association provides further reason to minimise exposure to allogeneic transfusions in the perioperative setting.
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Affiliation(s)
- H Chang
- Department of Medicine and Surgery, The Toronto Hospital, Mt. Sinai Hospital and The University of Toronto, Ontario, Canada
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Abstract
This study assessed family physicians' and pulmonary specialists' approaches to the treatment of adult outpatient asthma using a self-administered questionnaire consisting of six asthma scenarios of varying severity levels. One hundred sixty-three randomly selected family physicians and pulmonary specialists completed the questionnaire (response rate of 80%). We observed that, regardless of asthma severity, more than 75% of physicians (regardless of specialty) would not include oral theophylline or nonsteroidal anti-inflammatory preparations in their treatment approach. Pulmonary specialists' and family physicians' approaches to mild asthma were similar (more than 90% recommended an inhaled beta2-agonist). However, considerable differences existed among and between physician groups for the remaining scenarios. For example, with an exacerbation associated with an upper respiratory tract infection, family physicians were more likely to recommend oral antibiotics (p<0.0001) and a same-day outpatient visit (p<0.0001), whereas specialists were more likely to increase the inhaled corticosteroid dosage (p<0.0001). Overall, disagreement was observed almost twice as often among family physicians than among specialists. Our results suggest that physicians vary markedly in their reported use of most interventions available to treat asthma, even when the disease severity is specified.
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Affiliation(s)
- L C Cicutto
- Clinical Epidemiology and Health Care Research Program, Sunnybrook and Women's Health Science Centre, University of Toronto, Ontario, Canada.
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Chang H, Hall GA, Geerts WH, Greenwood C, McLeod RS, Sher GD. Allogeneic Red Blood Cell Transfusion Is an Independent Risk Factor for the Development of Postoperative Bacterial Infection. Vox Sang 2000. [DOI: 10.1046/j.1423-0410.2000.7810013.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Venous thromboembolism is a common disease in the community and the most frequent preventable cause of hospital death. Acquired and inherited risk factors for thrombosis have been extensively studied over the past two decades. These factors and the clinical setting allow the stratification of most hospitalized patients into low-, moderate-, and high-risk groups. For patients in the moderate- and high-risk categories, routine thromboprophylaxis can decrease the morbidity and mortality from thromboembolic complications as well as reduce patient care expenditures. Low-dose heparin is generally the most appropriate prophylaxis for moderate-risk patients, and either low molecular weight heparin or adjusted-dose warfarin is generally the most appropriate for high-risk patients.
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Affiliation(s)
- R Selby
- Division of Hematology, Department of Medicine and Health Administration, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario, Canada
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Cicutto LC, Llewellyn-Thomas HA, Geerts WH. Physicians' approaches to providing asthma education to patients and the level of patient involvement in management decisions. J Asthma 1999; 36:427-39. [PMID: 10461932 DOI: 10.3109/02770909909087285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The objectives of this study were to describe physicians' self-reported approaches to providing disease-specific education to adults with asthma in an outpatient setting and their opinions about the level of patient involvement in management decisions. A mailed questionnaire was completed by 163 randomly selected physicians, representing an 80% response rate. The educational actions provided most frequently included information about prescribed medications (90%-100% of physicians), general asthma information (87%-98%), and inhaler demonstration (85%-95%). Educational activities provided least frequently were action plans (7%-74%) and referral to a nonprofit community asthma organization for further information (18%-36%). The reported provision of asthma education was related to patients' asthma severity (p < 0.0001) and physician specialty (p < 0.005). Physicians indicated that their patients were less involved in asthma management decisions than they would prefer (p < 0.001). The results suggest that physicians vary markedly in their approaches to providing asthma education to patients. Future descriptive and intervention studies are needed to identify the most effective models for providing education and patient involvement.
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Affiliation(s)
- L C Cicutto
- Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Ontario, Canada.
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Leclerc JR, Gent M, Hirsh J, Geerts WH, Ginsberg JS. The incidence of symptomatic venous thromboembolism after enoxaparin prophylaxis in lower extremity arthroplasty: a cohort study of 1,984 patients. Canadian Collaborative Group. Chest 1998; 114:115S-118S. [PMID: 9726704 DOI: 10.1378/chest.114.2_supplement.115s] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J R Leclerc
- The Montreal General Hospital, McGill University, Quebec, Canada
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Leclerc JR, Gent M, Hirsh J, Geerts WH, Ginsberg JS. The incidence of symptomatic venous thromboembolism during and after prophylaxis with enoxaparin: a multi-institutional cohort study of patients who underwent hip or knee arthroplasty. Canadian Collaborative Group. Arch Intern Med 1998; 158:873-8. [PMID: 9570173 DOI: 10.1001/archinte.158.8.873] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite low molecular weight heparin prophylaxis, the incidence of venographically detected, residual deep vein thrombosis after hip and knee arthroplasty remains high, at approximately 15% and 30%, respectively. Most of these thrombi are asymptomatic and of unknown clinical significance. Nevertheless, because they have the potential to grow, limiting prophylaxis to the in-hospital period may provide inadequate protection. METHODS We studied a cohort of 1984 consecutive patients who had hip or knee arthroplasty at 1 of 28 participating hospitals. Patients received enoxaparin prophylaxis, 30 mg subcutaneously every 12 hours for up to 14 days, and underwent predischarge compression ultrasonography. Study end points were symptomatic deep vein thrombosis or pulmonary embolism during and after prophylaxis, asymptomatic venous thrombosis detected by predischarge compression ultrasonography, and major hemorrhage. The duration of follow-up was 84 days. RESULTS Enoxaparin treatment was started a mean (+/- SD) of 17.9 +/- 10.4 hours after the completion of surgery and was given for a mean of 18.0 +/- 6.9 doses. Eighty-two patients (4.1%; 95% confidence interval, 3.3%-5.0%) developed venous thromboembolism. The rates of thromboembolic events during and after prophylaxis were 2.1% and 2.0%, respectively. Only 3 patients (0.15%) had abnormal predischarge compression ultrasonography. Three patients (0.15%) died of pulmonary embolism. Major hemorrhage occurred in 58 patients (2.9%; 95% confidence interval, 2.2%-3.7%). CONCLUSIONS Postoperative prophylaxis with enoxaparin for a mean of 9 days is associated with a clinically acceptable rate of symptomatic venous thromboembolism and major hemorrhage. Predischarge compression ultrasonography cannot be justified.
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Affiliation(s)
- J R Leclerc
- The Montreal General Hospital, McGill University, Quebec.
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Abstract
The management of thromboembolic complications remains one of the most controversial issues in the care of patients with pelvic and acetabular fractures. Recent studies have indicated that the incidence of proximal deep vein thrombosis is much higher than was previously believed. These patients should be managed with a formal institutional protocol that includes universal prophylaxis, supplemented in some cases by screening for deep vein thrombosis.
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Affiliation(s)
- K D Montgomery
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Geerts WH, Jay RM, Code KI, Chen E, Szalai JP, Saibil EA, Hamilton PA. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996; 335:701-7. [PMID: 8703169 DOI: 10.1056/nejm199609053351003] [Citation(s) in RCA: 555] [Impact Index Per Article: 19.8] [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: 02/01/2023]
Abstract
BACKGROUND Patients who have had major trauma are at very high risk for venous thromboembolism if they do not receive thromboprophylaxis. We compared low-dose heparin and a low-molecular-weight heparin with regard to efficacy and safety in a randomized clinical trial in patients with trauma. METHODS Consecutive adult patients admitted to a trauma center who had Injury Severity Scores of at least 9 and no intracranial bleeding were randomly assigned to heparin (5000 units) or enoxaprin (30 mg), each given subcutaneously every 12 hours in a double-blind manner, beginning within 36 hours after the injury. The primary outcome was deep-vein thrombosis as assessed by contrast venography performed on or before day 14 after randomization. RESULTS Among 344 randomized patients, 136 who received low-dose heparin and 129 who received enoxaparin had venograms adequate for analysis. Sixty patients given heparin (44 percent) and 40 patients given enoxaparin (31 percent) had deep-vein thrombosis (P=0.014). The rates of proximal-vein thrombosis were 15 percent and 6 percent, respectively (P=0.012). The reductions in risk with enoxaparin as compared with heparin were 30 percent (95 percent confidence interval, 4 to 50 percent) for all deep-vein thrombosis and 58 percent (95 percent confidence interval, 12 to 87 percent) for proximal-vein thrombosis. Only six patients (1.7 percent) had major bleeding (one in the heparin group and five in the enoxaparin group, P=0.12). CONCLUSIONS Low-molecular-weight heparin was more effective than low-dose heparin in preventing venous thromboembolism after major trauma. Both interventions were safe.
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Affiliation(s)
- W H Geerts
- Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, ON, Canada
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Paradiso-Hardy FL, Cheung B, Geerts WH. Evaluation of an intravenous heparin nomogram in a coronary care unit. Can J Cardiol 1996; 12:802-8. [PMID: 8842133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To develop, implement and evaluate an effective and efficient heparin nomogram. DESIGN Retrospective and prospective data collection. SETTING Coronary care unit (CCU) of a university-affiliated hospital. PATIENTS Patients with acute coronary ischemic syndromes requiring intravenous (i.v.) heparin who were not receiving thrombolytic and/or warfarin therapy. INTERVENTIONS A retrospective chart review of 52 CCU patients receiving iv heparin provided the historical control group. The effectiveness of a heparin nomogram (5000 U bolus followed by an initial weight-based infusion of 15 U/kg/h with subsequent rate adjustments according to activated partial thromboplastin time [aPTT] results) was then prospectively assessed in a further 56 consecutive patients. MAIN RESULTS The historical control and nomogram groups did not significantly differ with respect to age, weight, duration of therapy or total number of aPTTs drawn. Approximately 79% and 84% of patients in the control and nomogram groups, respectively, achieved an aPTT within the therapeutic range (60 to 90 s, P > 0.05), whereas 89% and 100% of control and nomogram patients, respectively, surpassed the therapeutic threshold (longer than 60 s) at some point during treatment (P = 0.009). Compared with empiric dose adjustment, the nomogram more effectively avoided periods of inadequate anticoagulation. Similarly, the time to achieve the therapeutic threshold was significantly longer in the control than in the nomogram group (8.2 +/- 5.9 versus 6.7 +/- 3.7 h, P = 0.026). No adverse bleeding events were noted in either group. CONCLUSIONS Compared with conventional approaches, the heparin nomogram successfully achieved and maintained adequate anticoagulation in a greater proportion of patients with acute cardiovascular diseases without the need for additional aPTT measurements.
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Affiliation(s)
- F L Paradiso-Hardy
- Department of Pharmacy and Medicine, Sunnybrook Health Science Centre, University of Toronto, Ontario
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Abstract
Patients with pelvic trauma are known to be at increased risk for the development of thromboembolic complications. The incidence of deep venous thrombosis in patients with pelvic fractures is 35% to 60%. Proximal deep venous thrombosis, which is most likely to result in pulmonary embolism, occurs in 25% to 35% of these patients, and almost 1/2 of all proximal thrombi will be in the pelvic veins. The incidence of symptomatic pulmonary embolism in the pelvic trauma population is 2% to 10% whereas a greater proportion of patients will have clinically silent pulmonary embolism. Fatal pulmonary embolism occurs in 0.5% to 2% of patients with pelvic trauma. The cornerstone of effective management is prophylaxis and the most commonly used forms include low dose heparin, low molecular weight heparin, mechanical devices, and in some studies, inferior vena caval filters. Based on a critical review of the literature, in algorithm is proposed for the management of thromboprophylaxis in this trauma subgroup. This includes prophylaxis, screening, and treatment when proximal thrombosis is identified. Such a systematic approach to this potentially catastrophic problem may decrease the morbidity and mortality associated with thromboembolic complications in these patients.
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Affiliation(s)
- K D Montgomery
- Department of Orthopaedic Surgery, The Hospital for Special Surgery, New York, NY, USA
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Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, L'Espérance B, Demers C, Kassis J, Cruickshank M, Whitman L, Delorme F. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med 1996; 124:619-26. [PMID: 8607589 DOI: 10.7326/0003-4819-124-7-199604010-00001] [Citation(s) in RCA: 154] [Impact Index Per Article: 5.5] [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: 01/31/2023] Open
Abstract
OBJECTIVE To compare the effectiveness and safety of fixed-dose enoxaparin and adjusted dose warfarin in preventing venous thromboembolism after knee arthroplasty. DESIGN A randomized, double-blind controlled trial. SETTING 8 university hospitals. PATIENTS 670 consecutive patients who had knee arthroplasty. INTERVENTION Patients were randomly assigned to receive enoxaparin (30 mg subcutaneously every 12 hours) or adjusted-dose warfarin (international normalized ratio, 2.0 to 3.0). Both regimens were started after surgery. MEASUREMENTS The primary end point was the incidence of deep venous thrombosis in patients with adequate bilateral venograms; the secondary end point was hemorrhage. RESULTS Among the 417 patients with adequate venograms, 109 of 211 warfarin recipients (51.7%) had deep venous thrombosis compared with 76 of 206 enoxaparin recipients (36.9%) (P = 0.003). The absolute risk difference was 14.8% in favor of enoxaparin (95% Cl, 5.3% to 24.1%) Twenty-two warfarin recipients (10.4%) and 24 enoxaparin recipients (11.7%) had proximal venous thrombosis (P>0.2). The absolute risk difference was 1.2% in favor of warfarin (Cl, -7.2% to 4.8%). The incidence of major bleeding was 1.8% (6 of 334 patients) in the warfarin group and 2.1% (7 of 336 patients) in the enoxaparin group (P>0.2). The absolute risk difference was 0.3% in favor of warfarin (Cl, -2.4% to 1.8%). CONCLUSIONS A postoperative, fixed-dose enoxaparin regimen is more effective than adjusted-dose warfarin in preventing deep venous thrombosis after knee arthroplasty. No differences were seen in the incidence of proximal venous thrombosis or clinically overt hemorrhage.
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Gent M, Hirsh J, Ginsberg JS, Powers PJ, Levine MN, Geerts WH, Jay RM, Leclerc J, Neemeh JA, Turpie AG. Low-molecular-weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996; 93:80-4. [PMID: 8616946 DOI: 10.1161/01.cir.93.1.80] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [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: 01/31/2023]
Abstract
BACKGROUND The study objective was to determine the relative efficacy and safety of a low-molecular-weight heparinoid (Orgaran) compared with aspirin for the prevention of postoperative venous thromboembolism in patients undergoing surgery for fractured hips. A double-blind, randomized, controlled trial was used to study 251 consecutive eligible and consenting patients undergoing surgery for hip fracture in seven participating hospitals. METHODS AND RESULTS Patients received either fixed-dose Orgaran by subcutaneous injection every 12 hours in a dose of 750 anti-Factor Xa units or aspirin 100 mg orally twice daily; both regimens were started 12 to 24 hours after surgery and continued for 14 days or until discharge, if sooner. All patients had postoperative 125I-fibrinogen leg scanning and impedance plethysmography. If the results of one or both tests were positive, then venography was performed. Otherwise, venography was done at day 14, or sooner if the patient was ready for discharge. Pulmonary embolism in symptomatic patients was diagnosed on the basis of a high probability perfusion/ventilation lung scan, a positive angiogram, or a clinically significant embolism detected at autopsy. Evaluable venograms were obtained in 90 of the 125 patients randomly assigned to receive Orgaran and in 87 of the 126 patients assigned to receive aspirin. Venous thromboembolism was detected in 25 (27.8%) patients in the Orgaran group and in 39 (44.3%) patients in the aspirin group. Thus, there was a relative risk reduction of 37% with Orgaran (P=.028; 95% confidence interval, 3.7% to 59.7%). Six (6.8%) of 88 patients in the Orgaran group and 12 (14.3%) of 84 patients in the aspirin group developed proximal deep vein thrombosis or pulmonary embolism, a relative risk reduction of 52% with Orgaran (P=.137; 95% confidence interval, -30.7% to 84.6%). Hemorrhagic complications occurred in 2 (1.6%) patients given Orgaran and 8 (6.4%) patients given aspirin (P=.10). There was one major bleed in the Orgaran group compared with four in the aspirin group. CONCLUSIONS This study demonstrates that Orgaran is significantly more efficacious than aspirin in preventing postoperative venous thromboembolism in patients undergoing surgery for fractured hips, with no evidence of any increase in hemorrhagic complications.
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Affiliation(s)
- M Gent
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
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45
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Abstract
Controversy exists as to whether or not the dose of prednisone should be tapered in patients discharged from the emergency department after initial treatment for an acute exacerbation of asthma. We assessed the rates of relapse and rebound in a group of 28 patients treated with a nontapering course of prednisone and compared their outcomes to an historical control group of 48 patients treated with a typical tapering course of prednisone. We found no significant difference in the rates of relapse or rebound between the nontapering dose patients and the tapering dose patients within either 21 days of discharge or within 10 days after stopping prednisone. Fifty-four percent of study patients reported adverse effects that could be attributed to prednisone. Our preliminary findings suggest that tapering of prednisone may not be needed in these patients.
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Affiliation(s)
- P R Verbeek
- Division of Emergency Medicine, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada
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Abstract
BACKGROUND Although deep-vein thrombosis and pulmonary embolism are considered common complications after major trauma, their frequency and the associated risk factors have not been carefully quantified. METHODS We performed serial impedance plethysmography and lower-extremity contrast venography to detect deep-vein thrombosis in a cohort of 716 patients admitted to a regional trauma unit. Prophylaxis against thromboembolism was not used. RESULTS Deep-vein thrombosis in the lower extremities was found in 201 of the 349 patients (58 percent) with adequate venographic studies, and proximal-vein thrombosis was found in 63 (18 percent). Three patients died of massive pulmonary embolism before venography could be performed. Before venography, only three of the patients with deep-vein thrombosis had clinical features suggestive of the condition. Deep-vein thrombosis was found in 65 of the 129 patients with major injuries involving the face, chest, or abdomen (50 percent); in 49 of the 91 patients with major head injuries (53.8 percent); in 41 of the 66 with spinal injuries (62 percent); and in 126 of the 182 with lower-extremity orthopedic injuries (69 percent). Thrombi were detected in 61 of the 100 patients with pelvic fractures (61 percent), in 59 of the 74 with femoral fractures (80 percent), and in 66 of the 86 with tibial fractures (77 percent). A multivariate analysis identified five independent risk factors for deep-vein thrombosis: older age (odds ratio, 1.05 per year of age; 95 percent confidence interval, 1.03 to 1.06), blood transfusion (odds ratio, 1.74; 95 percent confidence interval, 1.03 to 2.93), surgery (odds ratio, 2.30; 95 percent confidence interval, 1.08 to 4.89), fracture of the femur or tibia (odds ratio, 4.82; 95 percent confidence interval, 2.79 to 8.33), and spinal cord injury (odds ratio, 8.59; 95 percent confidence interval, 2.92 to 25.28). CONCLUSIONS Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed.
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Affiliation(s)
- W H Geerts
- Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, ON, Canada
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Affiliation(s)
- J R Lieberman
- Department of Orthopaedic Surgery, University of California at Los Angeles School of Medicine 90024
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48
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Leclerc JR, Geerts WH, Desjardins L, Jobin F, Laroche F, Delorme F, Haviernick S, Atkinson S, Bourgouin J. Prevention of deep vein thrombosis after major knee surgery--a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo. Thromb Haemost 1992; 67:417-23. [PMID: 1321509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Consecutive patients undergoing knee arthroplasty or tibial osteotomy at four participating hospitals received either enoxaparin, 30 mg subcutaneously every 12 h (n = 66) or an identical-appearing placebo (n = 65). All study medications started the morning after the operation and were continued up to a maximum of 14 days. Patients underwent surveillance with 125I-fibrinogen leg scanning and impedance plethysmography. Bilateral contrast venography was performed routinely at Day 14 or at time of discharge, if sooner. Deep vein thrombosis was detected by venography in 35 of 54 patients (65%) in the placebo group and in 8 of 41 patients in the enoxaparin group (19%), a risk reduction of 71%, P less than 0.0001. For the entire study group, deep vein thrombosis was detected by either venography of non-invasive tests in 37 of 64 patients (58%) in the placebo group and in 11 of 65 patients (17%) in the enoxaparin group, a risk reduction of 71%, P less than 0.0001. Proximal vein thrombosis was found in 19% of the placebo patients and in none of the enoxaparin patients, a risk reduction of 100%, P less than 0.001. Bleeding complications occurred in 5 of 65 patients (8%) in the placebo group and in 4 of 66 patients (6%) in the enoxaparin group, P = 0.71. There were no differences in the amount of blood loss, minimum hemoglobin levels and number of units of packed red cells given between the two treatment groups. We conclude that a fixed dose regimen of enoxaparin, started post-operatively, is an effective and safe regimen for reducing the frequency of deep vein thrombosis after major knee surgery.
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Affiliation(s)
- J R Leclerc
- Department of Medicine, Montreal General Hospital, McGill University, Canada
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Hull RD, Raskob GE, Hirsh J, Jay RM, Leclerc JR, Geerts WH, Rosenbloom D, Sackett DL, Anderson C, Harrison L. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximal-vein thrombosis. N Engl J Med 1986; 315:1109-14. [PMID: 3531862 DOI: 10.1056/nejm198610303151801] [Citation(s) in RCA: 510] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We performed a randomized double-blind trial comparing continuous intravenous heparin with intermittent subcutaneous heparin in the initial treatment of 115 patients with acute proximal deep-vein thrombosis. Intermittent subcutaneous heparin as administered in this trial was inferior to continuous intravenous heparin in preventing recurrent venous thromboembolism. The subcutaneous heparin regimen induced an initial anticoagulant response below the target therapeutic range in the majority of patients and resulted in a high frequency of recurrent venous thromboembolism (11 of 57 patients, 19.3 percent), which was virtually confined to patients with a subtherapeutic anticoagulant response. In contrast, continuous intravenous heparin induced a therapeutic anticoagulant response in the majority of patients and a low frequency of recurrent events (3 of 58 patients, 5.2 percent; P = 0.024); the recurrences were limited to patients with an initial subtherapeutic anticoagulant response. The results of this trial establish the efficacy of intravenous heparin in the treatment of proximal venous thrombosis and suggest a relation between the effectiveness of heparin and the levels of anticoagulation achieved; such a relation could explain the observed failure of the subcutaneous regimen.
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