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Niznik S, Rapoport MJ, Avnery O, Kidon M, Shavit R, Ellis MH, Agmon-Levin N. Heart valve disease in primary antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:1397-1402. [PMID: 37572296 DOI: 10.1093/rheumatology/kead399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/17/2023] [Accepted: 07/16/2023] [Indexed: 08/14/2023] Open
Abstract
OBJECTIVES APS-associated heart valve disease (HVD) is well described. Nonetheless, limited data exist on clinical parameters associated with the course of primary APS (pAPS) patients with HVD. The goal of this study was to assess clinical features and related outcomes in patients with APS-associated HVD. METHODS In this multicentre retrospective study, we identified 33 pAPS patients with HVD (pAPS-HVD group) and compared their clinical course with 128 pAPS patients with normal heart valves on echocardiography (pAPS-control group). RESULTS pAPS-HVD patients had more cerebrovascular events (56.3% vs 25%, P = 0.005) and livedo reticularis (24.2% vs 7.8%, P = 0.013) than pAPS-controls. Furthermore, catastrophic-APS (CAPS) (12.1% vs 2.4%, P = 0.034), recurrent thrombosis (33.3% vs 4.7%, P < 0.001) and need for advanced therapy (i.e. IVIG, plasmapheresis or rituximab) were more frequent in pAPS-HVD patients. Anti-β2-glycoprotein 1 IgG (84.8% vs 63.2%, P = 0.034), anti-cardiolipin IgG (90.9% vs 64.8%, P = 0.005) and triple positive aPL (75.8% vs 56.5%, P = 0.047) were commoner in pAPS-HVD patients vs pAPS-controls. Ten of the 33 patients with pAPS-HVD underwent valve surgery, which was associated with male gender, smoking, arterial limb ischaemia and livedo reticularis. CONCLUSION pAPS-HVD patients had a more severe APS clinical course including CAPS and thrombotic events as well as a specific serology, namely IgG isotype aPL antibodies and triple positivity. Our data suggest that pAPS-HVD represents a high-risk subgroup of APS patients.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Micha J Rapoport
- Department of Internal Medicine 'C', Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Mona Kidon
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jarchowsky O, Avnery O, Ellis MH. Thrombosis in multiple myeloma: mechanisms, risk assessment and management. Leuk Lymphoma 2023; 64:1905-1913. [PMID: 37584485 DOI: 10.1080/10428194.2023.2247513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023]
Abstract
Multiple myeloma (MM) is associated with an increased risk of venous and arterial thrombosis. Pathophysiologic mechanisms include patient, disease and treatment related factors. Risk assessment models have been developed to determine whichpatients are at highest thrombotic risk and pursuant to this, risk adapted thrombosis prophylaxis has been suggested. Areas in which further basic and clinical research is imperative include the molecular and cellular mechanisms of thrombosis in myeloma, the inclusion of relevant biomarkers in risk assessment scores and controlled clinical trials of VTE prophylaxis and treatment using direct oral anticoagulants.
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Affiliation(s)
- Osnat Jarchowsky
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
| | - Orly Avnery
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
| | - Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
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Niznik S, Rapoport MJ, Avnery O, Ellis MH, Hajyahia S, Agmon-Levin N. Ethnicity and Antiphospholipid Syndrome in Israel. Arthritis Care Res (Hoboken) 2022; 74:1917-1923. [PMID: 34057315 DOI: 10.1002/acr.24720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/20/2021] [Accepted: 05/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is an acquired coagulopathy associated with the presence of antiphospholipid antibodies. Whether ethnicity modulates APS clinical course is not known. The aim of our study was to assess the interplay of ethnicity and APS in Israel. METHODS We retrospectively evaluated the ethnic distribution of APS patients from 3 medical centers in Israel compared to the general population. Ethnic groups were defined according to the Israeli Bureau of Statistics as Ashkenazi (European), former Union of Soviet Socialist Republics (USSR), North African, Asian (West Asia, Greece, and Turkey), Israeli Arab individuals, and others. RESULTS Our cohort included 382 patients. The prevalence of Ashkenazi and Asian ethnicities was more pronounced (33% versus 12.8% and 15.4% versus 7.7%, respectively; P < 0.001), while Israeli Arabs were less represented (5.2% versus 31.1%; P < 0.001) relative to their part in the general population. Arab patients were younger at presentation (mean ± SD 28 ± 10 years versus 34 ± 13 years; P < 0.001) and were more likely to present with venous thrombosis (50% versus 35%; P = 0.037) and to suffer from venous thrombotic recurrence (45% versus 16%; P < 0.001) compared to other ethnicities. Mortality was higher among patients of Asian ethnic origin (8.8% versus 1.1%; P = 0.005); intriguingly, this group experienced cardiovascular risk factors more often (i.e., dyslipidemia and hypertension). CONCLUSION Ethnicity may affect the prevalence and/or natural course of APS, which is less prevalent and differs clinically in Israeli Arab patients, while mortality was linked with Asian ethnicity.
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Affiliation(s)
| | - Micha J Rapoport
- Shamir Medical Center, Zerifin, Israel, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Soad Hajyahia
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nancy Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Rebetzke GJ, Zhang H, Ingvordsen CH, Condon AG, Rich SM, Ellis MH. Genotypic variation and covariation in wheat seedling seminal root architecture and grain yield under field conditions. Theor Appl Genet 2022; 135:3247-3264. [PMID: 35925366 DOI: 10.1007/s00122-022-04183-z] [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] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
Greater embryo size in a large and carefully phenotyped mapping population was genetically associated with a greater number of longer seminal roots to increase grain yield in droughted field environments. Breeding modification of root architecture is challenging in field environments owing to genetic and phenotypic complexity, and poor repeatability with root sampling. Seeds from a large mapping population varying in embryo size were harvested from a common glasshouse and standardised to a common size before assessing in rolled germination paper at 12 and 20 °C for seedling growth. Differences in genotype means were large and heritabilities high (h2 = 0.55-0.93) indicating strong and repeatable genotypic differences for most root traits. Seminal roots 1 to 3 were produced on all seedlings, whereas growth of seminal roots 4, 5 and 6 was associated with differences in embryo size. Increases in seminal root number from 4 to 6 per plant were strongly, genetically correlated with increases in total seminal length (rg = 0.84, < 0.01). Multivariate analysis confirmed initiation and growth of seminal roots 1, 2 and 3, and of roots 4, 5 and 6 behaved as genetically independent (rPg = 0.15 ns) cohorts. Tails representing extremes in seedling root length and number were associated with significant differences in grain yield of up to 35% in droughted field environments but were not different in irrigated environments. Increases in grain yield were linked to greater lengths of seminal roots 4, 5 and 6 and were largely independent of plant height or development. This is the first report on the genetic relationship of seedling root architecture and embryo size, and potential in selection of seminal root size for accessing deep-soil moisture in droughted environments.
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Affiliation(s)
- G J Rebetzke
- CSIRO Agriculture and Food, PO Box 1700, Canberra, ACT, 2601, Australia.
| | - H Zhang
- State Key Laboratory of Crop Stress Biology for Arid Areas, College of Agronomy, Northwest A&F University, Yangling, 712100, Shaanxi, China
| | - C H Ingvordsen
- Australian Grain Technologies, PO Box 341, Roseworthy, SA, 5371, Australia
| | - A G Condon
- CSIRO Agriculture and Food, PO Box 1700, Canberra, ACT, 2601, Australia
| | - S M Rich
- CSIRO Agriculture and Food, 147 Underwood Av, Floreat, WA, 6014, Australia
| | - M H Ellis
- Formerly CSIRO, Now 8 Avenue Piaton, Villeurbanne, France
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Ariëns RA, Hunt BJ, Agbani EO, Ahnström J, Ahrends R, Alikhan R, Assinger A, Bagoly Z, Balduini A, Barbon E, Barrett CD, Batty P, Carneiro JDA, Chan W, de Maat M, de Wit K, Denis C, Ellis MH, Eslick R, Fu H, Hayward CPM, Ho‐Tin‐Noé B, Klok F, Kumar R, Leiderman K, Litvinov RI, Mackman N, McQuilten Z, Neal MD, Parker WAE, Preston RJS, Rayes J, Rezaie AR, Roberts LN, Rocca B, Shapiro S, Siegal DM, Sousa LP, Suzuki‐Inoue K, Zafar T, Zhou J. Illustrated State-of-the-Art Capsules of the ISTH 2022 Congress. Res Pract Thromb Haemost 2022; 6:e12747. [PMID: 35814801 PMCID: PMC9257378 DOI: 10.1002/rth2.12747] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
The ISTH London 2022 Congress is the first held (mostly) face-to-face again since the COVID-19 pandemic took the world by surprise in 2020. For 2 years we met virtually, but this year's in-person format will allow the ever-so-important and quintessential creativity and networking to flow again. What a pleasure and joy to be able to see everyone! Importantly, all conference proceedings are also streamed (and available recorded) online for those unable to travel on this occasion. This ensures no one misses out. The 2022 scientific program highlights new developments in hemophilia and its treatment, acquired and other inherited bleeding disorders, thromboinflammation, platelets and coagulation, clot structure and composition, fibrinolysis, vascular biology, venous thromboembolism, women's health, arterial thrombosis, pediatrics, COVID-related thrombosis, vaccine-induced thrombocytopenia with thrombosis, and omics and diagnostics. These areas are elegantly reviewed in this Illustrated Review article. The Illustrated Review is a highlight of the ISTH Congress. The format lends itself very well to explaining the science, and the collection of beautiful graphical summaries of recent developments in the field are stunning and self-explanatory. This clever and effective way to communicate research is revolutionary and different from traditional formats. We hope you enjoy this article and will be inspired by its content to generate new research ideas.
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Affiliation(s)
| | | | - Ejaife O. Agbani
- Department of Physiology and Pharmacology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | - Robert Ahrends
- Institute of Analytical ChemistryUniversity of ViennaViennaAustria
| | - Raza Alikhan
- Haemostasis & ThrombosisUniversity Hospital of WalesCardiffUK
| | | | - Zsuzsa Bagoly
- Faculty of Medicine, Department of Laboratory Medicine, Division of Clinical Laboratory Sciences and ELKH‐DE Neurodegenerative and Cerebrovascular Research GroupUniversity of DebrecenDebrecenHungary
| | | | - Elena Barbon
- San Raffaele Telethon Institute for Gene TherapyIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Christopher D. Barrett
- Division of Acute Care Surgery and Surgical Critical Care, Department of SurgeryUniversity of Nebraska Medical CenterOmahaNebraskaUSA,Koch Institute, Center for Precision Cancer MedicineMassachusetts Institute of TechnologyCambridgeMassachusettsUSA,Division of Surgical Critical Care, Department of Surgery, Boston University Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | | | | | - Wee Shian Chan
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Moniek de Maat
- Department of HematologyErasmus MCRotterdamThe Netherlands
| | - Kerstin de Wit
- Queen’s University and McMaster UniversityKingstonONCanada
| | | | - Martin H. Ellis
- Hematology Institute and Blood Bank, Meir Medical Center and Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Renee Eslick
- Haematology DepartmentCanberra HospitalGarranAustralian Capital TerritoryAustralia
| | - Hongxia Fu
- Division of Hematology, Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Frederikus A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Riten Kumar
- Dana Farber/Boston Children’s Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | | | - Rustem I. Litvinov
- Department of Cell and Developmental BiologyUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - William A. E. Parker
- Cardiovascular Research Unit, Northern General HospitalUniversity of SheffieldSheffieldUK
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, Department of Pharmacy & Biomolecular SciencesRoyal College of Surgeons in IrelandDublin 2Ireland
| | | | - Alireza R. Rezaie
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOklahomaUSA
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | - Susan Shapiro
- Oxford University Hospitals NHS Foundation TrustOxfordUK,Radcliffe Department of MedicineOxford UniversityOxfordUK
| | - Deborah M. Siegal
- Ottawa Hospital Research Institute and University of OttawaOttawaOntarioCanada
| | - Lirlândia P. Sousa
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de FarmáciaUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Katsue Suzuki‐Inoue
- Department of Clinical and Laboratory MedicineUniversity of YamanashiYamanashiJapan
| | - Tahira Zafar
- Frontier Medical CollegeAbbotabadPakistan,Hemophilia Treatment CenterRawalpindiPakistan
| | - Jiaxi Zhou
- Institute of Hematology & Blood Diseases HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
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Duek A, Berla M, Ellis MH. Recent advances in the treatment of polycythemia vera. Leuk Lymphoma 2022; 63:1801-1809. [DOI: 10.1080/10428194.2022.2057491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Adrian Duek
- Hematology Institute Assuta Medical Center, Ashdod, Israel
| | - Maya Berla
- Hematology Institute Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H. Ellis
- Hematology Institute Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Haj Yahia S, Ellis MH, Agmon-Levin N. Patterns of Recurrent Thrombosis in Primary Antiphospholipid Syndrome-Multicenter, Real-Life Long-Term Follow-Up. Front Immunol 2022; 13:843718. [PMID: 35514968 PMCID: PMC9063725 DOI: 10.3389/fimmu.2022.843718] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is an acquired hypercoagulable condition associated with antiphospholipid antibody (aPL) presence. Data on re-thrombosis following APS-diagnosis are limited. Methods This is a retrospective analysis of new thrombotic events among primary APS (pAPS) patients followed for up to 15 years in three medical centers in Israel. Results Among 312 primary-APS patients, 143 (46%) had new thrombotic event classified to three patterns: (1) Arterial—associated with heart valve disease (OR 7.24, 95% C.I. 2.26–24.6), hypertension (OR 3, 95% C.I. 1.44–6.25), elevated anti-B2-GPI IgM (OR 1.04, 95% C.I. 0.996–1.08), arterial thrombosis at presentation (OR 1.74 95% C.I. 0.992–3.26), and older age (41 vs. 34 years, p < 0.001). (2) Venous—linked with venous thrombosis at presentation (OR 12.9, 95% C.I. 5.27–31.6, p < 0.001), heart valve disease (OR 9.81 95% C.I. 1.82–52.9, p = 0.018), aGAPSS (OR 1.15 95% C.I. 1.02–1.29), and younger age (31 vs. 36.5 years, p = 0.001); and (3) Combined pattern—associated with heart valve disease (OR 40.5 95% C.I. 7.7–212) and pulmonary embolism (OR 7.47 95% C.I. 1.96–28.5). A 4th variant “the Breakthrough pattern” defined by re-thrombosis despite prophylactic therapy was observed in 100/143 (70%) patients and linked with heart valve disease (OR 8. 95% C.I. 2.43–26.3), venous thrombosis at presentation (OR 2.61 95% C.I. 1.47–4.66), leg ulcers (OR 12.2, 95% C.I. 1.4–107), hypertension (OR 1.99, 95% C.I. 0.92–4.34), and higher aGAPSS (OR 1.08, 95% C.I. 0.99–1.18). Conclusion In this real-life observation, re-thrombosis was common among pAPS patients including in those recommended to receive prophylactic therapy. Different patterns of recurrence were identified and linked with presenting symptoms, specific serological markers, APS manifestations, and comorbidities. Studies that will address interventions to prevent recurrences of APS-related events are needed.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel
| | - Micha J Rapoport
- Department of Internal Medicine "C", Shamir Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Ramat Gan, Israel
| | - Soad Haj Yahia
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Shavit R, Ellis MH, Agmon-Levin N. Long Term Follow up of Patients With Primary Obstetric Antiphospholipid Syndrome. Front Pharmacol 2022; 13:824775. [PMID: 35529433 PMCID: PMC9068935 DOI: 10.3389/fphar.2022.824775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Primary obstetric antiphospholipid syndrome (OAPS) is defined by specific morbidities and/or losses of pregnancy in the presence of persistent antiphospholipid antibodies (aPL). This variant of APS is usually treated during pregnancy and the post-partum period. Data on occurrence of thrombotic event during long term follow-up of OAPS patients is limited. Methods: A multi-centre retrospectively cohort of female patients with primary APS (pAPS) was assembled during 2004–2019. Patients were grouped according to disease presentation as pure OAPS or thrombotic APS (tAPS) for those presenting with thrombosis. Clinical and serological data were compared between groups. Results: Of 219 pAPS female patients 67 (30.6%) were diagnosed with OAPS and 152 (69.4%) with tAPS. During >10 years of follow-up 24/67 (35.8%) OAPS and 71/152 (50%) tAPS suffered a new thrombotic event (p = 0.06), while obstetric morbidity was more likely in the OAPS group (31.3 vs. 10.5%, p < 0.001) respectively. Among patients with OAPS at presentation heart valve disease and the presence of ANA were related to thrombosis following diagnosis (25 vs. 4.7%, p = 0.02; and 45.8 vs. 20.8%, p = 0.04 respectively). Conclusion: Thrombotic event following diagnosis were common among female patients with pAPS regardless of disease presentation. Heart valve disease and ANA positivity may be risk factors for thrombosis during follow-up of patients presenting with pure OAPS.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Micha J. Rapoport
- Department of Internal Medicine “C”, Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Martin H. Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Nancy Agmon-Levin,
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9
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Telerman A, Granot G, Leibovitch C, Yarchovsky-Dolberg O, Shacham-Abulafia A, Partouche S, Yeshurun M, Ellis MH, Raanani P, Wolach O. Neutrophil Extracellular Traps Are Increased in Chronic Myeloid Leukemia and Are Differentially Affected by Tyrosine Kinase Inhibitors. Cancers (Basel) 2021; 14:cancers14010119. [PMID: 35008283 PMCID: PMC8750902 DOI: 10.3390/cancers14010119] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/13/2021] [Accepted: 12/24/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Neutrophil extracellular traps (NETs) are a recently described form of neutrophil cellular death that has been associated with a thrombotic tendency in many diseases. We studied NET formation in neutrophils derived from patients with chronic myeloid leukemia (CML) and in CML neutrophil cell lines and demonstrated that NETs are increased in CML and that certain drugs used to treat CML (tyrosine kinase inhibitors—TKIs) increase NET formation. These findings may shed light on a novel mechanism linking CML, TKIs and vascular toxicity. Abstract Cardiovascular complications are increasingly reported with the use of certain tyrosine kinase inhibitors (TKIs) to treat chronic myeloid leukemia (CML). We studied neutrophil extracellular trap (NET) formation in CML and evaluated the effect of TKIs on NET formation. Neutrophils isolated from treatment-naïve patients with CML showed a significant increase in NET formation compared to matched controls at baseline and after stimulation with ionomycin (IO) and phorbol 12-myristate 13-acetate (PMA). Expression of citrullinated histone H3 (H3cit), peptidyl arginine deiminase 4 (PAD4) and reactive oxygen species (ROS) was significantly higher in CML samples compared to controls. Pre-treatment of neutrophils with TKIs was associated with a differential effect on NET formation, and ponatinib significantly augmented NET-associated elastase and ROS levels as compared to controls and other TKIs. BCR-ABL1 retroviral transduced HoxB8-immortalized mouse hematopoietic progenitors, which differentiate into neutrophils in-vitro, demonstrated increased H3cit & myeloperoxidase (MPO) expression consistent with excess NET formation. This was inhibited by Cl-amidine, a PAD4 inhibitor, but not by the NADPH inhibitor diphenyleneiodonium (DPI). Ponatinib pre-exposure significantly increased H3cit expression in HoxB8-BCR-ABL1 cells after stimulation with IO. In summary, CML is associated with increased NET formation, which is augmented by ponatinib, suggesting a possible role for NETs in promoting vascular toxicity in CML.
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Affiliation(s)
- Alona Telerman
- Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel; (A.T.); (G.G.); (S.P.)
| | - Galit Granot
- Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel; (A.T.); (G.G.); (S.P.)
| | - Chiya Leibovitch
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Osnat Yarchovsky-Dolberg
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba 4428164, Israel
| | - Adi Shacham-Abulafia
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Shirly Partouche
- Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva 4941492, Israel; (A.T.); (G.G.); (S.P.)
| | - Moshe Yeshurun
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Martin H. Ellis
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba 4428164, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, Petah-Tikva 4941492, Israel
| | - Ofir Wolach
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv 39040, Israel; (C.L.); (O.Y.-D.); (A.S.-A.); (M.Y.); (M.H.E.); (P.R.)
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, Petah-Tikva 4941492, Israel
- Correspondence: ; Tel.: +972-50-406-5590
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Abadi U, Weisz A, Kidron D, Katzav A, Hercbergs A, Davis PJ, Ellis MH, Ashur-Fabian O. αvβ3 Integrin Expression and Mitogenic Effects by Thyroid Hormones in Chronic Lymphocytic Leukemia. J Clin Med 2021; 10:jcm10081766. [PMID: 33921634 PMCID: PMC8073405 DOI: 10.3390/jcm10081766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Chronic lymphocytic leukemia (CLL) is the most common adult leukemia. The thyroid hormones, T3 and T4, bind the αvβ3 integrin and activate phosphorylates ERK (pERK). These tumor-promoting actions were reported in a number of malignancies, but not in CLL. Methods: Primary cells from 22 CLL patients were verified for disease markers (CD5/CD19/CD23) and analyzed for αvβ3 by flow cytometry (FC), ImageStream, Western blots (WB), and immunohistochemistry (IHC) in archival bone marrow (BM, n = 6) and lymph node (LN, n = 5) tissues. Selected samples (n = 8) were incubated with T3 (1–100 nM) or T4 (0.1–10 µM) for 30 min, and the expression levels of αvβ3, pERK and PCNA (cell proliferation marker) were determined (WB). Results: αvβ3 was detected on the membrane of circulating CLL cells and in the BM but not in the LN. T3 and T4 enhanced αvβ3 protein levels in primary CLL cells. Similarly, pERK and PCNA were rapidly induced in response to T3 and T4 exposure. Conclusions: αvβ3 integrin is expressed on primary CLL cells and is induced by thyroid hormones. We further suggest that the hormones are mitogenic in these cells, presumably via αvβ3-mediated signaling.
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Affiliation(s)
- Uri Abadi
- Translational Hemato-Oncology Laboratory, Hematology Institute and Blood Bank Meir Medical Center, Kfar-Saba 44821, Israel; (U.A.); (A.W.); (M.H.E.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Avivit Weisz
- Translational Hemato-Oncology Laboratory, Hematology Institute and Blood Bank Meir Medical Center, Kfar-Saba 44821, Israel; (U.A.); (A.W.); (M.H.E.)
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dvora Kidron
- Department of Pathology, Meir Medical Center, Kfar Saba 44821, Israel; (D.K.); (A.K.)
| | - Aviva Katzav
- Department of Pathology, Meir Medical Center, Kfar Saba 44821, Israel; (D.K.); (A.K.)
| | - Aleck Hercbergs
- Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA;
| | - Paul J. Davis
- Department of Medicine, Albany Medical College, Albany, NY 12208, USA;
| | - Martin H. Ellis
- Translational Hemato-Oncology Laboratory, Hematology Institute and Blood Bank Meir Medical Center, Kfar-Saba 44821, Israel; (U.A.); (A.W.); (M.H.E.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Osnat Ashur-Fabian
- Translational Hemato-Oncology Laboratory, Hematology Institute and Blood Bank Meir Medical Center, Kfar-Saba 44821, Israel; (U.A.); (A.W.); (M.H.E.)
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
- Correspondence: ; Tel.: +972-9-7472178
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11
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Ellis MH, Avnery O. Decision-Making in the Management of Venous Thromboembolism. Am J Med 2021; 134:317-325. [PMID: 33289662 DOI: 10.1016/j.amjmed.2020.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Venous thromboembolism comprising deep venous thrombosis and pulmonary embolus is common. Patients with venous thromboembolism may present to a variety of health care providers, and while a significant proportion of patients begin treatment in the hospital, ambulatory management of both deep venous thrombosis and pulmonary embolus is feasible and becoming more common. Initial anticoagulant management, investigation of venous thromboembolism etiology, and decisions about extended anticoagulation require coordinated care by physicians from multiple specialties. Comprehensive management of venous thromboembolism requires coordinated care from the time of presentation in order to expedite diagnosis, initiate timely anticoagulant treatment, determine the need for extended anticoagulation based on risk of bleeding and recurrent thrombosis, and advise on thromboprophylaxis during future high-risk periods for venous thromboembolism. In this review we use case scenarios to provide an operational framework, based on current evidence-based recommendations, for informed decision-making about a number of clinical practice issues that are frequently encountered in the management of venous thromboembolism patients.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Ellis MH. Novel approaches to the treatment of polycythemia vera. Hematol Transfus Cell Ther 2020. [DOI: 10.1016/j.htct.2020.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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13
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Avnery O, Martin M, Bura-Riviere A, Barillari G, Mazzolai L, Mahé I, Marchena PJ, Verhamme P, Monreal M, Ellis MH, Aibar MA, Aibar J, Amado C, Arcelus JI, Ballaz A, Barba R, Barrón M, Barrón‐Andrés B, Bascuñana J, ina A, Camon AM, Cañas I, Carrasco C, Castro J, Ancos C, Toro J, Demelo P, Díaz‐Peromingo JA, Falgá C, Farfán AI, Fernández‐Capitán C, Fernández‐Criado MC, Fernández‐Núñez S, Fidalgo MA, Font C, Font L, Freire M, Gallego M, García MA, García‐Bragado F, García‐Morillo M, García‐Raso A, Gavín O, Gayol MC, Gil‐Díaz A, Gómez V, Gómez‐Cuervo C, González‐Martínez J, Grau E, Gutiérrez J, Hernández‐Blasco LM, Iglesias M, Jara‐Palomares L, Jaras MJ, Jiménez R, Jiménez‐Castro D, Jiménez‐López J, Joya MD, Lima J, Llamas P, Lobo JL, López‐Jiménez L, López‐Miguel P, López‐Núñez JJ, López‐Reyes R, López‐Sáez JB, Lorente MA, Lorenzo A, Loring M, Madridano O, Maestre A, Martín del Pozo M, Martín‐Guerra JM, Martín‐Romero M, Mellado M, Morales MV, Muñoz N, Nieto‐Cabrera MA, Nieto‐Rodríguez JA, Núñez‐Ares A, Núñez MJ, Olivares MC, Otalora S, Otero R, Pedrajas JM, Pellejero G, Pérez‐Rus G, Peris ML, Porras JA, Rivas A, Rodríguez‐Dávila MA, Rodríguez‐Hernández A, Rubio CM, Ruiz‐Artacho P, Ruiz‐Ruiz J, Ruiz‐Torregrosa P, Ruiz‐Sada P, Sahuquillo JC, Salazar V, Sampériz A, Sánchez‐Muñoz‐Torrero JF, Sancho T, Soler S, Sopeña B, Suriñach JM, Tolosa C, Torres MI, Trujillo‐Santos J, Uresandi F, Valle R, Vidal G, Villares P, Gutiérrez P, Vázquez FJ, Vilaseca A, Vanassche T, Vandenbriele C, Hirmerova J, Malý R, Salgado E, Benzidia I, Bertoletti L, Debourdeau P, Farge‐Bancel D, Hij A, Moustafa F, Schellong S, Braester A, Brenner B, Tzoran I, Sharif‐Kashani B, Bilora F, Bortoluzzi C, Bucherini E, Ciammaichella M, Dentali F, Di Micco P, Di Pangrazio M, Maida R, Mastroiacovo D, Pace F, Pallotti G, Parisi R, Pesavento R, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tufano A, Visonà A, Vo Hong N, Gibietis V, Skride A, Strautmane S, Bosevski M, Zdraveska M, Bounameaux H, Fresa M, Ney B, Caprini J, Bui HM, Pham KQ. D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry. J Intern Med 2020; 287:32-41. [PMID: 31394000 DOI: 10.1111/joim.12969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy. METHODS We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel). RESULTS In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors. CONCLUSIONS Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.
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Affiliation(s)
- O Avnery
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Martin
- Hospital Infanta Sofia San Sebastian de los Reyes and Universidad Europea de Madrid, Madrid, Spain
| | - A Bura-Riviere
- Department of Vascular Medicine, Hôpital de Rangueil, Toulouse, France
| | - G Barillari
- Department of Internal Medicine, Ospedale S. Maria della Misericordia, Udine, Italy
| | - L Mazzolai
- Department of Angiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - I Mahé
- Department of Internal Medicine, Hôpital Louis Mourier, Colombes (APHP), University Paris 7, Colombes, France
| | - P J Marchena
- Department of Internal Medicine and Emergency, Parc Sanitari Sant Joan de Deu-Hospital General, Barcelona, Spain
| | - P Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - M Monreal
- Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - M H Ellis
- Meir Medical Center, Hematology Institute and Blood Bank, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rumi E, McMullin MF, Harrison C, Ellis MH, Barzilai M, Sarid N, Mesa R, Paoli C, Angona A, Sant’Antonio E, Ferretti VV, Cavalloni C, Casetti IC, Trotti C, Barbui T. Facing erythrocytosis: Results of an international physician survey. Am J Hematol 2019; 94:E225-E227. [PMID: 31148218 PMCID: PMC8204407 DOI: 10.1002/ajh.25545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Elisa Rumi
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Claire Harrison
- Department of Hematology, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Martin H. Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Merav Barzilai
- Hematology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nadav Sarid
- Hematology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ruben Mesa
- UT Health San Antonio Cancer Center, San Antonio, Texas
| | - Chiara Paoli
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, Florence, Italy
| | - Anna Angona
- Hematology Department-IMIM, Hospital del Mar, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | - Chiara Cavalloni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Chiara Trotti
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Tiziano Barbui
- Research Foundation Ospedale Papa Giovanni XXIII Bergamo, Bergamo, Italy
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15
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Arbel R, Sergienko R, Hammerman A, Greenberg-Dotan S, Batat E, Avnery O, Ellis MH. Effectiveness and Safety of Off-Label Dose-Reduced Direct Oral Anticoagulants in Atrial Fibrillation. Am J Med 2019; 132:847-855.e3. [PMID: 30776320 DOI: 10.1016/j.amjmed.2019.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation but may result in serious bleeding complications. Off-label dose-reduced use of DOACs to mitigate bleeding is common in routine clinical practice although data about its consequences on patient outcomes are limited. Therefore, our objective was to evaluate the effectiveness and safety of off-label dose-reduced vs per-label standard-dose DOAC treatment. METHODS The study cohort included newly diagnosed patients with nonvalvular atrial fibrillation that had initiated DOAC therapy between 2011 and 2017 in Clalit Health Services (Tel Aviv, Israel). Effectiveness was defined as the composite outcome of all-cause mortality, stroke, or myocardial infarction. The safety outcome was defined as bleeding events requiring hospitalization. Patients were followed until March 30, 2018 or until occurrence of an outcome event. Hazard ratios (HR) were adjusted for 21 variables, including comorbidities, concomitant medications, and socioeconomic factors, using multivariate regression. RESULTS A total of 8425 patients met the study criteria; 5140 (61%) patients were treated with DOACs at per-label dosing and 3285 (39%) patients were treated with off-label dose-reduced DOAC. Off-label dose-reduced treatment was associated with a higher rate of the composite effectiveness outcome: adjusted HR 1.57 (95% confidence interval, 1.34-1.83; P < .001) and a higher rate of bleeding: adjusted HR 1.63 (95% confidence interval, 1.14-2.34; P = .008). CONCLUSIONS Almost 4 of 10 patients were treated with off-label dose-reduced DOAC, which was associated with reduced effectiveness without a safety benefit. Compliance with per-label dosage may significantly improve outcomes of this population.
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Affiliation(s)
- Ronen Arbel
- Department of Technology Marketing, Sapir College, Sderot, Israel.
| | - Ruslan Sergienko
- Department of Public Health, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Ariel Hammerman
- Chief Physician's Office, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | | | - Erez Batat
- Chief Physician's Office, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Israel
| | - Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Israel
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16
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Abadi U, Peled L, Gurion R, Rotman-Pikielny P, Raanani P, Ellis MH, Rozovski U. Prevalence and clinical significance of hypercalcemia at diagnosis in diffuse large B-cell lymphoma. Leuk Lymphoma 2019; 60:2922-2926. [PMID: 31167584 DOI: 10.1080/10428194.2019.1620946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The reported prevalence of hypercalcemia at diagnosis in non-Hodgkin-lymphoma ranges between 1.3% and 7.4%. These studies included all patients, regardless of lymphoma subtype. We performed a retrospective case-control study to determine the prevalence of hypercalcemia at time of diagnosis in patients with diffuse large B-cell lymphoma (DLBCL). Among 250 newly diagnosed patients, 46 (18%) had hypercalcemia. When compared with age-sex matched patients and normal calcium levels, those with hypercalcemia had higher levels of LDH, lower levels of albumin and more advanced stage. These differences were translated to shorter progression-free-survival and overall survival, but only in patients with hypercalcemia and low levels of parathyroid hormone (PTH). These findings suggest that in newly diagnosed patients with DLBCL, hypercalcemia is more frequent than previously appreciated. Furthermore, lymphoma-related but not primary hyperparathyroidism-related hypercalcemia is associated with adverse prognostic factors and adverse clinical outcomes in DLBCL. Hence, PTH should be obtained in patients with DLBCL and hypercalcemia at diagnosis.
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Affiliation(s)
- Uri Abadi
- Institute of Hematology, Meir Medical Center, Kfar Saba, Israel.,Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Peled
- Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Gurion
- Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pnina Rotman-Pikielny
- Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Endocrinology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Pia Raanani
- Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Martin H Ellis
- Institute of Hematology, Meir Medical Center, Kfar Saba, Israel.,Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Department of Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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17
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Arbel R, Sergienko R, Hammerman A, Dotan-Greenberg S, Batat E, Avnery O, Greenberg D, Ellis MH. Direct oral anticoagulation and mortality in moderate to high-risk atrial fibrillation. Heart 2019; 105:1487-1492. [PMID: 30971403 DOI: 10.1136/heartjnl-2018-314476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Although direct oral anticoagulants (DOAC) are the recommended antithrombotic therapy for patients with non-valvular atrial fibrillation (NVAF), anticoagulation in patients with NVAF is still inadequate. The effect of withholding DOAC therapy on patient survival is unknown. Therefore, our objective was to compare all-cause mortality rates between DOAC-treated patients with NVAF and similar patients receiving no anticoagulation. METHODS We performed a retrospective cohort study analysing Clalit Health Services' extensive electronic database, regarding all newly diagnosed, anticoagulant-naïve patients with NVAF who were eligible for DOAC therapy from 1 January 2011 to 31 December 2016. Patients who received DOAC therapy were matched by propensity scoring to patients receiving no anticoagulation. The primary outcome was all-cause mortality. Final patient follow-up date was 15 May 2017. RESULTS 18 901 eligible patients were identified. 8298 received treatment with a DOAC and 10 603 received no anticoagulation therapy. Of those, 5657 patients who received DOAC therapy were matched with 5657 patients who did not receive any anticoagulant. Death occurred in 715 patients in the DOAC-treated group (7.6% per year) and in 2075 patients in the non-anticoagulated patient group (11.1% per year). DOAC therapy was associated with significantly lower risk for all-cause mortality (HR=0.69, 95% CI 0.63 to 0.75, p<0.001). The benefit of DOAC therapy was demonstrated across all subgroups analysed. CONCLUSIONS In this cohort of newly diagnosed patients with NVAF, DOAC therapy was associated with a significantly lower risk of death compared with no oral anticoagulation. Our findings provide further evidence for the importance of providing DOAC anticoagulation in patients with NVAF.
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Affiliation(s)
- Ronen Arbel
- Maximizing Health Outcomes Research Lab, Sapir College, Sderot, Israel
| | - Ruslan Sergienko
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | | | | | - Erez Batat
- Clalit Health Services Headquarters, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and BloodBank, Meir Medical Center, Kfar Saba, Israel
| | - Dan Greenberg
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Martin H Ellis
- Hematology Institute and BloodBank, Meir Medical Center, Kfar Saba, Israel
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18
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Ellis MH, Shapira S, Avnery O. [PRACTICAL ADVICE FOR THE APPROPRIATE USE OF DIRECT ORAL ANTICOAGULANTS]. Harefuah 2019; 158:200-204. [PMID: 30916511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The direct oral anticoagulants (DOACs) are a class of drugs used for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation and for prevention and treatment of venous thrombo-embolism. They are as effective and are safer than the vitamin K antagonists that were the oral drugs previously used for this purpose. The DOACs are convenient to use because of their fixed dose-response relationship which makes routine monitoring of drug levels unnecessary. Further, they have no food interactions and relatively few drug interactions. A number of practical considerations related to the routine clinical use of the DOACs have become apparent. These include choosing the appropriate drug and importantly dose-based on patient characteristics, managing the use of DOACs peri-operatively and the appropriate management of the acutely bleeding DOAC-treated patient. Recent controlled and observational studies provide guidance for dealing with these clinical situations thus enhancing the efficacy and safety of DOAC treatment in routine clinical practice.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute, Meir Medical Center
- Blood Bank, Meir Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv ISRAEL
| | | | - Orly Avnery
- Hematology Institute, Meir Medical Center
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv ISRAEL
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Avnery O, Kenet G, Ellis MH. A Genetic Origin? Purpura Fulminans. Am J Med 2019; 132:327-328. [PMID: 30367859 DOI: 10.1016/j.amjmed.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/14/2018] [Accepted: 10/04/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Orly Avnery
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv, Israel.
| | - Gili Kenet
- Sackler School of Medicine, Tel Aviv, Israel; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Chaim Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
| | - Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv, Israel
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Arbel R, Hammerman A, Sergeinko R, Batat E, Greenberg-Dotan S, Avnery O, Ellis MH. Abstract 36: Direct Oral Anticoagulant Underdosing Increases Rates of Stroke and Myocardial Infarction With No Reduction in Bleeding Rate. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Direct oral anticoagulants (DOACs) reduce the risk of stroke and systemic embolism in non-valvular atrial fibrillation (NVAF) patients. The off-label prescription of lower dose DOACs is very common and usually represents an attempt to mitigate bleeding risk. Data regarding the effects of off-label DOAC lower dose on patient outcomes is limited. We evaluated the effectiveness and safety of off-label lower dose DOAC therapy in NVAF patients treated in routine clinical practice.
Hypothesis:
Off-label lower dose DOAC use is associated with higher risk of mortality, stroke and myocardial infarction (MI) and is not associated with a reduced bleeding rate.
Methods:
We identified all newly diagnosed NVAF patients initiating DOAC therapy in Clalit Health Services from 2011 to 2016. Effectiveness was defined as a composite of all-cause mortality, stroke and MI and safety was defined as bleeding requiring hospitalization. Patients were followed until May 15,2017 or until occurrence of an outcome event. The DOAC dose was determined based on electronic drug dispensing records. We compared the outcomes in patients treated with DOACs at per-label standard dose with those treated with off-label lower dose. Hazard ratios (HR) were adjusted for 21 variables, including socio-economic factors, co-morbidities and concomitant medications using multivariate regression.
Results:
During the study period 3,395 patients were treated with DOACs at per-label standard dose and 2,438 patients were treated with an off-label lower dose. Adjusted HR for the composite of mortality, stroke and MI in patients treated with off-label lower dose was 1.38 (95% CI: 1.13- 1.69, P=0.001), and for bleeding 1.34 (95% CI: 0.92-1.95, P=NS).
Conclusions:
In this cohort of NVAF patients treated in routine clinical practice, off-label lower dose of DOACs was associated with a higher risk of mortality, stroke and myocardial infarction and was not associated with a reduced bleeding rate. Our findings provide further support for encouraging adherence to the per-label dosage of DOAC therapy.
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Affiliation(s)
| | | | | | - Erez Batat
- Clalit Health Services, Tel Aviv, Israel
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21
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De Stefano V, Carobbio A, Di Lazzaro V, Guglielmelli P, Iurlo A, Finazzi MC, Rumi E, Cervantes F, Elli EM, Randi ML, Griesshammer M, Palandri F, Bonifacio M, Hernandez-Boluda JC, Cacciola R, Miroslava P, Carli G, Beggiato E, Ellis MH, Musolino C, Gaidano G, Rapezzi D, Tieghi A, Lunghi F, Loscocco GG, Cattaneo D, Cortelezzi A, Betti S, Rossi E, Finazzi G, Censori B, Cazzola M, Bellini M, Arellano-Rodrigo E, Bertozzi I, Sadjadian P, Vianelli N, Scaffidi L, Gomez M, Cacciola E, Vannucchi AM, Barbui T. Benefit-risk profile of cytoreductive drugs along with antiplatelet and antithrombotic therapy after transient ischemic attack or ischemic stroke in myeloproliferative neoplasms. Blood Cancer J 2018. [PMID: 29535299 PMCID: PMC5849668 DOI: 10.1038/s41408-018-0048-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Indexed: 01/30/2023] Open
Abstract
We analyzed 597 patients with myeloproliferative neoplasms (MPN) who presented transient ischemic attacks (TIA, n = 270) or ischemic stroke (IS, n = 327). Treatment included aspirin, oral anticoagulants, and cytoreductive drugs. The composite incidence of recurrent TIA and IS, acute myocardial infarction (AMI), and cardiovascular (CV) death was 4.21 and 19.2%, respectively at one and five years after the index event, an estimate unexpectedly lower than reported in the general population. Patients tended to replicate the first clinical manifestation (hazard ratio, HR: 2.41 and 4.41 for recurrent TIA and IS, respectively); additional factors for recurrent TIA were previous TIA (HR: 3.40) and microvascular disturbances (HR: 2.30); for recurrent IS arterial hypertension (HR: 4.24) and IS occurrence after MPN diagnosis (HR: 4.47). CV mortality was predicted by age over 60 years (HR: 3.98), an index IS (HR: 3.61), and the occurrence of index events after MPN diagnosis (HR: 2.62). Cytoreductive therapy was a strong protective factor (HR: 0.24). The rate of major bleeding was similar to the general population (0.90 per 100 patient-years). In conclusion, the long-term clinical outcome after TIA and IS in MPN appears even more favorable than in the general population, suggesting an advantageous benefit-risk profile of antithrombotic and cytoreductive treatment.
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Affiliation(s)
- Valerio De Stefano
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | | | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Biomedico di Roma, Rome, Italy
| | - Paola Guglielmelli
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Alessandra Iurlo
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | | | - Elisa Rumi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Elena Maria Elli
- Hematology Division, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | | | - Martin Griesshammer
- University Clinic for Hematology and Oncology Minden, University of Bochum, Bochum, Germany
| | - Francesca Palandri
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | | | - Rossella Cacciola
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Palova Miroslava
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
| | - Giuseppe Carli
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Eloise Beggiato
- Unit of Hematology, Department of Oncology, University of Torino, Torino, Italy
| | - Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, and Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Caterina Musolino
- Division of Hematology, Dipartimento di Patologia Umana dell'Adulto e dell'Età Evolutiva, Policlinico G Martino, University of Messina, Messina, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Davide Rapezzi
- S.C. Ematologia, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
| | - Alessia Tieghi
- Divisione di Ematologia, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Francesca Lunghi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Giuseppe Gaetano Loscocco
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Daniele Cattaneo
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | - Agostino Cortelezzi
- Hematology Division, IRCCS Ca' Granda - Maggiore Policlinico Hospital Foundation, and University of Milan, Milan, Italy
| | - Silvia Betti
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Elena Rossi
- Institute of Hematology, Catholic University, Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Guido Finazzi
- Hematology Division, Papa Giovanni XXIII hospital, Bergamo, Italy
| | - Bruno Censori
- Neurology Division, Papa Giovanni XXIII hospital, Bergamo, Italy
| | - Mario Cazzola
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Department of Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marta Bellini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Irene Bertozzi
- Department of Medicine - DIMED, University of Padua, Padova, Italy
| | - Parvis Sadjadian
- University Clinic for Hematology and Oncology Minden, University of Bochum, Bochum, Germany
| | - Nicola Vianelli
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Montse Gomez
- Hematology Department, Hospital Clínico Universitario, Valencia, Spain
| | - Emma Cacciola
- Department of Medical, Surgical and Advanced Technologies Sciences "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Alessandro M Vannucchi
- CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, and Departmentt Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII hospital, Bergamo, Italy.
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22
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Ellis MH, Koren-Michowitz M, Lavi N, Vannucchi AM, Mesa R, Harrison CN. Ruxolitinib for the management of myelofibrosis: Results of an international physician survey. Leuk Res 2017; 61:6-9. [PMID: 28843161 DOI: 10.1016/j.leukres.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/21/2017] [Accepted: 08/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ruxolitinib is established as treatment for symptomatic myeloproliferative neoplasm (MPN)-associated myelofibrosis. The strict inclusion and exclusion criteria and dose modification rules that applied to the COMFORTI and II studies that led to the licensing of ruxolitinib are not always applicable to routine clinical practice. Thus physicians now face decisions regarding ruxolitinib use that were not addressed in these pivotal trials. METHODS We performed an online survey of hematologists practicing in Europe, Israel, the United Kingdom and the United States. Demographic details regarding the physicians and their practice as relates to MPNs were collected. Management decisions pertaining to the use of ruxolitinib were obtained regarding 10 clinical scenarios relating to anemia, thrombocytopenia, frailty, infection and lack or loss of response to ruxolitnib in MF patients. RESULTS 140 physicians responded to the survey. There were marked differences regarding their decisions for ruxolitinib administration in MF patients with or developing anemia or thrombocytopenia. Similarly there was little consensus regarding management of patients refractory or losing a response to ruxolitinib. There were differences between "MPN-focused" and "non-MPN-focused" physicians in certain areas. CONCLUSION Physician practices regarding management of MF patients experiencing ruxolitinib-related toxicities or in whom response to the drug is lost was variable. This was true of "MPN-focused" and "non-MPN-focused" physicians in certain cases. Physician education and experience in using ruxolitinib may improve patient management.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Maya Koren-Michowitz
- Department of Hematology, Asaf HaRofeh Medical Center, Tzrifin, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Lavi
- Rambam Medical Center, Haifa, Israel; Bruce Rappoport Faculty of Medicine, Technion, Haifa, Israel
| | - Alessandro M Vannucchi
- Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Ruben Mesa
- Department of Hematology, Mayo Clinic Scottsdale, AZ, USA
| | - Claire N Harrison
- Department of Haematology, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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23
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Mausbach LS, Avnery O, Ellis MH. Ambulatory Versus In-Hospital Treatment of Proximal Lower-Limb Deep Vein Thrombosis in Adults: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2016; 23:859-864. [PMID: 27831528 DOI: 10.1177/1076029616677801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Complications of deep vein thrombosis (DVT) are related to adequacy of initial anticoagulant therapy. In this study, we analyze consecutive patients with lower-limb proximal DVT and compare the characteristics, treatment, and clinical outcomes of patients receiving entirely ambulatory treatment versus those hospitalized for initial treatment. METHODS This was a retrospective study of consecutive patients with a first proximal lower-limb DVT during a 2-year period. Patients were followed for 90 days. Major end points were all-cause mortality, bleeding requiring hospitalization, and recurrent venous thromboembolism (VTE). Events were determined for patients who were hospitalized versus those treated on an entirely ambulatory basis. RESULTS A total of 236 patients were included in the study. Of these, 147 patients were hospitalized and 89 patients received ambulatory treatment. There were 20 fatalities-18 in-hospital and 2 in-ambulatory patients ( P = .008). By multivariable Cox regression analysis, the presence of active cancer (hazard ratio [HR] = 5.44; confidence interval [CI]: 2.16-13.7; P = .001), age (HR = 1.06; CI: 1.02-1.1; P = .001), and hospitalization (HR = 5.73; CI: 1.33-24.69; P = .019) were associated with death. Eight hospitalized and 2 ambulatory patients required readmission because of bleeding. Age was the only variable associated with bleeding (HR = 1.10; CI: 1.03-1.18; P = .004). There were no recurrent VTE events. CONCLUSION In this study of routine management of proximal DVT, we demonstrate that patients suitable for ambulatory care are adequately identified by physicians and may be treated with equal safety and efficacy to hospitalized patients.
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Affiliation(s)
- Lisa S Mausbach
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orli Avnery
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H Ellis
- 1 Hematology Institute, Meir Medical Center, Kfar Saba, Israel.,2 Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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24
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De Stefano V, Vannucchi AM, Ruggeri M, Cervantes F, Alvarez-Larrán A, Iurlo A, Randi ML, Pieri L, Rossi E, Guglielmelli P, Betti S, Elli E, Finazzi MC, Finazzi G, Zetterberg E, Vianelli N, Gaidano G, Nichele I, Cattaneo D, Palova M, Ellis MH, Cacciola E, Tieghi A, Hernandez-Boluda JC, Pungolino E, Specchia G, Rapezzi D, Forcina A, Musolino C, Carobbio A, Griesshammer M, Barbui T. Splanchnic vein thrombosis in myeloproliferative neoplasms: risk factors for recurrences in a cohort of 181 patients. Blood Cancer J 2016; 6:e493. [PMID: 27813534 PMCID: PMC5148051 DOI: 10.1038/bcj.2016.103] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/16/2016] [Indexed: 12/13/2022] Open
Abstract
We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd–Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.
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Affiliation(s)
- V De Stefano
- Institute of Hematology, Catholic University, Roma, Italy
| | - A M Vannucchi
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - M Ruggeri
- Ospedale San Bortolo, Vicenza, Italy
| | | | - A Alvarez-Larrán
- Department of Hematology, Hospital del Mar-IMIM, Barcelona, Spain
| | - A Iurlo
- Oncohematology Division, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - M L Randi
- Clinica Medica 1, Università di Padova, Padova, Italy
| | - L Pieri
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - E Rossi
- Institute of Hematology, Catholic University, Roma, Italy
| | - P Guglielmelli
- Center for Research and Innovation of Myeloproliferative Neoplasms, A.O.U. Careggi, University of Florence, Florence, Italy
| | - S Betti
- Institute of Hematology, Catholic University, Roma, Italy
| | - E Elli
- Divisione di Ematologia, Ospedale San Gerardo, ASST Monza, Italy
| | - M C Finazzi
- Hematology Division, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - G Finazzi
- Hematology Division, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - N Vianelli
- Institute of Hematology and Medical Oncology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - G Gaidano
- Department of Translational Medicine, Università del Piemonte Orientale, Vercelli, Italy
| | - I Nichele
- Ospedale San Bortolo, Vicenza, Italy
| | - D Cattaneo
- Oncohematology Division, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - M Palova
- University Hospital of Olomouc, Olomouc, Czech Republic
| | - M H Ellis
- Department of Hematology, Institute Meir Medical Center, Kfar Saba, Israel
| | - E Cacciola
- Haemostasis Unit, Department of Medical, Surgical and Advanced Technologies Sciences 'G.F. Ingrassia', University of Catania, Catania, Italy
| | - A Tieghi
- Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | - E Pungolino
- A.O. Ospedale Niguarda Ca' Granda, Milano, Italy
| | - G Specchia
- A.O. Universitaria, Policlinico di Bari, Italy
| | - D Rapezzi
- A.O. Santa Croce e Carle, Cuneo, Italy
| | - A Forcina
- IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - A Carobbio
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - M Griesshammer
- Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - T Barbui
- FROM Research Foundation, ASST Papa Giovanni XXIII, Bergamo, Italy
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Ellis MH, Neuman T, Bitterman H, Dotan SG, Hammerman A, Battat E, Eikelboom JW, Ginsberg JS, Hirsh J. Bleeding in patients with atrial fibrillation treated with dabigatran, rivaroxaban or warfarin: A retrospective population-based cohort study. Eur J Intern Med 2016; 33:55-9. [PMID: 27296588 DOI: 10.1016/j.ejim.2016.05.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/20/2016] [Accepted: 05/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGOUND Randomized controlled trials (RCTs) have shown that dabigatran, rivaroxaban and warfarin cause similar bleeding rates. METHODS We performed a retrospective population-based cohort study to determine the incidence of bleeding in patients with atrial fibrillation (AF) beginning dabigatran, rivaroxaban or warfarin. Consecutive patients initiating anticoagulation for AF during a 3year period were identified using a computerized database. Patients who bled and required hospitalization underwent chart review. Bleeding incidences were calculated per 100 patient-years of treatment. RESULTS 18,249 patients were included: 9564 (52.4%) received warfarin, 5976 (32.7%) dabigatran, and 2709 (14.8%) rivaroxaban. Bleeding incidences were 3.9 (95% CI, 3.6-4.4) in warfarin-treated patients, 4.2 (95% CI, 3.7-4.7) in dabigatran patients, and 4.1 (95% CI, 3.0-5.3) in rivaroxaban patients. Intracranial hemorrhage (ICH) rates were 0.71 (95% CI, 0.56-0.90) for warfarin, 0.4 (95% CI, 0.18-0.87) for dabigatran, and 0.27 (95%CI, 0.10-0.80) for rivaroxaban. GI hemorrhage rates were 1.88 (95%CI, 1.62-2.20) for warfarin, 2.98 (95% CI, 2.4-3.5) for dabigatran and 2.39 (95%CI, 1.6-3.5) for rivaroxaban. CONCLUSIONS We demonstrate similar bleeding rates with both dabigatran 150mg and 110mg and rivaroxaban compared to warfarin.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, 59 Tchernichovsky St, Kfar Saba 44281 ISRAEL; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tsipora Neuman
- Department of Medicine D, Meir Medical Center, 59 Tchernichovsky St Kfar Saba 44281, ISRAEL
| | - Haim Bitterman
- Chief Physician's Office Clalit Health Services, 101 Arlozorov St 62098 Tel Aviv ISRAEL
| | - Sari Greenberg Dotan
- Chief Physician's Office Clalit Health Services, 101 Arlozorov St 62098 Tel Aviv ISRAEL
| | - Ariel Hammerman
- Chief Physician's Office Clalit Health Services, 101 Arlozorov St 62098 Tel Aviv ISRAEL
| | - Erez Battat
- Chief Physician's Office Clalit Health Services, 101 Arlozorov St 62098 Tel Aviv ISRAEL
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26
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Ellis MH, Hadari R, Tchuvrero N, Shapira S, Kovlenko I, Kozmiakova M, Zissin R, Elis A. Hemorrhagic Complications in Patients Treated with Anticoagulant Doses of a Low Molecular Weight Heparin (Enoxaparin) in Routine Hospital Practice. Clin Appl Thromb Hemost 2016; 12:199-204. [PMID: 16708122 DOI: 10.1177/107602960601200208] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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: 11/16/2022] Open
Abstract
Low molecular weight heparins (LMWHs) are a rapidly growing class of anticoagulant drug. Their efficacy has been demonstrated in several clinical settings where they are rapidly becoming the anticoagulant of choice. Controlled clinical studies in patients with deep vein thrombosis, pulmonary embolism, and unstable angina have documented that the frequency of major hemorrhage is 0.5-4%. The purpose of the study was to determine the frequency of minor and major hemorrhage occurring in patients receiving anticoagulant doses of an LMWH (enoxaparin) during routine clinical practice. A prospective, observational study of consecutive patients receiving enoxaparin 1 mg/kg twice daily for at least 24 hours in five internal medicine wards of a university teaching hospital was performed. Five hundred forty-nine patients were studied. The mean age was 67.5±15.5 years and the mean duration of enoxaparin therapy was 3.8±1.5 days. Hemorrhage was documented in a total of 94 patients (17.3%). Major hemorrhage occurred in 14 patients (2.6%), injection-site hemorrhage occurred in 55 patients (10%), and minor hemorrhage (noninjection site) was documented in 25 patients (4.7%). There were two deaths attributed to hemorrhage. Patients with major hemorrhage were older than patients with minor or no hemorrhage (75.5±10.4 versus 66.8±15.2 years; p=0.03) and occurred in patients receiving enoxaparin for a longer period (5.14±3.8 days) than those with minor (4±2.5 days) or no hemorrhage (2.9±2.1 days). Major hemorrhage was significantly associated with impaired renal function, chronic liver disease, and concomitant treatment with warfarin or a proton pump inhibitor. Enoxaparin used in anticoagulant doses in unselected medical patients is not associated with more major hemorrhagic complications than observed in controlled clinical trials. Major hemorrhage may be more likely in older patients, in patients with chronic liver disease and impaired renal function, in patients receiving prolonged enoxaparin therapy, and in patients receiving warfarin or proton pump inhibitors.
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Affiliation(s)
- Martin H Ellis
- Division of Transfusion Medicine, Meir Hospital and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Ellis MH, Lavi N, Mishchenko E, Dally N, Lavie D, Courevitch A, Gutwein O, Bulvik S, Braester A, Chubar E, Tavor S, Duek A, Kirgner I, Koren-Michowitz M. Ruxolitinib treatment for myelofibrosis: Efficacy and tolerability in routine practice. Leuk Res 2015; 39:S0145-2126(15)30356-8. [PMID: 26364797 DOI: 10.1016/j.leukres.2015.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/28/2015] [Accepted: 08/06/2015] [Indexed: 10/23/2022]
Abstract
Ruxolitinib has been shown in two randomized clinical trials to be effective in alleviating systemic symptoms and reducing spleen size in patients with myelofibrosis (MF). We retrospectively evaluated efficacy and tolerability of ruxolitinib in a cohort of unselected MF patients treated in routine clinical practice. One hundred and two patients who began ruxolitinib therapy were identified in 13 participating centers. Ninety three of the patients receiving ruxolitinib for at least 3 months were evaluated for treatment efficacy and toxicity. Median age at ruxolitinib initiation was 67 years. Indications for treatment were constitutional symptoms (15%), symptomatic splenomegaly (6%) or both (76%). Two patients received ruxolitinib for other indications. The median initial ruxolitinib dose was 30mg/day. Median duration of therapy was 11 months. Eighty two patients (88.2%) responded to therapy, 76 (84.4%) patients had improvement in constitutional symptoms and 60 patients (70.6%) had reduction in spleen length. While on ruxolitinib, 30% of patients had grade 3-4 anemia and 12.9% of patients had grade 3-4 thrombocytopenia. Thirteen patients (14%) discontinued therapy. This analysis of a cohort of MF patients treated with ruxolitinib in routine clinical practice demonstrates the efficacy and tolerability of this drug outside of a highly monitored clinical trial setting.
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Affiliation(s)
- Martin H Ellis
- Department of Hematology, Meir Medical Center, Kfar Saba, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Lavi
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel.
| | | | - Najib Dally
- Department of Hematology, Ziv Medical Center Associated with the Bar Ilan University, Faculty of Medicine, Safed, Israel
| | - David Lavie
- Department of Hematology and Bone Marrow Transplantation, Hebrew University-Hadassah Medical Organization, Jerusalem, Israel
| | - Anna Courevitch
- Department of Hematology and Bone Marrow Transplantation, Soroka Medical Center, Beer-Sheva, Israel
| | - Odit Gutwein
- Department of Hematology, Assaf Harofeh Medical Center, Ramla, Israel
| | - Shlomo Bulvik
- Department of Hematology, Laniado Hospital-Sanz Medical Center, Netanya, Israel
| | - Andrei Braester
- Department of Hematology, Western Galilee Hospital, Nahariya, Israel
| | - Evgeni Chubar
- Department of Hematology, The Emek Medical Center, Afula, Israel
| | - Sigal Tavor
- Maccabi Health Organization, Tel Aviv, Israel
| | - Adrian Duek
- Division of Hematology and Bone Marrow Transplantation, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilya Kirgner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Maya Koren-Michowitz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Hematology and Bone Marrow Transplantation, Sheba Medical Center, Tel Hashomer, Israel
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Abadi U, Ellis MH. [INTERNATIONAL NORMALIZED RATIO VALUES AND HEMORRHAGE IN HOSPITALIZED PATIENTS STARTING WARFARIN THERPY: AN OBSERVATIONAL STUDY]. Harefuah 2015; 154:490-542. [PMID: 26480611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Vitamin K antagonist (VKA) therapy is challenging because of the narrow therapeutic range, and the influence of numerous factors on the international normalized ratio (INR). During the beginning of warfarin treatment, INR must be assessed regularly in order to optimize treatment and minimize the risk for hemorrhage. In this study we examined the laboratory and clinical outcomes of a cohort of hospitalized patients starting warfarin treatment. AIMS To document the rate of patients with supra-therapeutic INR values and the rate of major hemorrhage, during the first month after starting warfarin. METHODS A prospective observational study of all patients admitted to Meir Medical Center starting warfarin treatment during a 3-month period. Baseline demographics, clinical data, warfarin dose, INR levels and bleeding events were documented. Patients were followed for 30 days after starting treatment with warfarin. RESULTS Fifty-seven patients who started VKA therapy were identified during the study period. The mean age was 71.2±13.1 years. Atrial fibrillation was the indication for treatment in 63.2% of patients, deep vein thrombosis in 19.3%, pulmonary embolus in 10.5% and other indications in 7% of patients. In the first 30 days of treatment, 60% of the patients had at least one INR value of >3. Of these patients, half had an INR of above 5. The number of concomitant medications were associated with INR values of >3. Arab patients tended to have a higher INR. Of note, there were 5 cases (8.8%) of major hemorrhage, which occurred with INR values ranging from 3.29 to >10, 4 of these patients were treated concomitantly with Aspirin. CONCLUSIONS In this cohort of hospitalized patients starting warfarin therapy, excessive INR values were commonly encountered. There was a significant incidence of major hemorrhage among the patients. Further studies to define risk factors for elevated INR values and hemorrhage in hospitalized patients are needed.
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Ellis MH. No(AC) free lunches: promises and pitfalls of novel oral anticoagulants. Isr Med Assoc J 2014; 16:377-378. [PMID: 25059002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Ellis MH, Lavi N, Vannucchi A, Harrison C. Treatment of thromboembolic events coincident with the diagnosis of myeloproliferative neoplasms: a physician survey. Thromb Res 2014; 134:251-4. [PMID: 24842684 DOI: 10.1016/j.thromres.2014.04.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [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: 01/31/2014] [Revised: 03/26/2014] [Accepted: 04/28/2014] [Indexed: 01/11/2023]
Abstract
The BCR-ABL1 negative myeloproliferative neoplasms (MPNs) are associated with an increased risk of both venous and arterial thromboembolic events. Thromboses may be the presenting clinical feature of an MPN or may occur during the course of the disease. Treatment comprises anticoagulant and antiaggregant agents as in non- MPN thromboses, and treatment of the particular MPN. The duration of anticoagulant treatment that is required for MPN thrombosis is unknown. This study was performed to survey the opinion of hematologists who treat patients with MPN regarding the duration of anticoagulation or antiaggregant therapy in patients in whom thrombosis is the presenting feature of MPN. Five clinical scenarios in which thromboembolism (cerebral vein thrombosis, pulmonary embolism, cerebrovascular accident, splanchnic vein thrombosis, portal vein thrombosis) was a presenting feature of MPN were created using a web-based tool and were sent by email to hematologists in Israel, Italy and England and to hematologists identified as key opinion leaders in the field of MPN. Physicians were asked to recommend duration of anticoagulation and/or aspirin use choosing from 4 alternatives provided. Seventy-three physicians responded to the survey. 42 physicians considered MPNs to be their main area of clinical interest, and 31 did not. 21 physicians saw more than 20 MPN patients per week, and 50 physicians had been in hematology practice for more than 10years. Responses regarding the duration of anticoagulation and/or the use of aspirin varied for all of the clinical vignettes. Neither physician area-of-interest, volume of MPN patients treated nor years in practice were related to the responses obtained. This study demonstrates that hematologists, including those specializing in MPNs, lack consensus in their approach to the long-term treatment of thromboses as the presenting feature of an MPN. Controlled clinical studies are needed to inform appropriate decision making in this area.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv university, Tel Aviv, Israel.
| | - Noa Lavi
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Alessandro Vannucchi
- Section of Hematology, Department of Critical Care, University of Florence, Florence, Italy
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder with an incidence of 3 to 5 per 100 000 individuals. In children, the disease is self-limited and is most commonly virus related (acute ITP) whereas in adults, the disease is typically chronic. The age distribution of adult ITP displays 2 peaks; the first in younger adults aged 18 to 40 with a female predominance and the second in people aged older than 60 with men and women affected equally. Our approach to ITP has evolved over the past several years: there has been a change in nomenclature and ITP now denotes “immune thrombocytopenia” (the “I” no longer denoting “idiopathic”) and “purpura” no longer features in the name of the disease; new insights into the pathogenesis of ITP have revealed the importance of impaired megakaryocytopoiesis in the condition; underlying mechanisms of secondary ITP have been elucidated and finally novel thrombopoietic agents have been shown to be effective in the treatment of ITP in randomized clinical trials. In this article, we review important recent advances in the pathogenesis and treatment of ITP.
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Affiliation(s)
- Uri Abadi
- Hematology Institute, Meir Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Osnat Yarchovsky-Dolberg
- Hematology Institute, Meir Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H. Ellis
- Hematology Institute, Meir Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
Superficial vein thrombosis (SVT) is an entity commonly encountered in practice. While the clinical diagnosis is reasonably straightforward, care must be taken to exclude concurrent thrombosis of the deep veins, and the possibility of the presence of occult systemic illness such as malignancy should be considered. Recent studies of the epidemiology of SVT demonstrate a high incidence of concurrent deep vein thrombosis emphasizing the need for surveying the deep veins using compression ultrasonography. Treatment decisions are may now be based upon the results of randomized clinical trials and should include a period of anticoagulation using fondaparinux or a low molecular weight heparin. The appropriate doses and duration of therapy are not fully established, and the cost-effectiveness of these drugs for the treatment of SVT needs further evaluation.
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Affiliation(s)
- Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel.
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Ellis MH, Baraf L, Shaish A, Har-Zahav A, Harats D, Ashur-Fabian O. Alteration of lipids and the transcription of lipid-related genes in myelodysplastic syndromes via a TP53-related pathway. Exp Hematol 2012; 40:540-547.e1. [DOI: 10.1016/j.exphem.2012.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/30/2012] [Accepted: 02/21/2012] [Indexed: 12/31/2022]
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Michaelov T, Blickstein D, Levy D, Berliner S, Ellis MH. Removal of retrievable vena cava filters in routine practice: a multicenter study. Eur J Intern Med 2011; 22:e87-9. [PMID: 22075319 DOI: 10.1016/j.ejim.2011.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [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] [Received: 07/20/2011] [Revised: 08/21/2011] [Accepted: 08/23/2011] [Indexed: 10/17/2022]
Abstract
UNLABELLED Vena cava filters (VCFs) are used to prevent pulmonary embolism when anticoagulation is contraindicated or in the event of progression of thrombosis despite adequate anticoagulation. Retrievable VCFs provide a potential advantage over permanent VCFs, but the appropriateness of their use and the frequency with which they are removed is not well established. OBJECTIVES Document the indications for insertion of retrievable VCFs, filter removal in hospital practice. METHODS Observational study conducted in three academic medical centers. Consecutive patients undergoing retrievable VCF insertion were identified. Clinical data was extracted from the patients' charts and follow up data were obtained from treating physicians after discharge. RESULTS 300 patients were studied. The indication for filter insertion was acute bleeding (46.1%) or surgery (24.2%) in patients with acute thrombosis, prevention of venous thromboembolism in trauma (13.3%), potential bleeding in patients with deep vein thrombosis (9.1%) thromboembolism while on adequate anticoagulation (5.7%) and other (1.3%). 21 (7%) filters were removed. An unsuccessful attempt at retrieval was undertaken in a further 9 (3%) patients. CONCLUSIONS The use of retrievable VCFs was appropriate, with the possible exception of their prophylactic use in major trauma. The majority of VCFs were not removed, for reasons that are not apparent.
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Abadi U, Butenero G, Kogan T, Ziv O, Paran H, Ellis MH. Prolonged Blood Storage Does Not Effect Survival in an Animal Model of Hemorrhagic Shock. ACTA ACUST UNITED AC 2011; 38:272-276. [PMID: 22016699 DOI: 10.1159/000330483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 05/10/2011] [Indexed: 01/25/2023]
Abstract
SUMMARY: BACKGROUND: Red blood cell (RBC) transfusion in hemorrhagic shock is life saving. However, several clinical trials have shown that blood transfusion in the critically ill patient might be associated with adverse outcomes. Furthermore, an association between prolonged blood storage and adverse effects of RBC transfusion has been postulated. The aim of this study is to examine the effect of blood storage time on resuscitation outcome, in an animal model of hemorrhagic shock. METHODS: 20 Wistar rats were phlebotomized in order to induce reversible hemorrhagic shock. Half of them were resuscitated with blood stored for a short period of time (4 days), and the other ones were resuscitated with blood stored for a prolonged time (14 days). Blood samples for hemoglobin, pH, lactate, bicarbonate and creatinine were drawn prior to the induction of shock and 24 h after resuscitation. Five days after resuscitation the animals were sacrificed, and liver, lung and kidney histology was examined. RESULTS: At 24 h after bleeding, the hemoglobin levels decreased by 3.2 and 1.7 g/dl, the pH decreased by 0.008 and 0.001, while the lactate levels increased by 1.6 and 2.7 mg/dl in the fresh and old blood resuscitation groups, respectively, with no significant difference between the groups. A trend toward more severe renal damage occurred in the old compared to the fresh blood resuscitation group (p = 0.089). CONCLUSION: The results of the present study show that in this animal model of hemorrhagic shock the duration of storage of RBCs used for transfusion did not affect the outcome of resuscitation.
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Affiliation(s)
- Uri Abadi
- Hematology Institute, Meir Medical Center Kfar Saba, Tel Aviv University, Israel
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Berger-Achituv S, Budde-Schwartzman B, Ellis MH, Shenkman Z, Erez I. Blood sampling through peripheral venous catheters is reliable for selected basic analytes in children. Pediatrics 2010; 126:e179-86. [PMID: 20566616 DOI: 10.1542/peds.2009-2920] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to determine the interchangeability of peripheral venous catheter (PVC) and venipuncture blood sampling (BS). METHODS Paired blood samples from hospitalized children were obtained through venipuncture and from existing PVCs, following discard of 2 mL of blood. Comparisons of 9 complete blood count indices (white and red blood cell counts, hemoglobin and hematocrit levels, mean corpuscular volume, mean corpuscular hemoglobin level, red blood cell distribution width, platelet count, and mean platelet volume) and 5 basic chemical analysis indices (sodium, potassium, glucose, chloride, and urea levels) were performed, and hemolysis was documented. RESULTS Irrespective of gauge, blood samples were obtained successfully from 40 (85.1%) of 47 PVCs, with no abnormal hemolysis. BS through venipuncture took longer than BS from PVCs (175.8 +/- 229.6 vs 104.5 +/- 53.4 seconds; P = .053) and was associated with significantly more distress/crying (73.1% vs 0%; P < .001). There were no significant differences between venipuncture and PVC samples (paired t test). Twenty-one (6%) of 348 pairs analyzed with the Clinical Laboratory Improvement Amendment standards fell outside the range of acceptable variance (8 of 21 aberrations were attributed to glucose measurements). Bland-Altman analysis indicated that, with the exclusion of glucose measurements, BS from PVCs is reliable, with 29 (6.5%) of 448 pairs exceeding the limits of agreement. Of those, 9 cases were clinically significant, but none would have altered clinical management. CONCLUSIONS PVC sampling was shown to be a pain-reducing method that can be used for children for selected basic analytes. The findings for glucose were unreliable.
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Abstract
OBJECTIVE To determine the prevalence of anemia in a cohort of patients with diabetes and normal serum creatinine concentration in a primary care clinic. METHODS We undertook a retrospective cohort study, comparing adult patients who had diabetes, with or without anemia. Patients older than 18 years who had diabetes were identified by using the computerized database for the years 2006 and 2007 in a primary care clinic. Patients with hemoglobin levels <13.7 g/dL (men <60 years old), < or =13.2 g/dL (men > or =60 years old), or <12.2 g/dL (women) with no known cause of anemia were identified and compared with patients who had diabetes but not anemia. All patients had normal serum creatinine levels (men < or =1.5 mg/dL and women < or =1.4 mg/dL). RESULTS Of 594 eligible patients with diabetes, 192 (32%) had anemia. Older age, higher serum urea and creatinine levels, lower estimated glomerular filtration rates, and reduced serum iron levels were more common in the patients with diabetes who had anemia than in those without anemia. The prevalence of anemia was higher in patients treated with "glitazones," insulin, and angiotensin receptor blockers in comparison with those receiving other orally administered hypoglycemic medications. In stepwise logistic regression analysis, only serum creatinine, age, and use of glitazones retained statistical significance. CONCLUSION In a community clinic, the prevalence of anemia in unselected patients with diabetes and normal serum creatinine levels was 32%. Factors associated with anemia were older age, higher serum creatinine levels, and use of glitazone therapy.
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Affiliation(s)
- Adiv Goldhaber
- Klalit Health Services, Family Practice, Eliezer Yafe, Ra'anana, Israel
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Hellmann I, Ellis MH. Prevention of venous thromboembolism in medical patients: recent advances and future directions. Isr Med Assoc J 2009; 11:753-757. [PMID: 20166345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Ilana Hellmann
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
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Kutchuk M, Edelstein Y, Ellis MH. Late relapse of Hodgkin's lymphoma presenting as fatal hematemesis caused by an esophago-tracheo-arterial fistula. Isr Med Assoc J 2009; 11:637-638. [PMID: 20077955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Michael Kutchuk
- Department of Pulmonology, Unit, Meir Medical Center, Kfar Saba , Israel
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Berger-Achituv S, Ellis MH, Curtis BR, Wolach B. Transfusion-related acute lung injury following intravenous anti-D administration in an adolescent. Am J Hematol 2008; 83:676-8. [PMID: 18383320 DOI: 10.1002/ajh.21185] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transfusion-related acute lung injury (TRALI) is associated with administration of all plasma containing blood products. We present a 14-year-old adolescent diagnosed with idiopathic thrombocytopenic purpura who developed acute respiratory insufficiency compatible with TRALI within 5 hr following intravenous anti-D. Full blown noncardiogenic pulmonary edema was noted after 9 hr. Mechanical ventilation was not required and the patient made a full recovery after 36 hr. Analysis of the anti-D preparation revealed reactivity against the neutrophil FcgammaRIIIb. A postinfusion serum sample contained antibodies against class I human HLA-A11 antigen. Clinicians should consider TRALI in patients developing unexplained dyspnea after receiving intravenous anti-D.
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Rebetzke GJ, Ellis MH, Bonnett DG, Richards RA. Molecular mapping of genes for Coleoptile growth in bread wheat (Triticum aestivum L.). Theor Appl Genet 2007; 114:1173-83. [PMID: 17294164 DOI: 10.1007/s00122-007-0509-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Accepted: 01/13/2007] [Indexed: 05/05/2023]
Abstract
Successful plant establishment is critical to the development of high-yielding crops. Short coleoptiles can reduce seedling emergence particularly when seed is sown deep as occurs when moisture necessary for germination is deep in the subsoil. Detailed molecular maps for a range of wheat doubled-haploid populations (Cranbrook/Halberd, Sunco/Tasman, CD87/Katepwa and Kukri/Janz) were used to identify genomic regions affecting coleoptile characteristics length, cross-sectional area and degree of spiralling across contrasting soil temperatures. Genotypic variation was large and distributions of genotype means were approximately normal with evidence for transgressive segregation. Narrow-sense heritabilities were high for coleoptile length and cross-sectional area indicating a strong genetic basis for differences among progeny. In contrast, heritabilities for coleoptile spiralling were small. Molecular marker analyses identified a number of significant quantitative trait loci (QTL) for coleoptile growth. Many of the coleoptile growth QTL mapped directly to the Rht-B1 or Rht-D1 dwarfing gene loci conferring reduced cell size through insensitivity to endogenous gibberellins. Other QTL for coleoptile growth were identified throughout the genome. Epistatic interactions were small or non-existent, and there was little evidence for any QTL x temperature interaction. Gene effects at significant QTL were approximately one-half to one-quarter the size of effects at the Rht-B1 and Rht-D1 regions. However, selection at these QTL could together alter coleoptile length by up to 50 mm. In addition to Rht-B1b and Rht-D1b, genomic regions on chromosomes 2B, 2D, 4A, 5D and 6B were repeatable across two or more populations suggesting their potential value for use in breeding and marker-aided selection for greater coleoptile length and improved establishment.
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Affiliation(s)
- G J Rebetzke
- CSIRO Plant Industry, GPO Box 1600, Canberra, ACT, 2601, Australia.
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Ellis MH, Ashur-Fabian O, Trakhtenbrot L, Amariglio N. A clonal hypereosinophilic syndrome with specific and effective therapy: a report of two cases. Isr Med Assoc J 2006; 8:836-7. [PMID: 17214097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Martin H Ellis
- Division of Transfusion Medicine, Meir Hospital, Kfar Saba, Israel.
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Abstract
INTRODUCTION Characteristics and outcomes of patients undergoing inferior vena cava (IVC) filter insertion are not well reported. Particularly, the role of long term anticoagulation in these patients is unclear. AIMS (1) To describe in a cohort of patients undergoing IVC filter insertion, underlying diseases, indications for filter insertion, complications, and survival. (2) To determine the effect of long term anticoagulant treatment on thromboembolism and patient survival. STUDY DESIGN A retrospective analysis of 109 consecutive patients undergoing IVC filter insertion in two university hospitals. RESULTS Average age was 67.4 years. Median duration of follow up was two years. Indications for IVC filter insertion were: contraindication to anticoagulation (n = 61, 56%), prophylactic insertion (n = 29, 27%), thromboembolism while receiving adequate anticoagulation (n = 17, 15%), and non-compliance with anticoagulation (n = 2, 2%). Insertion related complications were groin haematoma in four patients (3.5%) and localised infection at the puncture site in one patient (0.9%). Fifty six patients (51.4%) died during the study period. Of these, 22 received long term anticoagulants and 34 did not. Overall and thrombosis free survival was greater in the anticoagulant treated group (median survival not reached) than in the untreated group (median survival = 12 months). Patients not receiving long term anticoagulation after IVC filter insertion were nearly 2.5-fold more likely to die or experience venous thromboembolism. CONCLUSION IVC filter insertion was a safe procedure and was performed for appropriate indications in the patients studied. In patients surviving for longer than 30 days, prolonged administration of oral anticoagulants was associated with improved survival with no significant increase in haemorrhagic complications.
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Affiliation(s)
- Z Dovrish
- Department of Medicine C, Meir Hospital and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
The antiphospholipid (APLA) syndrome is defined as the occurrence of venous or arterial thromboembolism or recurrent fetal loss in patients with a positive anticardiolipin (aCL) or lupus anticoagulant test on two occasions, 3 months apart. In this study, we sought to determine whether the level of C-reactive protein (CRP), a non-specific inflammatory marker, at the time of the initial positive aCL test is a predictor of the transient vs. sustained nature of the aCL. Patients with a positive aCL antibody test underwent high sensitivity (hs) CRP testing. A repeat aCL antibody assay was performed on a serum sample obtained 3-4 months later. The positive and negative predictive values of the hs-CRP assay as a predictor of the second aCL result were calculated and correlation between the hs-CRP result and second aCL result was determined. Fifty-four consecutive patients with a positive aCL test were studied. Forty-two had a positive aCL-2. The predictive value of a negative CRP test for a positive aCL-2 was found to be 82.5% (33 of 42 patients). A positive CRP was able to predict a negative aCL-2 in 35.7% of cases (nine of 14 patients). Our results suggest that the hs-CRP test may be useful in the assessment of patients with a positive aCL antibody test. A concurrently performed negative hs-CRP test result may be useful in making diagnostic and therapeutic decisions.
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Affiliation(s)
- Orit Twito
- Department of Internal Medicine A, Meir Hospital, Kfar Saba and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ellis MH. Hemorrhagic complications of low molecular weight heparins (LMWHs). Isr Med Assoc J 2005; 7:822-3. [PMID: 16382711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Ellis MH, Rebetzke GJ, Azanza F, Richards RA, Spielmeyer W. Molecular mapping of gibberellin-responsive dwarfing genes in bread wheat. Theor Appl Genet 2005; 111:423-30. [PMID: 15968526 DOI: 10.1007/s00122-005-2008-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Accepted: 03/17/2005] [Indexed: 05/03/2023]
Abstract
Opportunities exist for replacing reduced height (Rht) genes Rht-B1b and Rht-D1b with alternative dwarfing genes for bread wheat improvement. In this study, the chromosomal locations of several height-reducing genes were determined by screening populations of recombinant inbred lines or doubled haploid lines varying for plant height with microsatellite markers. Linked markers were found for Rht5 (on chromosome 3BS), Rht12 (5AL) and Rht13 (7BS), which accounted for most of the phenotypic variance in height in the respective populations. Large height differences between genotypes (up to 43 cm) indicated linkage to major height-reducing genes. Rht4 was associated with molecular markers on chromosome 2BL, accounting for up to 30% of the variance in height. Confirming previous studies, Rht8 was linked to markers on chromosome 2DS, whereas a population varying for Rht9 revealed a region with a small but significant height effect on chromosome 5AL. The height-reducing effect of these dwarfing genes was repeatable across a range of environments. The molecular markers developed in this study will be useful for marker-assisted selection of alternative height-reducing genes, and to better understand the effects of different Rht genes on wheat growth and agronomic performance.
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Affiliation(s)
- M H Ellis
- Graingene, 65 Canberra Avenue, Griffith, ACT 2603, Australia.
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Segev A, Ellis MH, Segev F, Friedman Z, Reshef T, Sparkes JD, Tetro J, Pauzner H, David D. High prevalence of thrombophilia among young patients with myocardial infarction and few conventional risk factors. Int J Cardiol 2005; 98:421-4. [PMID: 15708174 DOI: 10.1016/j.ijcard.2003.10.057] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [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] [Received: 07/02/2003] [Revised: 10/15/2003] [Accepted: 10/25/2003] [Indexed: 11/17/2022]
Abstract
BACKGROUND Thrombophilia refers to series of acquired and inherited conditions that confer a tendency to thrombus formation. The exact relationship between thrombophilia and MI is not well established. OBJECTIVES To determine the prevalence of thrombophilia in young patients with their first MI and few conventional risk factors. METHODS We evaluated the baseline characteristics and the thrombophilia profile, including anti-cardiolipin antibodies, activated protein C resistance (APCR) with the factor V Leiden mutation, prothrombin G20210A mutation, protein C, protein S, and antithrombin-III levels, among 85 consecutive patients (<50 year old) who were admitted to CCU with their first MI. Patients were divided into two groups: group A-patients with < or =1 risk factor and group B-patients with > or =2 risk factors. RESULTS 92% were male and 55% with anterior wall MI. Overall, the risk factor profile was: smoking in 60%, hyperlipidemia in 42%, positive family history in 29%, hypertension in 18%, diabetes mellitus in 13%, and obesity in 8%. Forty-seven percent of patients had < or =1 risk factor (n=40, group A) and 53% had > or =2 risk factors (n=45, group B). The prevalence of the prothrombin mutation was 15% in group A compared to 7% in group B (p=0.12). APCR secondary to a heterozygous genotype of factor V Leiden mutation was found in 20% in group A compared to 2% in group B (p<0.01). Anti-cardiolipin antibodies were found in 16% in group A compared to 22% in group B (p=ns). Finally, we have found that the likelihood of identifying at least one thrombophilia marker was 50% in group A compared to 29% in group B (p=0.046). CONCLUSIONS The likelihood to detect at least one thrombophilia marker in young patients with MI and few conventional risk factors is significantly high. Thrombophilia may contribute to the development of MI in this specific group of young patients.
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Affiliation(s)
- Amit Segev
- Department of Cardiology, Meir General Hospital, Kfar-Saba, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Ellis MH. Artificial neural networks for anticoagulant management--think again! Isr Med Assoc J 2004; 6:770-1. [PMID: 15609893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Abstract
BACKGROUND While extensive data support the clinical benefit and cost-effectiveness of routine thromboprophylaxis in surgical patients, the use of this approach in medical patients has been controversial. However, recent data, mainly from the MEDENOX trial, support routine thromboprophylaxis in acutely ill medical patients. AIM To determine attitudes towards VTE prevention in such patients, in departments of internal medicine in Israel. DESIGN Questionnaire-based survey. METHODS A questionnaire regarding aspects of VTE prophylaxis was mailed to all heads of internal medicine departments in Israel (n = 90). The questionnaire also included data concerning VTE prevention measures in specific acute medical illnesses, based on the MEDENOX study population. RESULTS Fifty-eight (64%) departments returned the questionnaire. Forty-seven (81%) of them considered VTE a clinical problem in their departments, but only 37 (63%) had a routine VTE prevention policy. The most frequently used modality for VTE prophylaxis was low-molecular-weight heparin. There was little agreement concerning the exact indications or risk factors in which VTE prophylaxis measures should be used, except the combination of acute medical disabling illness and previous VTE. DISCUSSION The results emphasize the need for detailed guidelines and risk assessment models for VTE prevention treatments in acutely ill medical patients, as well as better education for physicians.
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Affiliation(s)
- A Elis
- Department of Medicine 'A', Sapir Medical Center, Meir Hospital, 44281 Kfar Saba, Israel.
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Abstract
OBJECTIVE Postoperative venous thromboembolism (VTE) represents a serious threat to patients undergoing surgical procedures. Without thromboprophylaxis, deep vein thrombosis occurs in up to 60% of patients undergoing major orthopedic surgery and 15% of patients undergoing major abdominal surgery. Although, many studies have shown the efficacy of pharmacologic and mechanical means of VTE prophylaxis, practice variations in this area abound worldwide. The purpose of this study was to determine the attitudes and practice of VTE prophylaxis of academic surgical department heads in Israel. METHODS A questionnaire covering various aspects of VTE prophylaxis was mailed to all surgical department heads of university teaching hospitals in Israel. Three months later, the same questionnaire was sent to department heads who had not yet replied. Data retrieved from the returned questionnaires were analyzed. RESULTS A total of 250 departments in 23 hospitals affiliated to the four medical schools in Israel were identified; 130 department heads (52%) returned the questionnaires. The current study analyzes results obtained from the general surgical, orthopedic, urological, vascular and gynecological departments only. The total number of responses from these departments was 90 (69% response rate). Sixty-seven percent of the departments considered VTE to be a clinical problem. Ninety-four percent of departments have a policy for VTE prophylaxis. The most frequently used modalities for VTE prophylaxis (more than one option possible) were low-molecular-weight heparin (LMWH) (59%), unfractionated heparin (43%) and an intermittent pneumatic compression device (20%). VTE prophylaxis is begun 12 h preoperatively by 33% of departments, 2-4 h preoperatively by 20% of departments and with premedication by 8% of departments. VTE prophylaxis was continued during the postoperative period by all departments, with 52% stopping prophylaxis upon patient mobilization. Bleeding complications have been noted by 55% of departments, of these 9% were considered major. In general surgical, orthopedic and gynecologic departments, VTE prophylaxis was widely used for those procedures for which published guidelines exist, while considerable variation in VTE prophylaxis administration was demonstrated in a number of commonly encountered clinical situations for which there are no published recommendations. CONCLUSIONS This study confirms that academic surgical departments in Israel conform to standard VTE prophylaxis guidelines. However, considerable variations in practice exist regarding the means of prophylaxis, onset of prophylaxis and its duration. These areas should be the focus of ongoing educational efforts including the development of uniform practice guidelines to improve the quality of care regarding VTE prophylaxis. Furthermore, attention should be given to methods for decreasing hemorrhage caused by LMWH and unfractionated heparin usage.
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Affiliation(s)
- Martin H Ellis
- Blood Bank, Meir Hospital, Kfar Saba and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Irael.
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