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Klaserner EL, Popova KJ, Gaudet RL. Venous Thromboembolism Prophylaxis in Obstetric Patients. J Pharm Pract 2024; 37:1183-1196. [PMID: 38621760 DOI: 10.1177/08971900241247628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Venous thromboembolism (VTE), including both pulmonary embolism (PE) and deep vein thrombosis (DVT), is the leading cause of maternal death in developed countries. Pregnancy is associated with an increased risk of VTE due to physiologic changes during the obstetric period that promote a hypercoagulable state. Appropriate use of prophylactic anticoagulants can decrease the event rate of thrombus formation in at-risk patients. In the United States, there is not a validated risk-assessment tool for VTE in obstetric patients or a clear consensus on initiation and optimal dosing strategy for the prophylactic use of anticoagulants. This article reviews the mechanism of coagulation disturbance that leads to an increased risk of VTE in obstetric patients, as well as the available literature surrounding pharmacologic prophylaxis.
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Affiliation(s)
- Emma L Klaserner
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Kayla J Popova
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Rikki-Leigh Gaudet
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
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2
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Geerts WH, Jeong E, Robinson LR, Khosravani H. Venous Thromboembolism Prevention in Rehabilitation: A Review and Practice Suggestions. Am J Phys Med Rehabil 2024; 103:934-948. [PMID: 38917440 DOI: 10.1097/phm.0000000000002570] [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: 06/27/2024]
Abstract
ABSTRACT Venous thromboembolism is a frequent complication of acute hospital care, and this extends to inpatient rehabilitation. The timely use of appropriate thromboprophylaxis in patients who are at risk is a strong, evidence-based patient safety priority that has reduced clinically important venous thromboembolism, associated mortality and costs of care. While there has been extensive research on optimal approaches to venous thromboembolism prophylaxis in acute care, there is a paucity of high-quality evidence specific to patients in the rehabilitation setting, and there are no clinical practice guidelines that make recommendations for (or against) thromboprophylaxis across the broad spectrum of rehabilitation patients. Herein, we provide an evidence-informed review of the topic with practice suggestions. We conducted a series of literature searches to assess the risks of venous thromboembolism and its prevention related to inpatient rehabilitation as well as in major rehabilitation subgroups. Mobilization alone does not eliminate the risk of venous thromboembolism after another thrombotic insult. Low molecular weight heparins and direct oral anticoagulants are the principal current modalities of thromboprophylaxis. Based on the literature, we make suggestions for venous thromboembolism prevention and include an approach for consideration by rehabilitation units that can be aligned with local practice.
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Affiliation(s)
- William H Geerts
- From the Thromboembolism Program, Sunnybrook Health Sciences Centre (WHG); Department of Medicine, University of Toronto, Toronto, ON, Canada (WHG); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (EJ); Sunnybrook Health Sciences Centre, Toronto, ON, Canada (LRR, HK); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (LRR); and Division of Neurology, University of Toronto, Toronto, ON, Canada (HK)
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Mittman BG, Hu B, Schulte R, Le P, Pappas MA, Hamilton A, Rothberg MB. What Constitutes High Risk for Venous Thromboembolism? Comparing Approaches to Determining an Appropriate Threshold. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.30.24312871. [PMID: 39252910 PMCID: PMC11383466 DOI: 10.1101/2024.08.30.24312871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Background Guidelines recommend pharmacological venous thromboembolism (VTE) prophylaxis only for high-risk patients, but the probability of VTE considered "high-risk" is not specified. Our objective was to define an appropriate probability threshold (or range) for VTE risk stratification and corresponding prophylaxis in medical inpatients. Methods Patients were adults admitted to any of 10 Cleveland Clinic Health System hospitals between December 2020 and August 2021 (N = 41,036). Hospital medicine physicians and internal medicine residents from included hospitals were surveyed between June and November 2023 (N = 214). We compared five approaches to determining a threshold: decision analysis, maximizing the sensitivity and specificity of a logistic regression model, deriving a probability from a point-based model, surveying physicians' understanding of VTE risk, and deriving a probability from physician behavior. For each approach, we determined the probability threshold above which a patient would be considered high-risk for VTE. We applied each threshold to the Cleveland Clinic VTE risk assessment model (CCM) and calculated the percentage of the 41,036 patients in our cohort who would be considered eligible for prophylaxis due to their high-risk status. We compared these hypothetical prophylaxis rates with physicians' observed prophylaxis rates. Results The different approaches yielded thresholds ranging from 0.3% to 5.4%, corresponding inversely with hypothetical prophylaxis rates of 0.2% to 75%. Multiple thresholds clustered between 0.52% to 0.55%, suggesting an average hypothetical prophylaxis rate of approximately 30%, whereas physicians' observed prophylaxis rates ranged from 48% to 76%. Conclusions Multiple approaches to determining a probability threshold for VTE prophylaxis converged to suggest an optimal threshold of approximately 0.5%. Other approaches yielded extreme thresholds that are unrealistic for clinical practice. Physicians prescribed prophylaxis much more frequently than the suggested rate of 30%, indicating opportunity to reduce unnecessary prophylaxis. To aid in these efforts, guidelines should explicitly quantify high-risk.
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Affiliation(s)
- Benjamin G Mittman
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Schulte
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Phuc Le
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew A Pappas
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, OH, USA
- Department of Hospital Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Hamilton
- Department of Hospital Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, OH, USA
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Olt CK, Hu B, Rothberg MB. Upper Extremity Deep Vein Thrombosis: Incidence, Risk Factors, and Effectiveness of Chemoprophylaxis. South Med J 2024; 117:534-538. [PMID: 39227045 PMCID: PMC11376984 DOI: 10.14423/smj.0000000000001728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Upper extremity deep vein thrombosis (UEDVT) is associated with pulmonary embolism and other complications, but there are no recommendations for UEDVT prophylaxis. The purpose of this study was to establish incidence and risk factors for UEDVT and to determine efficacy of pharmacologic prophylaxis for UEDVT prevention. METHODS For this retrospective cohort study, we identified medical patients aged 18 years and older admitted to 13 Cleveland Clinic hospitals from January 2011 to December 2019. Patients with venous thromboembolism (VTE) on admission, length of stay <1 day, and who received therapeutic anticoagulation were excluded. The potential risk factors included demographics, comorbidities, and medical procedures. Comorbidities were identified via International Classification of Diseases codes, (ICD9 and ICD10), procedures from flowsheets, and prophylaxis from medications administered in the electronic medical record. DVT events were identified by a combination of International Classification of Diseases codes and confirmed by chart review. We performed multivariable logistic regression to identify independent risk factors and the association between VTE prophylaxis and UEDVT. The model's C statistic was obtained using 1000 bootstrap runs. RESULTS Of 194,809 patients, 496 (0.25% of cohort, 36.8% of all VTE) developed UEDVT by 14 days. In the logistic regression model (bias-corrected C statistic 0.87), 11 risk factors predicted UEDVT, the strongest being peripherally inserted central catheter (odds ratio [OR] 4.62, 95% confidence interval [CI] 3.81-5.60) and central venous catheter (OR 3.57, 95% CI 2.91-4.37). The predicted risk among individuals ranged from 0.02% to 23.4%. Prophylaxis was negatively associated with the development of UEDVT (OR 0.72, 95% CI 0.60-0.87). CONCLUSIONS UEDVT is rare but some patients are high risk. Therefore, UEDVT risk factors should be added to VTE risk assessment models, and patients at high risk for UEDVT should receive chemoprophylaxis.
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Affiliation(s)
| | - Bo Hu
- Department of Quantitative Health Sciences
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Al Yami MS, Alshehri AM, Alay SM, Aljoufi AY, Alsulimani MS, Algarni SM, Almohareb SN, Hafiz AM, Alshaya OA, Badawoud AM. Extended thromboprophylaxis in heart failure patients; the unmet need. Heart Fail Rev 2024; 29:1107-1116. [PMID: 39014135 DOI: 10.1007/s10741-024-10422-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 07/18/2024]
Abstract
Heart failure (HF) is considered one of a leading cause of cardiovascular morbidity and mortality worldwide. The association between HF and venous thromboembolism (VTE) has been reported in several studies owing to many physiological and thromboembolic risk factors. Thus, the need for extended thromboprophylaxis during the post-discharge period in HF patients has been evaluated. Most guidelines do not recommend extended thromboprophylaxis because of its uncertain benefits and increased risk of bleeding. However, recent evidence in HF patients revealed no increased risk of bleeding with extended thromboprophylaxis, which highlights the importance of identifying ideal candidates who might benefit from extended thromboprophylaxis. Several risk assessment models (RAMs) have been developed to identify patients at a high risk of VTE who would benefit from in-hospital and post-discharge prophylactic anticoagulation therapy based on the risk-benefit principle. However, their accuracy in predicting VTE is questionable, and none have a standardized approach for evaluating the risk of VTE in HF patients. In this review, we provided an overview of the incidence and pathophysiology of VTE in HF patients, a summary of guideline recommendations for VTE prevention, and a summary of studies evaluating the use of extended thromboprophylaxis, with a focus on subgroup or post-hoc analyses of HF patients. We also discussed the need to design an ideal RAM that can identify candidate patients for extended thromboprophylaxis by stratifying the risk of VTE and identifying the key risk factors for bleeding in medically ill patients, including those with HF.
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Affiliation(s)
- Majed S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia.
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Abdulmajeed M Alshehri
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Saeed M Alay
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Abdulmalik Y Aljoufi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Mariam S Alsulimani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Shatha M Algarni
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
| | - Sumaya N Almohareb
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Awatif M Hafiz
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar A Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Kingdom of Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Amal M Badawoud
- Princess Nourah bint Abdulrahman University, College of Pharmacy, Department of Pharmacy Practice, Riyadh, Saudi Arabia
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Koskinas KC, Van Craenenbroeck EM, Antoniades C, Blüher M, Gorter TM, Hanssen H, Marx N, McDonagh TA, Mingrone G, Rosengren A, Prescott EB. Obesity and cardiovascular disease: an ESC clinical consensus statement. Eur J Prev Cardiol 2024:zwae279. [PMID: 39210708 DOI: 10.1093/eurjpc/zwae279] [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: 05/14/2024] [Revised: 07/08/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024]
Abstract
The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.
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Affiliation(s)
- Konstantinos C Koskinas
- Department of Cardiology, Bern University Hospital-INSELSPITAL, University of Bern, Freiburgstrasse 18, Bern 3010, Switzerland
| | - Emeline M Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, Drie Eikenstraat 655, Antwerp 2650, Belgium
- Research group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
| | - Charalambos Antoniades
- Acute Multidisciplinary Imaging and Interventional Centre Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Matthias Blüher
- Helmholtz Zentrum München at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Henner Hanssen
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Nikolaus Marx
- Department of Internal Medicine I-Cardiology, RWTH Aachen University, Aachen, Germany
| | - Theresa A McDonagh
- Cardiology Department, King's College Hospital, London, UK
- King's College, London, UK
| | - Geltrude Mingrone
- Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli & Catholic University, Rome, Italy
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital/Ostra, Västra Götaland Region, Gothenburg, Sweden
| | - Eva B Prescott
- Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, Copenhagen 2400, Denmark
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Koskinas KC, Van Craenenbroeck EM, Antoniades C, Blüher M, Gorter TM, Hanssen H, Marx N, McDonagh TA, Mingrone G, Rosengren A, Prescott EB. Obesity and cardiovascular disease: an ESC clinical consensus statement. Eur Heart J 2024:ehae508. [PMID: 39210706 DOI: 10.1093/eurheartj/ehae508] [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: 05/14/2024] [Revised: 07/08/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024] Open
Abstract
The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.
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Affiliation(s)
- Konstantinos C Koskinas
- Department of Cardiology, Bern University Hospital-INSELSPITAL, University of Bern, Freiburgstrasse 18, Bern 3010, Switzerland
| | - Emeline M Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, Drie Eikenstraat 655, Antwerp 2650, Belgium
- Research group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
| | - Charalambos Antoniades
- Acute Multidisciplinary Imaging and Interventional Centre Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Matthias Blüher
- Helmholtz Zentrum München at the University of Leipzig and University Hospital Leipzig, Leipzig, Germany
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Henner Hanssen
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Nikolaus Marx
- Department of Internal Medicine I-Cardiology, RWTH Aachen University, Aachen, Germany
| | - Theresa A McDonagh
- Cardiology Department, King's College Hospital, London, UK
- King's College, London, UK
| | - Geltrude Mingrone
- Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
- Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli & Catholic University, Rome, Italy
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska University Hospital/Ostra, Västra Götaland Region, Gothenburg, Sweden
| | - Eva B Prescott
- Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, Copenhagen 2400, Denmark
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Wang R, Tang LV, Hu Y. Genetic factors, risk prediction and AI application of thrombotic diseases. Exp Hematol Oncol 2024; 13:89. [PMID: 39192370 DOI: 10.1186/s40164-024-00555-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
In thrombotic diseases, coagulation, anticoagulation, and fibrinolysis are three key physiological processes that interact to maintain blood in an appropriate state within blood vessels. When these processes become imbalanced, such as excessive coagulation or reduced anticoagulant function, it can lead to the formation of blood clots. Genetic factors play a significant role in the onset of thrombotic diseases and exhibit regional and ethnic variations. The decision of whether to initiate prophylactic anticoagulant therapy is a matter that clinicians must carefully consider, leading to the development of various thrombotic risk assessment scales in clinical practice. Given the considerable heterogeneity in clinical diagnosis and treatment, researchers are exploring the application of artificial intelligence in medicine, including disease prediction, diagnosis, treatment, prevention, and patient management. This paper reviews the research progress on various genetic factors involved in thrombotic diseases, analyzes the advantages and disadvantages of commonly used thrombotic risk assessment scales and the characteristics of ideal scoring scales, and explores the application of artificial intelligence in the medical field, along with its future prospects.
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Affiliation(s)
- Rong Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Key Lab of Molecular Biological Targeted Therapies of the Ministry of Education, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- Key Lab of Molecular Biological Targeted Therapies of the Ministry of Education, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Ma SG, Yang Y, Huang Y. Venous thromboembolism risk assessment scale for prediction of venous thromboembolism in inpatients with cancer: A meta-analysis. Thromb Res 2024; 240:109058. [PMID: 38875848 DOI: 10.1016/j.thromres.2024.109058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/05/2024] [Accepted: 05/31/2024] [Indexed: 06/16/2024]
Abstract
AIMS This meta-analysis was conducted to evaluate the validity of the Caprini venous thromboembolism (VTE) risk assessment scale in predicting the risk of VTE in inpatients with cancer. METHODS Studies relating to the Caprini VTE risk assessment scale were systematically retrieved from the MEDLINE, EMBASE, Web of Science, Cochrane Library, BIOSIS Previews, EBSCOhost, and China National Knowledge Infrastructure (CNKI) databases up to May 1, 2022. Two reviewers independently conducted data extraction and quality evaluation. MetaDisc 1.4 and Stata 15.0 software were used for data analysis. RESULTS We included 10 studies with 23,644 subjects in our analyses. The results showed that the pooled sensitivity (SEN) and specificity (SPE) were 0.59 (95 % CI: 0.55 to 0.63) and 0.57 (95 % CI:0.57 to 0.58), respectively; the pooled diagnostic odds ratio (DOR) was 6.05 (95 % CI: 2.70 to 13.58); and the area under the curve (AUC) of the summary receiver operating characteristic (SROC) curve was 0.76. Subgroup analysis was performed according to ethnicity (Chinese or non-Chinese), study design (prospective/retrospective), Caprini RAM version (2005/2009), and cut-off (≤7 or > 7). CONCLUSION The Caprini VTE risk assessment scale has a moderate ability to predict VTE in surgical inpatients with cancer, as well as in Western populations; Caprini 2009 has a stronger predictive ability than 2005, and its predictive power is better if the cut-off value is >7. Future studies in clinical practice and specific specialties are needed to explore the optimal cut-off value of different cancers. This will improve our accuracy in understanding the risk of VTE in inpatients and help promote timely and targeted prevention. In turn, this will reduce the incidence of VTE and improve the quality of life of inpatients with cancer.
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Affiliation(s)
- Se-Ge Ma
- First People's Hospital of Liangshan Yi Autonomous Prefecture, Xichang, Sichuan 615000, PR China
| | - Yi Yang
- Department of Nursing, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education/West China College of Nursing, Sichuan University, Chengdu, Sichuan Province 610041, PR China
| | - Yan Huang
- Department of Nursing, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education/West China College of Nursing, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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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; 137:776-781. [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] [MESH Headings] [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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11
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Li R, Shen S, Jiang J, Liu Y. Prognostic Value of Neutrophil/Lymphocyte Ratio for Pulmonary Embolism: A Meta-Analysis and External Validation. Ann Vasc Surg 2024; 105:48-59. [PMID: 38582200 DOI: 10.1016/j.avsg.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/26/2023] [Accepted: 01/21/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Prognostic value of neutrophil/lymphocyte ratio (NLR) for pulmonary embolism (PE) has been reported in several retrospective studies. The purpose of this investigation was to perform a pooled analysis and external validation of predictive value of NLR. METHODS PubMed, Embase, and Cochrane databases were searched from inception to November 5, 2022. A random effects model was used. Grade was used to evaluate the certainty of evidence. External validation was conducted in clinical cohorts before and after a propensity scoring matching (PSM). Covariates include basic clinical characteristics, such as age, gender, etc. The value of NLR in prediction model was also evaluated. RESULTS A total of 15 studies comprising 5,874 patients were included. Pooled risk ratio of NLR was 2.33 (95% confidence interval [CI]: 1.97-2.75), with an area under the curve of 0.78 (95% CI: 0.74-0.81), a sensitivity of 0.75 (95% CI: 0.71-0.79), a specificity of 0.67 (95% CI: 0.61-0.73), and a median cut-off value of 5.7. Grade of Recommendations Assessment Development and Evaluation (GRADE) certainty analysis showed the quality of the evidence was moderate. Before (n = 336) and after (n = 152) propensity scoring matching, risk ratio of NLR was 2.69 (95% CI: 1.04-6.97) and 6.58 (95% CI: 1.99-17.75). A prediction model consisting of NLR, age, D-dimer, and simplified PE severity index had an area under the curve of 0.809 (95% CI: 0.738-0.88), a sensitivity of 0.638 (95% CI: 0.511-0.745), and a specificity of 0.851 (95% CI: 0.709-0.917). Net reclassification index (12%, P = 0.035) and integrated discrimination improvement (17%, P = 0.022) indicated an improvement caused by NLR. CONCLUSIONS Prognostic value of NLR for PE was confirmed by meta-analysis and validated in an independent cohort, deserving further clinical application.
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Affiliation(s)
- Ruihua Li
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shuohao Shen
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jianjun Jiang
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Yang Liu
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.
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12
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Chen W, Wu G, Niu P, Wu S, Lv M, Wu T, Jiang S, Zhang J. The Alfalfa-inpatient-CAT assessment model: a thrombotic risk assessment model for inpatient cancer patients. BMC Cancer 2024; 24:919. [PMID: 39080579 PMCID: PMC11289990 DOI: 10.1186/s12885-024-12678-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
PURPOSE To construct a venous thromboembolism (VTE) risk assessment model specifically for inpatients with cancer. METHOD Patients were included according to the inclusion criteria. Univariate and multivariate analyses of all variables were included to develop a VTE risk assessment model applicable to the derivation cohort. Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve were used to test the fit degree and identification validity of the model. The patient data from separate validation cohorts verified the external population. RESULT A total of 944 cancer patients were included in this study. Alfalfa-inpatient-CAT model, a risk assessment model for VTE in hospitalized cancer patients, was established, which mainly includes hypertension, surgical history (nearly one month), history of VTE, peripherally inserted central venous catheters (PICC), chemotherapy, PT < 12.85 s, D-dimer ≥ 1.805 μg/mL, hemoglobin ≤ 114.5 g/L, CRP ≥ 7.575 mg/L. Hosmer-Lemeshow test results showed P = 0.353 > 0.05, (χ2 = 8.872, Df = 8). The area under ROC curve was 0.906 [95%CI (0.881-0.930), P < 0.001]. The authenticity evaluation in the model database showed that the risk of thrombosis in the high-risk group (score ≥ 3) was 72.63%, significantly higher than that in the low-risk group (score 0-2) (27.37%) [χ2 = 144.00, Df = 1, P < 0.001]. CONCLUSION This study developed a new VTE risk assessment model - Alfalfa-inpatient-CAT model - for hospitalized cancer patients at high risk of thrombosis. This model has a good fitting degree and discriminant validity. It is expected to provide some reference for the clinical treatment of inpatients with cancer through continuous optimization.
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Affiliation(s)
- Wenjun Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Guilan Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, 350001, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China.
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Liu L, Li L, Zhou J, Ye Q, Meng D, Xu G. Machine learning-based prediction model of lower extremity deep vein thrombosis after stroke. J Thromb Thrombolysis 2024:10.1007/s11239-024-03010-0. [PMID: 39068348 DOI: 10.1007/s11239-024-03010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
This study aimed to apply machine learning (ML) techniques to develop and validate a risk prediction model for post-stroke lower extremity deep vein thrombosis (DVT) based on patients' limb function, activities of daily living (ADL), clinical laboratory indicators, and DVT preventive measures. We retrospectively analyzed 620 stroke patients. Eight ML models-logistic regression (LR), support vector machine (SVM), random forest (RF), decision tree (DT), neural network (NN), extreme gradient boosting (XGBoost), Bayesian (NB), and K-nearest neighbor (KNN)-were used to build the model. These models were extensively evaluated using ROC curves, AUC, PR curves, PRAUC, accuracy, sensitivity, specificity, and clinical decision curves (DCA). Shapley's additive explanation (SHAP) was used to determine feature importance. Finally, based on the optimal ML algorithm, different functional feature set models were compared with the Padua scale to select the best feature set model. Our results indicated that the RF algorithm demonstrated superior performance in various evaluation metrics, including AUC (0.74/0.73), PRAUC (0.58/0.58), accuracy (0.75/0.77), and sensitivity (0.78/0.80) in both the training set and test set. DCA analysis revealed that the RF model had the highest clinical net benefit. SHAP analysis showed that D-dimer had the most significant influence on DVT, followed by age, Brunnstrom stage (lower limb), prothrombin time (PT), and mobility ability. The RF algorithm can predict post-stroke DVT to guide clinical practice.
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Affiliation(s)
- Lingling Liu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Liping Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Juan Zhou
- Department of Ultrasonography, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Qian Ye
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China
| | - Dianhuai Meng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China.
| | - Guangxu Xu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Road, Nanjing, 210029, China.
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Mittman BG, Sheehan M, Kojima L, Casacchia NJ, Lisheba O, Hu B, Pappas MA, Rothberg MB. Development and internal validation of the Cleveland Clinic Bleeding Model to predict major bleeding risk at admission in medical inpatients. J Thromb Haemost 2024:S1538-7836(24)00389-1. [PMID: 39002732 DOI: 10.1016/j.jtha.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Guidelines recommend pharmacologic VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment. OBJECTIVES We developed and internally validated a risk assessment model (RAM) to predict major in-hospital bleeding using risk factors at admission and compared our model with IMPROVE. METHODS We selected patients admitted to medical services at 10 hospitals in the Cleveland Clinic Health System from 2017 to 2020. We identified major bleeding according to the International Society on Thrombosis and Haemostasis criteria, using a combination of diagnostic codes and laboratory values, and confirmed events with chart review. We fit a least absolute shrinkage selection operator logistic regression model in the training set and compared the discrimination and calibration of our model with the IMPROVE model in the validation set. RESULTS Among 46 314 admissions, 268 (0.58%) had a major bleed. The final RAM included 16 risk factors, of which prior bleeding (odds ratio [OR] = 4.83), peptic ulcer (OR = 3.82), history of sepsis (OR = 3.26), and steroid use (OR = 2.59) were the strongest. The Cleveland Clinic Bleeding Model had better discrimination than IMPROVE (area under the receiver operating characteristics curve = 0.85 vs 0.70; P < .001) and, at equivalent sensitivity (52%), categorized fewer patients as high risk (7.2% vs 11.8%; P < .001). Calibration was adequate (Brier score = 0.0057). CONCLUSION Using a large population of medical inpatients with verified major bleeding events, we developed and internally validated a RAM for major bleeding whose performance surpassed the IMPROVE model.
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Affiliation(s)
- Benjamin G Mittman
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Megan Sheehan
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Kojima
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas J Casacchia
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oleg Lisheba
- Enterprise Analytics eResearch Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Hu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew A Pappas
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Community Care, Cleveland Clinic, Cleveland, Ohio, USA
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Amorim NTS, Cavalcanti FCB, Moura ECSCD, Sobral Filho D, Leitão CCDS, Almeida MMD, Marinho PÉDM. Does whole-body vibration improve risk of falls, balance, and heart rate variability in post-COVID-19 patients? A randomized clinical trial. J Bodyw Mov Ther 2024; 39:518-524. [PMID: 38876678 DOI: 10.1016/j.jbmt.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Whole-Body Vibration (WBV) can be a therapeutic recovery strategy for patients hospitalized for COVID-19. OBJECTIVES To evaluate the effects of a 36-session WBV protocol on the risk of falls, balance, mobility and heart rate variability (HRV). STUDY DESIGN A randomized clinical trial. METHODS 13 patients affected by COVID-19, trained with WBV, 3×/week on alternate days, totaling 36 sessions, were evaluated before and after the intervention. RESULTS WBV training at 2 mm and 4 mm amplitude resulted in a reduction in the risk of falls when compared to Sham (p = 0.023), with effect size of 0.530. No changes were observed for mobility and balance outcomes (p = 0.127) or for any of the HRV variables (p = 0.386). CONCLUSION WBV training reduced the risk of falls in post-COVID patients. No changes were observed regarding balance and mobility, nor for HRV.
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Affiliation(s)
| | | | | | - Dário Sobral Filho
- Coronary Care Unit of Pernambuco Cardiac Emergency Hospital, Universidade de Pernambuco, Recife, PE, Brazil
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Lee D, Kim S, Lee S, Kim HJ, Kim JH, Lim MC, Cho H. Deep Learning-Based Dynamic Risk Prediction of Venous Thromboembolism for Patients With Ovarian Cancer in Real-World Settings From Electronic Health Records. JCO Clin Cancer Inform 2024; 8:e2300192. [PMID: 38996199 DOI: 10.1200/cci.23.00192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/19/2024] [Accepted: 04/16/2024] [Indexed: 07/14/2024] Open
Abstract
PURPOSE Patients with epithelial ovarian cancer (EOC) have an elevated risk for venous thromboembolism (VTE). To assess the risk of VTE, models were developed by statistical or machine learning algorithms. However, few models have accommodated deep learning (DL) algorithms in realistic clinical settings. We aimed to develop a predictive DL model, exploiting rich information from electronic health records (EHRs), including dynamic clinical features and the presence of competing risks. METHODS We extracted EHRs of 1,268 patients diagnosed with EOC from January 2007 through December 2017 at the National Cancer Center, Korea. DL survival networks using fully connected layers, temporal attention, and recurrent neural networks were adopted and compared with multi-perceptron-based classification models. Prediction accuracy was independently validated in the data set of 423 patients newly diagnosed with EOC from January 2018 to December 2019. Personalized risk plots displaying the individual interval risk were developed. RESULTS DL-based survival networks achieved a superior area under the receiver operating characteristic curve (AUROC) between 0.95 and 0.98 while the AUROC of classification models was between 0.85 and 0.90. As clinical information benefits the prediction accuracy, the proposed dynamic survival network outperformed other survival networks for the test and validation data set with the highest time-dependent concordance index (0.974, 0.975) and lowest Brier score (0.051, 0.049) at 6 months after a cancer diagnosis. Our visualization showed that the interval risk fluctuating along with the changes in longitudinal clinical features. CONCLUSION Adaption of dynamic patient clinical features and accounting for competing risks from EHRs into the DL algorithms demonstrated VTE risk prediction with high accuracy. Our results show that this novel dynamic survival network can provide personalized risk prediction with the potential to assist risk-based clinical intervention to prevent VTE among patients with EOC.
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Affiliation(s)
- Dahhay Lee
- Department of Cancer AI and Digital Health, National Cancer Center Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Republic of Korea
- School of Mathematics and Computing (Computational Science and Engineering), Yonsei University, Seoul, Republic of Korea
| | - Seongyoon Kim
- School of Mathematics and Computing (Computational Science and Engineering), Yonsei University, Seoul, Republic of Korea
| | - Sanghee Lee
- Department of Cancer AI and Digital Health, National Cancer Center Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Republic of Korea
- Health Insurance Research Institute, National Health Insurance Service, Wonju, Republic of Korea
| | - Hak Jin Kim
- Department of Cardiology, Gumdan Top General Hospital, Incheon, Republic of Korea
- Branch of Cardiology, Department of Internal Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Ji Hyun Kim
- Center for Gynecologic Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Myong Cheol Lim
- Center for Gynecologic Cancer, National Cancer Center, Goyang, Republic of Korea
- Division of Tumor Immunology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
- Center for Clinical Trials, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Hyunsoon Cho
- Department of Cancer AI and Digital Health, National Cancer Center Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Republic of Korea
- Integrated Biostatistics Research Branch, National Cancer Center, Goyang, Republic of Korea
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Hu Z, He R, Zhao Y, Luo M, Fan Y, Li J. Risk assessment models for PICC-related venous thrombosis in adult patients with cancer: A network meta-analysis. Thromb Res 2024; 239:109030. [PMID: 38735166 DOI: 10.1016/j.thromres.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES This review aims to compare the performance of available risk assessment models (RAMs) for predicting peripherally inserted central catheter-related venous thrombosis (PICC-RVT) in adult patients with cancer. METHODS A systematic search was conducted across ten databases from inception to October 20, 2023. Studies were eligible if they compared the accuracy of a RAM to that of another RAM for predicting the risk of PICC-RVT in adult patients with cancer. Two reviewers independently performed the study selection, data extraction and risk of bias assessments. A Bayesian network meta-analysis (NMA) was used to evaluate the performance of the RAMs. RESULTS A total of 1931 studies were screened, and 7 studies with 10 RAMs were included in the review. The most widely used RAMs were the Caprini (4 studies), Padua prediction score (3 studies), Autar (3 studies), Michigan risk score (2 studies) and Seeley score (2 studies). The sensitivity, specificity and accuracy varied markedly between the models. Notably, the Caprini score achieved higher sensitivity than 4 RAMs (Wells, Revised Geneva, modified MRS, MRS). The Michigan risk score had greater specificity than did the other 6 RAMs (Caprini, Autar, Padua, Seeley, the novel RAM, Wells). The predictive accuracy of the MRS is significantly greater than that of the Caprini and Autar RAM. CONCLUSION The MRS could be the most accurate RAM for identifying patients at high risk of PICC-RVT. However, as limited studies are available, more rigorous studies should be conducted to examine the accuracy of the Michigan risk score for PICC-RVT in different contexts.
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Affiliation(s)
- Zeyin Hu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, PR China
| | - Ruoying He
- Peking University Shenzhen Hospital, Shenzhen 518035, PR China
| | - Yu Zhao
- Peking University Shenzhen Hospital, Shenzhen 518035, PR China
| | - Mengna Luo
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, PR China
| | - Yuying Fan
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, PR China.
| | - Jia Li
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou 510060, PR China.
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Arunothai S, Sutherasan Y, Panpikoon T, Theerawit P, Angchaisuksiri P, Boonyawat K. Low incidence of deep vein thrombosis in critically ill medical patients in Thais: a prospective study. Res Pract Thromb Haemost 2024; 8:102522. [PMID: 39221448 PMCID: PMC11364007 DOI: 10.1016/j.rpth.2024.102522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024] Open
Abstract
Background Critically ill medical patients face a heightened risk of developing venous thromboembolism. In Thailand, routine thromboprophylaxis is not employed. The incidence of deep vein thrombosis (DVT) in the medical intensive care unit (ICU) has not been elucidated in the Thai population. Objectives The aims were to evaluate the incidence of DVT and identify associated risk factors in critically ill medical patients. Methods A single-center, prospective cohort study was conducted from 2019 to 2020. Consecutive patients underwent screening for proximal DVT by duplex ultrasound of both legs. Results A total of 200 patients were enrolled, with 115 being male (57%). The mean (SD) age was 66.5 (16.4) years. The mean (SD) Acute Physiology and Chronic Health Evaluation II score was 27 (8). The cumulative incidence of DVT over 5 days was 7% (95% CI, 3.4%-10.6%). No clinically or radiologically diagnosed pulmonary embolism occurred in patients with DVT. No independent risk factor associated with DVT was identified. Hospital mortality in those with and those without DVT was 42.9% and 32.3%, respectively. There was no significant difference in the length of ICU or hospital stay or inpatient mortality between those with and those without DVT. Conclusion Without thromboprophylaxis, the incidence of DVT in the Thai population remains low. A strategy of screening ultrasound 5 to 7 days after admission to the ICU may be a suitable alternative to anticoagulant prophylaxis in critically ill Thai patients without symptoms of venous thromboembolism.
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Affiliation(s)
- Saengrawee Arunothai
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tanapong Panpikoon
- Division of Body Intervention, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pongdhep Theerawit
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kochawan Boonyawat
- Division of Hematology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abdulelah M, Haider O, McAuliffe M, Al-Faris L, Paadam J, Medarametla V, Kleppel R, Joshi K. Do Decision Support Tools Decrease the Prevalence of Hospital-Acquired Venous Thromboembolisms When Compared to Clinical Judgement? A Single-Center Pre-Post Study. J Clin Med 2024; 13:3854. [PMID: 38999420 PMCID: PMC11242558 DOI: 10.3390/jcm13133854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals' perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre-post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] -1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI -14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals' satisfaction with DST.
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Affiliation(s)
- Mohammad Abdulelah
- Department of Internal Medicine, University of Massachusetts Chan Medical School—Baystate Regional Campus, Springfield, MA 01199, USA (R.K.)
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Huang T, Huang Z, Peng X, Pang L, Sun J, Wu J, He J, Fu K, Wu J, Sun X. Construction and validation of risk prediction models for pulmonary embolism in hospitalized patients based on different machine learning methods. Front Cardiovasc Med 2024; 11:1308017. [PMID: 38984357 PMCID: PMC11232034 DOI: 10.3389/fcvm.2024.1308017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 06/11/2024] [Indexed: 07/11/2024] Open
Abstract
Objective This study aims to apply different machine learning (ML) methods to construct risk prediction models for pulmonary embolism (PE) in hospitalized patients, and to evaluate and compare the predictive efficacy and clinical benefit of each model. Methods We conducted a retrospective study involving 332 participants (172 PE positive cases and 160 PE negative cases) recruited from Guangdong Medical University. Participants were randomly divided into a training group (70%) and a validation group (30%). Baseline data were analyzed using univariate analysis, and potential independent risk factors associated with PE were further identified through univariate and multivariate logistic regression analysis. Six ML models, namely Logistic Regression (LR), Decision Tree (DT), Random Forest (RF), Naive Bayes (NB), Support Vector Machine (SVM), and AdaBoost were developed. The predictive efficacy of each model was compared using the receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC). Clinical benefit was assessed using decision curve analysis (DCA). Results Logistic regression analysis identified lower extremity deep venous thrombosis, elevated D-dimer, shortened activated partial prothrombin time, and increased red blood cell distribution width as potential independent risk factors for PE. Among the six ML models, the RF model achieved the highest AUC of 0.778. Additionally, DCA consistently indicated that the RF model offered the greatest clinical benefit. Conclusion This study developed six ML models, with the RF model exhibiting the highest predictive efficacy and clinical benefit in the identification and prediction of PE occurrence in hospitalized patients.
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Affiliation(s)
- Tao Huang
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhihai Huang
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xiaodong Peng
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Lingpin Pang
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jie Sun
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jinbo Wu
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jinman He
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Kaili Fu
- Respiratory and Critical Care Medicine, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jun Wu
- Respiratory and Critical Care Medicine, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xishi Sun
- Emergency Medicine Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
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Graafsma J, Klopotowska JE, Derijks HJ, van de Garde EMW, Hoge RHL, Kruip MJHA, Meijer K, Karapinar-Carkit F, van den Bemt PMLA. Adoption of antithrombotic stewardship and utilization of clinical decision support systems-A questionnaire-based survey in Dutch hospitals. PLoS One 2024; 19:e0306033. [PMID: 38905283 PMCID: PMC11192363 DOI: 10.1371/journal.pone.0306033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
Antithrombotics require careful monitoring to prevent adverse events. Safe use can be promoted through so-called antithrombotic stewardship. Clinical decision support systems (CDSSs) can be used to monitor safe use of antithrombotics, supporting antithrombotic stewardship efforts. Yet, previous research shows that despite these interventions, antithrombotics continue to cause harm. Insufficient adoption of antithrombotic stewardship and suboptimal use of CDSSs may provide and explanation. However, it is currently unknown to what extent hospitals adopted antithrombotic stewardship and utilize CDSSs to support safe use of antithrombotics. A semi-structured questionnaire-based survey was disseminated to 12 hospital pharmacists from different hospital types and regions in the Netherlands. The primary outcome was the degree of antithrombotic stewardship adoption, expressed as the number of tasks adopted per hospital and the degree of adoption per task. Secondary outcomes included characteristics of CDSS alerts used to monitor safe use of antithrombotics. All 12 hospital pharmacists completed the survey and report to have adopted antithrombotic stewardship in their hospital to a certain degree. The median adoption of tasks was two of five tasks (range 1-3). The tasks with the highest uptake were: drafting and maintenance of protocols (100%) and professional's education (58%), while care transition optimization (25%), medication reviews (8%) and patient counseling (8%) had the lowest uptake. All hospitals used a CDSS to monitor safe use of antithrombotics, mainly via basic alerts and less frequently via advanced alerts. The most frequently employed alerts were: identification of patients using a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) with one or more other antithrombotics (n = 6) and patients using a VKA to evaluate correct use (n = 6), both reflecting basic CDSS. All participating hospitals adopted antithrombotic stewardship, but the adopted tasks vary. CDSS alerts used are mainly basic in their logic.
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Affiliation(s)
- Jetske Graafsma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joanna E. Klopotowska
- Department of Medical Informatics Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | | | - Ewoudt M. W. van de Garde
- Department of Pharmacy, St. Antonius Hospital, Nieuwegein, Utrecht, the Netherlands
- Division Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Rien H. L. Hoge
- Department of Pharmacy, Wilhelmina Hospital, Assen, the Netherlands
- Gaston Medical, Eindhoven, the Netherlands
| | - Marieke J. H. A. Kruip
- Department of Hematology, Erasmus MC, Erasmus University medical center, Rotterdam, the Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fatma Karapinar-Carkit
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Patricia M. L. A. van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Miano N, Todaro G, Di Marco M, Scilletta S, Bosco G, Di Giacomo Barbagallo F, Scicali R, Piro S, Purrello F, Di Pino A. Malnutrition-Related Liver Steatosis, CONUT Score and Poor Clinical Outcomes in an Internal Medicine Department. Nutrients 2024; 16:1925. [PMID: 38931279 PMCID: PMC11206738 DOI: 10.3390/nu16121925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Fatty liver disease has been identified as a marker of malnutrition in different clinical settings. Recently, the COntrolling NUTritional status score (CONUT score) emerged as a promising tool for malnutrition assessment. Our aim was to evaluate short-term outcomes among patients with malnutrition-related liver steatosis in an Internal Medicine department. Furthermore, we evaluated the association of the CONUT score with malnutrition-related liver steatosis. Data from 247 patients hospitalized in an Internal Medicine department were retrospectively collected. The study population was stratified into three groups based on hepatic radiodensity assessed with computed tomography: mild steatosis (≥56.1 HU), moderate steatosis (between 49.7 and 56 HU), and severe steatosis (≤49.6 HU). We then calculated the CONUT score. Severe steatosis patients had higher in-hospital mortality (18.2 vs. 15.5%) and longer in-hospital stays compared with the mild steatosis group (length of in-hospital stay longer than 12 days: 45% vs. 40%). Logistic regression analysis showed that severe steatosis was not significantly associated with in-hospital all-cause death, while a high CONUT score was an independent risk factor for sepsis. We found an independent relationship between malnutrition-associated liver steatosis and the CONUT score. These results identified the CONUT score as a tool for nutritional assessment of hospitalized patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Antonino Di Pino
- Department of Clinical and Experimental Medicine, University of Catania, 95122 Catania, Italy; (N.M.); (G.T.); (M.D.M.); (S.S.); (G.B.); (F.D.G.B.); (R.S.); (S.P.); (F.P.)
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Xiong W, Du H, Luo Y, Cheng Y, Xu M, Guo X, Zhao Y. A Prediction Rule for Occurrence of Chronic Thromboembolic Disease After Acute Pulmonary Embolism. Heart Lung Circ 2024:S1443-9506(24)00194-X. [PMID: 38876846 DOI: 10.1016/j.hlc.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/28/2023] [Accepted: 03/05/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Occurrence of chronic thromboembolic disease (CTED) after 3 or 6 months of standard and effective anticoagulation is not uncommon in patients with acute pulmonary embolism (PE). To date, there has been no scoring model for the prediction of CTED occurrence. METHODS A Prediction Rule for CTED (PRC) was established in the establishment cohort (n=1,124) and then validated in the validation cohort (n=211). Both original and simplified versions of the PRC score were provided by using different scoring and cut-offs. RESULTS The PRC score included 10 items: active cancer (3.641; 2.338-4.944; p<0.001), autoimmune diseases (2.218; 1.545-2.891; p=0.001), body mass index >30 kg/m2 (2.186; 1.573-2.799; p=0.001), chronic immobility (2.135; 1.741-2.529; p=0.001), D-dimer >2,000 ng/mL (1.618; 1.274-1.962; p=0.005), PE with deep vein thrombosis (3.199; 2.356-4.042; p<0.001), previous venous thromboembolism (VTE) history (5.268; 3.472-7.064; p<0.001), thromboembolism besides VTE (4.954; 3.150-6.758; p<0.001), thrombophilia (3.438; 2.573-4.303; p<0.001), and unprovoked VTE (2.227; 1.471-2.983; p=0.001). In the establishment cohort, the sensitivity, specificity, Youden index (YI), and C-index were 85.5%, 79.7%, 0.652, and 0.821 (0.732-0.909) when using the original PRC score, whereas they were 87.9%, 74.6%, 0.625, and 0.807 (0.718-0.897) when using the simplified one, respectively (Kappa coefficient 0.819, p-value of McNemar's test 0.786). In the validation cohort, the sensitivity, specificity, YI, and C-index were 86.3%, 76.3%, 0.626, and 0.815 (0.707-0.923) when using the original PRC score, whereas they were 85.0%, 78.6%, 0.636, and 0.818 (0.725-0.911) when using the simplified one, respectively (Kappa coefficient 0.912, p-value of McNemar's test 0.937); both were better than that of the DASH score (72.5%, 69.5%, 0.420, and 0.621 [0.532-0.710]). CONCLUSIONS A prediction score for CTED occurrence, termed PRC, predicted the likelihood of CTED occurrence after 3 or 6 months of standard anticoagulation in hospitalised patients with a diagnosis of acute PE.
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Affiliation(s)
- Wei Xiong
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - He Du
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong Luo
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital Chongming Branch, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Service Center, Hongkou District, Shanghai, China
| | - Xuejun Guo
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
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Landi E, Mugnaini M, Vatansever T, Fort A, Vignoli V, Giurranna E, Argento FR, Fini E, Emmi G, Fiorillo C, Becatti M. Advancing Thrombosis Research: A Novel Device for Measuring Clot Permeability. SENSORS (BASEL, SWITZERLAND) 2024; 24:3764. [PMID: 38931548 PMCID: PMC11207702 DOI: 10.3390/s24123764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/28/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
Thromboembolism, a global leading cause of mortality, needs accurate risk assessment for effective prophylaxis and treatment. Current stratification methods fall short in predicting thrombotic events, emphasizing the need for a deeper understanding of clot properties. Fibrin clot permeability, a crucial parameter in hypercoagulable states, impacts clot structure and resistance to lysis. Current clot permeability measurement limitations propel the need for standardized methods. Prior findings underscore the importance of clot permeability in various thrombotic conditions but call for improvements and more precise, repeatable, and standardized methods. Addressing these challenges, our study presents an upgraded, portable, and cost-effective system for measuring blood clot permeability, which utilizes a pressure-based approach that adheres to Darcy's law. By enhancing precision and sensitivity in discerning clot characteristics, this innovation provides a valuable tool for assessing thrombotic risk and associated pathological conditions. In this paper, the authors present a device that is able to automatically perform the permeability measurements on plasma or fibrinogen in vitro-induced clots on specific holders (filters). The proposed device has been tailored to distinguish clot permeability, with high precision and sensitivity, between healthy subjects and high cardiovascular-risk patients. The precise measure of clot permeability represents an excellent indicator of thrombotic risk, thus allowing the clinician, also on the basis of other anamnestic and laboratory data, to attribute a risk score to the subject. The proposed instrument was characterized by performing permeability measurements in plasma and purified fibrinogen clots derived from 17 Behcet patients and 15 sex- and age-matched controls. As expected, our results clearly indicate a significant difference in plasma clot permeability in Behcet patients with respect to controls (0.0533 ± 0.0199 d vs. 0.0976 ± 0.0160 d, p < 0.001). This difference was confirmed in the patient's vs. control fibrin clots (0.0487 ± 0.0170 d vs. 0.1167 ± 0.0487 d, p < 0.001). In conclusion, our study demonstrates the feasibility, efficacy, portability, and cost-effectiveness of a novel device for measuring clot permeability, allowing healthcare providers to better stratify thrombotic risk and tailor interventions, thereby improving patient outcomes and reducing healthcare costs, which could significantly improve the management of thromboembolic diseases.
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Affiliation(s)
- Elia Landi
- Department of Information Engineering and Mathematics, University of Siena, 53100 Siena, Italy; (M.M.); (T.V.); (A.F.); (V.V.)
| | - Marco Mugnaini
- Department of Information Engineering and Mathematics, University of Siena, 53100 Siena, Italy; (M.M.); (T.V.); (A.F.); (V.V.)
| | - Tunahan Vatansever
- Department of Information Engineering and Mathematics, University of Siena, 53100 Siena, Italy; (M.M.); (T.V.); (A.F.); (V.V.)
| | - Ada Fort
- Department of Information Engineering and Mathematics, University of Siena, 53100 Siena, Italy; (M.M.); (T.V.); (A.F.); (V.V.)
| | - Valerio Vignoli
- Department of Information Engineering and Mathematics, University of Siena, 53100 Siena, Italy; (M.M.); (T.V.); (A.F.); (V.V.)
| | - Elvira Giurranna
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Firenze, 50121 Florence, Italy; (E.G.); (F.R.A.); (E.F.); (C.F.); (M.B.)
| | - Flavia Rita Argento
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Firenze, 50121 Florence, Italy; (E.G.); (F.R.A.); (E.F.); (C.F.); (M.B.)
| | - Eleonora Fini
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Firenze, 50121 Florence, Italy; (E.G.); (F.R.A.); (E.F.); (C.F.); (M.B.)
| | - Giacomo Emmi
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Claudia Fiorillo
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Firenze, 50121 Florence, Italy; (E.G.); (F.R.A.); (E.F.); (C.F.); (M.B.)
| | - Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Firenze, 50121 Florence, Italy; (E.G.); (F.R.A.); (E.F.); (C.F.); (M.B.)
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Jin ZY, Li CM, Qu H, Yang WT, Wen JH, Ren HL. Validation of a pulmonary embolism risk assessment model in gynecological inpatients : Clinical trial: A single-center, retrospective study. Thromb J 2024; 22:47. [PMID: 38840142 PMCID: PMC11151723 DOI: 10.1186/s12959-024-00616-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024] Open
Abstract
OBJECTIVE To compare the predictive efficacy of the PADUA and Caprini models for pulmonary embolism (PE) in gynecological inpatients, analyze the risk factors for PE, and validate whether both models can effectively predict mortality rates. METHODS A total of 355 gynecological inpatients who underwent computed tomography pulmonary angiography (CTPA) were included in the retrospective analysis. The comparative assessment of the predictive capabilities for PE between the PADUA and Caprini was carried out using receiver operating characteristic (ROC) curves. Logistic regression analysis was used to identify risk factors associated with PE. Additionally, Kaplan-Meier survival analysis plots were generated to validate the predictive efficacy for mortality rates. RESULTS Among 355 patients, the PADUA and Caprini demonstrated the area under the curve (AUC) values of 0.757 and 0.756, respectively. There was no statistically significant difference in the AUC between the two models (P = 0.9542). Multivariate logistic analysis revealed immobility (P < 0.001), history of venous thromboembolism (VTE) (P = 0.002), thrombophilia (P < 0.001), hormonal treatment (P = 0.022), and obesity (P = 0.019) as independent risk factors for PE. Kaplan-Meier survival analysis demonstrated the reliable predictive efficacy of both the Caprini (P = 0.00051) and PADUA (P = 0.00031) for mortality. ROC for the three- and six-month follow-ups suggested that the Caprini model exhibited superior predictive efficacy for mortality. CONCLUSIONS The PADUA model can serve as a simple and effective tool for stratifying high-risk gynecological inpatients before undergoing CTPA. The Caprini model demonstrated superior predictive efficacy for mortality rates.
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Affiliation(s)
- Zhen-Yi Jin
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Chun-Min Li
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Hong Qu
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Wen-Tao Yang
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Jia-Hao Wen
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China
| | - Hua-Liang Ren
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Beijing, 100020, China.
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Yifang H, Jun D, Jingting Y, Ying S, Ping Z, Xiaomei D. Comparison of the PADUA and IMPROVE scores in assessing venous thromboembolism risk in 42,257 medical inpatients in China. J Thromb Thrombolysis 2024; 57:775-783. [PMID: 38643438 DOI: 10.1007/s11239-024-02979-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/22/2024]
Abstract
Venous thromboembolism (VTE) is a major contributor to hospital mortality and disability-adjusted life-year (DALY) loss. Multiple guidelines recommend using the Padua or IMPROVE scores to stratify VTE risk in hospitalized medical patients. However, the IMPROVE score is not recommended in Chinese guidelines, and there is very little evaluation of its clinical application and effectiveness in the Chinese population. The objective of this study is to compare the efficacy of the Padua and IMPROVE scoring models for assessing VTE risk in Chinese medical inpatients. We conducted a retrospective analysis of the clinical characteristics and thrombotic risk of 42,257 medical inpatients at a tertiary hospital in Guangdong, China, between 2021 and 2022. Logistic regression was used to assess thrombotic risk factors. The Receiver Operating Characteristic (ROC) curves, Area Under the Curve (AUC), sensitivity, and specificity were employed to evaluate the performance of the two models. Of the 42,257 patients included, 948 (2.24%) experienced VTE during hospitalization. According to the Padua score, 3,7513 (88.78%) of patients were considered low risk, while 4,744 (18.22%) were classified as high risk. The IMPROVE score identified 20,744 (49.09%) of patients as low risk, 20799(49.22%) as intermediate risk, and 714(1.69%) as high risk. The AUC for the Padua score was 0.735 (95% CI: 0.717-0.753), with a sensitivity of 49.4% and specificity of 89.6%. For the IMPROVE score, the AUC was 0.711 (95% CI: 0.693-0.729), with a sensitivity of 32.5% and specificity of 99.0%. The DeLong test, used to compare the AUCs, yielded a z-value of 1.886 with a P-value of 0.059, indicating no statistical difference. When assessing VTE risk in patients with stroke, cancer, nephrotic syndrome, and critical illness (ICU/CCU stay), both scoring models showed comparable predictive performance with AUCs ranging between 0.7 and 0.8. Both the Padua score and IMPROVE score have good predictive ability for VTE events during hospitalization in medical patients. Among them, the IMPROVE score has objective assessment items, simpler operation, and more detailed risk stratification, which is beneficial for clinicians to take physical and pharmacological preventive measures at different levels.ChiCTR2200056903, February 22, retrospectively registered.
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Affiliation(s)
- Hou Yifang
- Operating Room, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Duan Jun
- Medical Records Department, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Yan Jingting
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Shan Ying
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zhang Ping
- School of Nursing, Southern Medical University, Guangzhou, Guangdong, China
| | - Deng Xiaomei
- General Ward, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China.
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Tolera BD, Gebremedhin KB. Nurses' knowledge and practice regarding venous-thromboembolism prevention in tertiary hospitals of Addis Ababa, Ethiopia: A cross-sectional study. JOURNAL OF VASCULAR NURSING 2024; 42:123-130. [PMID: 38823972 DOI: 10.1016/j.jvn.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 01/19/2024] [Accepted: 02/19/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND The prevalence of venous thromboembolism is steadily increasing in developing nations including Ethiopia. Nurses play a vital role in the prevention of venous thromboembolism. However, the level of nurses' knowledge, practice, and associated factors in venous thromboembolism prevention is not well-known across Ethiopia. This study aimed to assess nurses' knowledge, practice, and associated factors regarding venous-thromboembolism prevention in tertiary Hospitals of Addis Ababa, Ethiopia METHODS: An institutional-based cross-sectional study was conducted among 339 randomly selected nurses working at tertiary hospitals in Addis Ababa, Ethiopia. A validated questionnaire was used to collect data. Data were analyzed with SPSS version 25. Both descriptive and inferential statistics were used to describe and test the association between selected variables. RESULTS Out of the total 339 participants, only (51.6%) and (45.4%) had adequate knowledge and practice towards venous thromboembolism prevention respectively. Attending in-service training (AOR=1.701, p = 0.044) was significantly associated with knowledge of VTE prevention. Educational level (AOR= 3.871, P = 0.048), work experience (AOR=5.207, P<0.001), work location (AOR= 0.507, P = 0.019), working department (AOR= 2.959, P = 0.048), knowledge level (AOR= 0.477, P=0.005) were significantly associated with better preventive practice. CONCLUSION This study suggests that nurses' level of knowledge and practice towards venous thromboembolism prevention was inadequate. Nurses' educational level, attending in-service training, work experience, work location, and working department were determinant factors associated with nurses' knowledge and practice towards venous thromboembolism prevention. Therefore, upgrading nurses' educational level and providing in-service training on venous thromboembolism prevention is crucial for positive patient outcomes.
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Affiliation(s)
- Boka Dugassa Tolera
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Ethiopia.
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Xu J, Neeman E, Thai KK, Mishra P, Schlessinger D, Clancy H, Myers L, Roubinian N, Liu V, Liu R. Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California. J Hosp Med 2024; 19:449-459. [PMID: 38606546 DOI: 10.1002/jhm.13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Hospital-acquired venous thromboembolism (HA VTE) is a preventable complication in hospitalized patients. OBJECTIVE We aimed to examine the use of pharmacologic prophylaxis (pPPX) and compare two risk assessment methods for HA VTE: a retrospective electronic Padua Score (ePaduaKP) and admitting clinician's choice of risk within the admission orderset (low, moderate, or high). DESIGN, SETTINGS AND PARTICIPANTS We retrospectively analyzed prophylaxis orders for adult medical admissions (2013-2019) at Kaiser Permanente Northern California, excluding surgical and ICU patients. INTERVENTION ePaduaKP was calculated for all admissions. For a subset of these admissions, clinician-assigned HA VTE risk was extracted. MAIN OUTCOME AND MEASURES Descriptive pPPX utilization rates between ePaduaKP and clinician-assigned risk as well as concordance between ePaduaKP and clinician-assigned risk. RESULTS Among 849,059 encounters, 82.2% were classified as low risk by ePaduaKP, with 42.3% receiving pPPX. In the subset with clinician-assigned risk (608,512 encounters), low and high ePaduaKP encounters were classified as moderate risk in 87.5% and 92.0% of encounters, respectively. Overall, 56.7% of encounters with moderate clinician-assigned risk received pPPX, compared to 7.2% of encounters with low clinician-assigned risk. pPPX use occurred in a large portion of low ePaduaKP risk encounters. Clinicians frequently assigned moderate risk to encounters at admission irrespective of their ePaduaKP risk when retrospectively examined. We hypothesize that the current orderset design may have negatively influenced clinician-assigned risk choice as well as pPPX utilization. Future work should explore optimizing pPPX for high-risk patients only.
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Affiliation(s)
- James Xu
- Internal Medicine, Kaiser Foundation Hospitals, San Francisco, California, USA
| | - Elad Neeman
- Department of Hematology and Oncology, The Permanente Medical Group, San Rafael, California, USA
| | - Khanh K Thai
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Pranita Mishra
- Blue Shield of California, Oakland, California, USA
- Department of Pulmonary/Critical Care, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - David Schlessinger
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heather Clancy
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Laura Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Nareg Roubinian
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vincent Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Raymond Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Hematology and Oncology, The Permanente Medical Group, San Francisco, California, USA
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Falanga A, Lorusso D, Colombo N, Cormio G, Cosmi B, Scandurra G, Zanagnolo V, Marietta M. Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention. Cancers (Basel) 2024; 16:1769. [PMID: 38730721 PMCID: PMC11083004 DOI: 10.3390/cancers16091769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University “A. Moro”, 70124 Bari, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppa Scandurra
- Unità Operativa Oncologia Medica, Ospedale Cannizzaro di Catania, 95126 Catania, Italy;
| | | | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy;
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30
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Pugliese ME, Battaglia R, Ursino M, Lucca LF, Quintieri M, Vatrano M, Tonin P, Cerasa A. Prevalence and Risk Factors of Deep Venous Thrombosis in Intensive Inpatient Neurorehabilitation Unit. Healthcare (Basel) 2024; 12:936. [PMID: 38727493 PMCID: PMC11082945 DOI: 10.3390/healthcare12090936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Venous thromboembolism (VTE) (deep vein thrombosis and its complication, pulmonary embolism) is a major cause of morbidity and mortality in hospitalized patients and about 7% of these cases are due to immobility secondary to a neurological impairment. Acquired brain injury (ABI) has also been recognized as one of the main risk factors for VTE. Numerous epidemiological studies have been conducted to assess the risk factors for VTE in institutionalized polytrauma patients, although there is a lack of information about neurorehabilitation wards. Since VTE is often undiagnosed, this prospective study aimed to determine the prevalence and clinical characteristics of lower-limb deep venous thrombosis (DVT) in ABI patients at neurorehabilitation admission. METHODS ABI patients were screened for DVT on admission to the intensive rehabilitation unit (IRU) with compression ultrasonography and basal D-dimer assay and were daily clinically monitored until discharge. A total of 127 consecutive ABI patients (mean age: 60.1 ± 17.6 years; 63% male; time from event: 30.9 ± 22.1 days; rehabilitation time in IRU: 84.6 ± 58.4 days) were enrolled. RESULTS On admission to the IRU, the DVT prevalence was about 8.6%. The mean D-dimer level in patients with DVT was significantly higher than in patients without DVT (6 ± 0.9 vs. 1.97 ± 1.61, p-value = 0.0001). ABI patients with DVT did not show any significant clinical characteristics with respect to ABI without DVT, although a prevalence of hemorrhagic strokes and patients originating from the Intensive Care Unit and Neurosurgery ward was revealed. During the rehabilitation period, patients with DVT showed a significant difference in pharmacological DVT prophylaxis (high prevalence of nadroparin with 27.3% vs. 1.7%, p-value = 0.04) and a prevalence of transfers in critical awards (36% versus 9.5% of patients without DVT, p-value = 0.05). The mortality rate was similar in the two groups. CONCLUSIONS Our research offers a more comprehensive view of the clinical development of DVT patients and confirms the prevalence rate of DVT in ABI patients as determined upon IRU admission. According to our findings, screening these individuals regularly at the time of rehabilitation admission may help identify asymptomatic DVT quickly and initiate the proper treatment to avoid potentially fatal consequences. However, to avoid time-consuming general ultrasonography observation, a more precise selection of patients entering the rehabilitation ward is required.
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Affiliation(s)
- Maria Elena Pugliese
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Riccardo Battaglia
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Maria Ursino
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Lucia Francesca Lucca
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Maria Quintieri
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Martina Vatrano
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Paolo Tonin
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
| | - Antonio Cerasa
- Intensive Rehabilitation Unit, S’Anna Institute, 88900 Crotone, Italy; (R.B.); (M.U.); (L.F.L.); (M.Q.); (M.V.); (P.T.)
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy, 98164 Messina, Italy
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health Science and Nutrition, University of Calabria, 87036 Rende, Italy
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Häfliger E, Kopp B, Darbellay Farhoumand P, Choffat D, Rossel JB, Reny JL, Aujesky D, Méan M, Baumgartner C. Risk Assessment Models for Venous Thromboembolism in Medical Inpatients. JAMA Netw Open 2024; 7:e249980. [PMID: 38728035 PMCID: PMC11087835 DOI: 10.1001/jamanetworkopen.2024.9980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. Objectives To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. Design, Setting, and Participants This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. Exposures At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. Main Outcomes and Measures Symptomatic VTE within 90 days. Results Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. Conclusions and Relevance This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.
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Affiliation(s)
- Emmanuel Häfliger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Basil Kopp
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Jean-Luc Reny
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Roberts LN, Arya R, Hunt BJ. Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism. Br J Haematol 2024; 204:1635-1648. [PMID: 38577829 DOI: 10.1111/bjh.19424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, UK
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Nemeth B, Smeets MJ, Cannegieter SC, van Smeden M. Tutorial: dos and don'ts in clinical prediction research for venous thromboembolism. Res Pract Thromb Haemost 2024; 8:102480. [PMID: 39099799 PMCID: PMC11295571 DOI: 10.1016/j.rpth.2024.102480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 08/06/2024] Open
Abstract
Clinical prediction modeling has become an increasingly popular domain of venous thromboembolism research in recent years. Prediction models can help healthcare providers make decisions regarding starting or withholding therapeutic interventions, or referrals for further diagnostic workup, and can form a basis for risk stratification in clinical trials. The aim of the current guide is to assist in the practical application of complicated methodological requirements for well-performed prediction research by presenting key dos and don'ts while expanding the understanding of predictive research in general for (clinical) researchers who are not specifically trained in the topic; throughout we will use prognostic venous thromboembolism scores as an exemplar.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark J.R. Smeets
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Maas AF, Wyers C, Dielis A, Barten DG, van Kampen VE, van der Krieken TE, de Kruif M, Simsek S, Spaetgens B, van Haaps T, Appelman B, Gritters NC, Doornbos S, Moeniralam HS, Noordzij PG, Reidinga A, Douma RA, Nossent EJ, Beudel M, Elbers P, Middeldorp S, van Es N, van den Bergh JP, van Osch FH. The Incidence of Pulmonary Embolism in Hospitalized Non-ICU Patients with COVID-19 during the First Wave: A Multicenter Retrospective Cohort Study in the Netherlands. J Vasc Res 2024; 61:142-150. [PMID: 38631294 PMCID: PMC11151976 DOI: 10.1159/000538312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 03/05/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION During the first COVID-19 outbreak in 2020 in the Netherlands, the incidence of pulmonary embolism (PE) appeared to be high in COVID-19 patients admitted to the intensive care unit (ICU). This study was performed to evaluate the incidence of PE during hospital stay in COVID-19 patients not admitted to the ICU. METHODS Data were retrospectively collected from 8 hospitals in the Netherlands. Patients admitted between February 27, 2020, and July 31, 2020, were included. Data extracted comprised clinical characteristics, medication use, first onset of COVID-19-related symptoms, admission date due to COVID-19, and date of PE diagnosis. Only polymerase chain reaction (PCR)-positive patients were included. All PEs were diagnosed with computed tomography pulmonary angiography (CTPA). RESULTS Data from 1,852 patients who were admitted to the hospital ward were collected. Forty patients (2.2%) were diagnosed with PE within 28 days following hospital admission. The median time to PE since admission was 4.5 days (IQR 0.0-9.0). In all 40 patients, PE was diagnosed within the first 2 weeks after hospital admission and for 22 (55%) patients within 2 weeks after onset of symptoms. Patient characteristics, pre-existing comorbidities, anticoagulant use, and laboratory parameters at admission were not related to the development of PE. CONCLUSION In this retrospective multicenter cohort study of 1,852 COVID-19 patients only admitted to the non-ICU wards, the incidence of CTPA-confirmed PE was 2.2% during the first 4 weeks after onset of symptoms and occurred exclusively within 2 weeks after hospital admission.
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Affiliation(s)
- Arno F.G. Maas
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Caroline Wyers
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Arne Dielis
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Dennis G. Barten
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, The Netherlands
| | | | | | - Martijn de Kruif
- Zuyderland Hospital, Department of Pulmonology, Heerlen, The Netherlands
| | - Suat Simsek
- Northwest Clinics, Department of Internal Medicine, Alkmaar, The Netherlands
- Department of Internal Medicine/Endocrinology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Thijs van Haaps
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, The Netherlands
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location University of Amsterdam, Department(s), Amsterdam, the Netherlands
| | - Niels C. Gritters
- Treant Zorggroep, Department of Intensive Care, Emmen,The Netherlands
| | - Stefan Doornbos
- Treant Zorggroep, Department of Intensive Care, Emmen,The Netherlands
| | - Hazra S. Moeniralam
- St Antonius Hospital, Department of Internal Medicine, Nieuwegein, The Netherlands
| | - Peter G. Noordzij
- St Antonius Hospital, Department of Intensive Care, Nieuwegein, The Netherlands
| | - Auke Reidinga
- Department of Intensive Care, Martini Ziekenhuis, Groningen, The Netherlands
| | - Renée A. Douma
- Flevo Hospital, Department of Internal Medicine, Almere, The Netherlands
| | - Esther J. Nossent
- Department of Pulmonary Medicine, Free University Amsterdam, Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Martijn Beudel
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam, The Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Institute for Infection and Immunity, Vrije Universiteit, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Nick van Es
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Joop P.W. van den Bergh
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
- Maastricht University, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Frits H.M. van Osch
- Maastricht University, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
- VieCuri Medical Center, Department of Clinical Epidemiology, Venlo, The Netherlands
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Tsaftaridis N, Goldin M, Spyropoulos AC. System-Wide Thromboprophylaxis Interventions for Hospitalized Patients at Risk of Venous Thromboembolism: Focus on Cross-Platform Clinical Decision Support. J Clin Med 2024; 13:2133. [PMID: 38610898 PMCID: PMC11013003 DOI: 10.3390/jcm13072133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/23/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
Thromboprophylaxis of hospitalized patients at risk of venous thromboembolism (VTE) presents challenges owing to patient heterogeneity and lack of adoption of evidence-based methods. Intuitive practices for thromboprophylaxis have resulted in many patients being inappropriately prophylaxed. We conducted a narrative review summarizing system-wide thromboprophylaxis interventions in hospitalized patients. Multiple interventions for thromboprophylaxis have been tested, including multifaceted approaches such as national VTE prevention programs with audits, pre-printed order entry, passive alerts (either human or electronic), and more recently, the use of active clinical decision support (CDS) tools incorporated into electronic health records (EHRs). Multifaceted health-system and order entry interventions have shown mixed results in their ability to increase appropriate thromboprophylaxis and reduce VTE unless mandated through a national VTE prevention program, though the latter approach is potentially costly and effort- and time-dependent. Studies utilizing passive human or electronic alerts have also shown mixed results in increasing appropriate thromboprophylaxis and reducing VTE. Recently, a universal cloud-based and EHR-agnostic CDS VTE tool incorporating a validated VTE risk score revealed high adoption and effectiveness in increasing appropriate thromboprophylaxis and reducing major thromboembolism. Active CDS tools hold promise in improving appropriate thromboprophylaxis, especially with further refinement and widespread implementation within various EHRs and clinical workflows.
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Affiliation(s)
- Nikolaos Tsaftaridis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Alex C. Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY 11030, USA; (N.T.); (M.G.)
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY 10075, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY 11030, USA
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36
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Keating M, Yoo LJH, Lane-O'Neill B, Moran T, Ni Ainle F, Moloney FJ, Potter S. Staphylococcus Scalded Skin Syndrome-Induced Thrombosis Leading to Free Flap Complications: A Case Report and Review. Cureus 2024; 16:e58173. [PMID: 38741872 PMCID: PMC11089487 DOI: 10.7759/cureus.58173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Staphylococcal scalded skin syndrome (SSSS) is a clinical term used for a spectrum of blistering skin conditions induced by the epidermolytic toxins of the Staphylococcus aureus bacteria. The complications of SSSS include thrombosis; however, the pathophysiology of this is still poorly understood. We present a case of free anterolateral thigh (ALT) flap failure in a patient as a result of widespread flap thrombosis associated with staphylococcal scalded skin syndrome (SSSS). This is the first reported case of free flap failure associated with SSSS. Free flap failure due to acquired prothrombotic conditions, such as infection, is a rare and potentially under-reported phenomenon. This article aims to further explore the role of both thrombophilias and provoked thrombotic events in free flap failure. A review of the literature will also be presented, and cases of free flap failure in patients with infection-induced vascular complications will be summarised.
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Affiliation(s)
- Muireann Keating
- Department of Plastic and Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, IRL
| | - Li Jie Helena Yoo
- Department of Dermatology, Mater Misericordiae University Hospital, Dublin, IRL
| | - Billy Lane-O'Neill
- Department of Plastic and Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, IRL
| | - Tom Moran
- Department of Otolaryngology, Head and Neck Surgery, Mater Misericordiae University Hospital, Dublin, IRL
- Department of Medicine, University College Dublin, Dublin, IRL
| | - Fionnula Ni Ainle
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, IRL
| | - Fergal J Moloney
- Department of Medicine, University College Dublin, Dublin, IRL
- Department of Dermatology, Mater Misericordiae University Hospital, Dublin, IRL
| | - Shirley Potter
- Department of Plastic and Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, IRL
- Department of Medicine, University College Dublin, Dublin, IRL
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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Zhang J, Yang L, Tian H, Xu R, Liu D. The value of performance status in predicting venous thromboembolism in lung cancer patients treated with immune checkpoint inhibitors. Eur J Oncol Nurs 2024; 69:102527. [PMID: 38377652 DOI: 10.1016/j.ejon.2024.102527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/01/2024] [Accepted: 02/04/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION The incidence of venous thromboembolism (VTE) is notably high in lung cancer patients, particularly among those treated with immune checkpoint inhibitors (ICIs). Previous studies have focused on the relationship between Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) and VTE risk in immune checkpoint inhibitor therapy, but available evidence is inconsistent. METHODS The clinical data of lung cancer patients treated with ICIs were collected and analyzed from West China Hospital between January 2018 and March 2022. ECOG PS score was measured on admission. The primary outcome was the incidence of VTE, encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE). Multivariate logistic regression analysis was conducted to calculate the odds ratio (OR) and 95% confidence interval (95% CI). RESULTS A total of 1115 lung cancer patients receiving ICIs were eligible for this study, VTE developed in 105 (9.4%) during the 12-month follow-up, of which 95 (8.5%) had DVT,14 (1.3%) had definite PE. Poor ECOG PS (PS ≥ 2) was associated with an increased risk for VTE (OR = 5.405, 95% CI = 3.067-9.525, P < 0.001), DVT (OR = 4.669, 95% CI = 2.588-8.427, P < 0.001) and PE (OR = 8.413, 95% CI = 2.565-27.600, P < 0.001) after multivariable adjustment in the study cohort. CONCLUSION VTE occurred in 9.4% of lung cancer patients treated with ICIs, and poor performance status was associated with an increased risk of VTE.
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Affiliation(s)
- Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Linhui Yang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Huohuan Tian
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Rui Xu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Dan Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Zhou J, Zhu Y, Liu Y, Zhan H, Niu P, Chen H, Zhang J. Risk factors for venous thromboembolism in a single pediatric intensive care unit in China. Thromb J 2024; 22:26. [PMID: 38491391 PMCID: PMC10941433 DOI: 10.1186/s12959-024-00596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Analyses of extensive, nationally representative databases indicate a rising prevalence of venous thromboembolism (VTE) among critically ill children. However, the majority of studies on childhood VTE have primarily concentrated on Caucasian populations in the United States and European countries. There is a lack of epidemiological studies on VTE in Chinese children. METHODS We conducted a retrospective cohort study of data from the Pediatric Intensive Care (PIC) database. Data were obtained and extracted by using Structured Query Language (SQL) and the administrative platform pgAdmin4 for PostgreSQL. Bivariate analyses were conducted in which categorical variables were analyzed by a chi-square test and continuous variables were analyzed by a Student's t-test. Separate multivariable logistic regressions were employed to investigate the associations between VTE and sociodemographic factors as well as clinical factors. RESULTS Our study included 12,881 pediatric patients from the PIC database, spanning the years 2010 to 2018. The incidence rate of pediatric VTE was 0.19% (24/12,881). The venous thrombotic locations were deep venous thrombosis extremities (n = 18), superior vena cava (n = 1), cerebral sinovenous (n = 1), and other deep venous thrombosis (n = 4). Univariate analysis showed that age, weight, shock, sepsis, cancer and vasopressor receipt were statistically significant risk factors for pediatric VTE (all p ≤ 0.05). After multivariable logistic regression analysis, only shock (aOR: 6.77, 95%CI: 1.33-34.73, p = 0.019) and admission for sepsis (aOR: 6.09, 95%CI: 1.76-21.09, p = 0.004) were statistically significant associated with pediatric VTE. CONCLUSIONS In conclusion, data obtained from the Pediatric Intensive Care (PIC) database revealed a prevalence of VTE in pediatric patients of 0.19%. The most common location for venous thrombi was deep venous thrombosis (DVT) in the extremities. We identified that shock and sepsis were statistically significant factors associated with pediatric VTE.
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Affiliation(s)
- Jintuo Zhou
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Yanting Zhu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Ying Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Hairong Zhan
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Huajiao Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, China.
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Bryk-Wiązania AH, Minasyan M, Świątkowska-Stodulska R, Undas A, Hubalewska-Dydejczyk A, Webb SM, Valassi E, Gilis-Januszewska A. The thrombotic risk in Cushing's syndrome-questions, answers, and the algorithm to consider in its assessment: part I-thrombotic risk not related to surgery. Front Endocrinol (Lausanne) 2024; 15:1350010. [PMID: 38529392 PMCID: PMC10961355 DOI: 10.3389/fendo.2024.1350010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Recently, it has been reported that there is a great diversity in strategies used for thromboprophylaxis in patients with Cushing's syndrome (CS). An aim of this review was to discuss these practices in light of the existing data on the thrombotic risk in patients with CS and guidelines for medically ill patients. Methods The four relevant topics and questions on thrombotic risk in CS were identified. The current guidelines on prevention and diagnosis of venous thromboembolism (VTE) were reviewed for the answers. An algorithm to consider in the assessment of the thrombotic risk in patients with CS was proposed. Results To address both generic and CS-specific risk factors for VTE, the algorithm includes the stepwise approach consisting of Padua Score, urine free cortisol, and CS-VTE score, with no indication for routine thrombophilia testing in the prediction of an index VTE episode. Having confirmed VTE, selected patients require thrombophilia testing to aid the duration of anticoagulant treatment. The separate part of the algorithm is devoted to patients with ectopic adrenocorticotropic hormone syndrome in whom exclusion of VTE precedes introducing routine thromboprophylaxis to prevent VTE. The cancer-related VTE also prompts thromboprophylaxis, with the possible vessel invasion. The algorithm presents a unifactorial and multifactorial approach to exclude high-bleeding risks and safely introduce thromboprophylaxis with low-molecular-weight heparin. Summary Our article is the first to present an algorithm to consider in the thrombotic risk assessment among patients with Cushing's syndrome as a starting point for a broader discussion in the environment. A plethora of factors affect the VTE risk in patients with CS, but no studies have conclusively evaluated the best thromboprophylaxis strategy so far. Future studies are needed to set standards of care.
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Affiliation(s)
- Agata Hanna Bryk-Wiązania
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Mari Minasyan
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anetta Undas
- The John Paul II Hospital, Kraków, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Alicja Hubalewska-Dydejczyk
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Susan M. Webb
- Department of Endocrinology, Hospital S Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Research Center for Pituitary Diseases, Barcelona, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Valassi
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Endocrinología, Hospital e Institut de Recerca Germans Trias i Pujol, Badalona, Barcelona, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Aleksandra Gilis-Januszewska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
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Yin Q, Han L, Wang Y, Kang F, Cai F, Wu L, Zheng X, Li L, Dong LE, Dong L, Liang S, Chen M, Yang Y, Bian Y. Unlocking the potential of fondaparinux: guideline for optimal usage and clinical suggestions (2023). Front Pharmacol 2024; 15:1352982. [PMID: 38529183 PMCID: PMC10961909 DOI: 10.3389/fphar.2024.1352982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024] Open
Abstract
Background: Thromboembolic disease is associated with a high rate of disability or death and gravely jeopardizes people's health and places considerable financial pressure on society. The primary treatment for thromboembolic illness is anticoagulant medication. Fondaparinux, a parenteral anticoagulant medicine, is still used but is confusing due to its disparate domestic and international indications and lack of knowledge about its usage. Its off-label drug usage in therapeutic settings and irrational drug use are also common. Objective: The aim of this guideline is to enhance the judicious clinical application of fondaparinux by consolidating the findings of evidence-based research on the drug and offering superior clinical suggestions. Methods: Seventeen clinical questions were developed by 37 clinical pharmacy experts, and recommendations were formulated under the supervision of three methodologists. Through methodical literature searches and the use of recommendation, assessment, development and evaluation grading techniques, we gathered evidence. Results: This guideline culminated in 17 recommendations, including the use of fondaparinux for venous thromboembolism (VTE) prevention and treatment, perioperative surgical prophylaxis, specific diseases, special populations, bleeding and overdose management. For different types of VTE, we recommend first assessing thrombotic risk in hospitalized patients and then administering the drug according to the patient's body mass. In surgical patients in the perioperative period, fondaparinux may be used for VTE prophylaxis, but postoperative use usually requires confirmation that adequate hemostasis has been achieved. Fondaparinux may be used for anticoagulation prophylaxis in patients hospitalized for oncological purposes, in patients with atrial fibrillation (AF) after resuscitation, in patients with cirrhosis combined with portal vein thrombosis (PVT), in patients with antiphospholipid syndrome (APS), and in patients with inflammatory bowel disease (IBD). Fondaparinux should be used with caution in special populations, such as pregnant female patients with a history of heparin-induced thrombocytopenia (HIT) or platelet counts less than 50 × 109/L, pregnant patients with a prethrombotic state (PTS) combined with recurrent spontaneous abortion (RSA), and children. For bleeding caused by fondaparinux, dialysis may partially remove the drug. Conclusion: The purpose of this guideline is to provide all healthcare providers with high-quality recommendations for the clinical use of fondaparinux and to improve the rational use of the drug in clinical practice. Currently, there is a lack of a dedicated antidote for the management of fondaparinux. The clinical investigation of activated prothrombin complex concentrate (APCC) or recombinant activated factor VII (rFⅦa) as potential reversal agents is still pending. This critical gap necessitates heightened scrutiny and research emphasis, potentially constituting a novel avenue for future inquiries into fondaparinux sodium. A meticulous examination of adverse events and safety profiles associated with the utilization of fondaparinux sodium will contribute significantly to a more comprehensive understanding of its inherent risks and benefits within the clinical milieu.
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Affiliation(s)
- Qinan Yin
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lizhu Han
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yin Wang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fengjiao Kang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fengqun Cai
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liuyun Wu
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingyue Zheng
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lian Li
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Li e Dong
- Department of Pharmacy, The Third People’s Hospital of Chengdu, Sichuan, China
| | - Limei Dong
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Shuhong Liang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Min Chen
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Bian
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Gal GL, Agnelli G, Darius H, Kahn SR, Owaidah T, Rocha AT, Zhai Z, Khan I, Djoudi Y, Ponomareva E, Cohen AT. Event rates and risk factors for venous thromboembolism and major bleeding in a population of hospitalized adult patients with acute medical illness receiving enoxaparin thromboprophylaxis. Eur J Intern Med 2024; 121:48-55. [PMID: 38030465 DOI: 10.1016/j.ejim.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND We aimed to describe the event rates and risk-factors for symptomatic venous thromboembolism (VTE) and major bleeding in a population of hospitalized acutely ill medical patients. METHODS Patients ≥40 years old and hospitalized for acute medical illness who initiated enoxaparin prophylaxis were selected from the US Optum research database. Rates of symptomatic VTE and major bleeding at 90-days were estimated via the Kaplan-Meier (KM) method. Risk factors were identified via the Cox proportional hazards model. RESULTS A total of 123,022 patients met the selection criteria. The KM rates of VTE and major bleeding at 90-days were 3.5 % and 2.2 %, respectively. Among subgroups, the risk of VTE varied from 3.0 % in patients with ischemic stroke to 6.9 % in patients with a cancer-related hospitalization, and the risk of major bleeding varied from 1.9 % in patients with inflammatory conditions to 3.6 % in patients with ischemic stroke. Key risk factors for VTE were prior VTE (HR=4.15, 95 % confidence interval [CI] 3.80-4.53), cancer-related hospitalization (HR=2.35, 95 % CI 2.10-2.64), and thrombophilia (HR=1.64, 95 % CI 1.29-2.08). Key risk factors for major bleeding were history of major bleeding (HR=2.17, 95 % CI 1.72-2.74), history of non-major bleeding (HR=2.46, 95 % CI 2.24-2.70), and hospitalization for ischemic stroke (2.42, 95 % CI 2.11-2.78). CONCLUSION There is substantial heterogeneity in the event rates for VTE and major bleeding in acute medically ill patients. History of VTE and cancer related hospitalization represent profiles with a high risk of VTE, where continued VTE prophylaxis may be warranted.
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Affiliation(s)
- Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, ON, Canada.
| | | | | | - Susan R Kahn
- McGill University, Montreal, QC, Canada, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Ana Thereza Rocha
- Federal University of Bahia, Salvador, Brazil, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | | | | | | | - Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
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Cimminiello C. The prophylaxis of venous thromboembolism in medical patients: If you do it, do it right. Eur J Intern Med 2024; 121:40-41. [PMID: 38105123 DOI: 10.1016/j.ejim.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Claudio Cimminiello
- Arianna Foundation On Anticoagulation, Via P. Fabbri 1/3, 40138 Bologna, Italy.
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Iam-Arunthai K, Chamnanchanunt S, Thungthong P, Intalapaporn P, Nakhahes C, Suwanban T, Rojnuckarin P. Thrombosis and Bleeding Risk Scores Are Strongly Associated with Mortality in Hospitalized Patients with COVID-19: A Multicenter Cohort Study. J Clin Med 2024; 13:1437. [PMID: 38592277 PMCID: PMC10932358 DOI: 10.3390/jcm13051437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVEVTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVEVTE and IMPROVEBRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate.
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Affiliation(s)
- Kunapa Iam-Arunthai
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Supat Chamnanchanunt
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Pravinwan Thungthong
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Poj Intalapaporn
- Division of Infectious Diseases, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Chajchawan Nakhahes
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Tawatchai Suwanban
- Division of Hematology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
| | - Ponlapat Rojnuckarin
- Center of Excellence in Translational Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
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Hayssen H, Sahoo S, Nguyen P, Mayorga-Carlin M, Siddiqui T, Englum B, Slejko JF, Mullins CD, Yesha Y, Sorkin JD, Lal BK. Ability of Caprini and Padua risk-assessment models to predict venous thromboembolism in a nationwide Veterans Affairs study. J Vasc Surg Venous Lymphat Disord 2024; 12:101693. [PMID: 37838307 PMCID: PMC10922503 DOI: 10.1016/j.jvsv.2023.101693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a preventable complication of hospitalization. Risk-stratification is the cornerstone of prevention. The Caprini and Padua are two of the most commonly used risk-assessment models (RAMs) to quantify VTE risk. Both models perform well in select, high-risk cohorts. Although VTE RAMs were designed for use in all hospital admissions, they are mostly tested in select, high-risk cohorts. We aim to evaluate the two RAMs in a large, unselected cohort of patients. METHODS We analyzed consecutive first hospital admissions of 1,252,460 unique surgical and non-surgical patients to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. Caprini and Padua scores were generated using the Veterans Affairs' national data repository. We determined the ability of the two RAMs to predict VTE within 90 days of admission. In secondary analyses, we evaluated prediction at 30 and 60 days, in surgical vs non-surgical patients, after excluding patients with upper extremity deep vein thrombosis, in patients hospitalized ≥72 hours, after including all-cause mortality in a composite outcome, and after accounting for prophylaxis in the predictive model. We used area under the receiver operating characteristic curves (AUCs) as the metric of prediction. RESULTS A total of 330,388 (26.4%) surgical and 922,072 (73.6%) non-surgical consecutively hospitalized patients (total N = 1,252,460) were analyzed. Caprini scores ranged from 0 to 28 (median, 4; interquartile range [IQR], 3-6); Padua scores ranged from 0-13 (median, 1; IQR, 1-3). The RAMs showed good calibration and higher scores were associated with higher VTE rates. VTE developed in 35,557 patients (2.8%) within 90 days of admission. The ability of both models to predict 90-day VTE was low (AUCs: Caprini, 0.56; 95% confidence interval [CI], 0.56-0.56; Padua, 0.59; 95% CI, 0.58-0.59). Prediction remained low for surgical (Caprini, 0.54; 95% CI, 0.53-0.54; Padua, 0.56; 95% CI, 0.56-0.57) and non-surgical patients (Caprini, 0.59; 95% CI, 0.58-0.59; Padua, 0.59; 95% CI, 0.59-0.60). There was no clinically meaningful change in predictive performance in any of the sensitivity analyses. CONCLUSIONS Caprini and Padua RAM scores have low ability to predict VTE events in a cohort of unselected consecutive hospitalizations. Improved VTE RAMs must be developed before they can be applied to a general hospital population.
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Affiliation(s)
- Hilary Hayssen
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Shalini Sahoo
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Phuong Nguyen
- Department of Computer Science, University of Miami, Miami, FL
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Tariq Siddiqui
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD
| | - Brian Englum
- Department of Surgery, University of Maryland, Baltimore, MD
| | - Julia F Slejko
- Department of Health Services Research, University of Maryland, Baltimore, MD
| | - C Daniel Mullins
- Department of Health Services Research, University of Maryland, Baltimore, MD
| | - Yelena Yesha
- Department of Computer Science, University of Miami, Miami, FL
| | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD.
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Qiao L, Yao Y, Wu D, Xu R, Cai H, Shen Y, Xu Z, Jiang Q. The Validation and Modification of the Caprini Risk Assessment Model for Evaluating Venous Thromboembolism after Joint Arthroplasty. Thromb Haemost 2024; 124:223-235. [PMID: 37402391 PMCID: PMC10890911 DOI: 10.1055/a-2122-7780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The Caprini risk assessment model (RAM) is the most commonly used tool for evaluating venous thromboembolism (VTE) risk, a high score for arthroplasty can result in patients being classified as high risk for VTE. Therefore, its value in post-arthroplasty has been subject to debate. METHODS Retrospective data were collected from patients who underwent arthroplasty between August 2015 and December 2021. The study cohort included 3,807 patients, all of whom underwent a thorough evaluation using Caprini RAM and vascular Doppler ultrasonography preoperatively. RESULTS A total of 432 individuals (11.35%) developed VTE, while 3,375 did not. Furthermore, 32 (0.84%) presented with symptomatic VTE, while 400 (10.51%) were detected as asymptomatic. Additionally, 368 (9.67%) VTE events occurred during the hospitalization period, and 64 (1.68%) cases were detected during postdischarge follow-up. Statistical analysis revealed significant differences between the VTE and non-VTE groups in terms of ages, blood loss, D-dimer, body mass index >25, visible varicose veins, swollen legs, smoking, history of blood clots, broken hip, percent of female, hypertension, and knee joint arthroplasty (p < 0.05). The Caprini score was found to be significantly higher in the VTE group (10.10 ± 2.23) compared with the non-VTE group (9.35 ± 2.14) (p < 0.001). Furthermore, there was a significant correlation between the incidence of VTE and the Caprini score (r = 0.775, p = 0.003). Patients with a score ≥9 are at a high-risk threshold for postoperative VTE. CONCLUSION The Caprini RAM shows a significant correlation with the occurrence of VTE. A higher score indicates a greater likelihood of developing VTE. The score ≥9 is at particularly high risk of developing VTE.
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Affiliation(s)
- Liang Qiao
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- Department of Orthopedics, The Second Affiliated Hospital of XuZhou Medical University, Xuzhou, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Yao Yao
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Dengxian Wu
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Ruijuan Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
| | - Honggang Cai
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Ying Shen
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Zhihong Xu
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
| | - Qing Jiang
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, PR China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, PR China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, PR China
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Salem KM, Padberg FT. Venous thromboembolism risk models may be ready for a makeover. J Vasc Surg Venous Lymphat Disord 2024; 12:101732. [PMID: 38368022 DOI: 10.1016/j.jvsv.2023.101732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/19/2024]
Affiliation(s)
- Karim M Salem
- Division of Vascular Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ
| | - Frank T Padberg
- Division of Vascular Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ; Department of Surgery, VA New Jersey Health Care System, East Orange, NJ
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Leong CH, Ranjan SR, Javed A, Alsaedi BSO, Nabi G. Predictive accuracy of boosted regression model in estimating risk of venous thromboembolism following minimally invasive radical surgery in pharmacological prophylaxis-naïve men with prostate cancer. World J Surg Oncol 2024; 22:67. [PMID: 38395873 PMCID: PMC10885400 DOI: 10.1186/s12957-023-03170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/02/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially life-threatening but preventable complication after urological surgery. Physicians are faced with the challenges of weighing the risks and benefits of thromboprophylaxis given scanty evidence for or against and practice variation worldwide. OBJECTIVE The primary objective of the study was to explore the possibility of a risk-stratified approach for thromboembolism prophylaxis following radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS A prospective database was accessed to cross-link venous thromboembolism events in 522 men who underwent minimally invasive prostatectomy between February 2010 and October 2021. A deterministic data linkage method was used to record events through electronic systems. Community Health Index (CHI) numbers were used to identify patients via electronic health records. Patient demographics and clinical characteristics such as age, comorbidities, Gleason staging, and readmission details accrued. OUTCOMES VTE within 90 days and development of a risk-stratified scoring system. All statistical analysis was performed using R-Statistical Software and the risk of VTE within 90 days of surgery was estimated via gradient-boosting decision trees (BRT) model. RESULTS AND LIMITATIONS 1.1% (6/522) of patients developed deep vein thrombosis or pulmonary embolism within 3 months post-minimally invasive prostatectomy. Statistical analysis demonstrated a significant difference in the body mass index (p = 0.016), duration of hospital stay (p < 0.001), and number of readmissions (p = 0.036) between patients who developed VTE versus patients who did not develop VTE. BRT analysis found 8 variables that demonstrated relative importance in predicting VTE. The receiver operating curves (ROC) were constructed to assess the discrimination power of a new model. The model showed an AUC of 0.97 (95% confidence intervals [CI]: 0.945,0.999). For predicting VTE, a single-center study is a limitation. CONCLUSIONS The incidence of VTE post-minimally invasive prostatectomy in men who did not receive prophylaxis with low molecular weight heparin is low (1.1%). The proposed risk-scoring system may aid in the identification of higher-risk patients for thromboprophylaxis. In this report, we looked at the outcomes of venous thromboembolism following minimally invasive radical prostatectomy for prostate cancer in consecutive men. We developed a new scoring system using advanced statistical analysis. We conclude that the VTE risk is very low and our model, if applied, can risk stratify men for the development of VTE following radical surgery for prostate cancer.
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Affiliation(s)
- Chie Hui Leong
- Academic Urology Unit, Division of Imaging Sciences and Technology, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Sushil Rodrigues Ranjan
- Academic Urology Unit, Division of Imaging Sciences and Technology, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Anna Javed
- Department of Pharmacology, AIIMS, Vijaypur, Jammu, India
| | - Basim S O Alsaedi
- Department of Statistics, University of Tabuk, 71491, Tabuk, Saudi Arabia
| | - Ghulam Nabi
- Academic Urology Unit, Division of Imaging Sciences and Technology, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
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Davis S, Goodacre S, Horner D, Pandor A, Holland M, de Wit K, Hunt BJ, Griffin XL. Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study. BMJ MEDICINE 2024; 3:e000408. [PMID: 38389721 PMCID: PMC10882286 DOI: 10.1136/bmjmed-2022-000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/03/2024] [Indexed: 02/24/2024]
Abstract
Objective To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission. Design Decision analysis modelling study. Setting NHS hospitals in England. Population Eligible adult medical inpatients, excluding patients in critical care and pregnant women. Interventions Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts. Main outcome measures Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival. Results Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% v base case sensitivity 49.3% and specificity 73.0%). Conclusions Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Department of Emergency and Intensive Care Medicine, Northern Care Alliance Foundation Trust, Salford, UK
- Division of Immunology, Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Beverley J Hunt
- Department of Thrombosis & Haemostasis, Kings Healthcare Partners, London, UK
| | - Xavier Luke Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Amin AN, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:44-56. [PMID: 38390025 PMCID: PMC10883471 DOI: 10.36469/001c.92408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.
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Affiliation(s)
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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