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Hoyer EH, Bhave A, Xue W, Haut ER, Lau BD, Kraus P, Turnbull AE, Shaffer D, Friedman LA, Young D, Brotman DJ, Streiff MB. Inaccuracy of Initial Clinical Mobility Assessment in Venous Thromboembolism Risk Stratification. Am J Med 2024:S0002-9343(24)00205-5. [PMID: 38649003 DOI: 10.1016/j.amjmed.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Venous thromboembolism risk increases in hospitals due to reduced patient mobility. However, initial mobility evaluations for thromboembolism risk are often subjective and lack standardization, potentially leading to inaccurate risk assessments and insufficient prevention. METHODS A retrospective study at a quaternary academic hospital analyzed patients using the Padua risk tool, which includes a mobility question, and the Johns Hopkins-Highest Level of Mobility (JH-HLM) scores to objectively measure mobility. Reduced mobility was defined as JH-HLM scores ≤3 over ≥3 consecutive days. The study evaluated the association between reduced mobility and hospital-acquired venous thromboembolism using multivariable logistic regression, comparing admitting health care professional assessments with JH-HLM scores. Symptomatic, hospital-acquired thromboembolisms were diagnosed radiographically by treating providers. RESULTS Of 1715 patients, 33 (1.9%) developed venous thromboembolism. Reduced mobility, as determined by the JH-HLM scores, showed a significant association with thromboembolic events (adjusted OR: 2.53, 95%CI:1.23-5.22, P = .012). In contrast, the initial Padua assessment of expected reduced mobility at admission did not. The JH-HLM identified 19.1% of patients as having reduced mobility versus 6.5% by admitting health care professionals, suggesting 37 high-risk patients were misclassified as low risk and were not prescribed thrombosis prophylaxis; 4 patients developed thromboembolic events. JH-HLM detected reduced mobility in 36% of thromboembolic cases, compared to 9% by admitting health care professionals. CONCLUSION Initial mobility evaluations by admitting health care professionals during venous thromboembolism risk assessment may not reflect patient mobility over their hospital stay. This highlights the need for objective measures like JH-HLM in risk assessments to improve accuracy and potentially reduce thromboembolism incidents.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md.
| | - Aditya Bhave
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
| | - Wingel Xue
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Md; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Md
| | - Peggy Kraus
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Md
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Md; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Md
| | - Dauryne Shaffer
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Lisa Aronson Friedman
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md
| | - Daniel Young
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, Md; Department of Physical Therapy, University of Nevada Las Vegas, Nev
| | - Daniel J Brotman
- Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Michael B Streiff
- Department of Internal Medicine, School of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md; Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Md
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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Ali AB, Khawaja AM, Reilly A, Tahir Z, Rao SS, Bernstock JD, Chen P, Molino J, Gormley W, Izzy S. Venous Thromboembolism Risk and Outcomes Following Decompressive Craniectomy in Severe Traumatic Brain Injury: An Analysis of the Nationwide Inpatient Sample Database. World Neurosurg 2022; 161:e531-e545. [DOI: 10.1016/j.wneu.2022.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
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Paro A, Dalmacy D, Hyer JM, Tsilimigras DI, Diaz A, Pawlik TM. Impact of Perioperative Thromboembolic Complications on Future Long-term Risk of Venous Thromboembolism among Medicare Beneficiaries Undergoing Complex Gastrointestinal Surgery. J Gastrointest Surg 2021; 25:3064-3073. [PMID: 34282525 DOI: 10.1007/s11605-021-05080-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a common cause of morbidity and mortality following complex gastrointestinal surgery. Whether perioperative VTE also exposes patients to a higher long-term risk of VTE events remains poorly defined. METHODS The Medicare 100% Standard Analytic Files were used to identify patients undergoing esophageal, hepatic, pancreatic, and colorectal resection between 2013 and 2017. The impact of perioperative VTE, defined as a VTE episode occurring during the index hospitalization or within 30 days of discharge, on the risk of developing subsequent long-term VTE episodes (i.e., more than 30 days following discharge) was examined. RESULTS Among 253,212 patients who underwent complex gastrointestinal surgery, 1.9% (n=4763) developed a VTE episode perioperatively. With a median follow-up period of 553 days (IQR 194-1052), a total of 11,052 patients (4.4%) developed a long-term VTE episode. Of note, patients who developed a DVT perioperatively had a higher risk of experiencing a long-term VTE episode than patients who had no perioperative thromboembolic complications (HR 6.50, 95%CI 6.04-6.98). The increase in risk was more pronounced among patients who had a PE (HR 27.97, 95%CI 25.39-30.80) at the time of surgery. Risk factors for long-term thromboembolic events following complex GI surgery included Black patients (HR 1.20, 95%CI 1.11-1.30), receipt of surgery at a teaching hospital (HR 1.09, 95%CI 1.04-1.13), nonelective surgery (HR 1.19, 95%CI 1.14-1.24), as well as a diagnosis of cancer (HR 1.10, 95%CI 1.05-1.16). The development of a perioperative DVT was associated with an increased long-term risk of VTE in both cancer (HR 5.59, 95%CI 5.29-6.61) and non-cancer patients (HR 6.98, 95%CI 6.37-7.64). Similarly, experiencing a PE at the time of surgery led to a higher long-term risk of VTE in cancer (HR 24.30, 95%CI 21.08-28.02), as well as non-cancer (HR 30.81, 95%CI 27.01-35.15) patients. CONCLUSIONS Patients with a history of perioperative VTE had a higher risk of developing subsequent VTE events within 1-2 years following complex GI surgery. The risk was more pronounced among patients who had perioperative PE rather than DVT. These findings were consistent among both cancer and non-cancer patients.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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Implementation of automatic data extraction from an enterprise database warehouse (EDW) for validating pediatric VTE decision rule: a prospective observational study in a critical care population. J Thromb Thrombolysis 2021; 50:782-789. [PMID: 32529550 DOI: 10.1007/s11239-020-02158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Multiple clinical risk prediction tools for hospital acquired venous thromboembolism (HA-VTE) have been developed. The objectives of this study were to develop and assess the feasibility of data extraction from Electronic Medical Records (EMR) from an enterprise database warehouse (EDW) and to test the validity of a previously developed Pediatric Clot Decision Rule (PCDR). This single-center prospective observational cohort study was conducted between March 2016 and March 2017 and included eligible patients admitted to the intensive care units. Risk score was calculated using the PCDR tool. Sensitivity, specificity, positive and negative predicted value (PPV and NPV) were calculated based on a cut-point of 3. A total of 2822 children were eligible for analysis and 5.1% (95% CI 4.2-6.2) children had a PCDR score of 3. Children with PCDR score of ≥ 3 had a 3 times higher odd of developing VTE compared to those with scores < 3 (OR 3.1; 95% CI 1.93-4.80; p < 0.001). The model performance showed that at the cutoff point of ≥ 3, both the specificity and sensitivity of the PCDR in predicting VTE was 69% and NPV of 98%. We successfully demonstrated using our EDW to populate a research database using an automatic data import. A PCDR score of ≥ 3 was associated with VTE. Collaboration through large registries will be useful in informing practices and guidelines for rare disorders such as pediatric VTE.
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Chan GK, Guo N, Goyena JP, Schmidt K, Shannon A. Improving Patients' Early Mobility Through Innovative Interprofessional Education Using Educational Neuroscience Theory. J Contin Educ Nurs 2021; 52:362-366. [PMID: 34324376 DOI: 10.3928/00220124-20210714-05] [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: 11/20/2022]
Abstract
Ambulation is one of the most frequently reported components of unfinished nursing care, yet early mobilization can prevent patient deconditioning. This project was designed as an interprofessional mobility training program by using educational neuroscience theory to engage learners in appreciating the need for early ambulation and change behaviors. This article reviews one initiative that incorporated neuroscience and learning science in the teaching methodologies to achieve high rates of successful educational outcomes. [J Contin Educ Nurs. 2021;52(8):362-366.].
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Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232. Obstet Gynecol 2021; 138:e1-e15. [PMID: 34259490 DOI: 10.1097/aog.0000000000004445] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively referred to as "venous thromboembolic events" (VTE). Despite advances in prophylaxis, diagnosis, and treatment, VTE remains a leading cause of cost, disability, and death in postoperative and hospitalized patients (1, 2). Beyond the acute sequelae of leg pain, edema, and respiratory distress, VTE may result in chronic conditions, including postthrombotic syndrome (3), venous insufficiency, and pulmonary hypertension. This Practice Bulletin has been revised to reflect updated literature on the prevention of VTE in patients undergoing gynecologic surgery and the current surgical thromboprophylaxis guidelines from the American College of Chest Physicians (4). Discussion of gynecologic surgery and chronic antithrombotic therapy is beyond the scope of this document.
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Venous thromboembolism in non-COVID-19 population during the pandemic: a nationwide multicenter retrospective survey. J Thromb Thrombolysis 2021; 52:1094-1100. [PMID: 33988823 PMCID: PMC8120766 DOI: 10.1007/s11239-021-02442-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 01/10/2023]
Abstract
Impact of pandemic on the incidence of venous thromboembolism (VTE) in non-COVID-19 patients is undetermined. Thus, a nationwide multicenter retrospective survey was conducted to evaluate the disease burden in non-COVID-19 population. This multi-center survey involved 94 hospitals from 24 provinces in the mainland of China, and collected data on non-COVID-19 patients admitted to the radiology departments due to VTE between January 24 and April 16, 2020. Baseline characteristics, VTE risk factors, clinical manifestations and the treatments were compared with those in the same period of 2019. 3,358 patients with VTE from 74 hospitals were included in this study (1,458 in 2020, 1,900 in 2019). Most aged ≥ 50 years (80.6% in the pandemic, 81.2% in 2019). The number of patients aged 30-39 years increased from 3.9% in 2019 period to 5.8% in the pandemic (p = 0.009). Among the VTE risk factors, the rate of decreased activity increased significantly in the pandemic, and was much higher than that in 2019 (30.7% vs 22.6%, p < 0.0001). Under the risk of decreased activity, patients with comorbidities chronic diseases, especially diabetes, showed significantly a higher incidence of VTE (30.4% vs 22.0%, p < 0.0001). In the pandemic period, fewer patients were treated with anticoagulation alone (33.5% vs 36.7%, p = 0.05), and more underwent inferior vena cava filter (IVCF) implantation, compared with those in 2019 (66.5% vs 63.2%, p = 0.046). The pandemic increased the VTE risk of decreased activity among the non-COVID-19 population. Patients with comorbidities, especially diabetes, have a significant higher risk of VTE during the pandemic.
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10
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Pang H, Wang L, Liu J, Wang S, Yang Y, Yang T, Wang C. The prevalence and risk factors of venous thromboembolism in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease. CLINICAL RESPIRATORY JOURNAL 2018; 12:2573-2580. [PMID: 30207643 DOI: 10.1111/crj.12959] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/25/2018] [Accepted: 07/30/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is not rare, which would affect the patient's prognosis. OBJECTIVES To examine the prevalence, risk factors and clinical characteristics of AECOPD patients with VTE. METHODS We performed this multi-center, prospective, observational study that involved 16 hospitals in China. Patients admitted to hospital due to AECOPD were consecutively enrolled. Baseline characteristics, VTE risk factors, symptoms, signs and auxiliary examination results were collected. Lower limb venous ultrasound and computed tomography pulmonary angiography were examined. RESULTS Between June 2009 and October 2010, a total of 1144 AECOPD patients (the average age 72.0 ± 9.1 years, 761 males) were enrolled in this study. Seventy-eight (6.8%) were diagnosed with VTE, including 24 PE, 64 DVT, 10 combined PE and DVT. VTE patients were older than non-VTE patients. History of venous thromboembolism and lower extremity varicose vein, and presence of longer immobility (≥3 days), lower limbs problems of swelling, pain and walking difficulties, diuretics use, fever, syncope, higher d-dimer and lower hemoglobin were more common in VTE patients than in non-VTE patients. After adjusting the covariates, venous thrombosis history, prolonged immobility (≥3 days), lower limb pain before hospitalization, higher d-dimer independently associated with VTE development. Regular glucocorticoid use was not associated with increased risk of VTE in this set of patients. CONCLUSION VTE is relatively common among hospitalized AECOPD patients. Conventional prophylactic anticoagulant therapy may be considered for those hospitalized AECOPD patients with risk factors.
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Affiliation(s)
- Hongyan Pang
- Department of Pulmonary and Critical Care Medicine, Chaoyang Hospital, Capital Medical University, Beijing, 100029, P.R. China.,Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China
| | - Lei Wang
- Department of Pulmonary and Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, 100053, P.R. China.,Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China
| | - Jie Liu
- Department of Physiology and Pathophysiology, Capital Medical University, Beijing, 100069, P.R. China.,Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China
| | - Shengfeng Wang
- Institute of Public Health, Peking University, Beijing, 100871, P.R. China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Chaoyang Hospital, Capital Medical University, Beijing, 100029, P.R. China.,Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China
| | - Ting Yang
- Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100029, P.R. China
| | - Chen Wang
- Department of Respiratory Medicine, Capital Medical University, Beijing, 100069, P.R. China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, 100029, P.R. China.,Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, P.R. China
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Kawada T. Infection and Venous Thromboembolism: A Risk Assessment. Am J Med 2018; 131:e401. [PMID: 30266278 DOI: 10.1016/j.amjmed.2018.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 03/16/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Tomoyuki Kawada
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
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Giant Left Ventricular Thrombus in a Patient with Acute Ischemic Stroke: A Case Report and Minireview. Case Rep Cardiol 2018; 2018:3714742. [PMID: 29581898 PMCID: PMC5821988 DOI: 10.1155/2018/3714742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022] Open
Abstract
A 56-year-old healthy male with no obvious risk factors or significant past medical history was admitted to the emergency room with acute ischemic stroke. On his transthoracic echocardiography (TTE), an extremely large thrombus was detected at the apex involving the distal anterior wall. The thrombus was predominantly adherent but with a mobile tip. The patient was subsequently managed with dual antiplatelet therapy. In this report, we present an interesting case of an acute ischemic stroke secondary to a giant left ventricular thrombus in a patient with no past significant cardiac or neurologic medical history.
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Jönsson AK, Schill J, Olsson H, Spigset O, Hägg S. Venous Thromboembolism During Treatment with Antipsychotics: A Review of Current Evidence. CNS Drugs 2018; 32:47-64. [PMID: 29423659 PMCID: PMC5843694 DOI: 10.1007/s40263-018-0495-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This article summarises the current evidence on the risk of venous thromboembolism (VTE) with the use of antipsychotics. An increasing number of observational studies indicate an elevated risk of VTE in antipsychotic drug users. Although the use of certain antipsychotics has been associated with VTE, current data can neither conclusively verify differences in occurrence rates of VTE between first- and second-generation antipsychotics or between individual compounds, nor identify which antipsychotic drugs have the lowest risk of VTE. The biological mechanisms involved in the pathogenesis of this adverse drug reaction are still to be clarified but hypotheses such as drug-induced sedation, obesity, increased levels of antiphospholipid antibodies, enhanced platelet aggregation, hyperhomocysteinaemia and hyperprolactinaemia have been suggested. Risk factors associated with the underlying psychiatric disorder may at least partly explain the increased risk. Physicians should be aware of this potentially serious and even sometimes fatal adverse drug reaction and should consider discontinuing or switching the antipsychotic treatment in patients experiencing a VTE. Even though supporting evidence is limited, prophylactic antithrombotic treatment should be considered in risk situations for VTE.
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Affiliation(s)
- Anna K Jönsson
- Department of Drug Research, Section of Clinical Pharmacology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Forensic Genetics and Forensic Chemistry, National Board of Forensic Medicine, Linköping, Sweden
| | - Johan Schill
- Department of Psychiatry, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Hans Olsson
- Department of Psychiatry, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Staffan Hägg
- Futurum, Region Jönköping County, Department of Medical and Health Sciences, Linköping University, Sweden.
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Witmer CM, Takemoto CM. Pediatric Hospital Acquired Venous Thromboembolism. Front Pediatr 2017; 5:198. [PMID: 28975127 PMCID: PMC5610717 DOI: 10.3389/fped.2017.00198] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 08/29/2017] [Indexed: 11/13/2022] Open
Abstract
Pediatric hospital acquired venous thromboembolism (HA-VTE) is an increasing problem with an estimated increase from 5.3 events per 10,000 pediatric hospital admissions in the early 1990s to a current estimate of 30-58 events per 10,000 pediatric hospital admissions. Pediatric HA-VTE is associated with significant morbidity and mortality. The etiology is multifactorial but central venous catheters remain the predominant risk factor. Additional HA-VTE risk factors include both acquired (recent surgery, immobility, inflammation, and critical illness) and inherited risk factors. Questions remain regarding the most effective method to assess for HA-VTE risk in hospitalized pediatric patients and what preventative strategies should be implemented. While several risk-assessment models have been published in pediatric patients, these studies have limited power due to small sample size and require prospective validation. Potential thromboprophylactic measures include mechanical and pharmacologic methods both of which have associated harms, the most significant of which is bleeding from anticoagulation. Standard anticoagulation options in pediatric patients currently include unfractionated heparin, low molecular weight heparin, or warfarin all of which pose a monitoring burden. Ongoing pediatric studies with direct oral anticoagulants could potentially revolutionize the prevention and treatment of pediatric thrombosis with the possibility of a convenient route of administration and no requirement for monitoring. Further studies assessing clinical outcomes of venous thromboembolism (VTE) prevention strategies are critical to evaluate the effectiveness and harm of prophylactic interventions in children. Despite HA-VTE prevention efforts, thrombotic events can still occur, and it is important that clinicians have a high clinical suspicion to ensure prompt diagnosis and treatment to prevent further associated harms.
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Affiliation(s)
- Char M Witmer
- Department of Pediatrics, Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Clifford M Takemoto
- Pediatric Hematology, The Johns Hopkins University, Baltimore, MD, United States
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