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McKerrow Johnson I, Shatzel J, Olson S, Kohl T, Hamilton A, DeLoughery TG. Travel-Associated Venous Thromboembolism. Wilderness Environ Med 2022; 33:169-178. [PMID: 35370084 DOI: 10.1016/j.wem.2022.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Long-distance travel is assumed to be a risk factor for venous thromboembolism (VTE). However, the available data have not clearly demonstrated the strength of this relationship, nor have they shown evidence for the role of thromboprophylaxis. METHODS We performed a systematic review of the literature. We also summarized available guidelines from 5 groups. RESULTS We found 18 studies that addressed this question. Based on the data presented in the review, we conclude that there is an association between VTE and length of travel, but this association is mild to moderate in effect size with odds ratios between 1.1 and 4. A dose-response relationship between VTE and travel time was identified, with a 26% higher risk for every 2 h of air travel (P=0.005) starting after 4 h. The quality of evidence for both travel length and thromboprophylaxis was low. However, low-risk prophylactic measures such as graduated compression stockings were shown to be effective in VTE prevention. There is heterogeneity among the different practice guidelines. The guidelines generally concur that no prophylaxis is necessary in travelers without known thrombosis risk factors and advocate for conservative treatment such as compression stockings over pharmacologic prophylaxis. CONCLUSIONS We conclude air travel is a risk factor for VTE and that there is a dose relationship starting at 4 h. For patients with risk factors, graduated compression stockings are effective prophylaxis.
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Affiliation(s)
| | - Joseph Shatzel
- Division of Hematology-Medical Oncology, Oregon Health & Science University, Portland, Oregon; Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Sven Olson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Tovah Kohl
- Oregon Health & Science University Office of Clinical Integration and Evidence Based Practice, Portland, Oregon
| | - Andrew Hamilton
- Oregon Health & Science University Office of Clinical Integration and Evidence Based Practice, Portland, Oregon
| | - Thomas G DeLoughery
- Division of Hematology-Medical Oncology, Oregon Health & Science University, Portland, Oregon.
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Schünemann HJ, Cushman M, Burnett AE, Kahn SR, Beyer-Westendorf J, Spencer FA, Rezende SM, Zakai NA, Bauer KA, Dentali F, Lansing J, Balduzzi S, Darzi A, Morgano GP, Neumann I, Nieuwlaat R, Yepes-Nuñez JJ, Zhang Y, Wiercioch W. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018; 2:3198-3225. [PMID: 30482763 PMCID: PMC6258910 DOI: 10.1182/bloodadvances.2018022954] [Citation(s) in RCA: 489] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/19/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is the third most common vascular disease. Medical inpatients, long-term care residents, persons with minor injuries, and long-distance travelers are at increased risk. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about preventing VTE in these groups. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 19 recommendations for acutely ill and critically ill medical inpatients, people in long-term care facilities, outpatients with minor injuries, and long-distance travelers. CONCLUSIONS Strong recommendations included provision of pharmacological VTE prophylaxis in acutely or critically ill inpatients at acceptable bleeding risk, use of mechanical prophylaxis when bleeding risk is unacceptable, against the use of direct oral anticoagulants during hospitalization, and against extending pharmacological prophylaxis after hospital discharge. Conditional recommendations included not to use VTE prophylaxis routinely in long-term care patients or outpatients with minor VTE risk factors. The panel conditionally recommended use of graduated compression stockings or low-molecular-weight heparin in long-distance travelers only if they are at high risk for VTE.
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Affiliation(s)
- Holger J Schünemann
- Department of Medicine and
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mary Cushman
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Allison E Burnett
- Inpatient Antithrombosis Service, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus," Dresden, Germany
- Kings Thrombosis Service, Department of Hematology, Kings College London, United Kingdom
| | | | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Neil A Zakai
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT
| | - Kenneth A Bauer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | | | - Sara Balduzzi
- Cochrane Italy, Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy; and
| | - Andrea Darzi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Juan J Yepes-Nuñez
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Delate T, Hsiao W, Kim B, Witt DM, Meyer MR, Go AS, Fang MC. Assessment of algorithms to identify patients with thrombophilia following venous thromboembolism. Thromb Res 2015; 137:97-102. [PMID: 26585762 DOI: 10.1016/j.thromres.2015.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Routine testing for thrombophilia following venous thromboembolism (VTE) is controversial. The use of large datasets to study the clinical impact of thrombophilia testing on patterns of care and patient outcomes may enable more efficient analysis of this practice in a wide range of settings. We set out to examine how accurately algorithms using International Classification of Diseases 9th Revision (ICD-9) codes and/or pharmacy data reflect laboratory-confirmed thrombophilia diagnoses. MATERIALS AND METHODS A random sample of adult Kaiser Permanente Colorado patients diagnosed with unprovoked VTE between 1/2004 and 12/2010 underwent medical record abstraction of thrombophilia test results. Algorithms using "ICD-9" (positive if a thrombophilia ICD-9 code was present), "Extended anticoagulation (AC)" (positive if AC therapy duration was >6 months), and "ICD-9 & Extended AC" (positive for both) criteria to identify possible thrombophilia cases were tested. Using positive thrombophilia laboratory results as the gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each algorithm were calculated, along with 95% confidence intervals (CIs). RESULTS In our cohort of 636 patients, sensitivities were low (<50%) for each algorithm. "ICD-9" yielded the highest PPV (41.5%, 95% CI 26.3-57.9%) and a high specificity (95.9%, 95% CI 94.0-97.4%). "Extended AC" had the highest sensitivity but lowest specificity, and "ICD-9 & Extended AC" had the highest specificity but lowest sensitivity. CONCLUSIONS ICD-9 codes for thrombophilia are highly specific for laboratory-confirmed cases, but all algorithms had low sensitivities. Further development of methods to identify thrombophilia patients in large datasets is warranted.
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Affiliation(s)
- Thomas Delate
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, USA; Department of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, 12850 East Montview Boulevard, Aurora, CO 80045, USA.
| | - Wendy Hsiao
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA.
| | - Benjamin Kim
- Division of Hematology/Oncology, Department of Medicine, University of California, 505 Parnassus Avenue, M1286, Box 1270, San Francisco, CA 94143, USA.
| | - Daniel M Witt
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, USA; Department of Pharmacotherapy, University of Utah College of Pharmacy, 30 South 2000 East, Room 4926, Salt Lake City, UT 84112, USA.
| | - Melissa R Meyer
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, 16601 East Centretech Parkway, Aurora, CO 80011, USA.
| | - Alan S Go
- Division of Research, Kaiser Permanente of Northern California, 2000 Broadway, Oakland, CA 94612, USA; Departments of Epidemiology, Biostatistics, and Medicine, University of California, 550 16th Street, 2nd floor, San Francisco, CA 94158, USA; Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane, Stanford, CA 94305, USA.
| | - Margaret C Fang
- Division of Hospital Medicine, Department of Medicine, University of California, 533 Parnassus Avenue, Box 0131, Room U135, San Francisco, CA 94143, USA.
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Abstract
Pulmonary embolism is the third most common cardiovascular disease after myocardial infarction and stroke. The death rate from pulmonary embolism exceeds the death rate from myocardial infarction, because myocardial infarction is much easier to detect and to treat. Among survivors of pulmonary embolism, chronic thromboembolic pulmonary hypertension occurs in 2-4 of every 100 patients. Post-thrombotic syndrome of the legs, characterized by chronic venous insufficiency, occurs in up to half of patients who suffer deep vein thrombosis or pulmonary embolism. We have effective pharmacological regimens using fixed low dose unfractionated or low molecular weight heparin to prevent venous thromboembolism among hospitalized patients. There remains the problem of low rates of utilization of pharmacological prophylaxis. The biggest change in our understanding of the epidemiology of venous thromboembolism is that we now believe that deep vein thrombosis and pulmonary embolism share similar risk factors and pathophysiology with atherothrombosis and coronary artery disease.
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