Case-control analysis of venous thromboembolism risk in non-alcoholic steatohepatitis diagnosed by transient elastography

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Studies have shown a strong association between non-alcoholic steatohepatitis (NASH) cirrhosis and portal vein thrombosis. Specifically, there is paucity of data on the association of NASH and venous thromboembolism (VTE), with one such study predicting a 2.5-fold increased risk for VTE compared to other liver diseases in hospitalized patients. The mechanism is believed to be a hepatocellular injury, which causes a chronic inflammatory state leading to the unregulated activation of procoagulant factors. There has been no prior analysis of the degree of steatosis and fibrosis (measured using transient elastography, commonly known as FibroScan) in NASH and its association with VTE.

AIM

To examine the association between the degree of hepatic steatosis and fibrosis, quantified by transient elastography, and the incidence of VTE in patients with NASH.

METHODS

In our case-control study, we included patients with a documented diagnosis of NASH. We excluded patients with inherited thrombophilia, hemoglobinopathy, malignancy, alcohol use disorder, autoimmune hepatitis, and primary biliary cirrhosis. The collected data included age, demographics, tobacco use, recreational drug use, medical history, and vibration controlled transient elastography scores. VTE-specific data included the location, type of anticoagulant, need for hospital stay, and history of VTE recurrence. Steatosis was categorized as S0-S1 (mild) and S2-S3 (moderate to severe) based on the controlled attenuation parameter score. Fibrosis was classified based on the kilopascal score and graded as F0-F1 (Metavir stage), F2, F3, and F4 (cirrhosis). χ2 and Mann-Whitney U tests were used for the qualitative and quantitative variable analyses, respectively. Furthermore, we performed a logistic regression using VTE as the dependent variable.

RESULTS

A total of 415 patients were analyzed, and 386 met the inclusion criteria. 51 and 335 patients were included in the VTE and non-VTE groups, respectively. Patients with VTE had a mean age of 60.63 years compared to 55.22 years in the non-VTE group (P < 0.014). Patients with VTE had a higher body mass index (31.14 kg/m² vs 29.30 kg/m²) and a higher prevalence of diabetes mellitus (29.4% vs 13.1%). The history of NASH was significantly higher in the VTE group (45.1% vs 30.4%, P < 0.037). Furthermore, moderate-to-severe steatosis was significantly higher in the VTE group (66.7% vs 47.2%, P < 0.009). Similarly, the F2-F4 fibrosis grade had a prevalence of 58.8% in the VTE group compared to 38.5% in the non-VTE group (P < 0.006). On logistic regression, using VTE as a dependent variable, diabetes mellitus had an odds ratio (OR) =1.702 (P < 0.015), and F2-F4 fibrosis grade had an OR = 1.5 (P < 0.033).

CONCLUSION

Our analysis shows that NASH is an independent risk factor for VTE, especially deep vein thrombosis. There was a statistically significant association between the incidence of VTE, moderate-to-severe steatosis, and fibrosis. All hospitalized patients should be considered for medical thromboprophylaxis, particularly those with NASH.

Long term follow-up of a multicentre cohort of COVID-19 patients with pulmonary embolism: Anticoagulation management and outcomes

BACKGROUND AND AIMS

Pulmonary embolism (PE) is a frequent complication in COVID19 hospitalized patients. Inflammatory storm and endothelial dysfunction due to the virus seem to be the two major risk factors for PE. Consequently, PE related to COVID19 could be consider as triggered by a transient inflammatory acute phase and treated for no longer than 3 months. However, few data are available on management of anticoagulation and risk of venous thromboembolic (VTE) recurrences in these patients and guidelines are still undefined. Aim of the present study is to evaluate the long-term follow-up of a cohort of covid-19 patients with PE.

METHODS

We conducted a retrospective multicenter study in four Italian hospitals between March 1st, 2020, and May 31st, 2021 in patients who experienced a PE during hospitalization for a COVID-19 pneumonia, excluding patients who died during hospitalization. Baseline characteristics were collected and patients were grouped according to duration of anticoagulant treatment (< 3 months or > 3 months). The primary outcome was incidence of VTE recurrence while secondary outcome was the composite of deaths, major hemorrhages and VTE recurrence during follow-up.

RESULTS

106 patients with PE were discharged, of these 95 (89.6 %) had follow up longer than 3 months (seven patients were lost to follow up and four died within three months). The median follow-up was 13 months (IQR 1-19). Overall, 23 % of subjects (22/95) were treated for 3 months or less and 76.8 % (73/95) received anticoagulation for >3 months. Of patients in the short treatment group, 4.5 % died, compared with 5.5 % of those in the longer treatment group (p = NS); no difference was shown in risk of VTE recurrence (0 % vs 4.1 %, p = NS), major bleeding (4.5 % vs 4.1 %, p = NS) or in composite outcome (9.1 % vs 11 %, p = NS). No difference was found between the two treatment groups for composite outcome using the Kaplan-Meier analysis (Log Rank Test p = 0.387).

CONCLUSION

In our retrospective multi-center cohort, prolongation of duration of anticoagulation seems not to affect risk of VTE recurrences, deaths and bleeding after a PE related to COVID-19.

Challenging clinical scenarios for therapeutic anticoagulation: A practical approach

Therapeutic anticoagulation remains a fundamental backbone in the treatment and prevention of venous thromboembolism. However, while modern therapies are increasingly safe, anticoagulation is not without risks, particularly in those at high risk for or with recent bleeding. When weighing concurrent risks and benefits in each challenging clinical scenario, an individualized assessment of the risk and acuity of bleeding should be balanced by the indication for anticoagulation. Addressing modifiable risk factors and routine re-evaluation of any changes in this balance is critical. This review outlines available data and current guidelines for the management of anticoagulation in high-risk populations, including those with thrombocytopenia, elderly and high-fall risk, inherited bleeding disorders, and in acute coronary syndrome. We also examine management after clinically significant bleeding episodes, including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, retroperitoneal bleeding, hematuria, and abnormal uterine bleeding. The aim is to provide a comprehensive review of available literature to guide clinicians in providing optimal, safe, and individualized care for patients in these challenging scenarios.

A smartphone application for remote adjustment of warfarin dose: Development and usability study

AIM

The aim of this article is (a) to design and develop a smartphone app called Alfalfa that can provide remote dose adjustment (b) to evaluate its usability.

BACKGROUND

Patients taking warfarin need to spend substantial time, money, and energy frequently visiting the hospital in order to adjust its dose. Internet technology may be able to provide convenient dose adjustment services for these patients.

METHODS

We thought and discussed repeatedly about how to ensure the safety and effectiveness of remote administration of warfarin, and finally designed and developed the Alfalfa app. In addition, patients and medical practitioners were invited to participate in a system usability scale (SUS) to assess the usability of Alfalfa.

RESULTS

As of July 5, 2021, the number of Alfalfa accounts was 1736, including 1624 patients and 112 medical staff, and it provided a total of 12,968 remote dose adjustments. A total of 26 people participated in the questionnaire, including 15 patients and 11 medical staff. The results of SUS show that the usability score of patient terminal and medical terminal is 61.8 and 82.7, respectively. And age does not affect the usability of patient terminal. The usability of the Alfalfa app was rated similarly by younger and older adults (63.5 vs. 58.5, P = .535).

CONCLUSIONS

This study proves that the Alfalfa app can be used for remote management of warfarin. The usability of medical terminal is acceptable to medical practitioners, while the usability of patient terminal needs further improvement.

TRIAL REGISTRATION

ChiCTR1900021920.

Pharmacists views on participating in New Zealand's community pharmacy anticoagulation management service: a mixed-methods study

Background Optimal anticoagulation management is key for improving outcomes. The Community Pharmacy Anticoagulation Management Service (CPAMS) has beneficial effects on anticoagulant management. However, limited research exists on pharmacists' views of CPAMS provision, particularly the perspectives of pharmacists who do not provide CPAMS. Objectives To explore the experience and attitudes of pharmacists who do and do not provide CPAMS, and to identify factors that may influence further uptake of CPAMS. Setting CPAMS providing and non-providing pharmacies throughout New Zealand. Methods A mixed-methods study design was employed. Separate online surveys were conducted with CPAMS providers (N = 35) and non-providers (N = 73) to explore their views on the service. Twelve interviews were conducted with purposively selected participants, equally distributed between CPAMS providers and non-providers, to gain further insight into the issues surrounding CPAMS provision. Quantitative data were analysed using student's t-test and Mann Whitney U-test, and thematic analysis was used for qualitative data. Main outcome measure Experiences of and attitudes towards CPAMS. Results Our survey findings demonstrated that community pharmacists have high self-efficacy and motivation to providing CPAMS, and CPAMS had increased job satisfaction amongst providers. The overwhelming majority of CPAMS providers' survey participants believed that CPAMS improves the pharmacist-patient relationship, allowing them to assist patients with other aspects of their healthcare. Most non-provider survey participants also believed that their patients would benefit from CPAMS. The two most frequently reported barriers by non-providers survey participants were remuneration and staffing of pharmacists. The interview findings fell within five overarching themes: self-efficacy, CPAMS benefits to patients, barriers to providing CPAMS, the impact of CPAMS on pharmacist-patient and pharmacist-general practitioner relationships. Overall, the current funding model, the capping on the number of enrolled patients, and staffing were the main factors perceived by interview participants preventing the further uptake and implementation of CPAMS. CPAMS non-providers are willing to provide CPAMS; the main factor preventing this is availability of contracts. Conclusions Overall, pharmacists have favourable experiences of and attitudes towards CPAMS and strongly supported its wider implementation. Promoting the benefits and addressing the barriers highlighted in this study may lead to wider implementation of CPAMS.

Patient satisfaction with community pharmacist-led anticoagulation management services and its relationship with patient characteristics in New Zealand

Background Community pharmacist-led anticoagulation management service (CPAMS) offers international normalised ratio point-of-care testing of warfarin in a community pharmacy setting. It has now expanded with 7,344 patients enrolled in the service across 164 pharmacies in New Zealand. The clinical benefit of CPAMS has been shown to be superior, but patient satisfaction with the service has not been fully explored. Objective To develop a questionnaire to assess patient satisfaction with CPAMS and evaluate its psychometric properties. Additionally, to determine the level of patient satisfaction with CPAMS and identify determinants of satisfaction with CPAMS. Settings 1071 patients enrolled in CPAMS across New Zealand invited to take part in the study. Main outcome measure Satisfaction with CPAMS service. Methods Adult patients taking warfarin and currently enrolled in CPAMS were recruited through the national international normalised ratio online system and invited to complete a 36-item survey assessing satisfaction with CPAMS. To identify the most important dimensions of patient satisfaction, exploratory factor analysis was used. Multivariate linear regression models were used to examine the effect of independent variables on patient satisfaction. Results A total of 305 patients completed the survey. The mean overall satisfaction score was 94.5% ± 13.1 out of maximum possible points. Five dimensions of patient satisfaction were identified by factor analysis: patient-centred communication, confidence in pharmacist competence, patient-pharmacist relationship, confidence in CPAMS, and pharmacy environment. Being older and more frequent visits to a pharmacy were positively associated with patient satisfaction. Living more than 1 km away from a pharmacy, and 'poor' self-perceived health status were negative predictors of patient satisfaction. Being Māori or of other ethnic minority was also associated with lower satisfaction scores, exploratory analysis suggests patient-pharmacist relationship is an important driver of these differences. Conclusions The high level of patient satisfaction further supports the effectiveness of CPAMS as a delivery model. Patient satisfaction is affected by age, frequency of pharmacy visits, ethnicity, travel distance to pharmacy, and perceived health status. Policy makers and practitioners should consider the characteristics of patients with low levels of satisfaction to improve and enhance CPAMS engagement.

[Reconstruction of lower limbs in old age-an interdisciplinary approach : Geriatric assessment, perioperative management, diagnostics and treatment targets]

Complex injuries of the lower extremities in geriatric patients with multiple pre-existing comorbidities represent an increasing challenge to an interdisciplinary team of surgeons. Functional reconstruction of the extremity through osteosynthesis, revascularization and defect coverage aims to preserve mobility and achieve an early return to activities of daily life at home, while avoiding major amputation and the associated risks regarding morbidity and mortality. An interdisciplinary assessment of geriatric patients regarding dystrophy of soft tissue and skín, cardiovascular and metabolic comorbidities as well as specific geriatric diagnostics are crucial steps in ensuring favorable outcomes. Perioperatively, all improvable risk factors should be actively optimized and a specialized interdisciplinary approach to treatment planning (extremity board) is absolutely necessary for success of treatment. It outlines the special features of the geriatric assessment, diagnostics, perioperative management and treatment targets.

Pulmonary Embolism Response Team: Inpatient Structure, Outpatient Follow-up, and Is It the Current Standard of Care?

Pulmonary Embolism Response Teams (PERTs) are being created around the United States to immediately and simultaneously bring together multiple specialists to determine the best course of action and coordinate clinical care for patients with severe pulmonary embolism (PE). The organization and structure of each PERT will depend on local clinical demands and resources. Creating a follow up clinic for PE patients after discharge from the hospital is an essential component of any PERT program. PERT programs, which have come together to form the PERT Consortium®, are changing the landscape of PE treatment and may represent a new standard of care.

Periprocedural anticoagulation during left atrial ablation: interrupted and uninterrupted vitamin K-antagonists or uninterrupted novel anticoagulants

Background

There is a lack of data on anticoagulation requirements during ablation of atrial fibrillation (AF). This study compares different oral anticoagulation (OAC) strategies to evaluate risk of bleeding and thromboembolic complications.

Methods

We conducted a single-centre study in patients undergoing left atrial ablation of AF. Three groups were defined: 1) bridging: interrupted vitamin-K-antagonists (VKA), INR ≤2, and bridging with heparin; 2) VKA: uninterrupted VKA and INR of > 2; 3) DOAC: uninterrupted direct oral anticoagulants. Bleeding complications, thromboembolic events and peri-procedural heparin doses were assessed.

Results

In total, 780 patients were documented. At 48 h, major complications were more common in the bridging group compared to uninterrupted VKA and DOAC groups (OR: 3.42, 95% CI: 1.29–9.10 and OR: 3.01, 95% CI: 1.19–7.61), largely driven by differences in major pericardial effusion (OR: 4.86, 95% CI: 1.56–15.99 and OR: 4.466, 95% CI, 1.52–13.67) and major vascular events (OR: 2.92, 95% CI: 0.58–14.67 and OR: 9.72, 95% CI: 1.00–94.43). Uninterrupted VKAs and DOACs resulted in similar odds of major complications (overall OR: 1.14, 95% CI: 0.44–2.92), including cerebrovascular events (OR: 1.21, 95% CI: 0.27–5.45). However, whereas only TIAs were observed in DOAC and bridging groups, strokes also occurred in the VKA group. Rates of minor complications (pericardial effusion, vascular complications, gastrointestinal hemorrhage) and major/minor groin hemorrhage were similar across groups.

Conclusion

Our dataset illustrates that uninterrupted VKA and DOAC have a better risk-benefit profile than VKA bridging. Bridging was associated with a 4.5× increased risk of complications and should be avoided, if possible.

Poor anticoagulation relates to extended access times for cardioversion and is associated with long-term major cardiac and cerebrovascular events

BACKGROUND

Patients undergoing elective electrical cardioversion (ECV) for atrial fibrillation have a temporarily increased risk of thromboembolism. Current guidelines recommend adequate anticoagulation for ≥3 consecutive weeks precardioversion, i.e. consecutive INR values 2.0-3.0 in patients with vitamin K antagonists (VKA). We aimed to evaluate the occurrence and impact of subtherapeutic INRs precardioversion and to study factors associated with these unwanted fluctuations.

METHODS

We recruited 346 consecutive patients undergoing elective ECV in the Maastricht University Medical Centre between 2008 and 2013. Predictors of subtherapeutic INR values were identified and incorporated into a logistic regression model.

RESULTS

A subtherapeutic INR precardioversion occurred in 55.2% of patients. The only statistically significant predictor was VKA-naivety (Odds Ratio (OR) 4.78, 95% Confidence Interval (CI) 2.67-8.58, p<0.001). In patients with ≥1 subtherapeutic INR precardioversion, time from referral until cardioversion was 91.1±42.8days, compared to 41.7±26.6days (p<0.001) in patients without subtherapeutic INRs. No thromboembolic events occurred <30days after the ECV. Independent predictors for the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion (n=30, median follow-up of 374days) were coronary artery disease in the history (OR 3.35, 95%CI 1.54-7.25, p=0.002) and subtherapeutic INR precardioversion (OR 3.64, 95%CI 1.43-9.24, p=0.007).

CONCLUSIONS

The use of VKA often results in subtherapeutic INRs precardioversion and is associated with a significant delay until cardioversion, especially in patients with recent initiation of VKA therapy. Furthermore, subtherapeutic INR levels prior to ECV are associated with the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion.

Venous thromboembolism treatment outcomes in cancer patients and effect of third-party payers on anticoagulant choice

PURPOSE

The purpose of this study is to compare the rates of recurrent VTE among cancer patients treated with parenteral agents to the oral anticoagulants.

METHODS

This single-center study was a retrospective chart review of cancer patients with recurrent VTE between January 1, 2009 and December 31, 2014. The primary outcome of the study is the rate of recurrent VTE in patients who received a parenteral anticoagulant (enoxaparin, dalteparin, fondaparinux) versus those who received oral anticoagulants (warfarin and rivaroxaban). Other outcomes investigated include risk factors associated with recurrent VTE events and influence of third-party payer on anticoagulant selection.

RESULTS

Four hundred fifty-seven patients met inclusion criteria (178 in the oral anticoagulant group and 279 in the parenteral anticoagulant group). Patients with Medicare were more likely to have received an oral anticoagulant (P = 0.003) and patients with private insurance were more likely to have received a parenteral anticoagulant (P = 0.004). There were 23 recurrent VTE events, 12 events (6.7 %) in the oral anticoagulant group and 11 events (3.94 %) in the parenteral group (P = 0.182). The only significant risk factor noted to increase risk of recurrent VTE was the presence of an IVC filter (adjusted OR 4.38, 95 % CI 1.67-11.53, P = 0.003).

CONCLUSIONS

While there is no statistical difference in VTE events between groups, the oral anticoagulant group numerically had a higher rate. Important associations were found to have an influence on anticoagulant selection and risk of recurrent VTE. These factors must be incorporated into decision making when treating cancer patients with VTE.

Efficacy and safety of edoxaban compared with warfarin in patients with atrial fibrillation and heart failure: insights from ENGAGE AF-TIMI 48

AIMS

In the ENGAGE AF-TIMI 48 trial, edoxaban, a factor Xa inhibitor, was not found to be inferior to warfarin for the prevention of stroke or systemic embolic events (SEE) in patients with atrial fibrillation (AF) and was associated with significantly less bleeding. The higher-dose edoxaban regimen (HDER; 60 mg dose-reduced to 30 mg once daily) has been approved in various countries in Europe, the USA, and Japan. Among patients treated with vitamin K antagonists (VKAs), symptomatic heart failure (HF) is an independent risk factor for lower time-in-therapeutic range, which reduces the efficacy and safety of VKA therapy. We evaluated the efficacy and safety of edoxaban compared with warfarin across the spectrum of HF severity in the ENGAGE AF-TIMI 48 trial.

METHODS AND RESULTS

Of 14 071 patients randomized to well-controlled warfarin or the HDER, 5926 (42%) had no history of HF, 6344 (45%) were in New York Heart Association (NYHA) class I-II, and 1801 (13%) were in NYHA class III-IV. The efficacy of edoxaban compared with warfarin in preventing stroke/SEE was similar in patients without and with HF regardless of the severity of HF; [HDER vs. warfarin: No-HF: hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.69-1.11; NYHA class I-II: HR 0.88, 95% CI 0.69-1.12; NYHA class III-IV: HR 0.83, 95% CI 0.55-1.25; Pinteraction = 0.97]. Compared with warfarin, HDER was consistently associated with lower risk of major bleeding (No-HF: HR 0.82, 95% CI 0.68-0.99; NYHA class I-II: HR 0.79, 95% CI 0.65-0.96; NYHA class III-IV: HR 0.79, 95% CI 0.54-1.17; Pinteraction = 0.96).

CONCLUSION

The relative efficacy and safety of HDER compared with well-managed warfarin in AF patients with HF were similar to those without HF.