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Villiger R, Méan M, Stalder O, Limacher A, Rodondi N, Righini M, Aujesky D. Prediction of very early major bleeding risk in acute pulmonary embolism: an independent external validation of the Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score. J Thromb Haemost 2023; 21:2884-2893. [PMID: 37149148 DOI: 10.1016/j.jtha.2023.04.025] [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: 01/07/2023] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND The Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score was derived to predict very early major bleeding (MB) in patients with acute pulmonary embolism (PE). Before adoption into practice, the score requires external validation in different populations. OBJECTIVES We independently validated the PE-SARD score in a prospective multicenter Swiss cohort of 687 patients aged ≥65 years with acute PE. METHODS The PE-SARD score uses 3 variables (syncope, anemia, and renal dysfunction) to classify patients into 3 categories of increasing bleeding risk. The outcomes were very early MB at 7 days (primary) and MB at later time points (secondary). We calculated the PE-SARD score for each patient and classified the proportion of patients as being at low, intermediate, and high risk. To assess discrimination and calibration, we calculated the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS The prevalence of MB was 2.0% (14/687) at 7 days and 14.0% (96/687) after a median follow-up of 30 months. The PE-SARD score classified 40.2%, 42.2%, and 17.6% of patients as low, intermediate, and high risk for MB, respectively. The frequency of observed very early MB at 7 days was 1.8% in low-, 2.1% in intermediate-, and 2.5% in high-risk patients. The area under the receiver operating characteristic curve was 0.52 (95% CI, 0.48-0.56) at 7 days and increased to 0.60 (95% CI, 0.56-0.64) at the end of follow-up. Score calibration was adequate (p > .05) over the entire follow-up. CONCLUSION In our independent validation, the PE-SARD score did not accurately predict very early MB and may not be transportable to older patients with PE.
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Affiliation(s)
- Rahel Villiger
- 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 (CHUV), Lausanne, Switzerland
| | | | | | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospital (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Xie Z, Meng Z, Yang X, Duan Y, Wang Q, Liao C. Factor XIa Inhibitors in Anticoagulation Therapy: Recent Advances and Perspectives. J Med Chem 2023; 66:5332-5363. [PMID: 37037122 DOI: 10.1021/acs.jmedchem.2c02130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Factor XIa (FXIa) in the intrinsic pathway of the coagulation process has been proven to be an effective and safe target for anticoagulant discovery with limited or no bleeding. Numerous small-molecule FXIa inhibitors (SMFIs) with various scaffolds have been identified in the early stages of drug discovery. They have served as the foundation for the recent discovery of additional promising SMFIs with improved potency, selectivity, and pharmacokinetic profiles, some of which have entered clinical trials for the treatment of thrombosis. After reviewing the coagulation process and structure of FXIa, this perspective discusses the rational or structure-based design, discovery, structure-activity relationships, and development of SMFIs disclosed in recent years. Strategies for identifying more selective and druggable SMFIs are provided, paving the way for the design and discovery of more useful SMFIs for anticoagulation therapy.
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Affiliation(s)
- Zhouling Xie
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Zhiwei Meng
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Xiaoxiao Yang
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Yajun Duan
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Qin Wang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, P. R. China
| | - Chenzhong Liao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
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Dai Q, Mehawej J, Saczynski JS, Tran KV, Abu HO, Lessard D, Fillippaios A, Paul T, Hariri E, Wang W, Tisminetzky M, Soni A, Howard-Wilson S, Waring ME, Goldberg RJ, McManus DD. Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation. Am J Cardiol 2022; 181:32-37. [PMID: 35985871 PMCID: PMC10427165 DOI: 10.1016/j.amjcard.2022.07.010] [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: 05/16/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Abstract
Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.
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Affiliation(s)
- Qiying Dai
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts.
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Khanh-Van Tran
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O Abu
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Andreas Fillippaios
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tenes Paul
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Essa Hariri
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Weijia Wang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mayra Tisminetzky
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Apurv Soni
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sakeina Howard-Wilson
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Incidence and clinical impact of bleeding events in older patients with acute venous thromboembolism. Blood Adv 2022; 7:205-213. [PMID: 35381071 PMCID: PMC9841039 DOI: 10.1182/bloodadvances.2022007263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 01/21/2023] Open
Abstract
Older patients anticoagulated for venous thromboembolism (VTE) have an increased risk of bleeding compared with younger patients. Little is known about the clinical impact of anticoagulation-related bleeding in this growing patient group. To prospectively assess the incidence, clinical impact, and predictors of bleeding in older patients anticoagulated for VTE, we analyzed 981 patients aged ≥65 years with acute VTE in a prospective multicenter cohort. Eight-eight percent were anticoagulated with vitamin K antagonists. Outcomes were the occurrence of major bleeding (MB) or clinically relevant nonmajor bleeding (CRNMB) event during the initial anticoagulation period up to 36 months. We described the incidence and clinical impact of bleeding and examined the association between risk factors and time to a first bleeding using competing risk regression; 100 MB and 125 CRNMB events occurred during follow-up. The incidence of MB and CRNMB was 8.5 (95% confidence interval [CI], 7.0-10.4) and 13.4 events (95% CI, 11.4-15.7) per 100 patient-years, respectively. In patients with MB, 79% required hospitalization, 18% required surgical intervention, and 19% required permanent discontinuation of anticoagulation; 15% of MB were intracranial and 6% were fatal. After adjustment, active cancer (subhazard ratio [SHR], 1.81; 95% CI, 1.12-2.93) and low physical activity (SHR, 1.88; 95% CI, 1.19-2.98) were associated with MB and high risk of falls with CRNMB (SHR, 2.04; 95% CI, 1.39-3.00). Older patients anticoagulated for VTE had a high incidence of MB and CRNMB, and these bleeding episodes caused a great burden of disease. Physicians should carefully weigh the risks/benefits of extended anticoagulation in the older population with VTE.
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Xu JP, Zeng RX, Lu HN, Zhang YZ, Mai XY, Mao S, Zhang MZ. Analysis of the Dose-Response Effects of Physical Activity on Cardiocerebrovascular and All-Cause Mortality in Hypertension. Front Cardiovasc Med 2022; 9:844680. [PMID: 35369332 PMCID: PMC8969098 DOI: 10.3389/fcvm.2022.844680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Leisure-time moderate-to-vigorous physical activity (MV-PA) has been consistently regarded as a protective factor to prevent and treat hypertension. However, the effect of different levels of MV-PA against cardiocerebrovascular and all-cause mortality in hypertension is still unclear. The aim of this study was to explore the dose relationships of MV-PA on these adverse outcomes in hypertension. Methods In the National Health and Nutritional Examination Survey (NHANES) from 1999 to 2006, participants with hypertension were enrolled and classified into inactive (0 MET-h/week), low-active (0 < to < 7.5 MET-h/week), and high-active (≥ 7.5 MET-h/week) groups. A multivariate Cox regression analysis was conducted with a hazard ratio (HR) and corresponding 95% confidence interval (CI). To further explore the association between different levels of MV-PA and adverse outcomes, Kaplan-Meier survival curves, subgroup analysis, and restricted cubic spline curves were performed. Results During a median 10.93-year follow-up, 1,510 and 347 patients had died from any causes and cardiocerebrovascular, respectively. The high-active group had the highest event-free survivals of all outcomes compared with low-active and inactive groups. A multivariate Cox regression analysis demonstrated that the high-active and low-active groups were associated with reduced risks of all-cause [HR: 0.70, 95% CI: 0.60–0.82; 0.76 (0.68–0.86), respectively] and cardiocerebrovascular mortality [0.56 (0.41–0.77); 0.63 (0.50–0.81), respectively] compared with the inactive group. Subgroup analysis and restricted cubic spline curves showed that MV-PA surpassing 15 MET-h/week could decrease the risks of cardiovascular and all-cause mortality with inverse relationships, which was not the case for cerebrovascular mortality, indicating a U-shaped association. Conclusion Our study suggests that highly active MV-PA of 7.5 to < 15 MET-h/week was associated with the lowest risks of cardiocerebrovascular and all-cause mortality in hypertension.
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Affiliation(s)
- Jun-Peng Xu
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Rui-Xiang Zeng
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Hai-Ning Lu
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yu-Zhuo Zhang
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xiao-Yi Mai
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Shuai Mao
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Min-Zhou Zhang
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
- *Correspondence: Min-Zhou Zhang,
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Polan C, Meyer HL, Burggraf M, Herten M, Beck P, Braitsch H, Becker L, Vogel C, Dudda M, Kauther MD. Geriatric Proximal Femur Fractures During the Covid-19 Pandemic - Fewer Cases, But More Comorbidities. Geriatr Orthop Surg Rehabil 2021; 12:21514593211009657. [PMID: 34938592 PMCID: PMC8687435 DOI: 10.1177/21514593211009657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background: The COVID-19 pandemic is challenging healthcare systems worldwide. This study examines geriatric patients with proximal femur fractures during the COVID-19 pandemic, shifts in secondary disease profile, the impact of the pandemic on hospitalization and further treatment. Methods: In a retrospective monocentric study, geriatric proximal femur fractures treated in the first six months of 2020 were analyzed and compared with the same period of 2019. Pre-traumatic status (living in a care home, under supervision of a legal guardian), type of trauma, accident mechanism, geriatric risk factors, associated comorbidities, time between hospitalization and surgery, inpatient time and post-operative further treatment of 2 groups of patients, aged 65-80 years (Group 1) and 80+ years (Group 2) were investigated. Results: The total number of patients decreased (70 in 2019 vs. 58 in 2020), mostly in Group 1 (25 vs. 16) while the numbers in Group 2 remained almost constant (45 vs. 42). The percentage of patients with pre-existing neurological conditions rose in 2020. This corresponded to an increase in patients under legal supervision (29.3%) and receiving pre-traumatic care in a nursing home (14.7%). Fractures were mostly caused by minor trauma in a home environment. In 2020, total number of inpatient days for Group 2 was lower compared to Group 1 (p = 0.008). Further care differed between the years: fewer Group 1 patients were discharged to geriatric therapy (69.6% vs. 25.0%), whereas in Group 2 the number of patients discharged to a nursing home increased. Conclusions: Falling by elderly patients is correlated to geriatric comorbidities, consequently there was no change in the case numbers in this age group. Strategic measures to avoid COVID-19 infection in hospital setting could include reducing the length of hospital stays by transferring elderly patients to a nursing home as soon as possible and discharging independent, mobile patients to return home.
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Affiliation(s)
- Christina Polan
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Heinz-Lothar Meyer
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Manuel Burggraf
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Monika Herten
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Paula Beck
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Henrik Braitsch
- Central Department of Medical Controlling, University Hospital Essen, Essen, Germany
| | - Lars Becker
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Carsten Vogel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
| | - Max Daniel Kauther
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Essen, Germany
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Shaikh F, Wynne R, Castelino RL, Inglis SC, Ferguson C. Effectiveness of Direct Oral Anticoagulants in Obese Adults With Atrial Fibrillation: A Systematic Review of Systematic Reviews and Meta-Analysis. Front Cardiovasc Med 2021; 8:732828. [PMID: 34692784 PMCID: PMC8531486 DOI: 10.3389/fcvm.2021.732828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/13/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia. Obesity is an independent risk factor for AF. Anticoagulants have been strongly recommended by all international guidelines to prevent stroke. However, altered pathophysiology in obese adults may influence anticoagulant pharmacology. Direct oral anticoagulants (DOACs) in the context of obesity and AF have been examined in recent systematic reviews. Despite the similarities in included studies, their results and conclusions do not agree. Methods and Results: The protocol for this review was registered with PROSPERO (CRD42020181510). Seven key electronic databases were searched using search terms such as “atrial fibrillation,” “obese,*” “overweight,” “novel oral anticoagulant,” “direct oral anticoagulant,” “DOAC,” “NOAC,” “apixaban,” dabigatran,” “rivaroxaban,” and “edoxaban” to locate published and unpublished studies. Only systematic reviews with meta-analyses that examined the effect of DOACs in overweight or obese adults with AF, published in the English language, were included. A total of 9,547 articles were initially retrieved. After removing the duplicates, title and abstract review and full-text review, five articles were included in the systematic review. From these only RCTs were included in the meta-analyses. There was disagreement within the published systematic reviews on DOACs in obesity. The results from our meta-analysis did not show any significant difference between all body mass index (BMI) groups for all outcomes at both 12 months and for the entire trial duration. Non-significant differences were seen among the different types of DOACs. Conclusion: There was no difference between the BMI classes in any of the outcomes assessed. This may be due to the limited number of people in the trial that were in the obese class, especially obese class III. There is a need for large prospective trials to confirm which DOACs are safe and efficacious in the obese class III adults and at which dose.
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Affiliation(s)
- Fahad Shaikh
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Rochelle Wynne
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
| | - Ronald L Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | - Caleb Ferguson
- Western Sydney Nursing and Midwifery Research Centre, Western Sydney University & Western Sydney Local Health District, Blacktown, NSW, Australia
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Bertoletti L, Sanchez O. [What are the special features of treatment in "fragile" patients (elderly, renal failure)]. Rev Mal Respir 2021; 38 Suppl 1:e157-e160. [PMID: 33744077 DOI: 10.1016/j.rmr.2019.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L Bertoletti
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Équipe dysfonction vasculaire et hémostase, Inserm UMR1059, Inserm, CIC-1408, service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, université Jean-Monnet, 42000 Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Inserm UMRS 1140, service de pneumologie et de soins intensifs, université Paris Descartes, Sorbonne Paris cité, hôpital européen Georges-Pompidou, Assistance publique-hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France.
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Lange N, Méan M, Stalder O, Limacher A, Tritschler T, Rodondi N, Aujesky D. Anticoagulation quality and clinical outcomes in multimorbid elderly patients with acute venous thromboembolism. Thromb Res 2019; 177:10-16. [PMID: 30826719 DOI: 10.1016/j.thromres.2019.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/21/2019] [Accepted: 02/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multimorbid patients with acute venous thromboembolism (VTE) are often excluded from clinical trials and little is known about their prognosis. OBJECTIVES To examine whether multimorbidity is associated with adverse clinical outcomes and lower anticoagulation quality in older patients with VTE. PATIENTS/METHODS We studied 991 patients aged ≥65 years with acute VTE in a Swiss prospective multicenter cohort study. A modified Charlson Comorbidity Index was used to measure multimorbidity, which was defined as the presence ≥2 of 17 predefined comorbid conditions. We examined the association between multimorbidity and recurrent VTE and major bleeding, adjusting for confounders and periods of anticoagulation. We assessed whether the percentage of time spent in the therapeutic international normalized ratio (INR) range varied by the number of comorbidities present. RESULTS Overall, 708 (71%) patients were multimorbid. Multimorbid patients had a higher 3-year cumulative incidence of recurrent VTE (16.8 vs. 10.8%; P = 0.056) and major bleeding (18.7 vs. 9.0%; P = 0.001) than non-multimorbid patients. After adjustment, multimorbid patients had a significantly higher risk of recurrent VTE (sub-hazard ratio [SHR] 1.66, 95% confidence interval [CI] 1.08-2.57) and a higher risk of major bleeding (SHR 1.55, 95% CI 0.96-2.50), although the latter failed to achieve statistical significance. With increasing numbers of comorbid conditions, patients spent less time in and more time above and below the therapeutic INR range. CONCLUSIONS Multimorbid patients with acute VTE have not only a lower anticoagulation quality but also more complications. Clinical trials should explicitly enroll multimorbid patients to determine the optimal anticoagulation strategy in such patients.
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Affiliation(s)
- Naomi Lange
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Marie Méan
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Service of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Odile Stalder
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Association between insurance status, anticoagulation quality, and clinical outcomes in patients with acute venous thromboembolism. Thromb Res 2019; 173:124-130. [DOI: 10.1016/j.thromres.2018.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022]
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Palareti G, Poli D. The prevention of venous thromboembolism recurrence in the elderly: a still open issue. Expert Rev Hematol 2018; 11:903-909. [PMID: 30257119 DOI: 10.1080/17474086.2018.1526667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is frequent in the elderly, with an unclear recurrence risk. After the initial and early maintenance anticoagulant treatment, the decision about its extension versus recurrences is difficult because of the high risk of bleeding in this population. Areas covered: This paper analyzes recent literature on VTE recurrence and risk of bleeding associated with extended anticoagulation in elderly patients with VTE, focusing on available data regarding efficacy and safety of old anticoagulant or recent direct oral anticoagulant (DOACs). Expert commentary: The following are clinically important and still unmet needs in elderly patients with VTE: the current real risks for recurrence or for bleeding are still uncertain; the available clinical predictive rules for recurrence are of less use; in general, the phase III trials on DOACs proved less satisfactory in the elderly than in the general population; low dose DOACs use for extended treatment seems promising and data on long periods of therapy are needed; low dose aspirin does not seem an appropriate therapeutic alternative to anticoagulants due to the high rate of bleeding in the elderly; antithrombotic drugs, with low risk of bleeding should be assessed as alternative therapeutic options for extended treatment in the elderly.
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Affiliation(s)
| | - Daniela Poli
- b Thrombosis Centre , Azienda Ospedaliero-Universitaria Careggi , Florence , Italy
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Bleeding frequency and characteristics among hematologic malignancy inpatient rehabilitation patients with severe thrombocytopenia. Support Care Cancer 2018; 26:3135-3141. [PMID: 29594490 DOI: 10.1007/s00520-018-4160-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/12/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia. DESIGN Retrospective descriptive analysis. SETTING Comprehensive cancer center acute inpatient rehabilitation unit. PARTICIPANTS Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016. INTERVENTIONS Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients. MAIN OUTCOME MEASURES Bleeding events noted in the medical record. RESULTS Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15-20,000, 10-15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer. CONCLUSIONS This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.
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Seiler E, Limacher A, Mean M, Beer HJ, Osterwalder J, Frauchiger B, Righini M, Aschwanden M, Matter CM, Banyai M, Kucher N, Staub D, Lämmle B, Rodondi N, Squizzato A, Aujesky D. Derivation and validation of a novel bleeding risk score for elderly patients with venous thromboembolism on extended anticoagulation. Thromb Haemost 2017; 117:17-03-0162. [PMID: 28837210 DOI: 10.1160/th17-03-0162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 06/16/2017] [Indexed: 11/05/2022]
Abstract
Existing clinical scores do not perform well in predicting bleeding in elderly patients with acute venous thromboembolism (VTE). We sought to derive an easy-to-use clinical score to help physicians identify elderly patients with VTE who are at high-risk of bleeding during extended anticoagulation (>3 months). Our derivation sample included 743 patients aged ≥65 years with VTE who were enrolled in a prospective multicenter cohort study. All patients received extended anticoagulation with vitamin K antagonists. We derived our score using competing risk regression, with the time to a first major bleeding up to 36 months of extended anticoagulation as the outcome, and 17 candidate variables as predictors. We used bootstrapping methods for internal validation. Sixty-six (9 %) patients suffered major bleeding. The clinical score is based on seven clinical factors (previous bleeding, active cancer, low physical activity, anemia, thrombocytopenia, antiplatelet drugs/NSAIDs, and poor INR control). Overall, 48 % of patients were classified as low-risk, 37 % as moderate-risk, and 15 % as high-risk of bleeding. The rate of major bleeding was 1.4 events in low-risk, 5.0 events in moderate-risk, and 12.2 events per 100 patient-years in high-risk patients. The c-statistic was 0.78 at 3 months and 0.71 at 36 months of extended anticoagulation. Model calibration was excellent (p=0.93). Internal validation showed similar results. This simple clinical score accurately identified elderly patients with VTE who are at high risk of major bleeding and who may not benefit from extended anticoagulation. Further validation of the score is important before its implementation into practice. The study is registered to https://clinicaltrials.gov as NCT00973596.
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Affiliation(s)
- Eva Seiler
- Eva Seiler, Department of General Internal Medicine, Bern University Hospital, Inselspital, Freiburgstrasse 8, 3010 Bern, Switzerland, Tel.: +41 632 2111, Fax: +41 632 3743, E-mail: , Received: March 8, 2017, Accepted after major revision: June 16, 2017, Epub ahead of print: August 24, 2017, https://doi.org/10.1160/TH17-03-0162, Thromb Haemost 2017; 117: ■■■
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14
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Seiler E, Limacher A, Mean M, Beer HJ, Osterwalder J, Frauchiger B, Righini M, Aschwanden M, Matter CM, Banyai M, Kucher N, Staub D, Lämmle B, Rodondi N, Squizzato A, Aujesky D. Derivation and validation of a novel bleeding risk score for elderly patients with venous thromboembolism on extended anticoagulation. Thromb Haemost 2017. [DOI: 10.1160/th-17-03-0162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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15
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Tritschler T, Aujesky D. Venous thromboembolism in the elderly: A narrative review. Thromb Res 2017; 155:140-147. [DOI: 10.1016/j.thromres.2017.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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16
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López JM, Fortuny G, Puigjaner D, Herrero J, Marimon F, Garcia-Bennett J. Effects of walking in deep venous thrombosis: a new integrated solid and fluid mechanics model. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:e2819. [PMID: 27505011 DOI: 10.1002/cnm.2819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 07/01/2016] [Accepted: 07/10/2016] [Indexed: 06/06/2023]
Abstract
Deep venous thrombosis (DVT) is a common disease. Large thrombi in venous vessels cause bad blood circulation and pain; and when a blood clot detaches from a vein wall, it causes an embolism whose consequences range from mild to fatal. Walking is recommended to DVT patients as a therapeutical complement. In this study the mechanical effects of walking on a specific patient of DVT were simulated by means of an unprecedented integration of 3 elements: a real geometry, a biomechanical model of body tissues, and a computational fluid dynamics study. A set of computed tomography images of a patient's leg with a thrombus in the popliteal vein was employed to reconstruct a geometry model. Then a biomechanical model was used to compute the new deformed geometry of the vein as a function of the fiber stretch level of the semimembranosus muscle. Finally, a computational fluid dynamics study was performed to compute the blood flow and the wall shear stress (WSS) at the vein and thrombus walls. Calculations showed that either a lengthening or shortening of the semimembranosus muscle led to a decrease of WSS levels up to 10%. Notwithstanding, changes in blood viscosity properties or blood flow rate may easily have a greater impact in WSS.
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Affiliation(s)
- Josep M López
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Gerard Fortuny
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Dolors Puigjaner
- Departament d'Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Joan Herrero
- Departament d'Enginyeria Química, Universitat Rovira i Virgili, Av Països Catalans 26, Tarragona, Catalunya, Spain
| | - Francesc Marimon
- Departament de Medicina i Cirurgia, Universitat Rovira i Virgili, Hospital Sant Joan, Reus, Catalunya, Spain
| | - Josep Garcia-Bennett
- Servei de Radiologia i Diagnòstic per la Imatge, Hospital Sant Joan, Reus, Catalunya, Spain
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17
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Faller N, Limacher A, Méan M, Righini M, Aschwanden M, Beer JH, Frauchiger B, Osterwalder J, Kucher N, Lämmle B, Cornuz J, Angelillo-Scherrer A, Matter CM, Husmann M, Banyai M, Staub D, Mazzolai L, Hugli O, Rodondi N, Aujesky D. Predictors and Causes of Long-Term Mortality in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study. Am J Med 2017; 130:198-206. [PMID: 27742261 DOI: 10.1016/j.amjmed.2016.09.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/26/2016] [Accepted: 09/16/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Long-term predictors and causes of death are understudied in elderly patients with acute venous thromboembolism. METHODS We prospectively followed up 991 patients aged ≥65 years with acute venous thromboembolism in a multicenter Swiss cohort study. The primary outcome was overall mortality. We explored the association between patient baseline characteristics and mortality, adjusting for other baseline variables and periods of anticoagulation as a time-varying covariate. Causes of death over time were adjudicated by a blinded, independent committee. RESULTS The median age was 75 years. During a median follow-up period of 30 months, 206 patients (21%) died. Independent predictors of overall mortality were age (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.05-1.65, per decade), active cancer (HR, 5.80; 95% CI, 4.22-7.97), systolic blood pressure <100 mm Hg (HR, 2.77; 95% CI, 1.56-4.92), diabetes mellitus (HR, 1.50; 95% CI, 1.02-2.22), low physical activity level (HR, 1.92; 95% CI, 1.38-2.66), polypharmacy (HR, 1.41; 95% CI, 1.01-1.96), anemia (HR, 1.48; 95% CI, 1.07-2.05), high-sensitivity C-reactive protein >40 mg/L (HR, 1.88; 95% CI, 1.36-2.60), ultra-sensitive troponin >14 pg/mL (HR, 1.54; 95% CI, 1.06-2.25), and D-dimer >3000 ng/mL (HR, 1.45; 95% CI, 1.04-2.01). Cancer (34%), pulmonary embolism (18%), infection (17%), and bleeding (6%) were the most common causes of death. CONCLUSIONS Elderly patients with acute venous thromboembolism have a substantial long-term mortality, and several factors, including polypharmacy and a low physical activity level, are associated with long-term mortality. Cancer, pulmonary embolism, infections, and bleeding are the most common causes of death in the elderly with venous thromboembolism.
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Affiliation(s)
- Nicolas Faller
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Switzerland.
| | - Andreas Limacher
- Clinical Trials Unit Bern, Department of Clinical Research, and Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Marie Méan
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Switzerland; Division of Internal Medicine, Lausanne University Hospital, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, Switzerland
| | | | - Jürg Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Switzerland
| | - Beat Frauchiger
- Department of Internal Medicine, Cantonal Hospital of Frauenfeld, Switzerland
| | - Josef Osterwalder
- Department of Emergency Medicine, Cantonal Hospital of St Gallen, Switzerland
| | - Nils Kucher
- Division of Angiology, Bern University Hospital, Switzerland
| | - Bernhard Lämmle
- University Clinic of Hematology and Central Hematology Laboratory, Bern University Hospital, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Jacques Cornuz
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Switzerland
| | - Anne Angelillo-Scherrer
- University Clinic of Hematology and Central Hematology Laboratory, Bern University Hospital, Switzerland
| | - Christian M Matter
- Center for Molecular Cardiology, University of Zurich, and Clinic for Cardiology, University Heart Center, Zurich University Hospital, Switzerland
| | - Marc Husmann
- Division of Angiology, Zurich University Hospital, Switzerland
| | - Martin Banyai
- Division of Angiology, Cantonal Hospital of Lucerne, Switzerland
| | - Daniel Staub
- Division of Angiology, Basel University Hospital, Switzerland
| | - Lucia Mazzolai
- Division of Angiology, Lausanne University Hospital, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Switzerland
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Shah SM, Zaidi S, Ahmed J, Rehman SU. Motivation and Retention of Physicians in Primary Healthcare Facilities: A Qualitative Study From Abbottabad, Pakistan. Int J Health Policy Manag 2016; 5:467-475. [PMID: 27694660 PMCID: PMC4968250 DOI: 10.15171/ijhpm.2016.38] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 04/03/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Workforce motivation and retention is important for the functionality and quality of service delivery in health systems of developing countries. Despite huge primary healthcare (PHC) infrastructure, Pakistan's health indicators are not impressive; mainly because of under-utilization of facilities and low patient satisfaction. One of the major underlying issues is staff absenteeism. The study aimed to identify factors affecting retention and motivation of doctors working in PHC facilities of Pakistan. METHODS An exploratory study was conducted in a rural district in Khyber Puktunkhwa (KP) province, in Pakistan. A conceptual framework was developed comprising of three organizational, individual, and external environmental factors. Qualitative research methods comprising of semi-structured interviews with doctors working in basic health units (BHUs) and in-depth interviews with district and provincial government health managers were used. Document review of postings, rules of business and policy actions was also conducted. Triangulation of findings was carried out to arrive at the final synthesis. RESULTS Inadequate remuneration, unreasonable facilities at residence, poor work environment, political interference, inadequate supplies and medical facilities contributed to lack of motivation among both male and female doctors. The physicians accepted government jobs in BHUs with a belief that these jobs were more secure, with convenient working hours. Male physicians seemed to be more motivated because they faced less challenges than their female counterparts in BHUs especially during relocations. Overall, the organizational factors emerged as the most significant whereby human resource policy, career growth structure, performance appraisal and monetary benefits played an important role. Gender and marital status of female doctors was regarded as most important individual factor affecting retention and motivation of female doctors in BHUs. CONCLUSION Inadequate remuneration, unreasonable facilities at residence, poor work environment, political interference, inadequate supplies, and medical facilities contributed to lack of motivation in physicians in our study. Our study advocates that by addressing the retention and motivation challenges, service delivery can be made more responsive to the patients and communities in Pakistan and other similar settings.
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Affiliation(s)
| | - Shehla Zaidi
- Department of Community Health Sciences and Women and Child Health Division, Aga Khan University, Karachi, Pakistan
| | - Jamil Ahmed
- Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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[Atrial fibrillation and physical activity. An overview]. Herz 2015; 41:131-7. [PMID: 26407697 DOI: 10.1007/s00059-015-4352-x] [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: 06/16/2015] [Revised: 07/31/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
Abstract
A training-induced increase in vagal tone, left atrial enlargement and high atrial volume load due to exercise can theoretically favor induction and continuation of atrial fibrillation (AF) in (endurance) athletes. However, there is currently no evidence for a higher occurrence of AF in young endurance athletes in comparison to an age-matched normal population. The correlate of long-term endurance training results in proarrhythmogenic atrial remodeling in a rat model. The results of some studies also suggest that there may be atrial remodeling in humans, which might be an explanation for the comparatively higher incidence of AF in veteran athletes, whereby the relative risk might have been overestimated due to methodological problems, e.g. due to insufficient consideration of "new" AF risk factors. To date, there are no indications for an increased risk of AF due to normal physical activity: on the contrary, moderate physical activity seems to decrease the risk for AF. For an individual evaluation of sports participation of patients with AF, the overall cardiac situation, atrioventricular conduction during exercise, a possible oral anticoagulation as well as the sport and training intensity practiced are important. Well-adapted training for patients with AF has to be considered as safe and effective in terms of the overall positive effects of physical activity in patients with cardiovascular problems, for example due to a positive influence on cardiovascular risk factors.
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La Brooy B, Ho P. New oral anticoagulants: an approach in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Beth La Brooy
- Department of Geriatric Medicine St Vincent's Hospital Melbourne Australia
| | - Prahlad Ho
- Department of Haematology The Northern Hospital Epping Australia
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21
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Kruse-Jarres R. Acquired bleeding disorders in the elderly. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:231-236. [PMID: 26637727 DOI: 10.1182/asheducation-2015.1.231] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The hemostatic balance changes with advancing age which may be due to factors such as platelet activation, increase of certain clotting factor proteins, slowing of the fibrinolytic system, and modification of the endothelium and blood flow. Generally, this predisposes the elderly to thrombosis rather than bleeding. It often necessitates antiplatelet or anticoagulation therapy, which can cause significant bleeding problems in an aging population. Additionally, changing renal function, modification in immune regulation, and a multitude of other disease processes, can give rise to acquired bleeding disorders. Bleeding can prove difficult to treat in a dynamic environment and in a population that may have underlying thrombotic risk factors.This article discusses some specific challenges of acquired bleeding arising in the elderly. The use of anticoagulation and nonsteroidal anti-inflammatory medications is prevalent in the treatment of the elderly and predisposes them to increased bleeding risk as their physiology changes. When prescribing and monitoring these therapies, it is exceedingly important to weigh thrombotic versus bleeding risks. There are additional rare acquired bleeding disorders that predominantly affect the elderly. One of them is acquired hemophilia, which is an autoimmune disorder arising from antibodies against factor VIII. The treatment challenge rests in the use of hemostatic agents in a population that is already at increased risk for thrombotic complications. Another rare disorder of intensifying interest, acquired von Willebrand syndrome, has a multitude of etiologic mechanisms. Understanding the underlying pathophysiology is essential in making a treatment decision for this disorder.
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Affiliation(s)
- Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest and University of Washington, Seattle, WA
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