“Post-thrombotic panic syndrome”: A thematic analysis of the experience of venous thromboembolism

Hemostatic and Inflammatory Biomarkers are Associated with Functional Limitations after Venous Thromboembolism: A Prospective Cohort Study

Functional limitations often persist in patients with venous thromboembolism (VTE). The relevance of biomarkers for these outcomes remains unexplored. Therefore, we aimed to investigate the association of hemostatic, inflammatory, and cardiovascular biomarkers with functional limitations 3 months after VTE. We conducted a prospective cohort study, including patients with acute VTE within 21 days of diagnosis. Biomarker levels (D-dimer, fibrinogen, factor VIII [FVIII], von Willebrand factor antigen [VWF], C-reactive protein [CRP], troponin T, N-terminal pro-B-type natriuretic peptide [proBNP]) were measured at inclusion and 3 months. Functional limitations at 3 months were evaluated with the post-VTE functional status (PVFS) scale (0-4, higher indicating more limitations). The association of biomarkers with functional limitations was assessed with proportional odds models adjusted for confounders. Furthermore, we evaluated the area under the receiver operating characteristic curve (AUC-ROC) for the presence of slight-to-severe functional limitations. Overall, we included 290 patients (41.4% of women) with a median age of 54.9 years (interquartile range [IQR]: 43.1-64.2). D-dimer, fibrinogen, FVIII, VWF, and CRP measured at inclusion were independently associated with functional limitations at 3 months. VWF showed the most favorable AUC-ROC (0.62, 95% CI, 0.55-0.69). In patients with pulmonary embolism, troponin T and proBNP were not associated with functional limitations. At the 3-month follow-up, D-dimer was the only biomarker independently associated with functional limitations, yielding an area under the curve (AUC) of 0.62 (95% CI, 0.55-0.69). In conclusion, we identified biomarkers independently associated with functional limitations 3 months after VTE. Our results indicate a role of these biomarkers in the early identification of patients at risk of persistent functional limitations and suggest their involvement in the underlying mechanisms.

Patient-reported outcome measures: A key to patient-tailored and outcome-driven care in pulmonary embolism survivors

Almost half of the acute pulmonary embolism (PE) survivors suffer from long-term sequelae that limit quality of life and their reintegration in society. The post-PE syndrome involves a spectrum of complications ranging from life-threatening pulmonary hypertension to deconditioning and psychosocial issues. The follow-up of acute PE has been demonstrated to be rife with challenges including long diagnostic delays, inefficient use of healthcare resources and the ignorance of psychosocial complications such as depression and anxiety. The best way to monitor recovery of PE comprehensively and reproducibly is the application of patient-reported outcome measures (PROMs), including quality of life assessment. PROMs help to identify and guide diagnostic tests and therapeutic interventions as well as to monitor the impact of the latter. In our view, therefore, PROMs should be integrated as a fundamental part of routine PE follow-up.

The relationship between uncertainty in illness and psychological adjustment to chronic illness

Using Mishel's Uncertainty in illness theory, this integrative review sought to identify how uncertainty in illness and psychological adjustment to illness are associated with chronic illness to guide development of interventions to support psychological adjustment. A search was conducted via EBSCOHost to answer the question "What is the relationship between uncertainty in illness and psychological adjustment to chronic illness?" Two key factors were identified as having an impact on psychological adjustment to chronic illness in the presence of uncertainty in illness including uncertainty appraisal and the type of coping strategies used in response to the appraisal. Individuals with a chronic illness diagnosis are more likely to experience increased levels of uncertainty in illness and decreased psychological adjustment to illness. A better understanding of these two concepts is important to augment and or guide the development of interventions to support psychological adjustment.

Anxiety in patients with venous thromboembolism: quantification and risk factors in a prospective cohort study

BACKGROUND

Patients with venous thromboembolism (VTE) are at risk of psychological consequences. However, as opposed to physical sequelae of VTE, mental health issues are understudied.

OBJECTIVES

To assess anxiety after VTE and investigate associated clinical characteristics.

METHODS

We conducted a prospective cohort study, including patients with acute deep vein thrombosis (DVT) and/or pulmonary embolism. Patients with cancer, pregnancy, or puerperium were excluded. Anxiety was assessed with the Patient-Reported Outcome Measurement Information System short form 8a. Standardized T-scores were calculated (reference, 50; SD, 10), with higher values indicating more anxiety. We associated clinical characteristics at baseline with T-scores at 3-month follow-up in a multivariable linear regression model. Patient clusters depending on anxiety trajectories were explored.

RESULTS

We included 257 patients (38.5% women) with a median (IQR) age of 54.1 (42.2-63.5) years. While mean (SD) T-scores decreased from baseline to follow-up (51.03 [9.18] to 46.74 [8.89]; P < .001), we observed an increase in 23.7% of all patients. Female sex (T-score change, 3.09; 95% CI, 0.96-5.22), older age until 45 years, and anxiety at baseline were associated with increased T-scores at follow-up. VTE history (-1.55; 95% CI, -3.62 to 0.52) and pulmonary embolism (-1.23; 95% CI, -3.16 to 0.69) were associated with reduced T-scores, albeit not reaching statistical significance. In a cluster of older female patients with DVT, anxiety tended to increase over time.

CONCLUSION

While most patients with VTE reported reduced anxiety over time, some patients experienced worsening. Female sex, older age, more anxiety at baseline, no VTE history, and DVT were associated with increased anxiety 3 months after VTE.

Exploring the lived experiences of deep vein thrombosis patients in Lahore, Pakistan: a qualitative phenomenological study on healthcare challenges, resilience and social support

OBJECTIVE

This study aimed to explore and describe the lived psychological and emotional experiences of sufferers of deep vein thrombosis (DVT) and to narrate the effect of those experiences on their daily lives.

DESIGN, SETTING AND PARTICIPANTS

For data collection, a phenomenological qualitative design was used using semistructured, in-depth interviews of patients with DVT aged 18-70 years. Data were transcribed and analysed using the interpretative inductive approach to identify emergent themes.

RESULTS

The five major themes emerged were as follows: (1) experiences and challenges of managing pain and physical limitations in patients; (2) the high out-of-pocket cost of care as a financial challenge to access healthcare; (3) the struggle of patients with social isolation and lack of emotional support; (4) resilience and self-reliance in the face of illness for navigation through life and (5) inadequate healthcare system and challenges in accessing proper treatment.

CONCLUSIONS

Conclusively, chronic disease such as, DVT, negatively impacts the life of its sufferers in terms of their physical health, lifestyle and psychological behaviour. There is a high need to introduce rehabilitative services as a regular part of healthcare system, so that self-management strategies are promoted and the burden of long-term psychological, emotional and behaviour problems can be avoided.

Causal association between major depressive disorder and venous thromboembolism: a bidirectional mendelian randomization study

Purpose

Major depressive disorder (MDD) and venous thromboembolism (VTE) may be linked in observational studies. However, the causal association remains ambiguous. Therefore, this study investigates the causal associations between them.

Methods

We performed a two-sample univariable and multivariable bidirectional Mendelian randomization (MR) analysis to evaluate the associations between MDD and VTE. The summary genetic associations of MDD statistics were obtained from the Psychiatric Genomics Consortium and UK Biobank. Information on VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) were obtained from the FinnGen Biobank. Inverse-variance weighting was used as the main analysis method. Other methods include weighted median, MR-Egger, Simple mode, and Weighted mode.

Results

Univariable MR analysis revealed no significant associations between MDD and VTE risk (odds ratio (OR): 0.936, 95% confidence interval (CI): 0.736-1.190, p = 0.590); however, after adjusting the potential relevant polymorphisms of body mass index and education, the multivariable MR analysis showed suggestive evidence of association between them (OR: 1.163, 95% CI: 1.004-1.346, p = 0.044). Univariable MR analysis also revealed significant associations between MDD and PE risk (OR: 1.310, 95% CI: 1.073-1.598, p = 0.008), but the association between them was no longer significant in MVMR analysis (p = 0.072). We found no significant causal effects between MDD and DVT risk in univariable or multivariable MR analyses. There was also no clear evidence showing the causal effects between VTE, PE, or DVT and MDD risk.

Conclusion

We provide suggestive genetic evidence to support the causal association between MDD and VTE risk. No causal associations were observed between VTE, PE, or DVT and MDD risk. Further validation of these associations and investigations of potential mechanisms are required.

Post-pulmonary embolism syndrome: A reminder for clinicians

Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular emergencies and the third leading cause of death. Although efforts focus on treating the acute event, patients who survive APE may develop long-term sequelae. Research reveals that approximately half of patients who have suffered an APE do not regain their previous level of function and experience a reduction in their quality of life for several years after the episode. Acute pulmonary embolism can be classified according to the risk of short-term mortality, with most mortality and morbidity concentrated in high-risk and intermediate-risk cases. The first-line treatment for APE is systemic anticoagulation. However, identifying and more aggressively treating people with intermediate to high risk, who have a more favorable risk profile for reperfusion treatments, could reduce short-term mortality and mitigate post-pulmonary embolism syndrome (PPES). Post-pulmonary embolism syndrome refers to a variety of persistent symptoms and functional limitations that occur after an APE. The presence of persistent dyspnea, functional limitations, and/or decreased quality of life after an APE has been recently termed "PPES," although this entity encompasses different manifestations. The most severe cause of persistent dyspnea is chronic thromboembolic pulmonary hypertension, where increased pulmonary artery pressure is due to the fibrotic organization of unresolved APE. Post-PE Syndrome is not always systematically addressed in management guidelines, and its prevalence may be underestimated. More research is needed to fully understand its causes and risk factors. Interventions such as cardiopulmonary rehabilitation have been suggested to improve the quality of life of patients with PPES. A comprehensive, evidence-based approach is essential to effectively prevent and manage PPES and improve the long-term outcomes and well-being of affected patients.

Comparison of important factors to patients recovering from pulmonary embolism and items covered in patient-reported outcome measures: A mixed-methods systematic review

OBJECTIVE

Up to 50 % of patients recovering from pulmonary embolism (PE) experience negative long-term outcomes. Patient-reported outcome measures (PROMs) are important in identifying what matters to patients. We aimed to identify PROMs used in clinical studies and recommended by the International Consortium of Health Outcomes (ICHOM) and compare individual items with factors considered important by patients recovering from PE.

METHODS

This was a convergent mixed-methods systematic review, including quantitative studies, using PROMs and qualitative studies with non-cancer-related PE patients. Items from each PROM and qualitative findings were categorised using an International Classification of Function linking process to allow for integrated synthesis.

RESULTS

A total of 68 studies using 34 different PROMs with 657 items and 13 qualitative studies with 408 findings were included. A total of 104 individual ICF codes were used, and subsequently sorted into 20 distinct categories representing patient concerns. Identified PROMs were found to adequately cover 17/20 categories, including anxiety, fear of bleeding, stress, depression, dizziness/nausea, sleep disturbance, pain, dyspnea, fatigue, activity levels, family and friends, socializing, outlook on life, and medical treatment. PROMs from the ICHOM core set covered the same categories, except for dizziness/nausea.

CONCLUSIONS

No single PROM covered all aspects assessed as important by the PE population. PROMs recommended in the ICHOM core set cover 16/20 aspects. However, worrisome thoughts, hypervigilance around symptoms, and uncertainty of illness were experienced by patients with PE but were not covered by PROMS.

Measuring Quality of Life after Venous Thromboembolism: Who, When, and How?

There is a growing body of evidence revealing that many patients with a history of venous thromboembolism (VTE) suffer from long-lasting sequelae such as post-thrombotic syndrome and post-pulmonary embolism syndrome. These two syndromes are detrimental to patients as they affect their quality of life (QOL). From this perspective, monitoring QOL may play a crucial role to improve quality care in VTE patients. Many studies have explored possible temporal relations between VTE episodes and decreased functional status and/or QOL. However, studies exploring the implementation of QOL and functional status questionnaires in clinical practice are scarce. In this context, we discuss possible perspectives synthetized from available literature regarding in whom, when, and how QOL could be measured in clinical practice.

Measurement of adherence and health-related quality of life during anticoagulation therapy in cancer-associated venous thromboembolism (VTE): a multicenter quantitative study

PURPOSE

Therapy for cancer-associated venous thromboembolism (VTE) includes long-term anticoagulation, which may have substantial impact on the health-related quality of life (HRQL) of patients. We assessed patient-reported outcomes to characterize the HRQL associated with VTE treatment and to begin to examine those HRQL elements impacting anticoagulation adherence (AA).

METHODS

Participants were adult cancer patients with confirmed symptomatic acute lower extremity deep venous thrombosis. Patients were excluded if there was an indication for anticoagulation other than VTE, ECOG performance status >3, or life expectancy < 3 months. Participants were assessed with a self-reported adherence tool. HRQL was measured with a 6-domain questionnaire using a seven-point Likert scale. Evaluations were performed at 30 days and 3 months after enrollment. For the primary objective, an overall adherence rate was calculated at each time point of evaluation. For the HRQL domains, non-parametric testing was used to compare results between subgroups.

RESULTS

Seventy-four patients were enrolled. AA and HRQL at 30 days and 3 months were assessed in 50 and 36 participants, respectively. At 30 days the AA rate was 90%, and at 3 months it was 83%. In regard to HRQL, patients suffered frequent and moderate-severe distress in the domains of emotional and physical symptoms, sleep disturbance, and limitations to physical activity. An association between emotional or physical distress and AA was observed.

CONCLUSION

Patients with VTE suffer a substantial impairment of their HRQL. Increased emotional distress correlated with better long-term AA. These results can be used to inform additional research aimed at developing novel strategies to improve AA.

[Approaching patient experience following pulmonary embolism: A systematic review]

INTRODUCTION

Pulmonary embolism (PE) is the major complication of thromboembolic disease. While a few qualitative studies have explored patient experience after PE, to our knowledge no literature review is available to date. The aim of this work was to explore patient experience after a PE episode through a systematic review of the literature comprising: patient experience, clinicians' perception of the patients' attitude and knowledge, and the patients' perception of VTE prevention strategies.

METHODS

A search of PubMed, Web of science, Cochrane and EMBASE databases. The search was conducted without filters. Search results were combined and duplicates were removed. The selection was blinded by two independent researchers using the Rayyan application.

RESULTS

Fifty studies were assessed for quality and 23 were included. Individual semi-structured interviews and focus groups were widely used to explore patient experience after a PE episode. Patients described deterioration in their quality of life, their psychological state and an initial feeling of carer abandonment. The trends observed appear to be more pronounced in patients with an episode characterized as unprovoked.

CONCLUSION

These preliminary results call for further longitudinal studies, the objective being to better understand the evolution of these factors in the short and long terms.

Mental Health and Quality of Life in Pulmonary Embolism: A Literature Review

Pulmonary embolismis an acute disease with chronic complications and, although it is not considered a chronic disease, it requires close follow-up. The scope of the present literature review is to decode the existing data concerning quality of life and the mental health impact of PE during the acute and long-term phases of the disease. The majority of studies reported impaired quality of life in patients with PE when compared to population norms, both in the acute phase and >3 months after PE. Quality of life improves over time, irrespectively of the measurement used. Fear of recurrences, elderly, stroke, obesity, cancer and cardiovascular comorbidities are independently associated with worse QoL at follow-up. Although disease specific instruments exist (e.g., the Pulmonary Embolism Quality of Life questionnaire), further research is required in order to develop questionnaires that may fulfil international guideline requirements. The fear of recurrences and the development of chronic symptoms, such as dyspnea or functional limitations, may further impair the mental health burden of PE patients. Mental health may be implicated by post-traumatic stress disorder, anxiety and depressive symptoms present following the acute event. Anxiety may persist for 2 years following diagnosis and may be exaggerated by persistent dyspnea and functional limitations. Younger patients are at higher risk of anxiety and trauma symptoms while elderly patients and patients with previous cardiopulmonary disease, cancer, obesity or persistent symptoms exhibit more frequently impaired QoL. The optimal strategy for the assessment of mental health in this patient pool is not well defined in the literature. Despite mental burden being common following a PE event, current guidelines have not incorporated the assessment or management of mental health issues. Further studies are warranted to longitudinally assess the psychological burden and elucidate the optimal follow-up approach.

Outcomes of venous thromboembolism care: future directions

The complete picture of the outcomes of venous thromboembolism (VTE) care consists of conventional binary clinical outcomes (death, recurrent VTE, and bleeding), patient-centered outcomes, and society-level outcomes. Combined, these allow for the introduction of outcome-driven patient-centered health care. The emerging concept of valuing health care from such a holistic point of view, ie, value-based health care, holds a huge potential to revolutionize-and improve-the organization and evaluation of care. The ultimate goal of this approach was to achieve a high value for patients, ie, the best possible clinical outcomes at the right cost, providing a framework for evaluation and comparisons of different management strategies, patient pathways, or even complete health care delivery systems. To facilitate this, outcomes of care from a patient perspective, such as symptom burden, functional limitations, and quality of life, need to be routinely captured in clinical practice and trials, complementary to the conventional clinical outcomes, to fully capture the patients' values and needs. The aim of this review was to discuss the relevant outcomes of VTE care, explore value in VTE care from different perspectives, and propose future directions to inspire change. This is a call to action to shift the focus to outcomes that matter and make a larger difference in the lives of patients.

Depression and anxiety up to two years after acute pulmonary embolism: Prevalence and predictors

INTRODUCTION

Pulmonary embolism (PE) is an acute life-threatening event. Besides known physical long-term consequences such as persistent dyspnoea or reduced physical performance, less attention is given to the emotional experience.

METHODS

We used data from patients with PE of the 'Lungenembolie Augsburg (LEA)' cohort study at University Hospital Augsburg. Baseline characteristics were collected during hospital stay and participants received postal questionnaires 3, 6, 12, and 24 months after their PE event. Mental problems were assessed by the Hospital Anxiety and Depression Scale (HADS). Differences in baseline characteristics in patients with or without depression or anxiety at 3 months were tested. Linear mixed models were built to explore long-term effects.

RESULTS

About one-in-five of the 297 patients suffered from depressive or anxiety symptoms after PE. Patients with depressiveness 3 months after PE were found to be significantly older, had a higher simplified pulmonary embolism severity index (sPESI), higher education level, more frequently previous depression, lower oxygen saturation, and a longer hospital stay. Linear mixed models revealed significant associations of age, history of depression and sPESI with HADS depression score, and symptoms of dyspnoea with HADS anxiety score after PE. While the association with sPESI decreased over time, persistent dyspnoea and limitations in daily life showed constant associations over the two-year time period for both, depression and anxiety.

CONCLUSIONS

The findings highlight depression and anxiety to be common in patients with PE and reveal possible predictors. Careful monitoring the mental health of patients with PE is needed for early detection and intervention.

Psychological distress in pulmonary embolism survivors in a pulmonary embolism response team clinic: Protocol for a prospective observational study

Background

Pulmonary embolism (PE) is a leading cause of cardiovascular death. Psychological distress in PE is understudied and underrecognized.

Objectives

The primary aim of this proposed protocol was to describe the incidence of psychological distress symptoms (anxiety, depression, posttraumatic stress, and fear of recurrence) in the survivors of PE after discharge from hospitalization. The secondary aim was to assess the influence of acute disease, etiology, and treatment of PE on psychological distress.

Methods

This is a prospective observational cohort study in a large tertiary care referral center. The participants are adult patients presenting to the hospital with PE fulfilling objective pulmonary embolism response team (PERT) activation criteria. After discharge, patients complete a series of validated measures of psychological distress (anxiety, depression, posttraumatic stress, and fear of recurrence) and quality of life at follow-ups approximately 1, 3, 6, and 12 months after diagnosis and treatment of their PE. Factors influencing each type of distress are evaluated.

Conclusion

This protocol aims to identify the unmet needs of patients experiencing psychological distress following PE. It will describe anxiety, depression, fear of recurrence, and posttraumatic symptoms in PE survivors during the first year of outpatient follow-up in a PERT clinic.

Evidence-based health information about pulmonary embolism: Assessing the quality, usability and readability of online and offline patient information

Objective

Pulmonary embolism (PE) is the third most common cardiovascular disease worldwide. However, public awareness is considerably lower than for myocardial infarction or stroke. Patients suffering from PE complain about the lack of (understandable) information and express high informational needs. To uncover if reliable information is indeed scarce, this study evaluates the quantity and quality of existing patient information for tertiary prevention using an evidence-based health information paradigm.

Methods

We conducted a quantitative content analysis (n = 21 patient information brochures; n = 67 websites) evaluating content categories addressed, methodical quality, usability, and readability.

Results

Results show that there is not enough patient information material focusing on PE as a main topic. Existing patient information material is mostly incomplete, difficult to understand, and low in actionability as well as readability.

Conclusion

Our systematic analysis reveals the need for more high-quality patient information on PE as part of effective tertiary prevention.

Innovation

This is the first review analyzing content, methodical quality, readability, and usability of patient information on PE. The findings of this analysis are guiding the development of an innovative, evidence-based patient information on PE aiming to support patients' informational needs and their self-care behavior.

Understanding the experiences of anger in the onset and progression of psoriasis: A thematic analysis

Psoriasis is a chronic inflammatory skin condition, which can be affected by stress. Living with psoriasis can trigger negative emotions, which may influence quality of life. The present study explored the lived experiences of people with psoriasis with attention to the potential role of anger in the onset and progression of the chronic skin condition. Semi-structured qualitative interviews were conducted with 12 participants (n = 5 females, n = 7 males) recruited from an advert on a patient charity social media platform. Data were transcribed and analysed using thematic analysis. Four key themes were identified: (1) anger at the self and others, (2) the impact of anger on psoriasis: angry skin, (3) shared experiences of distress and (4) moving past anger to affirmation. Findings suggest that anger can have a perceived impact on psoriasis through contributing to sensory symptoms and unhelpful coping cycles, and points to a need for enhanced treatment with more psychological support. The findings also highlight the continued stigma which exists for those living with visible skin conditions and how this may sustain anger for those individuals. Future research could usefully focus on developing targeted psychosocial interventions to promote healthy emotional coping.

Integrative analyses of genes about venous thromboembolism: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

In recent years, many studies have found possible links between gene polymorphisms and venous thromboembolism (VTE). By identifying genetic risk factors before facing environmental risk factors such as surgical interventions and COVID-19 vaccination, we could rapidly respond to the risk of VTE. The aim of this study was to perform an umbrella review of genetic variants related to VTE. Integrative gene analysis of VTE was performed to identify critical genetic variations.

METHODS

This study conducted an umbrella review of systematic reviews and meta-analyses. All included studies were selected from the PubMed/MEDLINE database. To select eligible studies, the following variables were extracted: first author name; effect size of each study genetic variant; year of publication; the number of studies included in each article; ethnicity, sample size, P values, and heterogeneity estimates. To assess cumulative evidence in genetic epidemiology about effects of gene polymorphisms on VTE, Human Genome Epidemiology Network's Venice criteria were used. Methodological quality assessment was conducted with JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

Genes provided in the present study with genetic variants associated with VTE were FVL (G1691A), Prothrombin (G20210A), MTHFR (C677T, A1298C), PAI-1 (4G/5G), factor VII activating protease (1601G > A), and endothelial protein C receptor (g.6936A_G, c.4600A_G). Among them, variants in FVL, Prothrombin, MTHFR, and PAI-1 showed high significance. Particularly, variants in Prothrombin (G20210A), MTHFR (C677T), and PAI-1 (4G/5G) had more than 2 types of model significance.

CONCLUSION

The present study performed a systematic review of genetic variants associated with VTE. Our results could lead to a more comprehensive understanding of VTE etiology. These results could give a strategy of prediagnosis about evaluating individual risks of VTE who might be exposed to environmental risk factors.

Multidisciplinary Care for the Prevention and Treatment of Venous Thromboembolism in Patients with Cancer-Associated Thrombosis (CAT): Impact of Educational Interventions on CAT-Related Events and on Patients' and Clinicians' Awareness

Cancer is a leading cause of death. Venous thromboembolism (VTE) is an often-overlooked cause of morbidity and mortality in cancer patients that can be readily prevented and treated. Actions are needed to reduce the morbidity and mortality of patients with cancer-associated thrombosis (CAT). There is a need to increase awareness of the impact of CAT on cancer patients' morbidity and mortality, on their quality of life and to understand the importance of more effective preventions and treatments of VTE in cancer patients. Moreover, it is of great importance to systematically assess the risk of VTE in regard to patients, cancer and treatment-related factors. Unfortunately, there are unmet clinical needs in the prevention and treatment of cancer-associated VTE. In this review, we discuss an action plan to ensure an increased awareness of and education on the issues that need to be addressed in order to improve the provision of appropriate prevention, early diagnosis and effective and safe treatment of VTE to all cancer patients and, ultimately, to reduce morbidity and mortality.

Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation

The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.

Evaluation of patients' experience and related qualitative outcomes in venous thromboembolism: A scoping review

BACKGROUND

Venous thromboembolism (VTE) is a prevalent disease with high morbidity and mortality. VTE has well-documented physical sequelae; however, the psychological and emotional impacts are seldom evaluated in randomized controlled trials.

OBJECTIVE

We conducted a scoping review of published qualitative studies aiming to understand the physical, psychological, and emotional impact of VTE as reflected from patients' perspectives. This scoping review is part of a larger initiative to develop a core outcome set for VTE treatment studies.

METHODS

A systematic literature search was conducted to identify qualitative studies assessing patient experience of VTE. Two authors independently screened titles and abstracts using Covidence systematic review software. Full-text reviews were conducted independently by 2 study team members. A modified method of "thematic synthesis" was used to collate themes upon reading and rereading of the publications.

RESULTS

Our search strategy returned a total of 4944 citations; 28 were ultimately included in the analysis. The studies were conducted across 13 countries and representative of 436 participants including a spectrum of VTE subpopulations. There were seven major themes identified: Acute impacts: an unforeseen blow, Sustained psychological distress, Loss of self: life is changed, Challenges of thrombosis management, Balancing coping and control, Negative experience with the medical system, and VTE in the context of other conditions.

CONCLUSIONS

The physical, psychological, and emotional impacts of VTE extend beyond objective outcomes typically evaluated in clinical trials. An improved understanding of the outcomes most important to patients will improve patient-centered care in VTE.

Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation

The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.

Assessing quality of life after pulmonary embolism: Comparing results from the PEmb-QoL with semistructured interviews

Background

The Pulmonary Embolism Quality of Life questionnaire (PEmb-QoL) assesses quality of life (QoL) in patients with previous pulmonary embolism (PE).

Objective

Our aim was to assess the agreement between the PEmb-QoL and interviews and to explore other QoL concerns in patients diagnosed with PE.

Methods

This mixed-method study included interviews with 21 patients about QoL after PE, followed by the PEmb-QoL questionnaire. In interviews, patients were asked about their lived experiences and impact of PE. Our analysis identified the frequency and severity of decreased QoL in qualitative interviews and compared with the PEmb-QoL score. Excerpts that described the effect of PE on QoL in interview transcripts were transcoded to match the answers corresponding to the 1 to 6 numeric values for each question from the PEmb-QoL using a predetermined matrix (eg, "constant" and "daily" = all of the time = value 1) and directly compared with responses on the PEmb-QoL in the areas of emotional complaints and activities of daily living/social limitations.

Results

Interviews showed more functional impairment than predicted by PEmb-QoL. For fear of recurrence, 86% of participants had disagreements between PEmb-QoL scores and transcoded interview scores. We found 42% disagreement between reported descriptions of the inability to do or enjoy hobbies in interviews and the PEmb-QoL score.

Conclusion

Patient interviews showed discordances compared with a validated psychometric tool. To capture a more detailed and accurate picture of the effect of PE on QoL, providers and researchers should consider the addition of qualitative methods to assess outcomes.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

OBJECTIVE

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction.

METHODS

A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency.

RESULTS

A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001).

CONCLUSION

OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

The Importance of Exploring the Role of Anger in People With Psoriasis

Collapse

Cancer-associated venous thromboembolism

Cancer-associated thrombosis (including venous thromboembolism (VTE) and arterial events) is highly consequential for patients with cancer and is associated with worsened survival. Despite substantial improvements in cancer treatment, the risk of VTE has increased in recent years; VTE rates additionally depend on the type of cancer (with pancreas, stomach and primary brain tumours having the highest risk) as well as on individual patient's and cancer treatment factors. Multiple cancer-specific mechanisms of VTE have been identified and can be classified as mechanisms in which the tumour expresses proteins that alter host systems, such as levels of platelets and leukocytes, and in which the tumour expresses procoagulant proteins released into the circulation that directly activate the coagulation cascade or platelets, such as tissue factor and podoplanin, respectively. As signs and symptoms of VTE may be non-specific, diagnosis requires clinical assessment, evaluation of pre-test probability, and objective diagnostic testing with ultrasonography or CT. Risk assessment tools have been validated to identify patients at risk of VTE. Primary prevention of VTE (thromboprophylaxis) has long been recommended in the inpatient and post-surgical settings, and is now an option in the outpatient setting for individuals with high-risk cancer. Anticoagulant therapy is the cornerstone of therapy, with low molecular weight heparin or newer options such as direct oral anticoagulants. Personalized treatment incorporating risk of bleeding and patient preferences is essential, especially as a diagnosis of VTE is often considered by patients even more distressing than their cancer diagnosis, and can severely affect the quality of life. Future research should focus on current knowledge gaps including optimizing risk assessment tools, biomarker discovery, next-generation anticoagulant development and implementation science.

Application of pulmonary rehabilitation in patients with pulmonary embolism (Review)

As a common clinical emergency, pulmonary embolism (PE) is the third most fatal cardiovascular disease worldwide. Although current sophisticated medical technology has considerably improved the prognosis of patients with PE, they remain at risk of developing long-term complications such as post-PE syndrome. Pulmonary rehabilitation is of great value for patients with chronic lung diseases since it can improve their quality of life while also relieving clinical symptoms. Rehabilitation therapy has been demonstrated to improve recovery and prognosis of patients with PE. Due to short implementation time and the small number of studies, its effectiveness and safety in PE warrant further investigation. The present review focused on elucidating PE pathogenesis, post-PE syndrome and the clinical application of pulmonary rehabilitation in patients with PE.

A Systematic Review and Meta-Analysis of 12-Month Patency After Intervention for Iliofemoral Obstruction Using Dedicated or Non-Dedicated Venous Stents

BACKGROUND

Endovascular stenting of the deep venous system has been proposed as a method to treat patients with symptomatic iliofemoral outflow obstruction. The purpose of this systematic review and meta-analysis was to compare the effectiveness of this treatment at 1-year following the development of dedicated venous stents.

METHOD AND RESULTS

We searched MEDLINE and EMBASE for studies evaluating the effectiveness of venous stent placement. Data were extracted by disease pathogenesis: non-thrombotic iliac vein lesions (NIVL), acute thrombotic (DVT), or post-thrombotic syndrome (PTS). Main outcomes included technical success, stent patency at 1 year and symptom relief. A total of 49 studies reporting outcomes in 5154 patients (NIVL, 1431; DVT, 950; PTS, 2773) were included in the meta-analysis. Technical success rates were comparable among groups (97%-100%). There were no periprocedural deaths. Minor bleeding was reported in up to 5% of patients and major bleeding in 0.5% upon intervention. Transient back pain was noted in 55% of PTS patients following intervention. There was significant heterogeneity between studies reporting outcomes in PTS patients. Primary and cumulative patency at 1 year was: NIVL-96% and 100%; DVT-91% and 97%; PTS (stents above the ligament)-77% and 94%, and; PTS (stents across the ligament)-78% and 94%. There were insufficient data to compare patency outcomes of dedicated and nondedicated venous stents in patients with acute DVT. In NIVL and PTS patients, stent patency was comparable at 1 year. There was inconsistency in the use of validated tools for the measurement of symptoms before and after intervention. When reported, venous claudication, improved in 83% of PTS patients and 90% of NIVL patients, and ulcer healing occurred in 80% of PTS patients and 32% of NIVL patients.

CONCLUSIONS

The first generation of dedicated venous stents perform comparably in terms of patency and clinical outcomes to non-dedicated technologies at 1 year for the treatment of patients with NIVL and PTS. However, significant heterogeneity exists between studies and standardized criteria are urgently needed to report outcomes in patients undergoing deep venous stenting.

Prophylaxis and treatment of COVID-19 related venous thromboembolism

COVID-19 pneumonia has been associated with high rates of thrombo-embolic complications, mostly venous thromboembolism (VTE), which is thought to be a combination of conventional VTE and in situ immunothrombosis in the pulmonary vascular tree. The incidence of thrombotic complications is dependent on setting (intensive care unit (ICU) versus general ward) and the threshold for performing diagnostic tests (screening versus diagnostic algorithms triggered by symptoms). Since these thrombotic complications are associated with in-hospital mortality, all current guidelines and consensus papers propose pharmacological thromboprophylaxis in all hospitalized patients with COVID-19. Several trials are ongoing to study the optimal intensity of anticoagulation for this purpose. As for the management of thrombotic complications, treatment regimens from non-COVID-19 guidelines can be adapted, with choice of anticoagulant drug class dependent on the situation. Parenteral anticoagulation is preferred for patients on ICUs or with impending clinical deterioration, while oral treatment can be started in stable patients. This review describes current knowledge on incidence and pathophysiology of COVID-19 associated VTE and provides an overview of guideline recommendations on thromboprophylaxis and treatment of established VTE in COVID-19 patients.

The use of qualitative methods in venous thromboembolism research

INTRODUCTION

Qualitative research has been increasingly used in health care research to allow in-depth insights and understanding of patients' lived experiences for poorly understood phenomena. The psychological stress mechanisms underlying fear, dyspnea, and pain after venous thromboembolism (VTE) remain poorly understood. However, novice VTE researchers may not be familiar with the process of undertaking qualitative research.

OBJECTIVE

The aim of this article is to describe the planning, methodology and execution of qualitative methods, using the example of patients' lived experiences during and after the diagnosis of VTE. We discuss challenges and solutions in implementing qualitative research methods in health care research.

METHODS

Patients were recruited from the emergency department and clinic using in-person and phone contact. We used both in-person and video format to interview 24 patients. Interviews were guided by a set of questions to be explored but conducted to elucidate unique thoughts and opinions from patients.

RESULTS

For recruitment, "cold-calling" was found to be largely unsuccessful. Many patients have preexisting diagnoses of anxiety and depression. Video interviews were found to be at least as effective as in-person interviews. Interviews revealed unique post-VTE experiences from all participants, with a wide range of impact on quality of life. Themes that were most common included perceptions of physician communication, fear of recurrence, and concerns of death.

CONCLUSION

A qualitative research approach can reveal individual experiences and psychosocial impact in patients diagnosed with VTE, which allow the researchers to better comprehend the complexity of this phenomenon and its impact in health care.

"Whole life changed" - Experiences of how symptoms derived from acute pulmonary embolism affects life. A qualitative interview study

INTRODUCTION

Acute pulmonary embolism (PE) presents itself with a wide range of hemodynamic consequences. Respiratory symptoms as dyspnea and respiratory pain are common. The aim of this study was to explore patients' experiences of how symptoms affected their physical and social activities following the PE.

MATERIALS AND METHODS

Qualitative interviews were conducted with 14 patients, with median time of 7 months (range 3-34 months) since the PE and analysed with qualitative content analysis according to Graneheim and Lundman.

RESULTS

The findings indicated that respiratory symptoms affected many aspects of life, illustrated by an overall theme: "Whole life changed". Two major categories, on changes of psychological/social nature, and changes of perception towards physical activity, described how the participants experienced changes in themselves and their relations, and that the psychological affection resulted in an existential crisis. All participants experienced changes in their physical activity and that remaining respiratory symptoms hindered them from being active. Fear inhibited physical activity and created a feeling of low self-efficacy concerning activity in general.

CONCLUSIONS

To the best of our knowledge, this is the first study to present results on experiences of how the symptoms deriving from PE affected the physical and social activities of the participants during recovery phase. The results indicate that patients with PE need support from the health care system to manage both psychological and physical symptoms in the aftermath of their illness. Further research is needed to find out how optimal rehabilitation for these patients should be designed.

Determinants and Management of the Post-Pulmonary Embolism Syndrome

Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.

The psychological impact of pulmonary embolism: A mixed-methods study

BACKGROUND

Patients diagnosed with pulmonary embolism (PE) are reported to experience symptoms of posttraumatic stress disorder (PTSD) and existential anxiety following their diagnosis. They may also experience negative changes in perspective and hypervigilance of PE symptoms.

OBJECTIVE

The aim of this study was to document the mental and emotional experience associated with PE diagnosis through the lens of PTSD, to better understand the factors involved in psychological distress following receipt of a PE diagnosis.

PATIENTS/METHODS

This was a mixed-methods study in two parts: (i) measurement of self-reported PTSD symptoms among patients attending thrombosis clinic and (ii) semistructured interviews with patients about their experience of receiving a diagnosis of PE and its psychological aftermath.

RESULTS

Of 72 patients who participated in the survey, two met the criteria for a tentative diagnosis of PTSD. The semistructured interviews with 37 patients suggested that around half of respondents experienced some degree of ongoing psychological distress. Those with psychological distress often recalled painful symptoms, recalled diagnosis delivery as stressful, worried about PE recurrence, and had anxieties about stopping their anticoagulant medication. Few patients reported inclination to seek support from professional mental health services.

CONCLUSIONS

We found ongoing and untreated psychological distress among people who were previously diagnosed with PE.

Caging the dragon: Research approach to COVID-19-related thrombosis

The incidence of venous thrombosis, mostly pulmonary embolism (PE), ranging from local immunothrombosis to central emboli, but also deep vein thrombosis (DVT) in people with coronavirus disease 2019 (COVID-19) is reported to be remarkably high. The relevance of better understanding, predicting, treating, and preventing COVID-19-associated venous thrombosis meets broad support, as can be concluded from the high number of research, review, and guideline papers that have been published on this topic. The Dutch COVID & Thrombosis Coalition (DCTC) is a multidisciplinary team involving a large number of Dutch experts in the broad area of venous thrombosis and hemostasis research, combined with experts on virology, critically ill patients, pulmonary diseases, and community medicine, across all university hospitals and many community hospitals in the Netherlands. Within the consortium, clinical data of at least 5000 admitted COVID-19-infected individuals are available, including substantial collections of biobanked materials in an estimated 3000 people. In addition to considerable experience in preclinical and clinical thrombosis research, the consortium embeds virology-hemostasis research models within unique biosafety facilities to address fundamental questions on the interaction of virus with epithelial and vascular cells, in relation to the coagulation and inflammatory system. The DCTC has initiated a comprehensive research program to answer many of the current questions on the pathophysiology and best anticoagulant treatment of COVID-19-associated thrombotic complications. The research program was funded by grants of the Netherlands Thrombosis Foundation and the Netherlands Organization for Health Research and Development. Here, we summarize the design and main aims of the research program.

Quality of life outcomes for patients undergoing venous stenting for chronic deep venous disease

OBJECTIVE

The objective of the study was to evaluate change in venous disease-specific quality of life (QoL) after iliac vein stenting for chronic venous outflow obstruction.

METHODS

We performed a retrospective analysis of all Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaires completed at a single-center between 2016 and 2019 by patients treated with iliac vein stenting for chronic venous outflow obstruction. Patients were asked to complete the questionnaire at baseline (before stenting) and at subsequent follow-up appointments (after stenting), at 6, 12, 24, and 36 months. The Villalta score was recorded by a venous nurse specialist. The initial unpaired analysis compared all completed VEINES-QoL/Sym and Villalta scores at baseline to all follow-up time-points, and then compared them individually between baseline and each follow-up point. A secondary paired analysis included data only from patients who had completed the questionnaire at baseline and at least one follow-up.

RESULTS

A total of 385 questionnaires from 187 patients who completed the VEINES-QoL/Sym between 2016 and 2019 were included. The median follow-up was 12 months, 127 patients (68%) were female, and 148 (79%) were treated for post-thrombotic syndrome. The median VEINES-QoL score at baseline was 35.69 (interquartile range [IQR], 20.85-46.67). Significant improvement was observed postoperatively and sustained throughout the study period (6 months, 64.81 [IQR, 38.12-83.88]; 12 months, 60.52 [IQR, 33.6-82.3]; 24 months, 60.37 [IQR, 34.31-80.65]; 36 months, 55.98 [IQR, 39.18-81.47]). The VEINES-Sym scores demonstrated similar improvement. A secondary analysis of paired baseline/follow-up data from 61 patients confirmed significant improvement from baseline for VEINES-QoL (6 months +26.45; 12 months, +25.81; 24 months, +30.09; P ≤ .0001), VEINES-Sym (6 months, +23.86; 12 months, +20.43; 24 months, +27.55; P > .001), and Villalta scores (6 months, -3.7; 12 months, -4.2; 24 months, -6.4; P < .0001). The median Villalta score was 14 (IQR, 10-16). This score improved to 9 (IQR, 5-13) at 6 months of follow-up; to 8 (IQR, 5-11) at 12 months; to 7 (IQR, 4-12) at 24 months; and to 6 (IQR, 3.75-10.25) at 36 months (P ≤ .0001). Good correlation between the Villalta and both VEINES-QoL and SYM scores was observed at follow-up (r = 0.69 and r = 0.71, respectively; P < .0001).

CONCLUSIONS

Venous disease-specific QoL improves and severity of post-thrombotic syndrome is decreased after iliac vein stenting for chronic venous outflow obstruction. These improvements are sustained at 36-month follow-up.

Perspectives of patients and health professionals on important factors influencing rehabilitation following acute pulmonary embolism: A multi-method study

BACKGROUND

International guidelines on pulmonary embolism (PE) management and rehabilitation have recently been published. However, the contained recommendation about an efficient follow-up strategy after PE is difficult for health care professionals to implement because limited research exists about what strategies are efficient.

OBJECTIVES

The study aimed to 1) describe and explore perspectives and experiences of health care professionals (HCPs) and patients participating in a post-PE rehabilitation intervention, and 2) provide suggestions for future post-PE management and rehabilitation interventions.

PATIENTS/METHODS

The study was a multi-method study, nested in a larger randomized controlled trial, combining data from two focus group interviews with 10 HCPs, 16 individual interviews with patients, data from exercise diaries and logbooks from HCPs participating in a rehabilitation intervention.

RESULTS

Key factors for successful post-PE management, considered important for reducing anxiety and confusion by both patients and HCPs, were the presence of a multidisciplinary specialized team, initiation of management shortly after discharge, and having regular follow-ups, e.g. telephone consultations. In terms of rehabilitation, repeatedly testing physical performance, resuming exercise under the guidance and support of specialized personnel, and access to peer support, were considered important for increasing motivation and self-efficacy for engaging in physical activity again.

CONCLUSIONS

This study offers suggestions for key elements to include in post-PE management and rehabilitation interventions, as well as the structuring of care. However, research still needs to be undertaken before solid recommendations for the content and structure of successful post-PE management and rehabilitation can be given.

Intermittent pneumatic compression for venous thromboembolism prevention: a systematic review on factors affecting adherence

OBJECTIVE

Venous thromboembolism (VTE) is a potentially fatal complication of hospitalisation. Intermittent pneumatic compression (IPC) is one approach to reducing the likelihood of a VTE. Adherence to IPC is known to be inadequate though the reasons for this remain unclear. This systematic review explores factors that affect adherence to IPC in the inpatient context.

METHODS

Information sources-EMBASE, MEDLINE and PsycINFO were searched for literature between January 1960 and May 2019. Eligibility criteria-studies were included if they focused on inpatient care and examined factors affecting adherence to IPC devices.

RESULTS

Included studies-a total of 20 out of 1476 studies were included. Synthesis of results-eight factors were identified that affected adherence: patient discomfort (n=8), healthcare professionals' knowledge and behaviours (n=6), mobilisation (n=6), equipment supply and demand (n=3), the use of guidelines (n=3), intensive care context (n=2), computer-assisted prescribing (n=2) and patients' knowledge of IPC (n=1).

CONCLUSION

Overall while the evidence base is quite limited, a number of factors were shown to affect adherence to IPC. These findings could be used to inform future research and quality improvement efforts to increase adherence in this very important, but currently under-researched area.

Thrombosis in patients with myeloma treated in the Myeloma IX and Myeloma XI phase 3 randomized controlled trials

Newly diagnosed multiple myeloma (NDMM) patients treated with immunomodulatory drugs are at high risk of venous thromboembolism (VTE), but data are lacking from large prospective cohorts. We present thrombosis outcome data from Myeloma IX (n = 1936) and Myeloma XI (n = 4358) phase 3 randomized controlled trials for NDMM that treated transplant-eligible and transplant-ineligible patients before and after publication of thrombosis prevention guidelines. In Myeloma IX, transplant-eligible patients randomly assigned to cyclophosphamide, vincristine, doxorubicin, and dexamethasone (CVAD) induction had higher risk of VTE compared with patients treated with cyclophosphamide, thalidomide, and dexamethasone (CTD) (22.5% [n = 121 of 538] vs 16.1% [n = 89 of 554]; adjusted hazard ratio [aHR],1.46; 95% confidence interval [95% CI], 1.11-1.93). For transplant-ineligible patients, those randomly assigned to attenuated CTD (CTDa) induction had a higher risk of VTE compared with those treated with melphalan and prednisolone (MP) (16.0% [n = 68 of 425] vs 4.1% [n = 17 of 419]; aHR, 4.25; 95% CI, 2.50-7.20). In Myeloma XI, there was no difference in risk of VTE (12.2% [n = 124 of 1014] vs 13.2% [n = 133 of 1008]; aHR, 0.92; 95% CI, 0.72-1.18) or arterial thrombosis (1.2% [n = 12 of 1014] vs 1.5% [n = 15 of 1008]; aHR, 0.80; 95% CI, 0.37-1.70) between transplant-eligible pathways for patients treated with cyclophosphamide, lenalidomide, and dexamethasone (CRD) or CTD. For transplant-ineligible patients, there was no difference in VTEs between attenuated CRD (CRDa) and CTDa (10.4% [n = 95 of 916] vs 10.7% [n = 97 of 910]; aHR, 0.97; 95% CI, 0.73-1.29). However, arterial risk was higher with CRDa than with CTDa (3.1% [n = 28 of 916] vs 1.6% [n = 15 of 910]; aHR, 1.91; 95% CI, 1.02-3.57). Thrombotic events occurred almost entirely within 6 months of treatment initiation. Thrombosis was not associated with inferior progression-free survival (PFS) or overall survival (OS), apart from inferior OS for patients with arterial events (aHR, 1.53; 95% CI, 1.12-2.08) in Myeloma XI. The Myeloma XI trial protocol incorporated International Myeloma Working Group (IMWG) thrombosis prevention recommendations and compared with Myeloma IX, more patients received thromboprophylaxis (80.5% vs 22.3%) with lower rates of VTE for identical regimens (CTD, 13.2% vs 16.1%; CTDa, 10.7% vs 16.0%). However, thrombosis remained frequent in spite of IMWG-guided thromboprophylaxis, suggesting that new approaches are needed.

Patients experience of living with cancer associated thrombosis in France (Le PELICAN)

INTRODUCTION

Previous research in the United Kingdom and Spain has identified several areas of unmet clinical and support need for cancer patients diagnosed with cancer associated thrombosis (CAT). These included lack of information, which was directly associated with distress. Appropriate information has been shown to improve tolerance and compliance with self-injecting low molecular weight heparin (LMWH). It is not known whether such experiences are restricted to those particular countries healthcare systems and/or cultures.

METHODS

Purposive sampling of patients with CAT were recruited from an academic hospital in Colombes, France. Semi structured interviews were audio recorded and transcribed. Transcripts were coded using Invivo software. Analysis was undertaken using framework analysis.

RESULTS

Twenty four patients participated. Three major themes with associated subthemes were identified: Patients received minimal information regarding risks of CAT or how to treat it once diagnosed. However, this was not associated with distress. Patients adopted a passive role whereby the doctor was always right. They were intolerant injections and found it inconvenient to await community nurses.

CONCLUSION

The doctor patient relationship in France differs from other countries, with patients adopting a passive role with respect to information requirements. This dynamic appears to be a "two edged sword" whereby distress around CAT was minimal yet a lack of knowledge impacted on acceptability of LMWH. This has implications for the choice of anticoagulant particularly now that the DOACS have been evaluated for this indication.

Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale

INTRODUCTION

We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed.

METHODS

Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use.

RESULTS

A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58-1.0), and 1.0 (95%CI 0.83-1.0) between independent raters of the recorded interview of 16 focus groups members.

CONCLUSION

We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.

Patient values and preferences regarding VTE disease: a systematic review to inform American Society of Hematology guidelines

Values and preferences relate to the importance that patients place on health outcomes (eg, bleeding, having a deep venous thrombosis) and are essential when weighing benefits and harms in guideline recommendations. To inform the American Society of Hematology guidelines for management of venous thromboembolism (VTE) disease, we conducted a systematic review of patients' values and preferences related to VTE. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature from inception to April of 2018 (PROSPERO-CRD42018094003). We included quantitative and qualitative studies. We followed Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance for rating the certainty and presenting findings for quantitative research about the relative importance of health outcomes and a grounded theory approach for qualitative thematic synthesis. We identified 14 quantitative studies (2465 participants) describing the relative importance of VTE-related health states in a widely diverse population of patients, showing overall small to important impact on patients' lives (certainty of the evidence from low to moderate). Additionally, evidence from 34 quantitative studies (6424 participants) and 15 qualitative studies (570 participants) revealed that patients put higher value on VTE risk reduction than on the potential harms of the treatment (certainty of evidence from low to moderate). Studies also suggested a clear preference for oral medication over subcutaneous medication (moderate certainty). The observed variability in health state values may be a result of differences in the approaches used to elicit them and the diversity of included populations rather than true variability in values. This finding highlights the necessity to explore the variability induced by different approaches to ascertain values.

Plasminogen activator inhibitor-1 (PAI-1) 4G/5G promoter polymorphisms and risk of venous thromboembolism – a meta-analysis and systematic review

Summary: Background: A 4G/5G polymorphism in the promoter region of the plasminogen activator inhibitor type 1 (PAI-1) gene has been reported to enhance the plasma levels of PAI-1, which plays an important role in fibrinolysis disorders and venous thromboembolism, but a large number of studies have reported inconclusive results. Therefore, we performed a meta-analysis to analysis these associations. Materials and methods: We performed a publication search for articles published before April 2019 by using the electronic databases of web of Science, Embase, PubMed, CNKI, CBM and WanFang data with the following terms “PAI-1”, “polymorphism”, “Venous Thromboembolism”. Two investigators independently extracted data and assessed study quality. Statistical analyses were undertaken using Stata 14.0. Results: A total of 27 studies, with 3135 patients and 5346 controls were included. Overall, the variant PAI-1 4G/4G and PAI-1 4G/5G was associated with venous thromboembolism risk, compared with the PAI-1 5G/5G allele in the populations included in the analysis. Stratified analysis revealed that PAI-1 4G/4G and PAI-1 4G/5G genotypes were associated with an increased VTE risk among Asia populations in all five genetic models. Conclusions: The PAI-1 4G/5G polymorphism may be a potential biomarker of VTE risk, particularly in Asia populations. Further larger studies with multi-ethnic populations are required to further assess the association between PAI-1 4G/4G polymorphisms and VTE risk.