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Shibuya N, Zimmer C, Jupiter DC. Venous Thromboembolism in Foot and Ankle Trauma. Clin Podiatr Med Surg 2024; 41:607-617. [PMID: 38789173 DOI: 10.1016/j.cpm.2024.01.012] [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: 05/26/2024]
Abstract
Every surgeon may have experienced a tragic event associated with death or debilitation secondary to deep vein thrombosis (DVT) or pulmonary embolism (PE) after foot and ankle trauma and surgery. Nevertheless, the prevention of such a tragic event needs to be carefully evaluated rationally with currently available epidemiologic data. With great postoperative protocols and access to care, most PE events can be prevented. There are modifiable risk factors, such as length/type of immobilization and operative trauma/time that can lower the incidence of DVT/PE. In addition, chemical prophylaxis may be warranted in certain people within the foot and ankle trauma population.
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Affiliation(s)
- Naohiro Shibuya
- Department of Medicine, University of Texas Rio Grande Valley, School of Podiatric Medicine.
| | - Christopher Zimmer
- Department of Podiatric Medicine and Surgery, Baylor Scott and White Memorial Hospital, Texas A&M Health Science Center
| | - Danial C Jupiter
- Department of Biostatistics and Data Science, Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch
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2
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Kaya AD, Tekin O, Colak Y, Serin I. How complicated can be a case with immune thrombocytopenic purpura?: postsplenectomy arterial thrombosis. Blood Coagul Fibrinolysis 2024; 35:209-213. [PMID: 38407854 DOI: 10.1097/mbc.0000000000001290] [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: 02/27/2024]
Abstract
Arterial thrombus associated with the surgery can be seen in postsplenectomy cases, but there is no clear data in patients diagnosed with immune thrombocytopenic purpura (ITP). A 52-year-old female patient was admitted to the emergency department due to ecchymotic skin changes. Her initial platelet count was 6000/mm 3 ; after two courses of high dose-dexamethasone, intravenous immunoglobulin and rituximab, splenectomy was planned for the patient whose platelet count was again <40 000/mm 3 . She presented to the emergency department with complaints of pain and pallor in the right arm in the second week of follow-up. There was a mural thrombus that caused approximately 50% stenosis in the lumen at the division site in the aortic arch, proximal of the right subclavian artery. The patient's clinic was found to be associated with the presence of an aberrant right subclavian artery and postoperative thrombocytosis/inflammation after elimination other prothrombotic conditions.
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Affiliation(s)
- Ahmet Deniz Kaya
- Ibrahim Cecen University, Agri Training and Research Hospital, Department of Cardiovascular Surgery
| | - Oguzhan Tekin
- Ibrahim Cecen University, Agri Training and Research Hospital, Department of General Surgery
| | - Yasin Colak
- Ibrahim Cecen University, Agri Training and Research Hospital, Department of Hematology, Agri, Turkey
| | - Istemi Serin
- Ibrahim Cecen University, Agri Training and Research Hospital, Department of Hematology, Agri, Turkey
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3
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Lam BD, Dodge LE, Zerbey S, Robertson W, Rosovsky RP, Lake L, Datta S, Elavakanar P, Adamski A, Reyes N, Abe K, Vlachos IS, Zwicker JI, Patell R. The potential use of artificial intelligence for venous thromboembolism prophylaxis and management: clinician and healthcare informatician perspectives. Sci Rep 2024; 14:12010. [PMID: 38796561 PMCID: PMC11127994 DOI: 10.1038/s41598-024-62535-9] [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: 06/08/2023] [Accepted: 05/17/2024] [Indexed: 05/28/2024] Open
Abstract
Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Artificial intelligence (AI) and machine learning (ML) can support guidelines recommending an individualized approach to risk assessment and prophylaxis. We conducted electronic surveys asking clinician and healthcare informaticians about their perspectives on AI/ML for VTE prevention and management. Of 101 respondents to the informatician survey, most were 40 years or older, male, clinicians and data scientists, and had performed research on AI/ML. Of the 607 US-based respondents to the clinician survey, most were 40 years or younger, female, physicians, and had never used AI to inform clinical practice. Most informaticians agreed that AI/ML can be used to manage VTE (56.0%). Over one-third were concerned that clinicians would not use the technology (38.9%), but the majority of clinicians believed that AI/ML probably or definitely can help with VTE prevention (70.1%). The most common concern in both groups was a perceived lack of transparency (informaticians 54.4%; clinicians 25.4%). These two surveys revealed that key stakeholders are interested in AI/ML for VTE prevention and management, and identified potential barriers to address prior to implementation.
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Affiliation(s)
- Barbara D Lam
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
- Division of Clinical Informatics, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Laura E Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sabrina Zerbey
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - William Robertson
- Weber State University, Ogden, UT, USA
- National Blood Clot Alliance, Philadelphia, PA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Siddhant Datta
- Division of Hospital Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Pavania Elavakanar
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Alys Adamski
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nimia Reyes
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Karon Abe
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ioannis S Vlachos
- Department of Pathology, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jeffrey I Zwicker
- Division of Hematology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rushad Patell
- Division of Hematology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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4
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Huang S, Perry A, Sanchez Parra C, Gonzalez Torriente A, Ghumman H, Charkowick S, Colon J, Heide M, Jaglal M, Mhaskar R, Rico JF. Incidence of Thrombosis in COVID-19 Patients Compared to Non-COVID-19 Sepsis Patients in the Intensive Care Unit. J Clin Med 2024; 13:2974. [PMID: 38792515 PMCID: PMC11121895 DOI: 10.3390/jcm13102974] [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: 11/12/2023] [Revised: 05/01/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: The hypercoagulable state associated with COVID-19 infection is associated with adverse outcomes and mortality. Studies have also demonstrated high rates of venous thromboembolism (VTE) events among patients with sepsis. We aimed to evaluate how the increase in thrombotic events in critically ill patients with COVID-19 infection compares to that of critically ill patients with non-COVID-19 sepsis. Methods: A chart review was performed of patients 18 years or older admitted to the intensive care unit (ICU) at Tampa General Hospital between 1 January 2020 and 31 December 2020 diagnosed with COVID-19 or sepsis secondary to other pathogens. Non-COVID-19 sepsis patients and COVID-19 patients were propensity-matched 3:1 on the Charlson Comorbidity Index. Multivariate analyses adjusting for confounding were conducted to report odds ratio (OR) and 95% confidence intervals (95% CIs) of predictors for thrombotic events and overall mortality. Results: After propensity score matching, 492 sepsis patients and 164 COVID-19 patients were included in the analysis. COVID-19 patients were significantly older (p = 0.021) and showed higher BMI (p < 0.001) than sepsis patients. COVID-19 patients did not show significantly higher odds of thrombosis after adjustment for confounders (OR 0.85, 95% CI 0.42-1.72), but had significantly lower odds of mortality than sepsis patients (OR 0.33, 95% CI 0.16-0.66). Conclusions: Our results suggest that further study is required to lower the rate of VTE in COVID-19 and non-COVID-19 sepsis patients admitted to the ICU; it is also reasonable to consider similar thromboembolism practices between these two patient groups.
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Affiliation(s)
- Sherri Huang
- Department of Internal Medicine and Pediatrics, University of South Florida, Tampa, FL 33606, USA
| | - Ashley Perry
- Department of Internal Medicine and Pediatrics, University of South Florida, Tampa, FL 33606, USA
| | - Carlos Sanchez Parra
- Department of Internal Medicine and Pediatrics, University of South Florida, Tampa, FL 33606, USA
- Division of Pediatric Cardiology, Texas Children’s Hospital, Houston, TX 77030, USA
| | | | - Haider Ghumman
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Shaun Charkowick
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Joshua Colon
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - McKenzi Heide
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Michael Jaglal
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
- Department of Hematology and Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Rahul Mhaskar
- Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Juan Felipe Rico
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL 33606, USA
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Langanay L, Gonzalez Sanchez R, Hamroun A, Dauchet L, Amouyel P, Dallongeville J, Meirhaeghe A, Gauthier V. Ischemic stroke subtypes: risk factors, treatments, and 1-month prognosis - The Lille, France Stroke Registry. J Stroke Cerebrovasc Dis 2024; 33:107761. [PMID: 38723923 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107761] [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: 03/13/2024] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES First, this registry-based study aimed to comprehensively analyze patients' medical histories and treatments based on ischemic strokes' etiology. We focused on the management of atrial fibrillation among patients diagnosed with cardioembolic stroke. Then, our objective was to identify prognostic factors associated with 28-day mortality. MATERIALS AND METHODS All ischemic strokes occurring in adults between 2014 and 2021 in Lille, France, were categorized using the TOAST classification. Comparative analyses of patients' medical characteristics were conducted across subtypes. Survival rates within 28 days post-stroke were assessed, and factors influencing mortality were identified using a multivariate Cox model. RESULTS 1912 ischemic strokes were recorded, due to cardioembolism (36%), large-artery atherosclerosis (9%), small-artery occlusion (9%), other determined causes (6%), or undetermined causes (39%). The median NIHSS score after cardioembolic stroke (6, IQR: 3-13) was twice that after small-artery occlusion (3, IQR: 2-5). Among patients with cardioembolic stroke, 26% were diagnosed post-admission with atrial fibrillation. For the 42% diagnosed pre-admission, only 54% had prior prescriptions for oral anticoagulants. Reperfusion therapies were administered in 21% of cases, with significant variations across subtypes. Mortality rates were higher after cardioembolic strokes (17%) than after small-artery occlusions (3%). Prognostic factors included etiology, high NIHSS score, atrial fibrillation, and previous heparin prescription. CONCLUSIONS While atrial fibrillation was underdiagnosed and undertreated, patients with cardioembolic stroke exhibited high severity and elevated mortality rates. Etiology emerged as an independent predictor of early mortality, regardless of NIHSS score upon admission. These findings underscore the importance of targeted prevention to improve patient outcomes after ischemic stroke.
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Affiliation(s)
- Léonie Langanay
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Roberto Gonzalez Sanchez
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Aghiles Hamroun
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Luc Dauchet
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Philippe Amouyel
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Jean Dallongeville
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
| | - Aline Meirhaeghe
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France.
| | - Victoria Gauthier
- Lille University, Lille University Hospital, INSERM U1167 - RID-AGE, Institut Pasteur de Lille, U1167, 1 rue du Pr Calmette, Lille 59019, France
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Codling D, Mueller C, Patel J, Stewart R, Arya R, Roberts L. Rates of venous thromboembolism associated with acute psychiatric admission: A retrospective cohort study. Exp Ther Med 2024; 27:188. [PMID: 38533433 PMCID: PMC10964734 DOI: 10.3892/etm.2024.12476] [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: 09/12/2023] [Accepted: 01/30/2024] [Indexed: 03/28/2024] Open
Abstract
The present study aimed to identify rates of venous thromboembolism (VTE) amongst patients treated in inpatient mental health units using linked primary care and mental health care records. Patients resident in the London Borough of Lambeth admitted to mental health units in Southeast London between January 2008 and March 2019 were included, as well as a control group of patients being treated in the community for mental illness. The primary outcome measure was a diagnosis of VTE being recorded in GP records during or within 3 months of an admission to a mental health unit. For 7,198 psychiatric inpatient admissions, 11 episodes of VTE (1.5/1,000 admissions) were identified, with no VTE cases identified in 4,561 patients being treated in the community for mental illness during an equivalent window. This finding indicates that VTE rates following psychiatric inpatient admission might be similar to those following unselected acute medical admission. Larger scale studies are required to confirm the estimated incidence of VTE in patients with mental health conditions and the contribution of acute psychiatry hospitalisation to VTE risk.
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Affiliation(s)
- David Codling
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom
- South London and Maudsley NHS Foundation Trust, London SE5 8AZ, United Kingdom
| | - Christoph Mueller
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom
- South London and Maudsley NHS Foundation Trust, London SE5 8AZ, United Kingdom
| | - Jignesh Patel
- Institute of Pharmaceutical Science, King's College London, London SE1 9NH, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom
- South London and Maudsley NHS Foundation Trust, London SE5 8AZ, United Kingdom
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London SE5 9RS, United Kingdom
| | - Lara Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London SE5 9RS, United Kingdom
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7
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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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Li S, Zhang L, Yin H, Zhang G, Tan M, Cai Z, Huang T, Lin H, Lyu J. Venous thromboembolism prophylaxis and mortality in patients with spinal fractures in ICUs. Nurs Crit Care 2024; 29:564-572. [PMID: 37041106 DOI: 10.1111/nicc.12915] [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: 04/09/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Spinal fracture is a common traumatic condition in orthopaedics, accounting for 5%-6% of total body fractures, and is a high-risk factor for venous thromboembolism (VTE), which seriously affects patient prognosis. AIM The aim of this study was to determine the impact of VTE prophylaxis on the prognosis of patients with spinal fractures in intensive care units (ICUs) and to provide a scientific basis for clinical treatment and nursing. DESIGN A retrospective study of patients with spinal fractures from the multicenter eICU Collaborative Research Database. METHOD The outcomes of this study were ICU mortality and in-hospital mortality. Patients were divided into the VTE prophylaxis (VP) and no VTE prophylaxis (NVP) groups according to whether they had undergone VTE prophylaxis during their ICU admission. The association between groups and outcomes were analysed using Kaplan-Meier (KM) survival curve, log-rank test and the Cox proportional-hazards regression model. RESULTS This study included 1146 patients with spinal fractures: 330 in the VP group and 816 in the NVP group. KM survival curves and log-rank tests revealed that both ICU and in-hospital survival probabilities in the VP group were significantly higher than in the NVP group. After the Cox model was adjusted for all covariates, the hazard ratio for ICU mortality in the VP group was 0.38 (0.19-0.75); the corresponding value for in-hospital mortality in the VP group was 0.38 (0.21-0.68). CONCLUSIONS VTE prophylaxis is associated with reduced ICU and in-hospital mortality in patients with spinal fractures in ICUs. More research is necessary to further define specific strategies and optimal timing for VTE prophylaxis. RELEVANCE TO CLINICAL PRACTICE This study provides the basis that VTE prophylaxis may be associated with improved prognosis in patients with spinal fractures in ICUs. In clinical practice, an appropriate modality should be selected for VTE prophylaxis in such patients.
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Affiliation(s)
- Shaojin Li
- Department of Orthopaedics, The first affiliated hospital of Jinan University Guangzhou, Guangzhou, China
| | - Luming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Guowei Zhang
- Department of Orthopaedics, The first affiliated hospital of Jinan University Guangzhou, Guangzhou, China
| | - Minghui Tan
- Department of Orthopaedics, The first affiliated hospital of Jinan University Guangzhou, Guangzhou, China
| | - Zhenbin Cai
- Department of Orthopaedics, The first affiliated hospital of Jinan University Guangzhou, Guangzhou, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Hongsheng Lin
- Department of Orthopaedics, The first affiliated hospital of Jinan University Guangzhou, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
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Al Sulaiman KA, Al-Ramahi G, Aljuhani O, Al-Joudi K, Alhujayri AK, Al-Shomer F, Silas J, Al Dabbagh T, Al Harbi S, AlDekhayel S, Eldali A, Alqahtani R, Vishwakarma R, Al-Dorzi HM. Comparison of the safety and efficacy for different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial. Eur J Trauma Emerg Surg 2024; 50:567-579. [PMID: 38240791 DOI: 10.1007/s00068-024-02443-9] [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: 06/20/2023] [Accepted: 12/31/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE Venous thromboembolism (VTE) is a common complication in critically ill patients, including severe burn cases. Burn patients respond differently to medications due to pharmacokinetic changes. This study aims to assess the feasibility and safety of different VTE pharmaco-prophylaxis in patients admitted to the ICU with severe burns. METHODS A pilot, open-label randomized controlled trial was conducted on ICU patients with severe burns (BSA ≥ 20%). By using block randomization, patients were allocated to receive high-dose enoxaparin 30 mg q12hours (E30q12), standard-dose enoxaparin 40 mg q24hours (E40q24), or unfractionated heparin (UFH) 5000 Units q8hours. In this study, the primary outcomes assessed were the recruitment and consent rates, as well as bleeding or hematoma at both the donor and graft site. Additionally, secondary measures were evaluated to provide further insights. RESULTS Twenty adult patients out of 114 screened were enrolled and received E30q12 (40%), E40q24 (30%), and UFH (30%). The recruitment rate was one patient per month with a 100% consent rate. Donor site bleeding occurred in one patient (16.7%) in the UFH group. On the other hand, graft site bleeding was only reported in one patient (12.5%) who received E30q12. Major bleeding happened in two patients, one in E30q12 and one in the UFH group. Five patients (25.0%) had minor bleeding; two patients (25.0%) received E30q12, two patients E40q24, and one patient UFH. RBC transfusion was needed in four patients, two on E30q12 and two on UFH. Only one patient had VTE, while four patients died in the hospital. CONCLUSION The study observed a low recruitment rate but a high consent rate. Furthermore, there were no major safety concerns identified with any of the three pharmacologic prophylaxis regimens that were evaluated. TRIAL REGISTRATION NUMBER NCT05237726.
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Affiliation(s)
- Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia.
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia.
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia.
| | - Ghassan Al-Ramahi
- Plastic Surgery Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khuloud Al-Joudi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz K Alhujayri
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Feras Al-Shomer
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Johanna Silas
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Nursing Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Tarek Al Dabbagh
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Salah AlDekhayel
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Eldali
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City (KAMC) - Ministry of National Guard Health Affairs (MNGHA), King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, 11426, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | | | - Hasan M Al-Dorzi
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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10
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Di Mauro AL, Austin LJ, Zande J, Winckel K, Neale R, De Guzman KR. Real-world comparative effectiveness of dalteparin and enoxaparin for venous thromboembolism prophylaxis. Blood Coagul Fibrinolysis 2024; 35:101-107. [PMID: 38358899 DOI: 10.1097/mbc.0000000000001281] [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: 02/17/2024]
Abstract
Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients world-wide. In Australia, the low-molecular weight heparins (LMWHs) enoxaparin or dalteparin are usually used as first-line prophylaxis for VTE, though there is uncertainty whether dalteparin has the same effectiveness as enoxaparin in real-world settings. This is relevant because dalteparin is less renally cleared and may be more cost effective than enoxaparin. The aim of this study was to explore VTE event incidence in a general cohort of hospitalized adult inpatients who were prescribed enoxaparin or dalteparin for VTE prophylaxis. A retrospective observational study was conducted at a quaternary hospital in Brisbane, Australia, of patients who had experienced a hospital-acquired VTE from 1 September 2021 to 1 March 2023. Patients were identified from routinely collected data following an in-hospital VTE event, and further data was retrieved retrospectively from the integrated electronic Medical Record (ieMR). Incidence and type of VTE events, LMWH-prescribing patterns, and risk factors were assessed. The incidence of VTE events were similar across the dalteparin and enoxaparin cohorts (42.1 events/10 000 patients vs. 34.4 events/10 000 patients, respectively), although patients prescribed enoxaparin had a higher number of risk factors, particularly obesity and active cancer. Our research indicates comparable incidence of VTE in patients prescribed dalteparin compared with enoxaparin in an Australian hospital general cohort of adult inpatients. Dalteparin may be as effective as enoxaparin for VTE prophylaxis in a real-world cohort of patients, and as such dalteparin may be considered a suitable alternative to enoxaparin for VTE prophylaxis. Further research including large randomized controlled trials are required to confirm these results.
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Affiliation(s)
- Anna L Di Mauro
- Office of the Chief Clinical Information Officer, eHealth Queensland, Brisbane
| | - Lewis J Austin
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
| | | | - Karl Winckel
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
- School of Pharmacy, University of Queensland
| | - Rodney Neale
- Vascular Surgery & Medicine Department, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Keshia R De Guzman
- Pharmacy Department, Princess Alexandra Hospital, Woolloongabba
- School of Pharmacy, University of Queensland
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11
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Hu Z, Gao Y, Fan S. Case Report: A case of Crohn's disease with right atrial thrombosis. Front Pediatr 2024; 12:1353883. [PMID: 38577636 PMCID: PMC10991678 DOI: 10.3389/fped.2024.1353883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/08/2024] [Indexed: 04/06/2024] Open
Abstract
Crohn's disease (CD) is a chronic, non-specific inflammatory disease of the intestinal tract with an unknown etiology. It presents with clinical symptoms such as abdominal distension, abdominal pain, diarrhea, bloody stools containing mucus or pus, and other manifestations. CD has a prolonged and chronic course and can lead to various complications that significantly impact patients' quality of life. Patients with CD have hypercoagulable blood and are prone to thromboembolic diseases, which pose a serious threat to their lives. Several studies have indicated that inflammatory bowel disease is a risk factor for venous thromboembolism. The pathogenesis involves abnormalities in the coagulation-anticoagulation system, fibrinolytic system, platelets, vascular endothelial dysfunction, as well as the effects of therapeutic agents. In this case report, we present a rare case of a 15-year-old female patient with active CD complicated by the presence of a right atrial thrombus. Laboratory tests revealed abnormalities in both the coagulation-anticoagulation system and fibrinolysis system in the patient. The initial diagnosis, based on transthoracic echocardiography and contrast-enhanced echocardiography, confirmed the presence of a thrombus in the right atrium. Subsequent administration of anticoagulant and thrombolytic therapy resulted in gradual reduction in size until complete disappearance, as evidenced by dynamic monitoring. Ultrasound examination is considered as the preferred method for follow-up evaluation in patients with CD due to its ability not only to assess gastrointestinal complications but also to aid early identification of cardiovascular complications, thereby enabling timely intervention and treatment-which remains our primary focus of research and effort.
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Affiliation(s)
| | | | - Shumin Fan
- Department of Ultrasound, Shenzhen Children's Hospital of China Medical University, Shenzhen, China
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12
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Hall R, Suarez S, Majumdar M, Lee I, Zacharias N, Gee D, Dua A. Thromboelastography with Platelet Mapping Identifies High Platelet Reactivity is Associated with Obesity, Diabetes, and Thrombotic Events. Ann Vasc Surg 2024; 104:227-236. [PMID: 38490537 DOI: 10.1016/j.avsg.2023.12.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Metabolic comorbidities such as diabetes and obesity are considered pro-inflammatory states which theoretically increase the risk of perioperative thrombotic events across many surgical disciplines. Currently, there is a paucity of objective metrics to determine such risk and ideal pharmacologic targets. Thromboelastography with Platelet Mapping (TEG-PM) provides a comprehensive profile of coagulation and may provide insight into clot dysregulation. METHODS Patients undergoing lower extremity revascularization underwent serial TEG-PM analysis. The relationship between the TEG-PM metrics and thrombosis was evaluated. Preoperative TEG-PM samples of patients with body mass index (BMI)≥25 were compared to those of patients with a normal BMI, and between patients with diabetes mellitus (DM) and those without. RESULTS 218 TEG-PM samples from 202 patients were analyzed. The BMI≥25 cohort showed significantly greater platelet aggregation [81.9% (±20.9) vs. 68.6% (±27.7), P < 0.01]. Patients with DM were more frequently on full-dose anticoagulation [47.7% vs. 29.7% P = 0.01] yet demonstrated increased clot strength, or adenosine diphosphate (ADP)-Maximum Clot Amplitude (MA) [49.1 (±16.1) vs. 41.5 (±17.1) and 37.7 (±19.6) vs. 31.6 (±17.4) P < 0.01]. 49 patients experienced thrombosis and exhibited greater platelet aggregation [76.6% (±17.8) vs. 66.8% (±30.4) P = 0.03] and greater ADP/arachidonic acid MA [47.1 (±16.6) vs. 41.9 (±18.8) and 38.2 (±17.8) vs. 32.5 (±19.9) both P = 0.05]. Patients who thrombosed were more often diabetic [69.5% versus 51.0% P = 0.03] and on full-dose anticoagulation [75.0% vs. 56.8% P = 0.02]. CONCLUSIONS Patients with a BMI≥ 25 and those with diabetes demonstrated TEG-PM profiles similar to patients with thrombosis. Diabetes was independently associated with thrombosis, and full-dose anticoagulation was not protective. This suggests the potential utility of TEG-PM for thrombotic risk stratification based on metabolic factors and suggests antiplatelet agents may be effective at prevention of thrombotic events in this population.
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Affiliation(s)
- Ryan Hall
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Sasha Suarez
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Ivy Lee
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Denise Gee
- Division of Minimally Invasive Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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13
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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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14
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Zakai NA, Wilkinson K, Sparks AD, Packer RT, Koh I, Roetker NS, Repp AB, Thomas R, Holmes CE, Cushman M, Plante TB, Al-Samkari H, Pishko AM, Wood WA, Masias C, Gangaraju R, Li A, Garcia D, Wiggins KL, Schaefer JK, Hooper C, Smith NL, McClure LA. Development and validation of a risk model for hospital-acquired venous thrombosis: the Medical Inpatients Thrombosis and Hemostasis study. J Thromb Haemost 2024; 22:503-515. [PMID: 37918635 PMCID: PMC10872863 DOI: 10.1016/j.jtha.2023.10.015] [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: 06/20/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Regulatory organizations recommend assessing hospital-acquired (HA) venous thromboembolism (VTE) risk for medical inpatients. OBJECTIVES To develop and validate a risk assessment model (RAM) for HA-VTE in medical inpatients using objective and assessable risk factors knowable at admission. METHODS The development cohort included people admitted to medical services at the University of Vermont Medical Center (Burlington, Vermont) between 2010 and 2019, and the validation cohorts included people admitted to Hennepin County Medical Center (Minneapolis, Minnesota), University of Michigan Medical Center (Ann Arbor, Michigan), and Harris Health Systems (Houston, Texas). Individuals with VTE at admission, aged <18 years, and admitted for <1 midnight were excluded. We used a Bayesian penalized regression technique to select candidate HA-VTE risk factors for final inclusion in the RAM. RESULTS The development cohort included 60 633 admissions and 227 HA-VTE, and the validation cohorts included 111 269 admissions and 651 HA-VTE. Seven HA-VTE risk factors with t statistics ≥1.5 were included in the RAM: history of VTE, low hemoglobin level, elevated creatinine level, active cancer, hyponatremia, increased red cell distribution width, and malnutrition. The areas under the receiver operating characteristic curve and calibration slope were 0.72 and 1.10, respectively. The areas under the receiver operating characteristic curve and calibration slope were 0.70 and 0.93 at Hennepin County Medical Center, 0.70 and 0.87 at the University of Michigan Medical Center, and 0.71 and 1.00 at Harris Health Systems, respectively. The RAM performed well stratified by age, sex, and race. CONCLUSION We developed and validated a RAM for HA-VTE in medical inpatients. By quantifying risk, clinicians can determine the potential benefits of measures to reduce HA-VTE.
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Affiliation(s)
- Neil A Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA.
| | - Katherine Wilkinson
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Andrew D Sparks
- Department of Medical Biostatistics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Ryan T Packer
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Insu Koh
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; SyllogisTeks, Chesterfield, Missouri, USA
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Allen B Repp
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Ryan Thomas
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Chris E Holmes
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Timothy B Plante
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Hanny Al-Samkari
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William A Wood
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Camila Masias
- Miami Cancer Institute, Baptist Health South Florida, Coral Gables, Florida, USA
| | - Radhika Gangaraju
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - David Garcia
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kerri L Wiggins
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Craig Hooper
- Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicholas L Smith
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA; Department of Epidemiology, University of Washington, Seattle, Washington, USA; Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, Washington, USA
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, USA
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15
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Belcher RM, Kay AB, Fontaine GV, Baldwin M, Bledsoe JR, Collingridge DS, Majercik S. Post-discharge venous thromboembolism prophylaxis in hospitalized trauma patients: A retrospective comparison of patients receiving versus not receiving post-discharge prophylaxis. Am J Surg 2024; 228:247-251. [PMID: 37863796 DOI: 10.1016/j.amjsurg.2023.10.032] [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: 08/03/2023] [Revised: 10/04/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Risk of venous thromboembolism (VTE) in many trauma patients extends beyond hospitalization, but there is a paucity of evidence to guide the use of post-discharge prophylaxis (PDP). METHODS A retrospective cohort study of trauma patients deemed moderate-to-high risk for VTE (risk assessment profile score [RAP] ≥5) who were prescribed PDP based on an internal clinical guideline assessing injury pattern and mobility status. PDP patients were compared with those that did not receive post-discharge prophylaxis (NPDP). RESULTS 1512 patients were included. PDP group had higher mean RAP score (7.3 vs. 6.4, p < 0.001), more likely to have a complex orthopedic fracture and underwent a longer median hospital (4.7 vs. 2.9 days, p < 0.001). No difference between groups in 90-day VTE (11 [1.5 %] (PDP) vs. 8 [1.0 %] (NPDP), p = 0.50), clinically relevant bleeding (p = 0.58), or readmission (p = 0.46). CONCLUSIONS VTE incidence, clinically relevant bleeding, and readmission 90-days after hospital discharge were low and similar between PDP and NPDP groups. PDP prescribed in a presumably higher VTE risk trauma population may mitigate the long-term risk of VTE.
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Affiliation(s)
| | - Annika B Kay
- Intermountain Medical Center, Department of Trauma and Surgical Critical Care, USA.
| | | | | | - Joseph R Bledsoe
- Intermountain Medical Center, Department of Critical Care and Emergency Services, 5121 South Cottonwood Street, Murray, UT, 84107, USA.
| | | | - Sarah Majercik
- Intermountain Medical Center, Department of Trauma and Surgical Critical Care, USA.
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16
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Zhou Y, Moon C, Szatkowski J, Moore D, Stevens J. Evaluating ChatGPT responses in the context of a 53-year-old male with a femoral neck fracture: a qualitative analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:927-955. [PMID: 37776392 PMCID: PMC10858115 DOI: 10.1007/s00590-023-03742-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE The integration of artificial intelligence (AI) tools, such as ChatGPT, in clinical medicine and medical education has gained significant attention due to their potential to support decision-making and improve patient care. However, there is a need to evaluate the benefits and limitations of these tools in specific clinical scenarios. METHODS This study used a case study approach within the field of orthopaedic surgery. A clinical case report featuring a 53-year-old male with a femoral neck fracture was used as the basis for evaluation. ChatGPT, a large language model, was asked to respond to clinical questions related to the case. The responses generated by ChatGPT were evaluated qualitatively, considering their relevance, justification, and alignment with the responses of real clinicians. Alternative dialogue protocols were also employed to assess the impact of additional prompts and contextual information on ChatGPT responses. RESULTS ChatGPT generally provided clinically appropriate responses to the questions posed in the clinical case report. However, the level of justification and explanation varied across the generated responses. Occasionally, clinically inappropriate responses and inconsistencies were observed in the generated responses across different dialogue protocols and on separate days. CONCLUSIONS The findings of this study highlight both the potential and limitations of using ChatGPT in clinical practice. While ChatGPT demonstrated the ability to provide relevant clinical information, the lack of consistent justification and occasional clinically inappropriate responses raise concerns about its reliability. These results underscore the importance of careful consideration and validation when using AI tools in healthcare. Further research and clinician training are necessary to effectively integrate AI tools like ChatGPT, ensuring their safe and reliable use in clinical decision-making.
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Affiliation(s)
- Yushy Zhou
- Department of Surgery, The University of Melbourne, St. Vincent's Hospital Melbourne, 29 Regent Street, Clinical Sciences Block Level 2, Melbourne, VIC, 3010, Australia.
- Department of Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Australia.
| | - Charles Moon
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Jan Szatkowski
- Department of Orthopaedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Derek Moore
- Santa Barbara Orthopedic Associates, Santa Barbara, CA, USA
| | - Jarrad Stevens
- Department of Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Australia
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17
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Tufano A, Brenner B. Prevention of Venous Thromboembolism in Medical Patients with Thrombocytopenia or with Platelet Dysfunction: The Last 10 Years. Semin Thromb Hemost 2024; 50:96-103. [PMID: 37201536 DOI: 10.1055/s-0043-1769013] [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: 05/20/2023]
Abstract
Current guideline recommendations for primary prophylaxis of venous thromboembolism (VTE) are based on randomized clinical trials that usually exclude subjects at a potentially high risk of bleeding complications. For this reason, no specific guideline is available for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet dysfunction. However, except in patients with absolute contraindications to anticoagulant drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized cancer patients with thrombocytopenia, especially in those with multiple VTE risk factors. Low platelet number, platelet dysfunction, and clotting abnormalities are also very common in patients with liver cirrhosis, but these patients have a high incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies, a high thrombotic risk is usually present, even in the presence of thrombocytopenia. VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia, pharmacological prophylaxis should be considered on an individual basis. Aspirin is not as effective as heparins in lowering the risk of VTE. Studies in patients with ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these patients also during antiplatelet treatment. The use of direct oral anticoagulants in the prophylaxis of VTE in internal medicine patients has been recently evaluated, but no specific recommendation exists for patients with thrombocytopenia. The need for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should be evaluated after assessing the individual risk of bleeding complications. Finally, the selection of patients who require post-discharge pharmacological prophylaxis remains debated. New molecules currently under development (such as the inhibitors of factor XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in this setting of patients.
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Affiliation(s)
- Antonella Tufano
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Sergio Pansini, Naples, Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Haifa, Israel
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18
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Momenzadeh K, Yeritsyan D, Mortensen S, Kheir N, Khak M, Caro D, Kahe F, Abbasian M, Mo C, McNichol M, Paschos N, Nazarian A. While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension. Arthrosc Sports Med Rehabil 2024; 6:100815. [PMID: 38149088 PMCID: PMC10749995 DOI: 10.1016/j.asmr.2023.100815] [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: 01/12/2023] [Accepted: 09/20/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis. Methods A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable. Results Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk. Conclusion The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy. Level of Evidence Level IV, systematic review and meta-analysis of Level I-IV studies.
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Affiliation(s)
- Kaveh Momenzadeh
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Diana Yeritsyan
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Sharri Mortensen
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammad Khak
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniela Caro
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Farima Kahe
- Cardiovascular Department, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammadreza Abbasian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Chen Mo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Megan McNichol
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nikolaos Paschos
- Orthopaedic Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Yao Y, Chai S, Qiao L, Jiang Q, Xu R. An analysis of the prevalence and risk factors of deep vein thrombosis in non-fracture patients awaiting total hip arthroplasty: a retrospective study of 1244 cases. J Orthop Surg Res 2024; 19:84. [PMID: 38254120 PMCID: PMC10801973 DOI: 10.1186/s13018-023-04488-9] [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] [Received: 10/17/2023] [Accepted: 12/17/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Deep vein thrombosis (DVT) has been one of the most dangerous complications in total hip arthroplasty (THA). If a patient's pre-surgical DVT is overlooked, it can easily be mistaken for a post-operative thrombus and lead to an increased risk of DVT during and after surgery. This retrospective study was to explore the incidence and associated risk factors of deep vein thrombosis (DVT) in non-fracture patients before total hip arthroplasty (THA). METHODS From September 2015 to September 2020, 1242 patients admitted for THA were enrolled with 1120 patients (90.2%) for primary THA and 122 patients (9.8%) for revision THA. An experienced sonographer performed a bedside ultrasound to detect DVT in bilateral lower limbs preoperatively. Univariate and logistic regression analysis was performed to identify the independent risk factors. RESULTS 38 patients (3.1%) were detected with preoperative DVT. Univariate analysis showed that age (P < 0.001), D-dimer level (P = 0.002), female patients (P = 0.016), revision THA (P < 0.001), Barthel Index score (P = 0.010) were significantly associated with preoperative DVT. In subgroup comparison, the incidence of DVT increased with age significantly (P < 0.001) and D-dimer level (P < 0.001). In logistic regression analysis, age ≥ 75 years old (odds ratio [OR] 3.678, 95% CI [2.197-18.721], P < 0.001), gender (OR 2.709, 95% CI [1.244-5.896], P = 0.012), higher D-dimer ≥ 0.5 mg/l (OR 6.841, 95% CI [2.197-18.721], P < 0.001) and revision THA (OR 2.240, 95% CI [1.143-5.372], P = 0.05) were confirmed as the independent risk factors. CONCLUSIONS The incidence of preoperative DVT in non-fracture patients was 3.1%, with 2.4% in primary THA and 9.0% in revision THA. Age ≥ 75 years old, female, D-dimer ≥ 0.5 mg/l, and revision THA were independent risk factors. When evaluating the risk factors associated with thrombus formation preoperatively, it is important to take these into account before surgery.
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Affiliation(s)
- Yao Yao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Senlin Chai
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Liang Qiao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
- Department of Orthopedics, The Second Affiliated Hospital of XuZhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China.
| | - Rong Xu
- Department of Rehabilitation Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
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Yoo JH, Park SH, Oh HC, Ha JW, Yoon HK. Efficacy of pulse oximetry for early diagnosis of pulmonary embolism after total knee arthroplasty. Knee Surg Relat Res 2024; 36:6. [PMID: 38246998 PMCID: PMC10801930 DOI: 10.1186/s43019-023-00207-0] [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: 07/20/2023] [Accepted: 12/26/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Early diagnosis and aggressive treatment of pulmonary embolism (PE) are crucial for preventing severe complications after total knee arthroplasty (TKA). This study aimed to examine the efficacy of measuring oxygen saturation (SpO2) using a pulse oximeter for early diagnosis of PE after total knee arthroplasty (TKA). MATERIALS AND METHODS We consecutively examined 1645 patients who underwent TKA between January 2015 and November 2019. Postoperative SpO2 was measured with a pulse oximeter, which was stopped if SpO2 was maintained at ≥ 95% until postoperative day 2 (POD2). To diagnose PE, computed tomographic pulmonary angiography (CTPA) was performed for specific indications, including persistently low SpO2 < 95% (group 1), sudden decrease in SpO2 (group 2), and decrease in SpO2 after POD3 with presenting symptoms (group 3). Also, we divided the patients into unilateral, simultaneous and sequential TKA groups and compared the results with specific statistical techniques. RESULTS Of the 1645 patients who underwent TKA, there were 20 patients with PE (1.2%), and symptomatic PE was observed in only 4 patients (0.24%). CTPA was performed in 58 (3.5%) patients, of whom 20 were diagnosed with PE. In groups 1 (n = 34), 2 (n = 21), and 3 (n = 3), CTPA was performed 2.4, 2.6, and 8.3 days after TKA, respectively, and 12, 8, and 0 patients were diagnosed with PE, respectively. Of the 782, 416, and 447 unilateral, simultaneous, and sequential (done in same admission with interval 1 or 2 weeks) patients with TKA, 38, 18, and 2 received CTPA, and 13, 6, and 1 were diagnosed with PE, respectively. All patients diagnosed with PE have persistently low SpO2 < 95% (group 1), or sudden decrease in SpO2 (group 2) until POD2. Of the patients diagnosed with PE, SpO2 decreased without the presentation of symptoms in 16 patients (11 and 5 from groups 1 and 2, respectively) and with the presentation of symptoms, such as mild dyspnea and chest discomfort, in 4 patients (1 and 3 from groups 1 and 2, respectively). CONCLUSIONS Measuring SpO2 using a pulse oximeter until POD2 was an effective method for early diagnosis of PE after TKA. No case of morbidity or mortality was observed after early diagnosis with early stage CTPA and management of PE. We recommend measuring SpO2 with a pulse oximeter for early diagnosing of PE in TKA.
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Affiliation(s)
- Ju-Hyung Yoo
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
- Department of Orthopedic Surgery, Seran Hospital, Seoul, Korea
| | - Sang-Hoon Park
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea.
| | - Hyun-Cheol Oh
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
| | - Joong-Won Ha
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
| | - Han-Kook Yoon
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Ilsan-ro 100, Ilsandong-gu, Goyang, 10444, South Korea
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21
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Zheng X, Nong L, Song Y, Han L, Zhang Y, Yin Q, Bian Y. Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials. Front Pharmacol 2024; 14:1326224. [PMID: 38259284 PMCID: PMC10800895 DOI: 10.3389/fphar.2023.1326224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used. Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS). Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration's tool. Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053-1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499-1.815), all-cause mortality (RR = 1.208, 95% CI 0.459-3.177), and wound-related events (RR = 0.618, 95% CI 0.333-1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552-0.850) events and total bleeding (RR = 0.726, 95% CI 0.590-0.892). Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.
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Affiliation(s)
- Xingyue Zheng
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Nong
- Department of Pharmacy, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yujie Song
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Lizhu Han
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yuan Zhang
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Qinan Yin
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yuan Bian
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
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22
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Zhuang Z, Li Q, Yao Y, Shen Y, Chen D, Jiang Q. Incidence and risk factors of perioperative deep vein thrombosis in patients undergoing primary hip arthroplasty via the direct anterior approach. J Orthop Surg Res 2024; 19:10. [PMID: 38167482 PMCID: PMC10763199 DOI: 10.1186/s13018-023-04443-8] [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] [Received: 06/26/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a frequent complication following hip arthroplasty. There still has been a lack of studies analyzing the perioperative risk factors of DVT following hip arthroplasty via direct anterior approach (DAA). METHODS Patients who underwent unilateral primary hip arthroplasty via DAA in our hospital from August 2015 to January 2022 were included. Patients' data, including demographic data, clinical features, past medical history, operative data, and laboratory data, were analyzed and compared between patients with and without DVT. Logistic regression analysis was conducted to identify the independent risk factors. Receiver operating characteristic (ROC) curve analysis was used to assess the best cutoff value of continuous variables with statistical significance. RESULT A total of 651 patients were included. The incidence of DVT before and after hip arthroplasty was 12.7% and 6.7%, respectively. Logistic regression analysis indicated that age ≥ 65 years (OR 4.594, 95% CI 1.994-10.587), women (OR 2.331, 95% CI 1.285-4.227), and cerebral infarction (OR 1.984, 95% CI 1.138-3.460) were independent risk factors for preoperative DVT. And age ≥ 65 years (OR 4.859, 95% CI 1.062-22.226), tumor (OR 3.622, 95% CI 1.108-11.841), and preoperative D-dimer (OR 1.040, 95% CI 1.004-1.078) were risk factors for postoperative DVT. The ROC curve analysis showed that the best cutoff value of preoperative D-dimer for the diagnosis of postoperative DVT is 1.44 mg/L. CONCLUSIONS The incidence of DVT in patients undergoing DAA hip arthroplasty was low and the occurrence of DVT before and after unilateral primary hip arthroplasty performed through DAA was related to multiple factors.
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Affiliation(s)
- Zaikai Zhuang
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Qiangqiang Li
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Yao Yao
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Ying Shen
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China
| | - Dongyang Chen
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China.
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China.
| | - Qing Jiang
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.
- State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, Nanjing, Jiangsu, People's Republic of China.
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, People's Republic of China.
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Mérola V, Pizzarossa AC, López M, Peverelli F, Bruno G, González M, Roca F, Dentone L, Pérez G, Da Silveira L, Díaz L, Tafuri J, Cuadro R, Zaquiere M, Bartaburu G, Pacello F, Celio C, López MJ, Viana M, Fraga L, Blanco V, Chalart P, Leal D, Rodríguez X, Teti L, Goñi C, Infante E, Prícoli A, Altieri V, Guillermo C, Martínez R. Venous Thromboembolism Risk and Adherence to Pharmacological Thromboprophylaxis in Hospitalized Patients in Uruguay: First Nationwide Study. Clin Appl Thromb Hemost 2024; 30:10760296241256368. [PMID: 38798129 DOI: 10.1177/10760296241256368] [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: 05/29/2024] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a serious, frequent, and preventable medical complication in hospitalized patients. Although the efficacy of prophylaxis (pharmacological and/or mechanical) has been demonstrated, compliance with prophylaxis is poor at international and national levels. AIM To determine the indication and use of pharmacological thromboprophylaxis in hospitalized patients in Uruguay. METHODS An observational, descriptive, cross-sectional, multicentre study involving 31 nationwide healthcare facilities was conducted. Baseline characteristics associated with hospital admission, the percentage of the population with an indication for thromboprophylaxis, and the percentage of patients receiving pharmacological thromboprophylaxis were assessed. The VTE risk was determined using the Padua score for medical patients; the Caprini score for surgical patients; the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for pregnant-postpartum patients. RESULTS 1925 patients were included, representing 26% of hospitalized patients in Uruguay. 71.9% of all patients were at risk of VTE. Of all patients at risk of VTE, 58.6% received pharmacological thromboprophylaxis. The reasons for not receiving thromboprophylaxis were prescribing omissions in 16.1% of cases, contraindication in 15.9% and 9.4% of patients were already anticoagulated for other reasons. Overall, just 68% of patients were "protected" against VTE. Recommendations of major thromboprophylaxis guidelines were followed in 70.1% of patients at risk. CONCLUSIONS Despite the progress made in adherence to thromboprophylaxis indications, nonadherence remains a problem, affecting one in six patients at risk of VTE in Uruguay.
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Affiliation(s)
| | | | - Maynés López
- CASMU, Hospital de Clínicas "Dr Manuel Quintela", Montevideo, Uruguay
| | | | | | | | - Federico Roca
- Asociación Española de Socorros Mutuos, Hospital Pasteur, Montevideo, Uruguay
| | | | | | | | | | | | | | | | | | | | | | | | - Marcelo Viana
- INCA, Hospital de Canelones, Montevideo y Canelones, Uruguay
| | - Laura Fraga
- COSEM, Hospital de Clínicas "Dr Manuel Quintela", Montevideo, Uruguay
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24
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Pose RM, Knipper S, Ekrutt J, Kölker M, Tennstedt P, Heinzer H, Tilki D, Langer F, Graefen M. Prevention of thromboembolic events after radical prostatectomy in patients with hereditary thrombophilia due to a factor V Leiden mutation by multidisciplinary coagulation management. Asian J Urol 2024; 11:42-47. [PMID: 38312827 PMCID: PMC10837650 DOI: 10.1016/j.ajur.2022.01.007] [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: 09/10/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the perioperative impact of factor V Leiden mutation on thromboembolic events' risk in radical prostatectomy (RP) patients. With an incidence of about 5%, factor V Leiden mutation is the most common hereditary hypercoagulability among Caucasians and rarer in Asia. The increased risk of thromboembolic events is three- to seven-fold in heterozygous and to 80-fold in homozygous patients. Methods Within our prospectively collected database, we analysed 33 006 prostate cancer patients treated with RP between December 2001 and December 2020. Of those, patients with factor V Leiden mutation were identified. All patients received individualised recommendation of haemostaseologists for perioperative anticoagulation. Thromboembolic complications (deep vein thrombosis and pulmonary embolism) were assessed during hospital stay, as well as according to patient reported outcomes within the first 3 months after RP. Results Overall, 85 (0.3%) patients with known factor V Leiden mutation were identified. Median age was 65 (interquartile range: 61-68) years. There was at least one thrombosis in 53 (62.4%) patients and 31 (36.5%) patients had at least one embolic event in their medical history before RP. Within all 85 patients with factor V Leiden mutation, we experienced no thromboembolic complications within the first 3 months after surgery. Conclusion In our cohort of patients with factor V Leiden mutation, no thromboembolic events were observed after RP with an individualised perioperative coagulation management concept. This may reassure patients with this hereditary condition who are counselled for RP.
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Affiliation(s)
- Randi M Pose
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
| | - Sophie Knipper
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
| | - Jonas Ekrutt
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
| | - Mara Kölker
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Germany
| | - Pierre Tennstedt
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
| | - Hans Heinzer
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
- Department of Urology, University Hospital Hamburg-Eppendorf, Germany
| | - Florian Langer
- Department of Hematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Centre, University Hospital Hamburg-Eppendorf, Germany
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Pérez SG, Ruiz-Talero P, Velandia OMM. Factors associated with venous thromboembolic disease due to failed thromboprophylaxis. Thromb J 2023; 21:120. [PMID: 38057785 DOI: 10.1186/s12959-023-00566-4] [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: 07/28/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023] Open
Abstract
INTRODUCTION Available evidence to identify factors independently associated with failed thromboprophylaxis (FT) in medical patients is insufficient. The present study seeks to evaluate in hospitalized patients, which clinical factors are associated with the development of FT. MATERIALS AND METHODS A case-control study nested to a historical cohort, comparing patients who developed failed thromboprophylaxis (cases) with those who did not (controls). Univariate and multivariate regression analysis was performed to define the factors associated with FT. RESULTS We selected 204 cases and 408 controls (52.4% men, median age 63 years). Medical patients were 78.4%. The most frequent thromboprophylaxis scheme was enoxaparin. In the failed thromboprophylaxis group, most of the embolic events corresponded to pulmonary embolism (53.4%). Among cases, BMI was higher (26.3 vs. 25 kg/m2, p < 0.001), as was the proportion of patients with leukocytosis > 13,000 (27% vs. 18.9%, p:0.22), and patients who required intensive care management (48% vs. 24.8%, p < 0.001). Factors independently associated with FT were BMI (OR1.04;95%CI 1.00-1.09, p:0.39), active cancer (OR:1.63;95%IC 1.03-2.57, p:0.04), leukocytosis (OR:1.64;95%CI 1.05-2.57, p:0.03) and ICU requirement (OR:3.67;95%CI 2.31-5.83, p < 0.001). CONCLUSION Our study suggests that the failed thromboprophylaxis is associated with high BMI, active cancer, leukocytosis, and ICU requirement. Future studies should evaluate whether there is benefit in adjusting the thromboprophylaxis scheme in patients with one or more of these factors.
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Affiliation(s)
- Santiago Grillo Pérez
- Internal Medicine Department, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia.
- Internal Medicine Department, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - Paula Ruiz-Talero
- Internal Medicine Department, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Internal Medicine Department, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Oscar Mauricio Muñoz Velandia
- Internal Medicine Department, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Internal Medicine Department, Hospital Universitario San Ignacio, Bogotá, Colombia
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Kelly K, Blanck LM, Lim K, Norman A, Roberto CV, Assifi MM, Wright GP, Chung M. Apixaban for Extended Thromboprophylaxis After Oncologic Resection: Outcomes and Cost Analysis. Am Surg 2023; 89:5428-5435. [PMID: 36782104 DOI: 10.1177/00031348231156778] [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: 02/15/2023]
Abstract
BACKGROUND Patients undergoing oncologic resection are at risk of developing venous thromboembolism (VTE), and this can lead to increased morbidity and hospital costs. Low-molecular weight heparin (LMWH) is recommended as extended thromboprophylaxis (ETP) in high-risk patients and has been shown to reduce rates of VTE. METHODS This is a retrospective review of consecutive patients undergoing resection for oncologic indications at a single institution from May 2016 to May 2019. This study evaluated the use of apixaban as ETP at discharge. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), or mesenteric/portal venous thromboembolism at 30, 60, and 90 days postoperatively. RESULTS A total of 600 patients were included; 449 patients received no ETP, and 151 patients received apixaban. PE occurred in 1.1, 1.6, and 2.3% of patients without ETP and 0, 0, and .7% of patients in the apixaban group (at 30, 60, and 90 days; P = .338, P = .201, and P = .306, respectively). DVT occurred in 1.8, 2.1, and 2.8% of patients without ETP and 0, 0, and 1.4% in the apixaban group (P = .211, P = .121, and P = .535, respectively). The total cost, including ETP and readmission for VTE, per patient was US $5.51 more in the apixaban group. CONCLUSION Apixaban therapy for ETP did not produce a statistically significant reduction in VTE events in our patients. Future studies should include more patients in a prospective multicenter trial.
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Affiliation(s)
- Kathrine Kelly
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
| | - Lauren M Blanck
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Kelvin Lim
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Alexa Norman
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | | | - M Mura Assifi
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
| | - G Paul Wright
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
| | - Mathew Chung
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
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Scime NV, Brown HK, Metcalfe A, Simpson AN, Brennand EA. Bilateral salpingo-oophorectomy at the time of benign hysterectomy among females with disabilities: a population-based cross-sectional study. Am J Obstet Gynecol 2023; 229:658.e1-658.e17. [PMID: 37544349 DOI: 10.1016/j.ajog.2023.08.001] [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: 01/06/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Up to 40% of patients aged ≤55 years undergo concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy, with practice variation in bilateral salpingo-oophorectomy occurring along the lines of patient health and social factors. Disability is common in premenopausal women and is an important determinant of reproductive health more broadly; however, studies on bilateral salpingo-oophorectomy rates among women with disabilities are lacking. OBJECTIVE This study aimed to examine whether the use of concomitant bilateral salpingo-oophorectomy at the time of benign hysterectomy differs by preexisting disability status in adult females aged ≤55 years. STUDY DESIGN This population-based cross-sectional study used data from the 2016-2019 US National Inpatient Sample. Females undergoing inpatient hysterectomy for a benign gynecologic indication (n=74,315) were classified as having physical (6.1%), sensory (0.1%), intellectual or developmental (0.2%), or multiple (0.2%) disabilities and compared with those without a disability. Logistic regression was used to estimate risk ratios for differences in bilateral salpingo-oophorectomy rates by disability status, adjusted for patient and clinical factors. Models were stratified by potentially avoidable or potentially appropriate bilateral salpingo-oophorectomy based on the presence of clinical indications for ovarian removal and by age group. RESULTS Bilateral salpingo-oophorectomy at the time of benign hysterectomy occurred in 26.0% of females without a disability, with rates clearly elevated in those with a physical (33.2%; adjusted risk ratio, 1.10; 95% confidence interval, 1.05-1.14) or intellectual or developmental (31.1%; adjusted risk ratio, 1.32; 95% confidence interval, 1.02-1.64) disability, possibly elevated in those with multiple disabilities (38.2%; adjusted risk ratio, 1.20; 95% confidence interval, 0.94-1.45), and similar in those with a sensory disability (31.2%; adjusted risk ratio, 0.98; 95% confidence interval, 0.83-1.13). The results were similar but with lower statistical precision for potentially avoidable and potentially appropriate bilateral salpingo-oophorectomy, which occurred in 9.1% and 17.0% of females without a disability, respectively. The largest differences in bilateral salpingo-oophorectomy rates among women with any disability were observed in the perimenopausal 45- to 49-year age group. CONCLUSION Females with disabilities experienced elevated concomitant bilateral salpingo-oophorectomy rates at the time of benign hysterectomy, particularly those with an intellectual or developmental disability and those of perimenopausal age, although some estimates were imprecise. Equity-focused physician training in surgical counseling and research into the epidemiology and experiences of gynecologic conditions among females with a disability may be beneficial.
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Affiliation(s)
- Natalie V Scime
- Department of Health and Society, University of Toronto Scarborough, Toronto, Ontario, Canada
| | - Hilary K Brown
- Department of Health and Society, University of Toronto Scarborough, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Amy Metcalfe
- Department of Obstetrics and Gynaecology, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea N Simpson
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Erin A Brennand
- Department of Obstetrics and Gynaecology, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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Mody BS, Wadhwa M, Roy R, Echila S. Current Evidence and Expert Opinion on Thromboprophylaxis After Total Knee and Hip Replacement. Cureus 2023; 15:e51089. [PMID: 38274925 PMCID: PMC10808783 DOI: 10.7759/cureus.51089] [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: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
An effective anticoagulant provides a balance between the risk for venous thromboembolism (VTE) and bleeding and is crucial in achieving optimal clinical outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR) surgeries. We performed a review of the literature on thromboprophylaxis for patients undergoing total hip or knee replacement. This review article summarizes current guidelines and evidence for anticoagulation along with the expert opinion about pharmacological VTE prophylaxis, particularly non-Vitamin K antagonist oral anticoagulants (NOACs), for patients after total hip or knee replacement. Aspirin for VTE prophylaxis after TKR/THR has been controversial and most of the evidence is reported from observational research. Although the guidelines do not recommend any specific thromboprophylaxis agent, available evidence suggests that NOACs are as effective as low molecular weight heparins (LMWHs) in preventing VTE. Oral administration and the lack of dose monitoring make NOACs easy to use in outpatient settings in cases with challenging treatment compliances. They can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge. Owing to the lack of evidence for a head-to-head comparison of NOACs, an anticoagulant with better efficacy and safety may be suggested in special patient populations (elderly, obese patients, or those with renal dysfunction). The expert opinion on pharmacological VTE prophylaxis provided in this article could address some gaps in the management of anticoagulation in patients with total hip or knee replacement.
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Affiliation(s)
- Bharat S Mody
- Joint Replacement Surgery, Welcare Hospital, Vadodara, IND
| | - Manuj Wadhwa
- Orthopaedics & Joint Replacement, Elite Institutes of Orthopaedics & Joint Replacement, Mohali, IND
| | - Ronen Roy
- Orthopaedic Surgery, Fortis Hospitals, Kolkata, IND
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Khubdast S, Jalilian M, Rezaeian S, Abdi A, Khatony A. Prevalence and factors related with venous thromboembolism in patients admitted to the critical care units: A systematic review and meta-analysis. JOURNAL OF VASCULAR NURSING 2023; 41:186-194. [PMID: 38072571 DOI: 10.1016/j.jvn.2023.06.008] [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: 02/02/2023] [Revised: 04/28/2023] [Accepted: 06/27/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Venous thromboembolism is one of the most common cardiovascular disorders in the any intensive care units (ICUs), which annually leads to death and imposes great costs on patients and society worldwide. The present study was conducted with the aim of determining the prevalence and factors related to venous thromboembolism in the ICUs as a systematic review and meta-analysis. METHODS The current study was conducted in international databases, on all descriptive and analytical studies and clinical and semi-experimental trial studies, without time limit until November 2, 2021. The present study was designed and implemented based on PRISMA guideline. The quality of the studies was checked using STROBE checklist and meta-analysis was performed using CMA software. RESULTS Among the 3204 articles found, after the evaluations, 189 articles entered the full text review phase, and as a result, 38 articles were included in the study. The reported prevalence of thromboembolism was 1-45%. The prevalence of venous thromboembolism was 12% in overall. The chance of venous thromboembolism was higher in ICUs patients >57 years old and ICUs patients with a history of venous thromboembolism. CONCLUSION The results of this study showed that venous thromboembolism has a higher prevalence in ICUs patients in comparison to non-ICUs patients. It is recommended to nurses and healthcare staffs to provide accurate decision and care for prevention of venous thromboembolism and paying attention to the patient's warning signs, timely administration of anticoagulants, and monitor coagulation factors.
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Affiliation(s)
- Safura Khubdast
- Kermanshah School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Milad Jalilian
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahab Rezaeian
- Infectious Diseases Research Centre, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Abdi
- Kermanshah School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Khatony
- Social Development and Health Promotion Research Centre, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; Infectious Diseases Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Kyyak S, Jari A, Heimes D, Heider J, Kämmerer PW. Platelet-rich fibrin ensures hemostasis after single-tooth removal under factor Xa inhibitors - a clinical prospective randomized split-mouth study. Clin Oral Investig 2023; 27:7275-7283. [PMID: 37864605 PMCID: PMC10713775 DOI: 10.1007/s00784-023-05317-3] [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: 08/15/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVES In this prospective, double-blinded, randomized split-mouth study, the local hemostatic effect of platelet-rich fibrin (PRF) inserted into the extraction socket in patients taking factor Xa (FXa) inhibitors (apixaban, rivaroxaban, edoxaban) was compared to a hemostatic gelatine sponge (GS) as the "therapeutic gold standard" without withdrawal of oral anticoagulant therapy. MATERIALS AND METHODS Single-tooth extraction was conducted under local anesthesia in n = 21 patients using a split-mouth design (42 teeth). Using a double-blind approach, the extraction socket on one side of the jaw was filled with PRF and on the other with a GS. Bleeding was assessed immediately after surgery, in 30 min, 1 h, 1.5 h, and on follow-up appointments in 24 h and on the 7th day. RESULTS In 67% of cases, mild postoperative oozing could be stopped 30-90 min after tooth extraction via gauze pressure without any delayed bleeding. Concerning bleeding events, there was no difference among the PRF and GS groups and no significant difference among rivaroxaban, apixaban, and edoxaban (all p > 0.15). CONCLUSION PRF and GS are reliable hemostatic methods in postextraction sockets of patients taking FXa inhibitors. CLINICAL RELEVANCE Consequently, there is no need to discontinue FXa inhibitors because of a single-tooth removal, eliminating the risk of thrombus formation.
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Affiliation(s)
- Solomiya Kyyak
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Ali Jari
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Diana Heimes
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Julia Heider
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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Liu KC, Richardson MK, Mayfield CK, Kistler NM, Christ AB, Heckmann ND. Increased Complication Risk Associated With Simultaneous Bilateral Total Hip Arthroplasty: A Contemporary, Matched Cohort Analysis. J Arthroplasty 2023; 38:2661-2666.e1. [PMID: 37290568 DOI: 10.1016/j.arth.2023.05.090] [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: 03/13/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Simultaneous bilateral total hip arthroplasty (sbTHA) continues to be performed in patients who have bilateral end-stage osteoarthritis. However, few studies have evaluated the risk associated with this practice compared to unilateral total hip arthroplasty (THA). METHODS Using a large national database, primary, elective sbTHAs, and unilateral THAs were identified from January 1, 2015 to December 31, 2021. The sbTHAs were matched to unilateral THAs at a 1:5 ratio on age, sex, and pertinent comorbidities. Patient characteristics and comorbidities, and hospital factors were compared between both cohorts. Additionally, 90-day risk of postoperative complications, readmissions, and in-hospital deaths were assessed. After matching, 2,913 sbTHAs were compared to 14,565 unilateral THAs with an average age of 58.5 ± 10.0 years. RESULTS Compared to unilateral patients, sbTHA patients demonstrated higher rates of pulmonary embolism (PE) (0.4 versus 0.2%, P = .002), acute renal failure (1.2 versus 0.7%, P = .007), acute blood loss anemia (30.4 versus 16.7%, P < .001), and need for transfusion (6.6 versus 1.8%, P < .001). After accounting for confounders, sbTHA patients demonstrated increased risk of PE (adjusted odds ratio [aOR]: 3.76, 95% CI: 1.84 to 7.70, P < .001), acute renal failure (aOR: 1.83, 95% CI: 1.23 to 2.72, P = .003), acute blood loss anemia (aOR: 2.3, 95% CI: 2.10 to 2.53, P < .001), and transfusion (aOR: 4.08, 95% CI: 3.35 to 4.98, P < .001) compared to unilateral THA patients. CONCLUSION The practice of performing sbTHA was associated with an increased risk of PE, acute renal failure, and risk of transfusion. Careful evaluation of patient-specific risk factors is warranted when considering these bilateral procedures.
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Affiliation(s)
- Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Cory K Mayfield
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Natalie M Kistler
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Alexander B Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California
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Reiter CR, Wyatt PB, O'Neill CN, Satalich JR, O'Connell RS, Vap AR. Increased Age, Operative Time, American Society of Anesthesiologists Classification, Functional Dependency, and Comorbidity Burden Are Risk Factors for Adverse Events After Meniscectomy and Meniscus Repair: 10-Year Analysis of 64,223 Patients. Arthroscopy 2023:S0749-8063(23)00916-7. [PMID: 37967730 DOI: 10.1016/j.arthro.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE To use the National Surgical Quality Improvement Program (NSQIP) database to identify risk factors for 30-day adverse events and hospital readmission following isolated and unilateral meniscectomy or meniscus repair. METHODS A retrospective review of the NSQIP database from the years 2012 to 2021 identified all patients undergoing isolated, unilateral meniscectomy or meniscus repair. Multivariable analyses were performed for each procedure to identify patient characteristics associated with any adverse event (AAE) or unplanned hospital readmission within 30 days of surgery. RESULTS From 2012 to 2021, 59,450 (93%) patients underwent meniscectomy, and 4,773 (7%) patients underwent meniscus repair. Overall adverse event rate was 0.95% after meniscectomy and 1.40% after repair. Risk factors for AAE after meniscectomy included increased age (odds ratio [OR] = 1.010; P = .009), increased operative time (OR = 1.003; P = 0.011), American Society of Anesthesiologists (ASA) class IV (OR = 2.048; P = .045), functional dependency (OR = 3.527; P = .001), and current smoking (OR = 1.308; P = .018). Risk factors for AAE after meniscus repair included age (OR = 1.024; P = .016), operative time (OR = 1.004; P = .038), and bleeding disorders (OR = 7.000; P = .014). ASA class III increased risk of hospital readmission after both procedures (OR = 1.906; P = .008; OR = 4.101; P = .038), and medical comorbidities of heart failure (OR = 3.924; P = .016), hypertension (OR = 1.412; P = .011), and chronic obstructive pulmonary disease (OR = 2.350; P < .001) increased readmission risk after meniscectomy only. CONCLUSIONS Per analysis of the ACS-NSQIP database, surgical treatment of meniscal tears in the knee has been performed frequently over the past 10 years, with meniscectomies comprising over 90% of cases. Increased age and operative time were associated with a modest risk of adverse events after both meniscectomy and meniscus repair. Increased comorbidity burden, evidenced by ASA class, dependent functional status, current smoking, and systemic medical conditions, such as heart failure, hypertension, chronic obstructive pulmonary disease, and bleeding disorders, greatly increased rates of unfavorable outcomes within 30 days of meniscus surgery. LEVEL OF EVIDENCE Level III, retrospective prognostic comparative investigation.
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Affiliation(s)
- Charles R Reiter
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia, U.S.A..
| | - Phillip B Wyatt
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia, U.S.A
| | - Conor N O'Neill
- Duke University Health System, Department of Orthopaedic Surgery, Durham, North Carolina, U.S.A
| | - James R Satalich
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia, U.S.A
| | - Robert S O'Connell
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia, U.S.A
| | - Alexander R Vap
- Virginia Commonwealth University Health System, Department of Orthopaedic Surgery, Richmond, Virginia, U.S.A
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Kimball A, Gibson E, Quinn L, Cooksey R, Molony D, Lodge M, Carney B, Jeeves A. Thrombosis incidence in major paediatric burns. ANZ J Surg 2023; 93:2721-2726. [PMID: 37680024 DOI: 10.1111/ans.18664] [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: 01/04/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Major burns are associated with multiple risk factors for thrombosis such as decreased mobilization and systemic inflammation. It is unclear if these factors are offset by the inherent lower thrombosis risk in the paediatric patient. As such there is no consensus on thromboprophylaxis for paediatric burns patients, in contrast to this being a mainstay of treatment in the adult population. This retrospective cohort study examines the incidence of, and risk factors for, thrombotic events in major paediatric burns with a view to establish guidelines for prevention. METHOD Review of major paediatric burns, defined as % total body surface area (%TBSA) ≥30%, at the Adelaide Women's and Children's Hospital (WCH) over a 16-year period. Coding data and the local burns database were used to identify participants with subsequent review of case files. RESULTS Of the cohort (n = 23), six cases (26%) were complicated by thrombotic events. These patients had the most extensive burns averaging 68.5% TBSA, longer PICU admissions and associated interventions. These data points were more than doubled in the cohort diagnosed with a thrombus. Of the six events, five were secondary to central venous catheters (CVC) and one deep venous thrombosis (DVT) to the left calf. CONCLUSION The incidence of thrombotic events in our study was significant albeit in a small population. There is a strong association between large %TBSA and thrombus, with clots mostly forming around CVCs. While further research is required, this study demonstrates screening and targeted thromboprophylaxis may be required for major paediatric burns.
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Affiliation(s)
- Ashlee Kimball
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Edward Gibson
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Linda Quinn
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Rebecca Cooksey
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Darren Molony
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Michelle Lodge
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Bernard Carney
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Amy Jeeves
- Burns Service, Women's and Children's Health Network, North Adelaide, South Australia, Australia
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Marra JM, Samper IC, Abreu LAXD, Anelvoi RP, Uyeda MGBK, Sartori MGF, Marquini GV. Effectiveness of an Educational Intervention with Guidelines from the Total Acceleration of Postoperative Recovery Project (ACERTO) in Gynecology. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e699-e705. [PMID: 38029772 PMCID: PMC10686752 DOI: 10.1055/s-0043-1772484] [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: 01/23/2023] [Accepted: 06/12/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness of an educational intervention among gynecologists about recommendations of the Total Acceleration of Postoperative Recovery (ACERTO, in the Portuguese acronym) project derived from the solid foundations of Enhanced Recovery After Surgery (ERAS) guidelines to optimize hospital care for surgical-gynecological patients. METHODS Educational intervention through monthly 1-hour long meetings (3 months), with the application of an objective questionnaire about specific knowledge of the ACERTO project between before and after educational intervention phases, for gynecologists, after approval by the ethics committee and signature of informed consent by participants, in a federal university hospital. RESULTS Among the 25 gynecologists who agreed to participate, the educational intervention could be effective with a statistically significant difference between the phases before and after the intervention for the main recommendations of the ACERTO project, such as abbreviation of preoperative fasting (p = 0.006), venous thromboembolism prophylaxis (p = 0.024), knowledge and replication of ACERTO (p = 0.034), and multimodal analgesia (p = 0.021). CONCLUSION An educational intervention, through clinical meetings with exposition and discussion of the recommendations of the ACERTO project based on the ERAS protocol can be effective for the knowledge and possibility of practical application of the main measures, such as abbreviation of preoperative fasting, multimodal analgesia, and prophylaxis of thrombosis among gynecologists.
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Zhang Z, Cai H, Vleggeert-Lankamp CLA. Thromboembolic prophylaxis in neurosurgical practice: a systematic review. Acta Neurochir (Wien) 2023; 165:3119-3135. [PMID: 37796296 PMCID: PMC10624710 DOI: 10.1007/s00701-023-05792-3] [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: 06/21/2023] [Accepted: 09/01/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND In neurosurgical patients, the risk of developing venous thromboembolism (VTE) is high due to the relatively long duration of surgical interventions, usually long immobilization time after surgery, and possible neurological deficits which can negatively influence mobility. In neurosurgical clinical practice, there is lack of consensus on optimal prophylaxis against VTE, mechanical or pharmacological. OBJECTIVE To systematically review available literature on the incidence of VTE in neurosurgical interventions and to establish an optimum prevention strategy. METHODS A literature search was performed in PubMed, Embase, Web of Science, Cochrane Library, and EmCare, based on a sensitive search string combination. Studies were selected by predefined selection criteria, and risk of bias was assessed by Newcastle-Ottawa Quality Assessment Scale and Cochrane risk of bias. RESULTS Twenty-five studies were included, half of which had low risk of bias (21 case series, 3 comparative studies, 1 RCT). VTE was substantially higher if the evaluation was done by duplex ultrasound (DUS), or another systematic screening method, in comparison to clinical evaluation (clin). Without prophylaxis DVT, incidence varied from 4 (clin) to 10% (DUS), studies providing low molecular weight heparin (LMWH) reported an incidence of 2 (clin) to 31% (DUS), providing LMWH and compression stockings (CS) reported an incidence of 6.4% (clin) to 29.8% (DUS), and providing LMWH and intermittent pneumatic compression devices (IPC) reported an incidence of 3 (clin) to 22.3% (DUS). Due to a lack of data, VTE incidence could not meaningfully be compared between patients with intracranial and spine surgery. The reported incidence of pulmonary embolism (PE) was 0 to 7.9%. CONCLUSION Low molecular weight heparin, compression stockings, and intermittent pneumatic compression devices were all evaluated to give reduction in VTE, but data were too widely varying to establish an optimum prevention strategy. Systematic screening for DVT reveals much higher incidence percentages in comparison to screening solely on clinical grounds and is recommended in follow-up of neurosurgical procedures with an increased risk for DVT development in order to prevent occurrence of PE.
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Affiliation(s)
- Zhaoyuan Zhang
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Husule Cai
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Carmen L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Spaarne Hospital, Hoofddorp, Haarlem, The Netherlands
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Hagiwara K, Watanabe Y, Suzuki T, Okamura Y, Yamashita H. Prevalence of preoperative asymptomatic deep vein thrombosis in patients undergoing elective general surgery for benign disease. Ann Gastroenterol Surg 2023; 7:1042-1048. [PMID: 37927917 PMCID: PMC10623937 DOI: 10.1002/ags3.12709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 11/07/2023] Open
Abstract
Background The systemic inflammatory response following surgery as well as that of malignant disease itself is associated with a hypercoagulable state, and thromboprophylaxis is thus recommended during postoperative management of cancer patients. However, limited information is available on the prevalence of preoperative deep vein thrombosis (DVT) and its risk factors in surgical candidates, especially those receiving operations for benign diseases. Methods This is a retrospective observational study with data of all patients scheduled for elective general surgery between January 2011 and September 2020, undergoing lower extremity venous ultrasonography as preoperative screening for DVT. The prevalence of preoperative asymptomatic DVT was estimated and its associations with clinical variables were evaluated. Results Among 1512 patients included in the study, 161 (10.6%) had asymptomatic DVT before surgery. DVT prevalence was 13.7% in patients with malignant disease, while it was 8.6% in those with benign disease. The site of the thrombus was distal type in 141 (87.6%) patients, most commonly in the soleal vein. Advanced age (>70 years), female sex, and decreased hemoglobin level were significantly associated with preoperative asymptomatic DVT by multivariate analysis. The odds ratio for advanced age was the highest and rose as age increased. Malignant disease was not an independent risk factor for preoperative DVT. Conclusion This study showed the prevalence of asymptomatic DVT to be equal in patients with and without malignant disease undergoing elective general surgery. Preoperative DVT assessment is necessary regardless of the disease indicated for surgery, especially in patients with the risk factors identified in this study.
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Affiliation(s)
- Ken Hagiwara
- Division of Digestive Surgery, Department of SurgeryNihon University School of MedicineTokyoJapan
| | - Yutaka Watanabe
- Department of Cardiovascular SurgeryToride Medical Association HospitalIbarakiJapan
| | - Takeki Suzuki
- Department of SurgeryToride Medical Association HospitalIbarakiJapan
| | - Yukiyasu Okamura
- Division of Digestive Surgery, Department of SurgeryNihon University School of MedicineTokyoJapan
| | - Hiroharu Yamashita
- Division of Digestive Surgery, Department of SurgeryNihon University School of MedicineTokyoJapan
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Gandhi J, Mages K, Kucine N, Chien K. Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Scoping Review. J Pediatr Gastroenterol Nutr 2023; 77:491-498. [PMID: 37455339 DOI: 10.1097/mpg.0000000000003889] [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] [Indexed: 07/18/2023]
Abstract
OBJECTIVES In addition to gastrointestinal symptoms, pediatric inflammatory bowel disease (pIBD) may present with extra-intestinal manifestations including venous thromboembolism (VTE). Prevention and treatment guidelines for VTE in pediatric patients are needed. In this scoping review, we sought to detail the available data on the prevention and management of VTE in pIBD. METHODS Using PRISMA extension for Scoping Reviews (PRISMA-ScR), we identified, screened, graded quality of, and analyzed, literature on VTE in pediatric IBD, published between 1967 and 2023. RESULTS Data were extracted from 107 studies (including 216 patients). IBD patients with VTE had a median age of 14 years. Children with VTE more frequently had ulcerative colitis (70%, n = 216), developed their VTE within the first year of IBD diagnosis (52%, n = 97), had recent steroid use (62%, n = 50), and had central venous catheters (38%, n = 42). Cerebral venous sinus thrombus was the most common VTE type (34% of all VTE). Testing for thrombophilia conditions was rarely available but 65% (n = 23) of subjects tested had elevated Factor VIII activity. While most patients made a full recovery, 5% (n = 11) died secondary to their VTE. CONCLUSIONS While randomized clinical trials assessing interventions to prevent and treat VTE in pIBD would be ideal, the feasibility of doing such studies is low. However, there has been an increase in interest in this topic and an increase in literature over the past decade. As such, a consensus statement from a multidisciplinary group of experts based on available literature and clinical experience would be valuable for practicing clinicians.
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Affiliation(s)
- Jermie Gandhi
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Weill Cornell Medicine, New York, NY
| | - Keith Mages
- Abbott Library, B5 Abbott Hall, University at Buffalo, Buffalo, NY
| | - Nicole Kucine
- the Division of Pediatric Hematology and Oncology, Weill Cornell Medicine, New York, NY. Email address:
| | - Kimberley Chien
- From the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Weill Cornell Medicine, New York, NY
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Jatis AJ, Nei SD, Zieminski JJ, Mara K, Krauter AK. Assessment of bleeding risk in low-weight patients receiving prophylactic subcutaneous unfractionated heparin. Vasc Med 2023; 28:443-448. [PMID: 37555546 DOI: 10.1177/1358863x231189758] [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: 08/10/2023]
Abstract
BACKGROUND Underweight patients may be at an increased risk of bleeding while receiving venous thromboembolism (VTE) prophylaxis. Additional evidence is needed to identify patient-specific factors associated with bleeding. The objective of the study was to describe the incidence and identify risk factors associated with bleeding in low-weight (⩽ 60 kg) adult patients receiving subcutaneous unfractionated heparin (SQH) for VTE prophylaxis. METHODS This was a single-center, retrospective, nested case-control study of low-weight patients receiving SQH for VTE prophylaxis for ⩾ 48 hours. Cases, patients with clinically relevant bleeding while receiving SQH, and controls, patients without a bleeding event, were matched in a 1:3 ratio for age, sex, primary service (surgical or medical), and time at risk of bleeding on SQH to determine factors associated with bleeding. RESULTS A total of 3761 patients met the inclusion criteria, of which 38 cases of clinically relevant bleeding were identified. The bleeding incidence was 1% at hospital day 6 and 2.8% at hospital day 14. Most patients in this study (69%) received SQH 5000 units three times daily. ICU admission at SQH start was associated with bleeding, OR 2.97 (95% CI 1.21-7.29). CONCLUSION Bleeding in low-weight patients on prophylactic SQH was uncommon. Patients admitted to the ICU at time of SQH start may be at a higher risk of bleeding. Further studies are needed to detect additional risk factors associated with bleeding and investigate the effects of reduced dosing in this population.
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Affiliation(s)
| | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | | | - Kristin Mara
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
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Negm AM, Yamaura L, Clarke A, Chaudhry D, Cherppukaran T, Schneider P. Effectiveness of Thromboprophylaxis Agents Following Hip Fracture: A Systematic Review and Network Meta-Analysis. JB JS Open Access 2023; 8:e23.00064. [PMID: 37936980 PMCID: PMC10624462 DOI: 10.2106/jbjs.oa.23.00064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Multiple studies have compared different pharmacologic thromboprophylaxis agents after hip fracture surgery, including aspirin, unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOAC), and warfarin, resulting in variability in clinical practice. To guide clinical management, a systematic review and network meta-analysis (NMA), which enables the simultaneous assessment of the effects of multiple interventions for the same patient population, was performed. This study aimed to determine the comparative effectiveness of thromboprophylaxis in reducing venous thromboembolism (VTE) in patients with surgically treated hip fractures. Methods The primary outcome was the effect of the treatment on the VTE rate, and the secondary outcome was the treatment effect on the bleeding rate. Relevant studies were identified by a systematic search of Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 2000 to February 2022. Title, abstract, and full-text screening; data extraction; and risk-of-bias assessment were performed. All studies examining thromboprophylaxis interventions (DOAC, LMWH, UFH, aspirin, and warfarin) in patients with a surgically treated hip fracture were included. Bayesian NMA was performed, and dichotomous outcome data were pooled using the odds ratio. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) for each outcome. Results A total of 19 studies were included after the screening of 466 citations and 77 full-text articles. Of the included studies, 15 studies had a high overall risk of bias. The NMA of the VTE outcome included 19 studies, 49,409 participants, and 6 thromboprophylaxis interventions. The NMA of the bleeding outcome included 3 studies, 18,163 participants, and 3 interventions. The mean age ranged from 43.5 to 86.2 years among the included studies. No thromboprophylaxis intervention was statistically different from any other intervention in its effect on the VTE or bleeding rate in hip fracture patients. Conclusions This NMA demonstrated that there was no difference between the thromboprophylaxis interventions in reducing VTE or bleeding rates in hip fracture patients. More robust randomized controlled trials are needed to determine the most effective thromboprophylaxis interventions for patients with hip fractures. Level of Evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ahmed M. Negm
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Yamaura
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ashley Clarke
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Daniyya Chaudhry
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Prism Schneider
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Ben-Jacob TK, Pasch S, Patel AD, Mueller D. Intraoperative cardiac arrest management. Int Anesthesiol Clin 2023; 61:1-8. [PMID: 37589144 DOI: 10.1097/aia.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Talia K Ben-Jacob
- Department of Anesthesiology, Division of Critical Care Cooper University Hospital, Camden, NJ
| | - Stuart Pasch
- Department of Anesthesiology Cooper University Hospital, Camden, NJ
| | - Akhil D Patel
- Department of Anesthesiology, Division of Critical Care, The George Washington University Hospital, Washington, DC
| | - Dorothee Mueller
- Department of Anesthesiology, Division of Critical Care Vanderbilt University Medical Center Nashville, TN
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Li Y, Zhu H, Xin W, Wang J, Yan C, Ying K. GDF15 affects venous thrombosis by promoting EndMT through smad2/p-smad2 pathway. Thromb J 2023; 21:98. [PMID: 37723495 PMCID: PMC10506185 DOI: 10.1186/s12959-023-00547-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Endothelial-to-mesenchymal transition (EndMT) is a pathophysiological change in the vascular endothelium commonly seen in the cardiovascular system. Elevated serum Growth differiention factor 15 (GDF15) has been reported in VTE patients, but the relationship and mechanism between GDF15, EndMT and VTE are still unclear. METHODS We performed a retrospective clinical study, and human serum GDF15 expression levels were detected. The mouse DVT model was established through subtotal ligation of the mouse inferior vena cava, and then we detected intimal changes and thrombi in the stenotic inferior vena cava by haematoxylin-eosin (HE) staining, Masson staining, and Sirius Red staining. The expression levels of GDF15 and SM22 were detected by immunohistochemistry and RT‒qPCR. Serum samples of mice were collected, and the expression level of GDF15 in serum was detected. Human umbilical vein endothelial cells (HUVECs) were stimulated with a cytokine mixture (TGF-β1 + TNF-α + IL-1β). The role and mechanism of GDF15 in EndMT and VTE were detected in HUVECs and in a DVT mice model. RESULTS We found that serum GDF15 levels in both VTE patients and mouse DVT models were higher than those in the control group. EndMT was increased in the stenotic vascular tissue of mice. Further experiments showed that GDF15 could promote the EndMT of HUVECs and reduce their anticoagulation and antifibrinolytic ability through the smad2/p-smad2/snail pathway. Inhibition of mature GDF15 release can significantly reduce venous thrombotic fibre deposition in mice. CONCLUSIONS GDF15 positively promotes EndMT through activation of the Smad2/psmad2/snail pathway, and inhibition of GDF15 expression can alleviate the EndMT process, further improving the coagulation and fibrinolytic function of endothelial cells and thus reducing the local fibre deposition of venous thrombi.
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Affiliation(s)
- Yeping Li
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China
| | - Huiqi Zhu
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China
| | - Wanghao Xin
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China
| | - Jiaoyan Wang
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China
| | - Chao Yan
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China
| | - Kejing Ying
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun East Road, Hangzhou, Zhejiang, 310016, China.
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Miao L, Shi J, Yu H, Song L, Zhu C, Shi D, Gao J. Studies on Atrial Fibrillation and Venous Thromboembolism in the Past 20 Years: A Bibliometric Analysis Via CiteSpace and VOSviewer. J Am Heart Assoc 2023; 12:e029810. [PMID: 37586071 PMCID: PMC10547310 DOI: 10.1161/jaha.123.029810] [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] [Indexed: 08/18/2023]
Abstract
The conjunction of atrial fibrillation (AF) and venous thromboembolism (VTE) is common in clinical practice. Over the last 2 decades, a significant number of articles (2500) have been published about AF and VTE. To effectively analyze and present these vast amounts of information, this study uses bibliometric research methods to categorize and consolidate these publications. The number of publications has increased yearly, especially since 2012. The United States was the most prolific country, with 1054 studies published. The most productive institution was McMaster University. Gregory Y.H. Lip was the most prolific author. The keyword analysis identified that the research focuses from 2003 to 2014 were factor Xa inhibitor, dabigatran etexilate, direct thrombin inhibitor, double-blind, deep vein thrombosis, molecular weight heparin, stroke prevention, etc. From 2015 to 2016, research mainly focused on venous thromboembolism, antithrombotic therapy, anticoagulant, warfarin, atrial fibrillation, stroke, and pulmonary embolism. Studies during 2017 to 2022 focused on apixaban, direct oral anticoagulant, rivaroxaban, dabigatran, hemorrhage, edoxaban, medicine efficacy and safety, risk factors, clinical management, and vitamin K antagonists. Since 2018, novel oral anticoagulants have been the most commonly used keywords. On the whole, most studies of AF and VTE focus on pathogenesis and therapeutic drugs. The causal relationship between AF and VTE, the effectiveness and safety of novel oral anticoagulants in the treatments, the anticoagulant regimen of AF and VTE co-disease, and the treatment regimen for vulnerable populations such as the elderly or obese people were the focus of current research and will continue to be the central point of future research.
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Affiliation(s)
- Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Junhe Shi
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Haixu Yu
- Beijing Jishuitan HospitalBeijingChina
| | - Lei Song
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Chunlin Zhu
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Dazhuo Shi
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
| | - Jie Gao
- Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical SciencesBeijingChina
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Reiter AJ, Prinz J, Li Y, Nagle AP, Hungness ES, Teitelbaum EN. Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery. Surg Endosc 2023; 37:6983-6988. [PMID: 37344753 DOI: 10.1007/s00464-023-10219-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery. METHODS This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups. RESULTS There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)). CONCLUSIONS An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.
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Affiliation(s)
- Audra J Reiter
- Northwestern Quality Improvement, Research, & Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joanne Prinz
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yan Li
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alexander P Nagle
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Eric S Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Baimas-George MR, Ross SW, Yang H, Matthews BD, Nimeri A, Reinke CE. Just What the Doctor Ordered: Missed Ordering of Venous Thromboembolism Chemoprophylaxis Is Associated With Increased VTE Events in High-risk General Surgery Patients. Ann Surg 2023; 278:e614-e619. [PMID: 36538621 DOI: 10.1097/sla.0000000000005779] [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: 12/24/2022]
Abstract
OBJECTIVE To define the impact of missed ordering of venous thromboembolism (VTE) chemoprophylaxis in high-risk general surgery populations. BACKGROUND The primary cause of preventable death in surgical patients is VTE. Although guidelines and validated risk calculators assist in dosing recommendations, there remains considerable variability in ordering and adherence to recommended dosing. METHODS All adult inpatients who underwent a general surgery procedure between 2016 and 2019 and were entered into Atrium Health National Surgical Quality Improvement Program registry were identified. Patients at high risk for VTE (2010 Caprini score ≥5) and without bleeding history and/or acute renal failure were included. Primary outcome was 30-day postoperative VTE. Electronic medical record identified compliance with "perfect" VTE chemoprophylaxis orders (pVTE): no missed orders and no inadequate dose ordering. Multivariable analysis examined association between pVTE and 30-day VTE events. RESULTS A total of 19,578 patients were identified of which 4252 were high-risk inpatients. Hospital compliance of pVTE was present in 32.4%. pVTE was associated with shorter postoperative length of stay and lower perioperative red blood cell transfusions. There was 50% reduced odds of 30-day VTE event with pVTE (odds ratio: 0.50; 95% CI, 0.30-0.80) and 55% reduction in VTE event/mortality (odds ratio: 0.45; 95% CI, 0.31-0.63). After controlling for relevant covariates, pVTE remained significantly associated with decreased odds of VTE event and VTE event/mortality. CONCLUSIONS pVTE ordering in high-risk general surgery patients was associated with 42% reduction in odds of postoperative 30-day VTE. Comprehending factors contributing to missed or suboptimal ordering and development of quality improvement strategies to reduce them are critical to improving outcomes.
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Affiliation(s)
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Hongmei Yang
- Atrium Health, Information and Analytics Services, Charlotte, NC
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Patel SV, Liberman SA, Burgess PL, Goldberg JE, Poylin VY, Messick CA, Davis BR, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Reduction of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum 2023; 66:1162-1173. [PMID: 37318130 DOI: 10.1097/dcr.0000000000002975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | | | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Joel E Goldberg
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vitaliy Y Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig A Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | | | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Dynako J, McCandless M, Covington R, Williams P, Robertson M, White P, Milby J, Morellato J. Timing of venous thromboemboli in patients with acetabular and pelvic ring fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03643-6. [PMID: 37468644 DOI: 10.1007/s00590-023-03643-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE To determine the timing of symptomatic venous thromboemboli (VTE) in patients sustaining a pelvic and/or acetabular fracture. Secondly, to evaluate for any factors that may influence this timing. METHODS A retrospective cohort of 47 patients with acetabular and/or pelvic ring injuries who developed VTEs at a single academic level I trauma center were identified from 2012 to 2018. The chronology of VTE diagnosis in relation to date of injury, initial surgery, final surgery, and date of discharge was evaluated. Patients who developed VTEs were then evaluated based on known risk factors for VTE to determine if any of these affected timing. RESULTS Symptomatic VTEs were diagnosed in 3.8% of patients with pelvic and/or acetabular fractures. In patients who developed a thromboembolism, diagnosis occurred on average 21.5 (± 19.2), 20.7 (± 19.9), 9.8 (± 23.4), and 4.3 (± 27.6) days after injury, index procedure, final procedure, and date of discharge. 25% of patients developed VTE more than 4 weeks after their initial injury. No known risk factors effected the timing of VTE. CONCLUSION The 2015 OTA expert panel recommends 4 weeks of anticoagulation for orthopedic trauma patients at high risk of VTE, which may be too short a duration. In our cohort, 25% of VTEs occurred greater than 4 weeks after injury. Additional research is needed to clarify the exact duration of anticoagulation after pelvic and acetabular fractures; however, surgeons may want to consider anticoagulating patients for greater than 4 weeks. LEVEL OF EVIDENCE Level III-retrospective cohort.
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Affiliation(s)
- Joseph Dynako
- University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA
| | - Martin McCandless
- University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA
| | - Richard Covington
- University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA
| | - Paul Williams
- Oschner Lafayette General Orthopedic Center, 4212 W Congress St. Ste. 3100, Lafayette, LA, 70506, USA
| | | | - Parker White
- University of South Alabama, 1601 Center St., Mobile, AL, 36604, USA
| | - Joshua Milby
- Cox Medical Center South, 3801 S National Ave., Springfield, MO, 65807, USA
| | - John Morellato
- University of Mississippi Medical Center, 2500 N State Street, Jackson, MS, 39216, USA.
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Yang T, Liu Z, Zhang B, Zhang J, Ma A, Cao D, Chen D. Comparison of the efficacy of low-molecular-weight heparin and fondaparinux sodium after total knee arthroplasty: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:552. [PMID: 37403062 DOI: 10.1186/s12891-023-06674-6] [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] [Received: 09/30/2022] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) and fondaparinux sodium (FPX) are routinely used to prevent deep vein thrombosis (DVT) after total knee arthroplasty (TKA). In this study, we compared the effects of these agents in preventing post-TKA DVT. METHODS Clinical data of patients who underwent unilateral TKA for unicompartmental knee osteoarthritis at the Ningxia Medical University General Hospital between September 2021 and June 2022 were retrospectively analyzed. Based on the anticoagulation agent used, the patients were divided into LMWH and FPX groups (34 and 37 patients, respectively). Changes in perioperative coagulation-related indicators, d-dimer and platelet count, perioperative complete blood count, amount of blood loss, lower-limb DVT, pulmonary embolism, and allogeneic blood transfusion were determined. RESULTS Intergroup differences in d-dimer or fibrinogen (FBG) levels before and 1 or 3 days after surgery were not significant (all p > 0.05); within-group pairwise comparisons indicated significant differences (all, p < 0.05). Intergroup differences in preoperative prothrombin time (PT), thrombin time, activated partial PT, and international normalized ratio were not significant (all p > 0.05), whereas significant differences were detected on postoperative days 1 and 3 (all p < 0.05). Intergroup differences in platelet counts before and 1 or 3 days after surgery were not significantly different (all p > 0.05). Pairwise comparisons of hemoglobin and hematocrit levels between patients in the same group before and 1 or 3 days after surgery revealed significant differences in both groups (all p < 0.05); however, intergroup differences were not significant (all p > 0.05). Although intergroup differences in visual analog scale (VAS) scores before and 1 or 3 days after surgery were not significant (p > 0.05), we detected significant intragroup differences in VAS scores before and 1 or 3 days after surgery (p < 0.05). The treatment cost ratio was significantly lower in the LMWH group than in the FPX group (p < 0.05). CONCLUSION Both LMWH and FPX can effectively prevent DVT after TKA. There are some suggestive signals that FPX may have more beneficial pharmacological effects and clinical significance, while LMWH is cheaper and therefore more economical.
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Affiliation(s)
- Tianxiang Yang
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Zige Liu
- Department of Clinical Medicine, Guangxi Medical University, Nanning, 530021, China
| | - Bowen Zhang
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Jinning Zhang
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Anning Ma
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Dede Cao
- Department of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Desheng Chen
- Department of Orthopedics, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, 750002, China.
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Wang X, Chen Y, Wen D, You C, Ma L. Effect of extended duration of thromboprophylaxis for medically ill patients. Eur J Intern Med 2023; 113:22-30. [PMID: 37029050 DOI: 10.1016/j.ejim.2023.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND There are knowledge gaps regarding the comparative efficacy and safety of various venous thromboprophylaxis regimens with extended timing in patients hospitalized for acute medical illnesses. This study aims to investigate the optimal regimen for the prevention of venous thromboembolism in these patients. METHODS We conducted a Bayesian network meta-analysis of randomized controlled trials (RCTs) comparing different venous thromboprophylaxis regimens for acutely ill medical patients. Outcomes included venous thromboembolism, major bleeding, and all-cause mortality. Risk ratios (RR) and associated 95% credible interval (CrI) were estimated. In addition, we assessed the most effective interventions in a subgroup of patients with stroke. RESULTS We identified five RCTs involving 40,124 patients. Extended thromboprophylaxis with direct oral anticoagulant (DOAC) (RR 0.78, 95% CrI 0.68 to 0.89) and low molecular weight heparin (LMWH) (RR 0.62, 95% CrI 0.45 to 0.84) were superior to standard therapy in the prevention of venous thromboembolism. However, both of them (DOAC: RR 1.99, 95% CrI 1.38 to 2.92; LMWH: RR 2.56, 95% CrI 1.26 to 5.68) lead to a significant increase in major bleeding). Moreover, both LMWH (RR 0.76, 95% CrI 0.57 to 1.00) and DOAC (RR 0.86, 95% CrI 0.76 to 0.98) with extended thromboprophylaxis showed favorable net clinical benefit compared to standard therapy. CONCLUSIONS Extended thromboprophylaxis, especially with LMWH, showed better efficacy in venous thromboembolism reduction with increased risk of major bleeding. The beneficial effect of LMWH with extended timing has also been shown in stroke patients. Overall, extended thromboprophylaxis is associated with a positive net clinical benefit.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China; West China Brain Research Centre, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan 610041, China.
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Meknas D, Brækkan SK, Hansen JB, Morelli VM. Surgery As a Trigger for Incident Venous Thromboembolism: Results from a Population-Based Case-Crossover Study. TH OPEN 2023; 7:e244-e250. [PMID: 37736074 PMCID: PMC10511275 DOI: 10.1055/a-2159-9957] [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: 04/21/2023] [Accepted: 07/14/2023] [Indexed: 09/23/2023] Open
Abstract
Background Surgery is a major transient risk factor for venous thromboembolism (VTE). However, the impact of major surgery as a VTE trigger has been scarcely investigated using a case-crossover design. Aim To investigate the role of major surgery as a trigger for incident VTE in a population-based case-crossover study while adjusting for other concomitant VTE triggers. Methods We conducted a case-crossover study with 531 cancer-free VTE cases derived from the Tromsø Study cohort. Triggers were registered during the 90 days before a VTE event (hazard period) and in four preceding 90-day control periods. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to major surgery and after adjustment for other VTE triggers. Results Surgery was registered in 85 of the 531 (16.0%) hazard periods and in 38 of the 2,124 (1.8%) control periods, yielding an OR for VTE of 11.40 (95% CI: 7.42-17.51). The OR decreased to 4.10 (95% CI: 2.40-6.94) after adjustment for immobilization and infection and was further attenuated to 3.31 (95% CI: 1.83-5.96) when additionally adjusted for trauma, blood transfusion, and central venous catheter. In a mediation analysis, 51.4% (95% CI: 35.5-79.7%) of the effect of surgery on VTE risk could be mediated through immobilization and infection. Conclusions Major surgery was a trigger for VTE, but the association between surgery and VTE risk was in part explained by other VTE triggers often coexisting with surgery, particularly immobilization and infection.
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Affiliation(s)
- Dana Meknas
- Department of Clinical Medicine, Thrombosis Research Group, UiT—The Arctic University of Norway, Tromsø, Norway
- Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Sigrid K. Brækkan
- Department of Clinical Medicine, Thrombosis Research Group, UiT—The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Department of Clinical Medicine, Thrombosis Research Group, UiT—The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
| | - Vânia M. Morelli
- Department of Clinical Medicine, Thrombosis Research Group, UiT—The Arctic University of Norway, Tromsø, Norway
- Division of Internal Medicine, Thrombosis Research Center, University Hospital of North Norway, Tromsø, Norway
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Leow TW, Rashid A, Lewis-Lloyd CA, Crooks CJ, Humes DJ. Risk of Postoperative Venous Thromboembolism After Benign Colorectal Surgery: Systematic Review and Meta-analysis. Dis Colon Rectum 2023; 66:877-885. [PMID: 37134222 DOI: 10.1097/dcr.0000000000002915] [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] [Indexed: 05/05/2023]
Abstract
BACKGROUND Venous thromboembolism is a well-established preventable complication after colectomy. Specific guidance on venous thromboembolism prevention after colectomy for benign disease is limited. OBJECTIVE This meta-analysis aimed to quantify the venous thromboembolism risk after benign colorectal resection and determine its variability. DATA SOURCES Following Preferred Reporting Items for Systematic Review and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology Guidelines (PROSPERO: CRD42021265438), Embase, MEDLINE, and 4 other registered medical literature databases were searched from the database inception to June 21, 2021. STUDY SELECTION Inclusion criteria: randomized controlled trials and large population-based database cohort studies reporting 30-day and 90-day venous thromboembolism rates after benign colorectal resection in patients aged ≥18 years. Exclusion criteria: patients undergoing colorectal cancer or completely endoscopic surgery. MAIN OUTCOME MEASURES Thirty- and 90-day venous thromboembolism incidence rates per 1000 person-years after benign colorectal surgery. RESULTS Seventeen studies were eligible for meta-analysis reporting on 250,170 patients. Pooled 30-day and 90-day venous thromboembolism incidence rates after benign colorectal resection were 284 (95% CI, 224-360) and 84 (95% CI, 33-218) per 1000 person-years. Stratified by admission type, 30-day venous thromboembolism incidence rates per 1000 person-years were 532 (95% CI, 447-664) for emergency resections and 213 (95% CI, 100-453) for elective colorectal resections. Thirty-day venous thromboembolism incidence rates per 1000 person-years after colectomy were 485 (95% CI, 411-573) for patients with ulcerative colitis, 228 (95% CI, 181-288) for patients with Crohn's disease, and 208 (95% CI, 152-288) for patients with diverticulitis. LIMITATIONS High degree of heterogeneity was observed within most meta-analyses attributable to large cohorts minimizing within-study variance. CONCLUSIONS Venous thromboembolism rates remain high up to 90 days after colectomy and vary by indication for surgery. Emergency resections compared to elective benign resections have higher rates of postoperative venous thromboembolism. Further studies reporting venous thromboembolism rates by type of benign disease need to stratify rates by admission type to more accurately define venous thromboembolism risk after colectomy. REGISTRATION NO CRD42021265438.
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Affiliation(s)
- Tjun Wei Leow
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Adil Rashid
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Christopher A Lewis-Lloyd
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - Colin J Crooks
- Gastrointestinal and Liver Theme, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
| | - David J Humes
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, School of Medicine, Nottingham, United Kingdom
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