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Westafer LM, Presti T, Shieh MS, Pekow PS, Barnes GD, Kapoor A, Lindenauer PK. Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020. Ann Emerg Med 2024:S0196-0644(24)00277-4. [PMID: 38888528 DOI: 10.1016/j.annemergmed.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 06/20/2024]
Abstract
STUDY OBJECTIVE Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA.
| | - Thomas Presti
- Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Penelope S Pekow
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alok Kapoor
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Department of Medicine, Division of Hospital Medicine, University of Massachusetts Chan Medical School, Worcester, MA
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA
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Wang TF, Chen Q, Deng J, Li SL, Xu Y, Ma SX. Research progress on venous thrombosis development in patients with malignant tumors. World J Clin Cases 2024; 12:1900-1908. [PMID: 38660542 PMCID: PMC11036524 DOI: 10.12998/wjcc.v12.i11.1900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/04/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
The coexistence of venous thromboembolism (VTE) within patients with cancer, known as cancer-associated thrombosis (CAT), stands as a prominent cause of mortality in this population. Over recent years, the incidence of VTE has demonstrated a steady increase across diverse tumor types, influenced by several factors such as patient management, tumor-specific risks, and treatment-related aspects. Furthermore, mutations in specific genes have been identified as potential contributors to increased CAT occurrence in particular cancer subtypes. We conducted an extensive review encompassing pivotal historical and ongoing studies on CAT. This review elucidates the risks, mechanisms, reliable markers, and risk assessment methodologies that can significantly guide effective interventions in clinical practice.
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Affiliation(s)
- Teng-Fei Wang
- Department of Vascular Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Qian Chen
- Department of Organ Transplantation, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Jie Deng
- Department of Vascular Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Shi-Liang Li
- Department of Vascular Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Yuan Xu
- Department of Organ Transplantation, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Si-Xing Ma
- Department of Vascular Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
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Cohen AT, Noxon V, Dhamane AD, Shah S, Hines DM, Alfred T, Chaves J, Luo X. Effectiveness and safety of anticoagulants among patients with venous thromboembolism and active cancer who also had prior bleed or prior renal disease. Curr Med Res Opin 2024; 40:545-553. [PMID: 38332714 DOI: 10.1080/03007995.2024.2313092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Patients with active cancer and venous thromboembolism (VTE) have elevated risk of recurrent VTE (rVTE) and major bleeding (MB). The risk is even higher within those with a prior bleeding event or renal disease. There is a need to understand the risk of rVTE and MB of commonly used anticoagulants among these high-risk patients. METHODS VTE patients with active cancer and treated with apixaban, warfarin, or low molecular weight heparin (LMWH) within 30 days of VTE were identified from five claims databases in the United States. Inverse probability of treatment weighting (IPTW) was used to balance patient characteristics. The post-IPTW population was stratified by prior bleed or renal disease status. Cox proportional hazards models were used to evaluate interactions between treatment and prior bleed or renal disease on risk of rVTE and MB, with p value <.1 considered significant. RESULTS Study criteria were met by 30,586 VTE cancer patients: 35.0% had prior bleed and 29.0% had renal disease. For apixaban, LMWH, and warfarin cohorts, the incidence (events per 100 person-years) of MB was higher in patients with prior bleed (17.48 vs 7.58, 25.61 vs 13.11, and 20.38 vs 8.97) or renal disease (15.79 vs 8.71, 22.11 vs 15.90, and 18.49 vs 10.39) vs those without the conditions. Generally, there were no significant interactions between anticoagulant use and prior bleed or renal disease on rVTE and MB (p for interaction >.1). CONCLUSION The incidence of MB was higher among those with prior bleed or renal disease. Effects of apixaban, warfarin, or LMWH were generally consistent regardless of prior bleed or renal disease status.
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Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, London, UK
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4
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Guo X, Zhu Z, Bulloch G, Huang W, Wang W. Impacts of Chronic Kidney Disease on Retinal Neurodegeneration: A Cross-Cohort Analysis. Am J Ophthalmol 2024; 258:173-182. [PMID: 37820988 DOI: 10.1016/j.ajo.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE To assess the cross-sectional and longitudinal associations between chronic kidney disease (CKD) and ganglion cell-inner plexiform layer (GCIPL) thickness in a UK Biobank population and a Chinese cohort. DESIGN Prospective observational cohort study and cross-sectional study. METHOD This study included 23,014 individuals without neurodegenerative diseases from the UK Biobank, and 3 years of annual follow-up data of 2197 individuals from a Chinese cohort. Three groups were defined by estimated glomerular filtration rate (eGFR) based on serum creatinine classifying CKD severity as no CKD, mild CKD, and moderate to severe CKD (MS-CKD). GCIPL thickness, measured using optical coherence tomography, was analyzed through linear regression over time to determine its decline rate in micrometers per year. Linear regression models were used to assess the correlation between renal function and both the baseline GCIPL thickness and the GCIPL decline rate. RESULTS The cross-sectional analysis in a largely white population showed that poorer renal function negatively correlated with GCIPL thickness with a mean of 0.15 µm thinner (95% confidence interval [CI] -0.30 to -0.01; P = .042) in mild CKD and 0.83 µm thinner (95% CI -1.34 to -0.32; P = .001) in MS-CKD compared with that of control subjects without CKD. Longitudinal analysis in the Chinese cohort showed that the GCIPL decreased more rapidly in persons with poorer renal function. After correcting for all confounding factors, the rate of GCIPL thinning was 0.30 µm/year (95% CI -0.41 to -0.19; P < .001) more in the mild CKD group and 0.52 µm/year (95% CI -0.79 to -0.26; P < .001) more in the MS-CKD group compared with control subjects without CKD. This relationship also occurred in individuals with diabetes or hypertension. CONCLUSIONS Poor renal function was associated with a lower baseline GCIPL thickness in the UK population and a faster decline rate in Chinese participants. However, the detailed underlying mechanisms still need further exploration.
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Affiliation(s)
- Xiao Guo
- From the State Key Laboratory of Ophthalmology (X.G., W.H., W.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Zhuoting Zhu
- Centre for Eye Research Australia (Z.Z., G.B.), Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Gabriella Bulloch
- Centre for Eye Research Australia (Z.Z., G.B.), Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Wenyong Huang
- From the State Key Laboratory of Ophthalmology (X.G., W.H., W.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China; Hainan Eye Hospital and Key Laboratory of Ophthalmology (W.H., W.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, 570311, Hainan Province, China.
| | - Wei Wang
- From the State Key Laboratory of Ophthalmology (X.G., W.H., W.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China; Hainan Eye Hospital and Key Laboratory of Ophthalmology (W.H., W.W.), Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, 570311, Hainan Province, China.
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Del Vecchio L, Balafa O, Dounousi E, Ekart R, Fernandez BF, Mark PB, Sarafidis P, Valdivielso JM, Ferro CJ, Mallamaci F. COVID-19 and cardiovascular disease in patients with chronic kidney disease. Nephrol Dial Transplant 2024; 39:177-189. [PMID: 37771078 PMCID: PMC10828215 DOI: 10.1093/ndt/gfad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 09/30/2023] Open
Abstract
Millions of people worldwide have chronic kidney disease (CKD). Affected patients are at high risk for cardiovascular (CV) disease for several reasons. Among various comorbidities, CKD is associated with the more severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This is particularly true for patients receiving dialysis or for kidney recipients. From the start of the SARS-CoV-2 pandemic, several CV complications have been observed in affected subjects, spanning acute inflammatory manifestations, CV events, thrombotic episodes and arrythmias. Several pathogenetic mechanisms have been hypothesized, including direct cytopathic viral effects on the myocardium, endothelial damage and hypercoagulability. This spectrum of disease can occur during the acute phase of the infection, but also months after recovery. This review is focussed on the CV complications of coronavirus disease 2019 (COVID-19) with particular interest in their implications for the CKD population.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Center Maribor, Maribor, Slovenia
| | | | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pantelis Sarafidis
- 1st Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group, Institute for Biomedical Research on Lleida (IRBLleida), Lleida, Spain
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham,UK
| | - Francesca Mallamaci
- Francesca Mallamaci Department of Nephrology, Dialysis, and Transplantation Azienda Ospedaliera “Bianchi-Melacrino-Morelli” & CNR-IFC, Reggio Calabria, Italy
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Elenjickal EJ, Travlos CK, Marques P, Mavrakanas TA. Anticoagulation in Patients with Chronic Kidney Disease. Am J Nephrol 2023; 55:146-164. [PMID: 38035566 PMCID: PMC10994631 DOI: 10.1159/000535546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Both atrial fibrillation and venous thromboembolism (VTE) are highly prevalent among patients with chronic kidney disease (CKD). Until recently, warfarin was the most commonly prescribed oral anticoagulant. Direct oral anticoagulants (DOACs) have important advantages and have been shown to be noninferior to warfarin with respect to stroke prevention or recurrent VTE in the general population, with lower bleeding rates. This review article will provide available evidence on the use of DOACs in patients with CKD. SUMMARY In post hoc analyses of major randomized studies with DOACs for stroke prevention in atrial fibrillation, in the subgroup of participants with moderate CKD, defined as a creatinine clearance (CrCl) of 30-50 mL/min, dabigatran 150 mg and apixaban were associated with lower rates of stroke and systemic embolism, whereas apixaban and edoxaban were associated with lower bleeding and mortality rates, compared with warfarin. In retrospective observational studies in patients with advanced CKD (defined as a CrCl <30 mL/min) and atrial fibrillation, DOACs had similar efficacy with warfarin with numerically lower bleeding rates. All agents warrant dose adjustment in moderate-to-severe CKD. In patients on maintenance dialysis, the VALKYRIE trial, which was designed initially to study the effect of vitamin K on vascular calcification progression, established superiority for rivaroxaban compared with a vitamin K antagonist (VKA) in the extension phase. Two other clinical trials using apixaban (AXADIA and RENAL-AF) in this population were inconclusive due to recruitment challenges and low event rates. In post hoc analyses of randomized studies with DOACs in patients with VTE, in the subgroup of participants with moderate CKD at baseline, edoxaban was associated with lower rates of recurrent VTE, whereas rivaroxaban and dabigatran were associated with lower and higher bleeding rates, respectively, as compared to warfarin. KEY MESSAGES DOACs have revolutionized the management of atrial fibrillation and VTE, and they should be preferred over warfarin in patients with moderate-to-severe CKD with appropriate dose adjustment. Therapeutic drug monitoring with a valid technique may be considered to guide clinical management in individualized cases. Current evidence questions the need for oral anticoagulation in patients on maintenance dialysis with atrial fibrillation as both DOACs and VKAs are associated with high rates of major bleeding.
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Affiliation(s)
- Elias John Elenjickal
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Christoforos K Travlos
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Pedro Marques
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
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Speed V, Czuprynska J, Patel JP, Arya R. Use of direct oral anticoagulants for venous thromboembolism treatment at extremes of body weight, renal and liver function: an illustrated review. Res Pract Thromb Haemost 2023; 7:102240. [PMID: 38193047 PMCID: PMC10772894 DOI: 10.1016/j.rpth.2023.102240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/07/2023] [Accepted: 10/19/2023] [Indexed: 01/10/2024] Open
Abstract
Direct oral anticoagulants (DOACs) have been a welcome addition to clinical practice due to the practical advantages they confer over traditional anticoagulants. In many countries, DOACs are now used as first-line treatment for the management of venous thromboembolism (VTE). Traditional anticoagulants allow for a degree of individualization, either through monitoring the international normalized ratio in the case of vitamin-K antagonists or through dose titration according to bodyweight in the case of low-molecular-weight heparin. However, the use of fixed doses and removal of the need for routine monitoring has created uncertainty in prescribing DOACs for patients at the extremes of bodyweight, renal function, and patients with liver impairment, who were not well represented in the DOAC licensing clinical trials. The discipline of pharmacokinetics is concerned with the movement of drugs through the body. Although the extremes of bodyweight and renal and liver function will influence the pharmacokinetics of DOACs, are these changes significant enough to affect clinical outcomes of bleeding and thrombosis? In other words, can the fixed-dosing strategy of DOACs accommodate these differences in physiology? In this review, we recap key pharmacokinetic principles for drug dosing; review venous thromboembolism trial and real-world data on patients prescribed DOACs at the extremes of bodyweight, renal function, and liver function; relate this to the pharmacokinetic properties of DOACs; and summarize the state of the field and current unknowns.
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Affiliation(s)
- Victoria Speed
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, United Kingdom
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Julia Czuprynska
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, United Kingdom
| | - Jignesh P. Patel
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, United Kingdom
- Institute of Pharmaceutical Science, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Roopen Arya
- King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital Foundation NHS Trust, London, United Kingdom
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Abstract
Cardiovascular diseases are highly prevalent among patients on dialysis. For these diseases, antiplatelets and antithrombotic therapies including heparin, vitamin K antagonists, and direct oral anticoagulants, are being used. However, the benefit-risk balance of these therapies could differ for dialysis patients compared with the general population. This review article focuses on the bleeding risk associated with the use of heparin, antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients receiving hemodialysis.
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Affiliation(s)
| | - Pearl Pai
- Department of Medicine, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong; Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Wenjuan Zhu
- Department of Medicine, University of Hong Kong Shenzhen Hospital, Shenzhen, China
| | - Gurbey Ocak
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Goto S, Goto S. Long-term outcome of chronic thromboembolic pulmonary hypertension in the era where direct oral anticoagulants become available. J Thromb Haemost 2023; 21:2058-2060. [PMID: 37468177 DOI: 10.1016/j.jtha.2023.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 04/25/2023] [Accepted: 04/29/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Shinichi Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Kanagawa, Japan.
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Chen HW, Wu WT, Wang JH, Lin CL, Hsu CY, Yeh KT. The Risk of Venous Thromboembolism after Thoracolumbar Spine Surgery: A Population-Based Cohort Study. J Clin Med 2023; 12:jcm12020613. [PMID: 36675542 PMCID: PMC9863533 DOI: 10.3390/jcm12020613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Background: Although venous thromboembolism (VTE) is rare, including deep vein thrombosis (DVT) and pulmonary embolism (PE), it is a catastrophic complication after spinal surgery. This study was aimed to investigate the risk factors and incidence of VTE after thoracolumbar spine surgery (TLSS). Methods: We retrieved the data of 8697 patients >20 years old who underwent TLSS between 2000 and 2013 from Taiwan’s Longitudinal Health Insurance Database 2000. Each patient was randomly frequency-matched with four individuals who did not undergo TLSS by age, sex, and index year (the control group). Results: The incidence rates of VTE in the TLSS and control groups were 1.84 and 0.69 per 1000 person-years, respectively. The TLSS group had a higher VTE risk (adjusted HR (aHR): 2.13, 95% confidence interval [95%CI]: 1.41−3.21), DVT (aHR: 2.20, 95%CI: 1.40−3.46), and PE (aHR: 1.60, 95%CI: 0.68−3.78) than the control group. The correlated risk factors of VTE included older age (50−64 years: aHR: 2.16, 95%CI: 1.14−4.09; ≥65 years: aHR: 3.18, 95%CI: 1.65−6.13), a history of cancer (aHR: 2.96, 95%CI: 1.58−5.54), heart failure (aHR: 2.19, 95%CI: 1.27−3.78), and chronic kidney disease (aHR: 1.83, 95%CI: 1.18−2.83). Conclusions: The overall VTE risk following TLSS was less than 2% but correlated with certain risk factors. This information could help the spine surgeon help the patient prevent this fatal complication.
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Affiliation(s)
- Hao-Wen Chen
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan
| | - Wen-Tien Wu
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 970, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan
| | - Chung-Yi Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung 404, Taiwan
| | - Kuang-Ting Yeh
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan
- Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-3-8561825-14713
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Erben Y, Marquez CP, Prudencio M, Fortich S, Gendron T, Sanghavi D, Hickson L, Li Y, Edwards MA, Ritchie C, Franco PM, Petrucelli L, Meschia JF. Race affects adverse outcomes of deep vein thrombosis, pulmonary embolism, and acute kidney injury in coronavirus disease 2019 hospitalized patients. J Vasc Surg Venous Lymphat Disord 2023; 11:19-24.e3. [PMID: 36100130 PMCID: PMC9463072 DOI: 10.1016/j.jvsv.2022.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 05/01/2022] [Accepted: 05/12/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of the present study was to explore the racial disparities in the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), and acute kidney injury (AKI) in hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS A retrospective analysis was performed of prospectively collected data of consecutive COVID-19 patients hospitalized from March 11, 2020 to May 27, 2021. The primary outcome measures were the incidence of DVT/PE and mortality. The secondary outcome measures included differences in the length of hospitalization, need for intensive care unit care, readmission, and AKI. Multivariable regression models were used to assess for independent predictors of the primary and secondary outcome measures. RESULTS The present study included 876 hospitalized patients with COVID-19. The mean age was 64.4 ± 16.2 years, and 355 were women (40.5%). Of the 876 patients, 694 (79.2%) had identified as White, 111 (12.7%) as Black/African American, 48 (5.5%) as Asian, and 23 (2.6%) as other. The overall incidence of DVT/PE was 8.7%. The DVT/PE incidence rates differed across the race groups and was highest for Black/African American patients (n = 18; 16.2%), followed by Asian patients (n = 5; 10.4%), White patients (n = 52; 7.5%), and other (n = 1; 4.4%; P = .03). All but one of the hospitalization outcomes examined demonstrated no differences according to race, including the hospitalization stay (P = .33), need for intensive care unit care (P = .20), readmission rates (P = .52), and hospital all-cause mortality (P = .29). The AKI incidence differed among races, affecting a higher proportion of Black/African American patients (P=.003). On multivariable regression analysis, Black/African American race (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.0; P = .04) and higher D-dimer levels (OR, 1.1; 95% CI, 1.1-1.2; P < .0001) were predictors of DVT/PE. In addition, Black/African American race (OR, 2.3; 95% CI, 1.4-3.7; P = .001), lower hemoglobin levels (OR, 0.84; 95% CI, 0.8-0.9; P ≤ .0001), male sex (OR, 1.7; 95% CI, 1.2-2.4; P = .005), hypertension (OR, 2.1; 95% CI, 1.4-3.1; P = .0005), and older age (OR, 1.02; 95% CI, 1.006-1.03; P = .003) were predictors of AKI. CONCLUSIONS In our single-center case series, we found a higher incidence of DVT/PE and AKI among Black/African American patients with COVID-19. Black/African American race and D-dimer levels were independent predictors of DVT/PE, and Black/African American race, hemoglobin, and D-dimer levels were independent predictors of AKI.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
| | | | - Mercedes Prudencio
- Department of Neuroscience and Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL
| | - Susana Fortich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | - Tania Gendron
- Department of Neuroscience and Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL
| | | | - LaTonya Hickson
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ
| | | | | | | | - Leonard Petrucelli
- Department of Neuroscience and Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Jacksonville, FL
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12
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Chen J, Cao Y, Li Z, Dong L. Association Between the Severity of Obstructive Sleep Apnea and the Risk Stratification of Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2023; 29:10760296231175654. [PMID: 37365833 DOI: 10.1177/10760296231175654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Obstructive sleep apnea (OSA) has been associated with the initiation and progression of cardiovascular disease. This study aimed to explore the relationship between the severity of OSA and the risk stratification of acute pulmonary embolism (PE). In this single-center cohort study, patients diagnosed with PE were evaluated for OSA via polygraphy monitoring. The simplified PE severity index (sPESI) and the number of patients requiring systemic thrombolysis were used to determine the severity of the disease. Echocardiography was performed on all participants. All patients were divided into 2 groups (OSA group and non-OSA group), and the patients in OSA group were then divided into 3 groups based on the severity of OSA. Patients with severe OSA had a significantly higher number of patients with sPESI ≥ 1 (P = .005). A higher proportion of patients with severe OSA require systemic thrombolysis (P = .010). Patients with apnea-hypopnea index (AHI) > 30/h had a much higher fibrinogen (P = .004) and D-dimer (P = .040) level than those in the non-OSA group. The levels of creatinine were significantly higher in patients with OSA (P = .040). Echocardiography showed a significant difference in left ventricular ejection fraction (LVEF) between patients in non-OSA and severe OSA groups (P = .035). And brain natriuretic peptide (BNP) also exhibited a progressive worsening related to the deepest desaturation and oxygen desaturation index. OSA, especially with AHI > 30/h, is correlated with the severity and prognosis of acute PE. This might be attributed to the prothrombotic effect, renal impairment, and cardiac dysfunction in patients with severe OSA.
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Affiliation(s)
- Jiayue Chen
- Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Yaoqian Cao
- Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Zhishu Li
- Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Lixia Dong
- Department of Respiratory and Critical Care Medicine, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
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13
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Wang TF. The 5 most frequently asked questions about factor Xa inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:515-521. [PMID: 36485108 PMCID: PMC9821165 DOI: 10.1182/hematology.2022000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Direct oral anticoagulants (DOACs) are commonly used oral factor Xa inhibitors in recent years. However, in some special clinical situations, the appropriate use of these anticoagulants may be of concern. In this article, we address the 5 commonly asked questions regarding their use for the treatment of venous thromboembolism, including in the setting of obesity, renal impairment, gastrointestinal (GI) malignancy, catheter-related thrombosis, and drug-drug interactions. Data on the use of DOACs in the presence of significant obesity or renal failure are mainly observational. Some DOACs are shown to have an increased risk of bleeding in patients with unresected luminal GI malignancy but not others, so selection of appropriate patients is the key. Furthermore, literature on the use of DOACs for catheter-related thrombosis or when drug-drug interactions are of concern is limited, and more research is welcome.
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Affiliation(s)
- Tzu-Fei Wang
- Correspondence Tzu-Fei Wang, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201A, Ottawa, ON K1H 8L6, Canada; e-mail:
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14
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Fu AZ, Feng X, Ashton V, Kharat A. Risk factors for recurrent venous thromboembolism: a real-world analysis. Blood Coagul Fibrinolysis 2022; 33:301-309. [PMID: 35834716 DOI: 10.1097/mbc.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study was conducted in patients treated for initial venous thromboembolism (VTE) for approximately 6 months to enhance understanding of the risk factors to inform clinical decision-making about long-term anticoagulation therapy. This retrospective cohort study was conducted using a large administrative claims database in the United States. A Cox proportional hazards model was used to examine demographic and clinical characteristics associated with recurrent VTE. A total of 13 831 patients had an index VTE event, and recurrent VTE occurred in 844 (6.1%) of these patients over a median follow-up of 22.8 months. Baseline comorbidities of arrhythmia, congestive heart failure, and chronic kidney disease were significantly associated with recurrent VTE. During the period of anticoagulation treatment after the index VTE, use of antidepressants was associated with an increased risk of recurrent VTE, whereas use of antibiotics and major surgery were associated with a decreased risk. In the 6 months prior to index VTE, anti-inflammatory agents and major surgery were associated with a decreased risk of recurrent VTE. The type of index VTE was also significantly associated with recurrent VTE, with an increased risk observed in patients with pulmonary embolism (PE) alone or PE with deep vein thrombosis (DVT) versus DVT alone. This real-world analysis identified baseline comorbidities, medications, and index VTE type to be factors predictive of recurrent VTE among patients treated for index VTE for approximately 6 months. Consideration of these factors may assist in the identification of patients who may benefit from extended anticoagulant therapy.
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Affiliation(s)
- Alex Z Fu
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
- Georgetown University Medical Center, Washington, DC, USA
| | - Xue Feng
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | | | - Akshay Kharat
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
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15
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Messi M, Beneyto Afonso C, Stalder O, Méan M, Righini M, Rodondi N, Aujesky D. Long-term clinical outcomes in older patients with acute venous thromboembolism who have renal impairment. Thromb Res 2022; 218:64-71. [PMID: 35994838 DOI: 10.1016/j.thromres.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Renal impairment (RI) may induce an inflammatory/procoagulant state as well as platelet dysfunction. Little is known on the prevalence of RI and long-term prognosis of older patients with venous thromboembolism (VTE) who have concomitant RI. METHODS In a prospective multicenter cohort, we analyzed 912 patients aged ≥65 years with acute VTE. Using the CKD-EPI formula, we defined three categories of baseline renal function: estimated glomerular filtration rate ≥60 ml/min/1.73m2 (no RI), 30-59 ml/min/1.73m2 (moderate RI), and <30 ml/min/1.73m2 (severe RI). The outcomes were VTE recurrence, major bleeding, and overall mortality. We examined the association between renal function and clinical outcomes using competing risk regression models, adjusting for relevant confounders and periods of anticoagulation. RESULTS We followed 912 patients over a median duration of 29.6 months. Overall, 313 (34%) patients had moderate and 51 (6%) severe RI. One hundred and seven patients (12%) had VTE recurrence, 125 (14%) had major bleeding, and 186 (20%) died during follow-up. After adjustment, severe RI was associated with a 2-fold increased risk of major bleeding (sub-hazard ratio [SHR] 2.1, 95% CI 1.1-4.0) compared to no RI, but not with VTE recurrence (SHR 0.6, 95% CI 0.2-1.8) or overall mortality (hazard ratio 1.0, 95% CI 0.6-1.9). Moderate RI was not significantly associated with adverse clinical outcomes. CONCLUSIONS RI was common among older patients with acute VTE. Severe RI was associated with a 2-fold increased long-term risk of major bleeding, without a risk increase in terms of VTE recurrence and overall mortality. Older patients with moderate RI did not carry worse prognosis.
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Affiliation(s)
- Mia Messi
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
| | - Carlota Beneyto Afonso
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
| | - Odile Stalder
- CTU Bern, University of Bern, Mittelstrasse 43, 3012 Bern, Bern, Switzerland.
| | - Marie Méan
- Department of General Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Vaud, Switzerland.
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Geneva, Switzerland.
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Bern, Switzerland.
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
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Pagkratis N, Matsagas M, Malli F, Gourgoulianis KI, Kotsiou OS. Prevalence of Hemorrhagic Complications in Hospitalized Patients with Pulmonary Embolism. J Pers Med 2022; 12:jpm12071133. [PMID: 35887630 PMCID: PMC9320949 DOI: 10.3390/jpm12071133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System “ASKLIPIOS™ HOSPITAL” implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population’s mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages.
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Affiliation(s)
| | - Miltiadis Matsagas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | - Foteini Malli
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | | | - Ourania S. Kotsiou
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
- Correspondence:
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17
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Wang D, Fan G, Lei J, Yang Y, Xu X, Ji Y, Yi Q, Chen H, Hu X, Liu Z, Mao Y, Zhang J, Shi J, Zhang Z, Wu S, Tao X, Xie W, Wan J, Zhang Y, Zhang S, Zhen K, Zhang Z, Fang B, Wang C, Zhai Z. LMWHs dosage and outcomes in acute pulmonary embolism with renal insufficiency, an analysis from a large real-world study. Thromb J 2022; 20:26. [PMID: 35513826 PMCID: PMC9074331 DOI: 10.1186/s12959-022-00385-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/22/2022] [Indexed: 02/08/2023] Open
Abstract
Background Renal function is associated with prognoses for acute pulmonary embolism (PE). Objective To investigate the application of anticoagulants and dosage of LMWH among patients with renal insufficiency (RI), and the association between LWMH dosage and the patients’ in-hospital outcomes. Methods Adult patients diagnosed with non-high risk acute PE from 2009 to 2015, with available data of creatinine clearance (CCr) were enrolled from a multicenter registry in China. Renal insufficiency (RI) was defined as CCr < 60 ml/min. LMWH dosage was converted into IU/kg daily dose and presented as adjusted dose (≤ 100 IU/kg/day) and conventional dose (> 100 IU/kg/day). All-cause death, PE-related death and bleeding events during hospitalization were analyzed as endpoints. Results Among the enrolled 5870 patients, RI occurred in 1311 (22.3%). 30 ≤ CCr < 60 ml/min was associated with higher rate of bleeding events and CCr < 30 ml/min was associated with all-cause death, PE-related death and major bleeding. Adjusted-dose LMWH was applied in 26.1% of patients with 30 ≤ CCr < 60 ml/min and in 26.2% of CCr < 30 ml/min patients. Among patients with RI, in-hospital bleeding occurred more frequently in those who were administered conventional dose of LMWH, compared with adjusted dose (9.2% vs 5.0%, p = 0.047). Adjusted dose of LMWH presented as protective factor for in-hospital bleeding (OR 0.62, 95%CI 0.27–1.00, p = 0.0496) and the risk of bleeding increased as length of hospital stay prolonged (OR 1.03, 95%CI 1.01–1.06, p = 0.0014). Conclusions The proportion of adjusted usage of LMWH was low. The application of adjusted-dose LMWH was associated with lower risk of in-hospital bleeding for RI patients, in real-world setting of PE treatment. Anticoagulation strategy for RI patients should be paid more attention and requires evidence of high quality. Trial Registration The CURES was registered in ClinicalTrias.gov, identifier number: NCT02943343. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00385-z.
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Affiliation(s)
- Dingyi Wang
- Institute of Clinical Medical Sciences, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Guohui Fan
- Institute of Clinical Medical Sciences, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jieping Lei
- Institute of Clinical Medical Sciences, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Beijing, China.,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qun Yi
- Department of Pulmonary and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, Chongqing Medical University First Affiliated Hospital, Chongqing, China
| | - Xiaoyun Hu
- First Hospital of Shanxi Medical University, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhihong Liu
- Department of Cardiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yimin Mao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Jie Zhang
- Department of Pulmonary Critical Care Medicine, Jilin University Second Hospital, Changchun, China
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Zhu Zhang
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Sinan Wu
- Institute of Clinical Medical Sciences, National Center for Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xincao Tao
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Wanmu Xie
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunxia Zhang
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Shuai Zhang
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Kaiyuan Zhen
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,National Center for Respiratory Medicine, Beijing, China
| | - Zhonghe Zhang
- Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Baomin Fang
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.,Department of Pulmonary and Critical Care Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Chen Wang
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China. .,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China. .,National Center for Respiratory Medicine, Beijing, China. .,National Clinical Research Center for Respiratory Diseases, Beijing, China. .,Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China. .,Department of Respiratory Medicine, Capital Medical University, Beijing, China.
| | - Zhenguo Zhai
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China. .,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China. .,National Center for Respiratory Medicine, Beijing, China.
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Mavrakanas TA. Treatment Options for Venous Thromboembolism in Patients Receiving Dialysis. Clin J Am Soc Nephrol 2022; 17:623-625. [PMID: 35470213 PMCID: PMC9269571 DOI: 10.2215/cjn.03410322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Quebec, Canada
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20
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Kinoshita T, Otsuka S, Torii S, Tsugeno Y, Fukaya S, Sobue M, Ishihara A, Sakakibara T, Takimoto N. Efficacy and safety of edoxaban tosylate hydrate 15 mg in the prevention of venous thromboembolism in patients with impaired renal function after orthopedic surgery of the lower extremities. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00387-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although not indicated in the USA, edoxaban tosylate hydrate 15 mg is used for venous thromboembolism (VTE) prophylaxis after orthopedic surgery of the lower extremities in Japan. However, its efficacy and safety in patients with impaired renal function have not been fully evaluated. We aimed to investigate the intervention’s effectiveness in these patients.
Methods
From 2018 to 2020, patients who underwent total hip arthroplasty, total knee arthroplasty, hip fracture surgery, or knee arthroplasty single granule replacement and with renal dysfunction were evaluated. Safety was evaluated according to bleeding occurrence during edoxaban treatment and liver function endpoints. Patients were divided into the 15- and 30-mg oral groups, including 23 patients with impaired renal function and 209 with normal renal function, respectively.
Results
VTE incidence in the 15- and 30-mg groups was 8.7% and 8.6%, respectively; the intergroup difference was insignificant (odds ratio [OR] 0.99; 95% confidence interval [CI] 0.22–4.56; p = 1.00). Bleeding did not occur in the 15-mg group and was noted in 9 patients in the 30-mg group during treatment with edoxaban; the intergroup difference was insignificant (p = 1.00). The increase in aspartate aminotransferase and alanine aminotransferase levels was 30% in the 15-mg group and 19% in the 30-mg group, with no difference between the groups (p = 0.27). Multivariate analysis showed that the dose of edoxaban was not a significant factor associated with the incidence of VTE (adjusted OR 2.31; 95% CI 0.39–13.8; p = 0.36).
Conclusions
Edoxaban 15 mg in patients with impaired renal function may be as effective as edoxaban 30 mg in patients with normal renal function. However, the number of cases included in this study was small and the power was insufficient; therefore, a study with a larger sample size is desirable.
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21
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Keller K, Wöllner J, Schmitt VH, Ostad MA, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis. J Clin Med 2021; 10:jcm10225412. [PMID: 34830695 PMCID: PMC8618323 DOI: 10.3390/jcm10225412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/04/2021] [Accepted: 11/15/2021] [Indexed: 01/10/2023] Open
Abstract
Background. Venous thromboembolism is a frequent complication and an important cause of death in patients with paralysis. We aimed to investigate predictors of pulmonary embolism (PE) and the impact of PE on the survival of patients with paralysis in comparison to those with deep venous thrombosis or thrombophlebitis (DVT). Methods: Patients were selected by screening the German nationwide inpatient sample (2005–2017) for paralysis, and were stratified for venous thromboembolism (VTE) and the VTE-sub-entity PE (ICD-code I26). Impact of PE on mortality and predictors for PE were analyzed. Results: Overall, 7,873,769 hospitalizations of patients with paralysis were recorded in Germany 2005–2017, of whom 1.6% had VTE and 7.0% died. While annual hospitalizations increased (2005: 520,357 to 2017: 663,998) (β 12,421 (95% CI 10,807 to 14,034), p < 0.001), in-hospital mortality decreased from 7.5% to 6.7% (β −0.08% (95% CI −0.10% to −0.06%), p < 0.001). When focusing on 82,558 patients with paralysis hospitalized due to VTE (51.8% females; 58.3% aged ≥ 70 years) in 2005–2017, in-hospital mortality was significantly higher in patients with paralysis and PE than in those with DVT only (23.8% vs. 6.3%, p < 0.001). Cancer (OR 2.18 (95% CI 2.09–2.27), p < 0.001), heart failure (OR 1.83 (95% CI 1.76–1.91), p < 0.001), COPD (OR 1.63 (95% CI 1.53–1.72), p < 0.001) and obesity (OR 1.42 (95% CI 1.35–1.50), p < 0.001) were associated with PE. PE (OR 4.28 (95% CI 4.07–4.50), p < 0.001) was a strong predictor of in-hospital mortality. Conclusions: In Germany, annual hospitalizations of patients with paralysis increased in 2005–2017, in whom VTE and especially PE substantially affected in-hospital mortality. Cancer, heart failure, COPD, obesity and acute paraplegia were risk factors of PE.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Jens Wöllner
- Swiss Paraplegic Center Nottwil, Department of Neuro-Urology, 6207 Nottwil, Switzerland;
- Department of Urology and Pediatric Urology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
| | - Volker H. Schmitt
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Mir A. Ostad
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
| | - Ingo Sagoschen
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany; (V.H.S.); (M.A.O.); (I.S.); (T.M.); (C.E.-K.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), 55131 Mainz, Germany
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Kim SY, Cho YS, Kim HS, Lee JK, Kim HM, Park HJ, Kim H, Kim J, Kang DR. Venous Thromboembolism Risk in Asian Patients with Inflammatory Bowel Disease: A Population-Based Nationwide Inception Cohort Study. Gut Liver 2021; 16:555-566. [PMID: 34789583 PMCID: PMC9289840 DOI: 10.5009/gnl210190] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Inflammatory bowel disease (IBD) is associated with the occurrence of venous thromboembolism (VTE). However, to date, there have been few studies on the risk of VTE in Asian IBD patients. We aimed to estimate the incidence of VTE in Asian IBD patients and to determine if IBD is related to increased VTE risk. Methods We performed a population-based cohort study between 2004 and 2015 using Korean National Health Insurance data. IBD and VTE were defined by ICD-10 codes. Incidence rates of VTE were calculated among patients with IBD and among age- and sex-matched controls. Hazard ratios were estimated using Cox regression with adjustment for multiple variables. We performed additional analyses stratifying by age, sex, Charlson comorbidity index (CCI) score, and disease type. Results Among the 45,037 patients with IBD (IBD cohort) and 133,019 matched controls (non-IBD cohort) included in our analysis, 411 IBD patients and 641 controls developed VTE. The IBD cohort had a higher incidence rate ratio and risk of VTE than the non-IBD cohort (incidence rate ratio 1.92 and hazard ratio 1.93). Older age, female sex, higher CCI scores, cardiovascular disease, chronic kidney disease, use of steroids, and hospitalization were significant risk factors for VTE in patients with IBD. Conclusions The IBD patients in this study were approximately two times more likely to develop VTE than the non-IBD individuals. Our findings support the need for thromboprophylaxis in Asian IBD patients with various factors that further increase the risk of VTE.
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Affiliation(s)
- Su Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeon Seo Cho
- Department of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Kuk Lee
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hee Man Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Jun Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyunil Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jihoon Kim
- Department of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
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Direct oral anticoagulant use in special populations. Curr Opin Pulm Med 2021; 27:311-318. [PMID: 34115699 DOI: 10.1097/mcp.0000000000000787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The pivotal phase III trials demonstrating efficacy and safety of direct oral anticoagulants (DOACs) in the treatment of venous thromboembolism (VTE) or nonvalvular atrial fibrillation (NVAF) excluded patients with important and common comorbidities, including obesity, advanced chronic kidney disease, cirrhosis, cancer and antiphospholipid antibody syndrome. Despite the lack of large prospective randomized control trials in these patient populations, the use of DOACs has led to a wealth of efficacy and safety data within these groups. RECENT FINDINGS Retrospective studies, meta-analyses, national databases and pharmacokinetic data have shed light on the efficacy and safety of DOACs in these patient populations. Although DOACs should be avoided in those with high-risk triple positive antiphospholipid antibody syndrome, advanced cirrhosis, advanced kidney disease and intact gastrointestinal cancers, and used with caution in genitourinary cancers, their use extends beyond the inclusion criteria of the initial randomized control trials. SUMMARY DOACs have revolutionized anticoagulant management and have become the cornerstone for VTE treatment and stroke prevention in NVAF. The decision to use DOACs must be individualized. Patient preference, underlying comorbidities and informed consent must always be considered when selecting the most appropriate anticoagulant.
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Singh J, Khadka S, Solanki D, Kichloo A, Shah H, Vyas MJ, Chugh S, Patel N, Solanki S. Pulmonary embolism in chronic kidney disease and end-stage renal disease hospitalizations: Trends, outcomes, and predictors of mortality in the United States. SAGE Open Med 2021; 9:20503121211022996. [PMID: 34158942 PMCID: PMC8182212 DOI: 10.1177/20503121211022996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background: It is well-known that patients with chronic kidney disease and end-stage
renal disease are at increased risk of pulmonary embolism than patients with
normal kidney function. However, the data on trends, outcomes, and
predictors of mortality in pulmonary embolism patients with chronic kidney
disease and end-stage renal disease in the United States are limited. Methods: We queried the National Inpatient Sample database from 2010 to 2014.
International Classification of Diseases-Ninth Revision-Clinical
Modification codes were used to identify patients with normal kidney
function, chronic kidney disease, and end-stage renal disease. The frequency
of pulmonary embolism, complications, in-hospital mortality, and length of
stay were calculated for each cohort. Multivariable logistic regression
models were constructed to determine the predictors of mortality. Results: In the study population (2010–2014), there were 766,176 pulmonary embolism
hospitalizations with normal kidney function, 79,824 with chronic kidney
disease, and 9147 with end-stage renal disease. Among the study cohorts, the
mortality rate was 2.7% in normal kidney function, 4.5% in chronic kidney
disease, and 6.8% in end-stage renal disease hospitalizations. Median length
of stay was highest in the end-stage renal disease cohort and lowest in the
normal kidney function cohort. After adjusting for confounders, pulmonary
embolism patients with chronic kidney disease died 1.15 times more often
than those with normal kidney function and pulmonary embolism patients with
end-stage renal disease died 4.2 times more often than those with normal
kidney function. Conclusion: The mortality rate and length of stay in pulmonary embolism patients with
chronic kidney disease and end-stage renal disease were significantly higher
than those in pulmonary embolism patients with normal kidney function. Also,
pulmonary embolism patients with chronic kidney disease and end-stage renal
disease were at higher risk of in-hospital mortality than those with normal
kidney function. There was statistically significant higher risk of
mortality in elderly and Black patients with pulmonary embolism and
concurrent chronic kidney disease or end-stage renal disease.
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Affiliation(s)
- Jagmeet Singh
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Sushmita Khadka
- Department of Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
| | | | - Asim Kichloo
- College of Medicine, Central Michigan University, Saginaw, MI, USA
| | - Harshil Shah
- Hospitalist Department, Guthrie Corning Hospital, Corning, NY, USA
| | - Manasee J Vyas
- Mahatma Gandhi Medical Institute of Health Sciences, Navi Mumbai, India
| | - Savneek Chugh
- Department of Nephrology, Westchester Medical Center, Valhalla, NY, USA
| | - Neil Patel
- Division of Cardiology, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Shantanu Solanki
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
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