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Toews I, Anglemyer A, Nyirenda JL, Alsaid D, Balduzzi S, Grummich K, Schwingshackl L, Bero L. Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials: a meta-epidemiological study. Cochrane Database Syst Rev 2024; 1:MR000034. [PMID: 38174786 PMCID: PMC10765475 DOI: 10.1002/14651858.mr000034.pub3] [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] [Indexed: 01/05/2024]
Abstract
BACKGROUND Researchers and decision-makers often use evidence from randomised controlled trials (RCTs) to determine the efficacy or effectiveness of a treatment or intervention. Studies with observational designs are often used to measure the effectiveness of an intervention in 'real world' scenarios. Numerous study designs and their modifications (including both randomised and observational designs) are used for comparative effectiveness research in an attempt to give an unbiased estimate of whether one treatment is more effective or safer than another for a particular population. An up-to-date systematic analysis is needed to identify differences in effect estimates from RCTs and observational studies. This updated review summarises the results of methodological reviews that compared the effect estimates of observational studies with RCTs from evidence syntheses that addressed the same health research question. OBJECTIVES To assess and compare synthesised effect estimates by study type, contrasting RCTs with observational studies. To explore factors that might explain differences in synthesised effect estimates from RCTs versus observational studies (e.g. heterogeneity, type of observational study design, type of intervention, and use of propensity score adjustment). To identify gaps in the existing research comparing effect estimates across different study types. SEARCH METHODS We searched MEDLINE, the Cochrane Database of Systematic Reviews, Web of Science databases, and Epistemonikos to May 2022. We checked references, conducted citation searches, and contacted review authors to identify additional reviews. SELECTION CRITERIA We included systematic methodological reviews that compared quantitative effect estimates measuring the efficacy or effectiveness of interventions tested in RCTs versus in observational studies. The included reviews compared RCTs to observational studies (including retrospective and prospective cohort, case-control and cross-sectional designs). Reviews were not eligible if they compared RCTs with studies that had used some form of concurrent allocation. DATA COLLECTION AND ANALYSIS Using results from observational studies as the reference group, we examined the relative summary effect estimates (risk ratios (RRs), odds ratios (ORs), hazard ratios (HRs), mean differences (MDs), and standardised mean differences (SMDs)) to evaluate whether there was a relatively larger or smaller effect in the ratio of odds ratios (ROR) or ratio of risk ratios (RRR), ratio of hazard ratios (RHR), and difference in (standardised) mean differences (D(S)MD). If an included review did not provide an estimate comparing results from RCTs with observational studies, we generated one by pooling the estimates for observational studies and RCTs, respectively. Across all reviews, we synthesised these ratios to produce a pooled ratio of ratios comparing effect estimates from RCTs with those from observational studies. In overviews of reviews, we estimated the ROR or RRR for each overview using observational studies as the reference category. We appraised the risk of bias in the included reviews (using nine criteria in total). To receive an overall low risk of bias rating, an included review needed: explicit criteria for study selection, a complete sample of studies, and to have controlled for study methodological differences and study heterogeneity. We assessed reviews/overviews not meeting these four criteria as having an overall high risk of bias. We assessed the certainty of the evidence, consisting of multiple evidence syntheses, with the GRADE approach. MAIN RESULTS We included 39 systematic reviews and eight overviews of reviews, for a total of 47. Thirty-four of these contributed data to our primary analysis. Based on the available data, we found that the reviews/overviews included 2869 RCTs involving 3,882,115 participants, and 3924 observational studies with 19,499,970 participants. We rated 11 reviews/overviews as having an overall low risk of bias, and 36 as having an unclear or high risk of bias. Our main concerns with the included reviews/overviews were that some did not assess the quality of their included studies, and some failed to account appropriately for differences between study designs - for example, they conducted aggregate analyses of all observational studies rather than separate analyses of cohort and case-control studies. When pooling RORs and RRRs, the ratio of ratios indicated no difference or a very small difference between the effect estimates from RCTs versus from observational studies (ratio of ratios 1.08, 95% confidence interval (CI) 1.01 to 1.15). We rated the certainty of the evidence as low. Twenty-three of 34 reviews reported effect estimates of RCTs and observational studies that were on average in agreement. In a number of subgroup analyses, small differences in the effect estimates were detected: - pharmaceutical interventions only (ratio of ratios 1.12, 95% CI 1.04 to 1.21); - RCTs and observational studies with substantial or high heterogeneity; that is, I2 ≥ 50% (ratio of ratios 1.11, 95% CI 1.04 to 1.18); - no use (ratio of ratios 1.07, 95% CI 1.03 to 1.11) or unclear use (ratio of ratios 1.13, 95% CI 1.03 to 1.25) of propensity score adjustment in observational studies; and - observational studies without further specification of the study design (ratio of ratios 1.06, 95% CI 0.96 to 1.18). We detected no clear difference in other subgroup analyses. AUTHORS' CONCLUSIONS We found no difference or a very small difference between effect estimates from RCTs and observational studies. These findings are largely consistent with findings from recently published research. Factors other than study design need to be considered when exploring reasons for a lack of agreement between results of RCTs and observational studies, such as differences in the population, intervention, comparator, and outcomes investigated in the respective studies. Our results underscore that it is important for review authors to consider not only study design, but the level of heterogeneity in meta-analyses of RCTs or observational studies. A better understanding is needed of how these factors might yield estimates reflective of true effectiveness.
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Affiliation(s)
- Ingrid Toews
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Andrew Anglemyer
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John Lz Nyirenda
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Dima Alsaid
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Sara Balduzzi
- Biometrics Department, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Kathrin Grummich
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Freiburg, Germany
| | - Lisa Bero
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Camperdown, Sydney, Australia
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2
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Zhou Y, Song M, Xie D, Yan S, Yu S, Xie S, Cai M, Li H, Shang L, Jiang L, Yuan C, Huang M, Li J, Xu P. Structural Dynamics-Driven Discovery of Anticancer and Antimetastatic Effects of Diltiazem and Glibenclamide Targeting Urokinase Receptor. J Med Chem 2023; 66:5415-5426. [PMID: 36854648 DOI: 10.1021/acs.jmedchem.2c01663] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Diltiazem and glibenclamide are commonly used hypotensive and antidiabetic drugs. This study reports the discovery of the potential antitumor and antimetastatic effects of these two drugs using a structural dynamics-driven virtual screening targeting urokinase receptor (uPAR). Owing to uPAR's high flexibility, currently resolved crystal structures of uPAR, all in ligand-bound states, provide limited representations of its physiological conformation. To improve the accuracy of screening, we performed a long-timescale molecular dynamics simulation and obtained the representative conformations of apo-uPAR as the targets for our screening. Experimentally, we demonstrated that diltiazem and glibenclamide bound uPAR with KD values in the micromolar range. In addition, both compounds effectively suppressed tumor growth and metastasis in a uPAR-dependent manner in vitro and in vivo. This work not only provides two potent uPAR inhibitors but also reports a proof-of-concept study on the potential off-label antitumor and antimetastatic uses of diltiazem and glibenclamide.
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Affiliation(s)
- Yang Zhou
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, P. R. China.,College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Meiru Song
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China.,Henan Academy of Sciences, Zhengzhou, Henan 450046, P. R. China
| | - Daoqing Xie
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Shufeng Yan
- Sanming University, Sanming, Fujian 365004, P. R. China
| | - Shujuan Yu
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Song Xie
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Meiqin Cai
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Hanlin Li
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Le Shang
- Fujian Institute of Research on the Structure of Matter, Chinese Academy of Science, Fuzhou, Fujian 350109, P. R. China
| | - Longguang Jiang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Mingdong Huang
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, P. R. China.,College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Jinyu Li
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
| | - Peng Xu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350108, P. R. China.,Fujian Key Laboratory of Marine Enzyme Engineering, Fuzhou University, Fuzhou, Fujian 350108, P. R. China
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3
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Bröckelmann N, Stadelmaier J, Harms L, Kubiak C, Beyerbach J, Wolkewitz M, Meerpohl JJ, Schwingshackl L. An empirical evaluation of the impact scenario of pooling bodies of evidence from randomized controlled trials and cohort studies in medical research. BMC Med 2022; 20:355. [PMID: 36274131 PMCID: PMC9590141 DOI: 10.1186/s12916-022-02559-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/09/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess treatment effects of medical interventions. We aimed to hypothetically pool bodies of evidence (BoE) from RCTs with matched BoE from cohort studies included in the same systematic review. METHODS BoE derived from systematic reviews of RCTs and cohort studies published in the 13 medical journals with the highest impact factor were considered. We re-analyzed effect estimates of the included systematic reviews by pooling BoE from RCTs with BoE from cohort studies using random and common effects models. We evaluated statistical heterogeneity, 95% prediction intervals, weight of BoE from RCTs to the pooled estimate, and whether integration of BoE from cohort studies modified the conclusion from BoE of RCTs. RESULTS Overall, 118 BoE-pairs based on 653 RCTs and 804 cohort studies were pooled. By pooling BoE from RCTs and cohort studies with a random effects model, for 61 (51.7%) out of 118 BoE-pairs, the 95% confidence interval (CI) excludes no effect. By pooling BoE from RCTs and cohort studies, the median I2 was 48%, and the median contributed percentage weight of RCTs to the pooled estimates was 40%. The direction of effect between BoE from RCTs and pooled effect estimates was mainly concordant (79.7%). The integration of BoE from cohort studies modified the conclusion (by examining the 95% CI) from BoE of RCTs in 32 (27%) of the 118 BoE-pairs, but the direction of effect was mainly concordant (88%). CONCLUSIONS Our findings provide insights for the potential impact of pooling both BoE in systematic reviews. In medical research, it is often important to rely on both evidence of RCTs and cohort studies to get a whole picture of an investigated intervention-disease association. A decision for or against pooling different study designs should also always take into account, for example, PI/ECO similarity, risk of bias, coherence of effect estimates, and also the trustworthiness of the evidence. Overall, there is a need for more research on the influence of those issues on potential pooling.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Stadelmaier
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Jörg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Yang M, Ariyo P, Perlstein B, Latif A, Frank SM, Merritt WT, Cameron AM, Philosophe B, Gottschalk A, Pustavoitau A. Prophylactic Recombinant Factor VIIa for Preventing Massive Transfusion During Orthotopic Liver Transplantation. EXP CLIN TRANSPLANT 2022; 20:817-825. [DOI: 10.6002/ect.2022.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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5
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Bröckelmann N, Balduzzi S, Harms L, Beyerbach J, Petropoulou M, Kubiak C, Wolkewitz M, Meerpohl JJ, Schwingshackl L. Evaluating agreement between bodies of evidence from randomized controlled trials and cohort studies in medical research: a meta-epidemiological study. BMC Med 2022; 20:174. [PMID: 35538478 PMCID: PMC9092682 DOI: 10.1186/s12916-022-02369-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess the treatment effects of medical interventions. To evaluate the agreement of effect estimates between bodies of evidence (BoE) from randomized controlled trials (RCTs) and cohort studies and to identify factors associated with disagreement. METHODS Systematic reviews were published in the 13 medical journals with the highest impact factor identified through a MEDLINE search. BoE-pairs from RCTs and cohort studies with the same medical research question were included. We rated the similarity of PI/ECO (Population, Intervention/Exposure, Comparison, Outcome) between BoE from RCTs and cohort studies. The agreement of effect estimates across BoE was analyzed by pooling ratio of ratios (RoR) for binary outcomes and difference of mean differences for continuous outcomes. We performed subgroup analyses to explore factors associated with disagreements. RESULTS One hundred twenty-nine BoE pairs from 64 systematic reviews were included. PI/ECO-similarity degree was moderate: two BoE pairs were rated as "more or less identical"; 90 were rated as "similar but not identical" and 37 as only "broadly similar". For binary outcomes, the pooled RoR was 1.04 (95% CI 0.97-1.11) with considerable statistical heterogeneity. For continuous outcomes, differences were small. In subgroup analyses, degree of PI/ECO-similarity, type of intervention, and type of outcome, the pooled RoR indicated that on average, differences between both BoE were small. Subgroup analysis by degree of PI/ECO-similarity revealed high statistical heterogeneity and wide prediction intervals across PI/ECO-dissimilar BoE pairs. CONCLUSIONS On average, the pooled effect estimates between RCTs and cohort studies did not differ. Statistical heterogeneity and wide prediction intervals were mainly driven by PI/ECO-dissimilarities (i.e., clinical heterogeneity) and cohort studies. The potential influence of risk of bias and certainty of the evidence on differences of effect estimates between RCTs and cohort studies needs to be explored in upcoming meta-epidemiological studies.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Sara Balduzzi
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Maria Petropoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany.
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Little M, Lipworth W, Kerridge I. An Archeology of Corruption in Medicine. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:109-116. [PMID: 35362930 DOI: 10.1007/s11673-022-10178-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Corruption is a word used loosely to describe many kinds of action that people find distasteful. We prefer to reserve it for the intentional misuse of the good offices of an established social entity for private benefit, posing as fair trading. The currency of corruption is not always material or financial. Moral corruption is all too familiar within churches and other ostensibly beneficent institutions, and it happens within medicine and the pharmaceutical industries. Corrupt behavior reduces trust, costs money, causes injustice, and arouses anger. Yet it persists, despite all efforts since the beginnings of societies. People who act corruptly may lack conscience and empathy in the same way as those with some personality disorders. Finding ways to prevent corruption from contaminating beneficent organizations is therefore likely to be frustratingly difficult. Transparency and accountability may go some way, but the determined corruptor is unlikely to feel constrained by moral and reporting requirements of this kind. Punishment and redress are complicated issues, unlikely to satisfy victims and society at large. Both perhaps should deal in the same currency-material or social-in which the corrupt dealing took place.
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Affiliation(s)
- Miles Little
- Sydney Health Ethics, University of Sydney, Sydney, Australia
| | - Wendy Lipworth
- Sydney Health Ethics, University of Sydney, Sydney, Australia
| | - Ian Kerridge
- Sydney Health Ethics, University of Sydney, Sydney, Australia
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7
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NAKAE R, MURAI Y, MORITA A, YOKOBORI S. Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies. Neurol Med Chir (Tokyo) 2022; 62:261-269. [PMID: 35466118 PMCID: PMC9259082 DOI: 10.2176/jns-nmc.2022-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.
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Affiliation(s)
- Ryuta NAKAE
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
| | - Yasuo MURAI
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Akio MORITA
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Shoji YOKOBORI
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Stanworth S, Callum J. The Paradox of Choice in Hemostatic Resuscitation: Still More Options Than Evidence, But a Good Start. Transfus Med Rev 2021; 35:71-72. [PMID: 34598875 DOI: 10.1016/j.tmrv.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, United Kingdom; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
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Morrison S, Lacey C, Attard C, Davies B, Monagle P, Davies P. Recombinant Factor VIIa in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:684-689. [PMID: 34479781 DOI: 10.1053/j.jvca.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Recombinant activated factor VIIa (rVIIa) is used off-label for refractory bleeding after cardiac surgery. This study reviewed the indications, usage rates, and complications of rVIIa. DESIGN A retrospective case-control observational study. SETTING A single quaternary pediatric hospital. PARTICIPANTS All children undergoing cardiac surgery with cardiopulmonary bypass over a three-year period. INTERVENTIONS Administration of rVIIa as rescue therapy for refractory bleeding after weaning from cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Onethousand, five hundred fifteen cardiopulmonary bypass procedures were reviewed. Patients receiving rVIIa were each matched to two control patients by age, procedure type, and bypass time. Data collected included weight, crossclamp time, anticoagulant and antifibrinolytic dose, return to the operating room for bleeding, thrombotic events, and extracorporeal membrane oxygenation (ECMO) circuit interventions. Forty-two patients received rVIIa (2.8%). Major systemic thrombotic complications were observed in 19% (controls 12.5%) of patients; 80% of recombinant factor VIIa patients requiring postoperative ECMO had interventions for circuit thrombosis (controls 31.25%); 4.76% of rVIIa recipients required reexploration for intractable bleeding (controls 1.39%). CONCLUSIONS This study added to understanding regarding the use of recombinant factor VIIa in pediatric cardiac surgery and reported increased thrombotic complications, especially for children who progress to ECMO. Prospective studies to better understand the pathophysiology of coagulopathy and hemorrhage in pediatric cardiac surgery and the role of hemostatic agents, such as rVIIa, are required.
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Affiliation(s)
- Shannon Morrison
- Department of Anesthesia and Pain Management, The Royal Children's Hospital, Parkville, Australia
| | - Cara Lacey
- Department of Clinical Haematology, The Royal Children's Hospital, Parkville, Australia
| | - Chantal Attard
- Haematology Research Laboratory, Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, The University of Melbourne, Reception Level 2, The Royal Children's Hospital, Parkville, Australia
| | - Ben Davies
- Department of Cardiac Surgery, The Royal Children's Hospital, Parkville, Australia
| | - Paul Monagle
- Department of Clinical Haematology, The Royal Children's Hospital, Parkville, Australia; Haematology Research Laboratory, Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, The University of Melbourne, Reception Level 2, The Royal Children's Hospital, Parkville, Australia; Kids Cancer Centre, Sydney Children's Hospital, High Street, Randwick, Australia
| | - Paul Davies
- Department of Anesthesia and Pain Management, The Royal Children's Hospital, Parkville, Australia.
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Galhardo C, Yamauchi LHI, Dantas H, Guerra JCDC. Clinical protocols for oral anticoagulant reversal during high risk of bleeding for emergency surgical and nonsurgical settings: a narrative review. Braz J Anesthesiol 2021; 71:429-442. [PMID: 33887335 PMCID: PMC9373671 DOI: 10.1016/j.bjane.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background and objectives Oral anticoagulants prevent thromboembolic events but expose patients to a significant risk of bleeding due to the treatment itself, after trauma, or during surgery. Any physician working in the emergency department or involved in the perioperative care of a patient should be aware of the best reversal approach according to the type of drug and the patient’s clinical condition. This paper presents a concise review and proposes clinical protocols for the reversal of oral anticoagulants in emergency settings, such as bleeding or surgery. Contents The authors searched for relevant studies in PubMed, LILACS, and the Cochrane Library database and identified 82 articles published up to September 2020 to generate a review and algorithms as clinical protocols for practical use. Hemodynamic status and the implementation of general supportive measures should be the first approach under emergency conditions. The drug type, dose, time of last intake, and laboratory evaluations of anticoagulant activity and renal function provide an estimation of drug clearance and should be taken into consideration. The reversal agents for vitamin K antagonists are 4-factor prothrombin complex concentrate and vitamin K, followed by fresh frozen plasma as a second-line treatment. Direct oral anticoagulants have specific reversal agents, such as andexanet alfa and idarucizumab, but are not widely available. Another possibility in this situation, but with less evidence, is prothrombin complex concentrates. Conclusion The present algorithms propose a tool to help healthcare providers in the best decision making for patients under emergency conditions.
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Affiliation(s)
- Carlos Galhardo
- Hospital São Lucas Copacabana, Departamento de Anestesia, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil.
| | | | - Hugo Dantas
- Clínica de Anestesiologia, Departamento de Anestesia, Salvador, BA, Brazil
| | - João Carlos de Campos Guerra
- Hospital Israelita Albert Einstein, Centro de Oncologia e Hematologia, Setor de Hematologia e Coagulação, Departamento de Patologia Clínica, São Paulo, SP, Brazil
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Chang Z, Chu X, Liu Y, Liu D, Feng Z. Use of recombinant activated factor VII for the treatment of perioperative bleeding in noncardiac surgery patients without hemophilia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2020; 62:164-171. [PMID: 33385773 DOI: 10.1016/j.jcrc.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/06/2020] [Accepted: 12/12/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of perioperative use of recombinant activated factor VII (rFVIIa) in noncardiac patients. MATERIALS AND METHODS We searched electronic databases for randomized controlled trials (RCTs) that involved the use of rFVIIa through December 13, 2019 in noncardiac patients without hemophilia. Two investigators extracted the related data and assessed the quality of the included trials. RESULTS Eleven RCTs examining 993 perioperative patients were ultimately included. The use of rFVIIa did not decrease all-cause mortality (RR:0.90; 95% CI:0.50,1.64; I2 = 0.0%; P = 0.738), shorten the length of ICU (SMD:-0.15; 95% CI:-0.47,0.17; I2 = 0.0%; P = 0.346) or hospital (SMD:0.42; 95% CI:-0.05,0.89; I2 = 0.0%; P = 0.078) stay, or increase incidence of the thromboembolic events (RR:1.30; 95% CI:0.70,2.41; I2 = 0.0%; P = 0.403) among perioperative patients. However, individual RCT analyses showed that the use of rFVIIa could reduce the volume of blood loss (including prostatic cancer, severe acute pancreatitis (SAP), and spinal disease) and the transfusion of RBCs (including prostatic cancer, SAP, and spinal disease) and FFP (SAP) in a subset of perioperative patients. Publication bias was not present. CONCLUSIONS For perioperative hemorrhagic patients, rFVIIa-based hemostatic therapy showed no effect on mortality, ICU or hospital LOS, or the rate of thromboembolic events, although it appears to decrease blood loss and reduce the need for blood product transfusion in a subset of patients.
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Affiliation(s)
- Zhigang Chang
- Department of Surgical Intensive Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, 1(st) Dahua Rd, Dongcheng District, Beijing 100730, PR China.
| | - Xin Chu
- Department of Surgical Intensive Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, 1(st) Dahua Rd, Dongcheng District, Beijing 100730, PR China
| | - Yalin Liu
- Department of Surgical Intensive Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, 1(st) Dahua Rd, Dongcheng District, Beijing 100730, PR China
| | - Dadong Liu
- Department of Critical Care Medicine, Affiliated Hospital of Jiangsu University, 438 Jiefang Road, Zhenjiang, Jiangsu 212001, PR China
| | - Zhe Feng
- Department of Surgical Intensive Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, 1(st) Dahua Rd, Dongcheng District, Beijing 100730, PR China
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Implementation and impact of a multidisciplinary coagulation factor stewardship program at an academic medical center. J Thromb Thrombolysis 2020; 50:715-717. [DOI: 10.1007/s11239-020-02071-1] [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: 10/24/2022]
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13
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Naymagon L, Mascarenhas J. Hemorrhage in acute promyelocytic leukemia: Can it be predicted and prevented? Leuk Res 2020; 94:106356. [PMID: 32445941 DOI: 10.1016/j.leukres.2020.106356] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022]
Abstract
Hemorrhagic death is the leading cause of treatment failure in acute promyelocytic leukemia (APL). Our ability to identify patients at greatest risk of hemorrhage, and to actively prevent hemorrhage, remains limited. Nevertheless, some data is available to guide contemporary clinical practice and future investigation. Circulating disease burden, best represented by the peripheral WBC / blast count, is the most consistent predictor of major and fatal bleeding risk. In contrast, laboratory markers of disseminated intravascular coagulation (DIC) appear to be poor predictors. A number of interventions have been posited to reduce bleeding risk. Prompt initiation of all-trans retinoic acid (ATRA), avoidance of invasive procedures, transfusion support, and cytoreduction all have theoretical merit. Though they lack strong evidence to support their benefit with respect to bleeding, they are associated with limited risks, and are therefore advisable. Low-dose therapeutic heparin and antifibrinolytics have not shown the ability to positively modify bleeding risk, and heparin has been associated with harm. Thrombomodulin has shown promise in limited retrospective studies however further prospective data are needed. rFVIIa may have a role in cases of life-threatening bleeding however evidence is largely anecdotal. Additional studies evaluating the above interventions, and investigating other potential interventions are needed.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Liu P, Hum J, Jou J, Scanlan RM, Shatzel J. Transfusion strategies in patients with cirrhosis. Eur J Haematol 2019; 104:15-25. [PMID: 31661175 DOI: 10.1111/ejh.13342] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
Abstract
Bleeding related to portal hypertension and coagulopathy is a common complication in patients with cirrhosis. Complications and management of bleeding is a significant source of healthcare cost and utilization, as well as morbidity and mortality. Due to the scarcity of evidence surrounding transfusion strategies and hemostatic interventions in patients with cirrhosis, there has been significant debate regarding the best practice. Emerging data suggest that evidence supporting transfusion of packed red blood cells to a hemoglobin threshold of 7-8 g/dL is strong. thrombopoietin (TPO) receptor agonists have shown promise in increasing platelet levels and reducing transfusions preprocedurally, although have not specifically been found to reduce bleeding risk. Data for viscoelastic testing (VET)-guided transfusions appear favorable for reducing blood transfusion requirements prior to minor procedures and during orthotopic liver transplantation. Hemostatic agents such as recombinant factor VIIa, prothrombin complex concentrates, and tranexamic acid have been examined but their role in cirrhotic patients is unclear. Other areas of growing interest include balanced ratio and whole blood transfusion. In the following manuscript, we summarize the most up to date evidence for threshold-guided, VET-guided, balanced-ratio, and whole blood transfusions as well as the use of hemostatic agents in cirrhotic patients to provide practice guidance to clinicians.
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Affiliation(s)
- Patricia Liu
- The Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Janice Jou
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Richard M Scanlan
- The Division of Laboratory Medicine, Department of Pathology, Oregon Health & Science University, Portland, Oregon
| | - Joseph Shatzel
- The Division of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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Abstract
PURPOSE OF REVIEW Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. RECENT FINDINGS Retrospective and prospective studies of PCCs (±fibrinogen concentrate) have demonstrated a decreased time to correction of trauma coagulopathy and decreased red cell transfusion with no obvious effect on mortality or thromboembolic outcomes. PCCs in a porcine model of dilutional coagulopathy demonstrated a sustained increase in thrombin generation, unlike recombinant human prothrombin which showed a transient increase and has been studied only in animals. In other retrospective studies, there is a suggestion that lower doses of PCCs may be effective in the setting of acquired coagulopathy. SUMMARY There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.
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Li Y, Zhao W, Luo Q, Wu X, Ding J, Yan F. A Propensity-Score Matched Analysis on Outcomes Using Recombinant Activated Factor VII in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1269-1275. [DOI: 10.1053/j.jvca.2018.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Indexed: 11/11/2022]
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Biancofiore G, Blasi A, De Boer MT, Franchini M, Hartmann M, Lisman T, Liumbruno GM, Porte RJ, Saner F, Senzolo M, Werner MJ. Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE). Minerva Anestesiol 2019; 85:782-798. [PMID: 30945514 DOI: 10.23736/s0375-9393.19.13468-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.
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Affiliation(s)
- Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy -
| | - Annabel Blasi
- Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Marieke T De Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Hospital of Mantua, Mantua, Italy
| | - Matthias Hartmann
- Department of Anesthesiology and Critical Care, University of Duisburg-Essen, Duisburg, Germany
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fuat Saner
- Department of General-, Visceral- and Transplant Surgery, University Duisburg-Essen, Duisburg, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maureen J Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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18
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de Vries PS, Sabater-Lleal M, Huffman JE, Marten J, Song C, Pankratz N, Bartz TM, de Haan HG, Delgado GE, Eicher JD, Martinez-Perez A, Ward-Caviness CK, Brody JA, Chen MH, de Maat MPM, Frånberg M, Gill D, Kleber ME, Rivadeneira F, Soria JM, Tang W, Tofler GH, Uitterlinden AG, van Hylckama Vlieg A, Seshadri S, Boerwinkle E, Davies NM, Giese AK, Ikram MK, Kittner SJ, McKnight B, Psaty BM, Reiner AP, Sargurupremraj M, Taylor KD, Fornage M, Hamsten A, März W, Rosendaal FR, Souto JC, Dehghan A, Johnson AD, Morrison AC, O'Donnell CJ, Smith NL. A genome-wide association study identifies new loci for factor VII and implicates factor VII in ischemic stroke etiology. Blood 2019; 133:967-977. [PMID: 30642921 PMCID: PMC6396174 DOI: 10.1182/blood-2018-05-849240] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023] Open
Abstract
Factor VII (FVII) is an important component of the coagulation cascade. Few genetic loci regulating FVII activity and/or levels have been discovered to date. We conducted a meta-analysis of 9 genome-wide association studies of plasma FVII levels (7 FVII activity and 2 FVII antigen) among 27 495 participants of European and African ancestry. Each study performed ancestry-specific association analyses. Inverse variance weighted meta-analysis was performed within each ancestry group and then combined for a trans-ancestry meta-analysis. Our primary analysis included the 7 studies that measured FVII activity, and a secondary analysis included all 9 studies. We provided functional genomic validation for newly identified significant loci by silencing candidate genes in a human liver cell line (HuH7) using small-interfering RNA and then measuring F7 messenger RNA and FVII protein expression. Lastly, we used meta-analysis results to perform Mendelian randomization analysis to estimate the causal effect of FVII activity on coronary artery disease, ischemic stroke (IS), and venous thromboembolism. We identified 2 novel (REEP3 and JAZF1-AS1) and 6 known loci associated with FVII activity, explaining 19.0% of the phenotypic variance. Adding FVII antigen data to the meta-analysis did not result in the discovery of further loci. Silencing REEP3 in HuH7 cells upregulated FVII, whereas silencing JAZF1 downregulated FVII. Mendelian randomization analyses suggest that FVII activity has a positive causal effect on the risk of IS. Variants at REEP3 and JAZF1 contribute to FVII activity by regulating F7 expression levels. FVII activity appears to contribute to the etiology of IS in the general population.
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Affiliation(s)
- Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria Sabater-Lleal
- Unit of Genomics of Complex Diseases, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jennifer E Huffman
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- The Framingham Heart Study, Framingham, MA
- Center for Population Genomics, Veterans Affairs (VA) Boston Healthcare System, Jamaica Plain, MA
| | - Jonathan Marten
- Medical Research Council (MRC) Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom
| | - Ci Song
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- The Framingham Heart Study, Framingham, MA
- Department of Medical Sciences and
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, MN
| | - Traci M Bartz
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Hugoline G de Haan
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Graciela E Delgado
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - John D Eicher
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- The Framingham Heart Study, Framingham, MA
| | - Angel Martinez-Perez
- Unit of Genomics of Complex Diseases, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Cavin K Ward-Caviness
- National Health and Environmental Effects Research Laboratory, US Environmental Protection Agency, Chapel Hill, NC
| | | | - Ming-Huei Chen
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- The Framingham Heart Study, Framingham, MA
| | - Moniek P M de Maat
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mattias Frånberg
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Dipender Gill
- Department of Epidemiology and Biostatistics and
- Department of Stroke Medicine, Imperial College London, London, United Kingdom
| | - Marcus E Kleber
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Institute of Nutrition, Friedrich Schiller University Jena, Mannheim, Germany
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - José Manuel Soria
- Unit of Genomics of Complex Diseases, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - André G Uitterlinden
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Sudha Seshadri
- The Framingham Heart Study, Framingham, MA
- Department of Neurology, Boston University, Boston, MA
- Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio, TX
| | - Eric Boerwinkle
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
- Human Genome Sequencing Center, College of Medicine, Baylor University, Houston, TX
| | - Neil M Davies
- MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Anne-Katrin Giese
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M Kamran Ikram
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Steven J Kittner
- Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD
- Baltimore VA Medical Center, Baltimore, MD
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Bruce M Psaty
- Department of Medicine
- Department of Epidemiology, and
- Department of Health Services, University of Washington, Seattle, WA
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Alex P Reiner
- Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Kent D Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Myriam Fornage
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
- Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Anders Hamsten
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Winfried März
- Vth Department of Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Synlab Academy, Synlab Holding Deutschland GmbH, Mannheim, Germany
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University Graz, Graz, Austria
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory of Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Juan Carlos Souto
- Unitat d'Hemostasia i Trombosi, Hospital de la Sant Creu i Sant Pau, Barcelona, Spain
| | - Abbas Dehghan
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology and Biostatistics and
- MRC-Public Health England Centre for Environment and Health, School of Public Health and
- UK Dementia Research Institute, Imperial College London, London, United Kingdom
| | - Andrew D Johnson
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- The Framingham Heart Study, Framingham, MA
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Christopher J O'Donnell
- Population Sciences Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Framingham, MA
- Cardiology Section, VA Boston Healthcare System, West Roxbury, MA; and
| | - Nicholas L Smith
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA
- Seattle Epidemiologic Research and Information Center, Office of Research and Development, Department of Veteran Affairs, Seattle, WA
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Dhir A, Tempe DK. Anemia and Patient Blood Management in Cardiac Surgery—Literature Review and Current Evidence. J Cardiothorac Vasc Anesth 2018; 32:2726-2742. [DOI: 10.1053/j.jvca.2017.11.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Indexed: 12/24/2022]
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20
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Abstract
Intraoperative bleeding can be minimized with optimal preoperative preparation but cannot be completely prevented. There are circumstances when patients need emergent operative intervention, and thorough hemostatic evaluation and preparation is not possible. In this review, the authors summarize the recommendations for rapid reversal of vitamin K antagonists and direct oral anticoagulants before procedures. The authors review the potential causes for intraoperative bleeding and the methods for rapid and accurate diagnosis. The authors summarize the current evidence for treatment options, including transfusion of platelets and coagulation factors and the use of topical agents, antidotes to direct-acting anticoagulants, antifibrinolytics, and desmopressin.
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Affiliation(s)
- Michal Bar-Natan
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA
| | - Kenneth B Hymes
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA.
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21
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A role for very low-dose recombinant activated factor VII in refractory bleeding after cardiac surgery: Lessons from an observational study. J Thorac Cardiovasc Surg 2018; 156:1564-1573.e8. [DOI: 10.1016/j.jtcvs.2018.03.167] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 03/22/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
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23
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Anti-Drug Antibodies: Emerging Approaches to Predict, Reduce or Reverse Biotherapeutic Immunogenicity. Antibodies (Basel) 2018; 7:antib7020019. [PMID: 31544871 PMCID: PMC6698869 DOI: 10.3390/antib7020019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022] Open
Abstract
The development of anti-drug antibodies (ADAs) following administration of biotherapeutics to patients is a vexing problem that is attracting increasing attention from pharmaceutical and biotechnology companies. This serious clinical problem is also spawning creative research into novel approaches to predict, avoid, and in some cases even reverse such deleterious immune responses. CD4+ T cells are essential players in the development of most ADAs, while memory B-cell and long-lived plasma cells amplify and maintain these responses. This review summarizes methods to predict and experimentally identify T-cell and B-cell epitopes in therapeutic proteins, with a particular focus on blood coagulation factor VIII (FVIII), whose immunogenicity is clinically significant and is the subject of intensive current research. Methods to phenotype ADA responses in humans are described, including T-cell stimulation assays, and both established and novel approaches to determine the titers, epitopes and isotypes of the ADAs themselves. Although rational protein engineering can reduce the immunogenicity of many biotherapeutics, complementary, novel approaches to induce specific tolerance, especially during initial exposures, are expected to play significant roles in future efforts to reduce or reverse these unwanted immune responses.
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Lubnin AY. [The use of activated recombinant factor VII in neurosurgery]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:112-119. [PMID: 29795095 DOI: 10.17116/oftalma2018822112-119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical institute, 4-ya Tverskaya-Yamskaya str., 16, Moscow, Russia, 125047
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25
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Devlin R, Bonanno L, Badeaux J. The incidence of thromboembolism formation following the use of recombinant factor VIIa in patients suffering from blunt force trauma compared with penetrating trauma: a systematic review. ACTA ACUST UNITED AC 2018; 14:116-38. [PMID: 27532142 DOI: 10.11124/jbisrir-2016-2063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Rapid replacement of blood loss is critical in patients suffering from traumatic hemorrhage. When the availability of blood products is limited, certain interventions have shown promise in conserving blood supplies. Recombinant factor (rF) VIIa has been administered, as an off-label use, to assist in controlling hemorrhage in trauma patients. Although rFVIIa has a tendency to remain localized to areas of vascular insult, there may be an increase in thromboembolism formation when patients suffer multiple sites of injury as seen in blunt force trauma. OBJECTIVES This review aimed to synthesize the best available evidence regarding the incidence of thromboembolism formation after receiving rFVIIa as an adjunct to hemorrhage control measures (standard resuscitation efforts consisting of varying amounts of packed red blood cells [PRBCs], fresh frozen plasma [FFP], platelets and crystalloid solutions) in patients suffering from traumatic injuries (blunt force and penetrating trauma). INCLUSION CRITERIA TYPES OF PARTICIPANTS Civilian and combat trauma patients who were 15 years and older suffering from blunt force and penetrating traumatic injuries. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST Use of rFVIIa as an adjunct to hemorrhage control measures (standard resuscitation efforts consisting of varying amounts of PRBCs, FFP, platelets and crystalloid solutions). TYPES OF STUDIES This review considered both experimental and epidemiological study designs. TYPES OF OUTCOMES Confirmed formation of thromboembolism (confirmation based on specific diagnostic tests such as ultrasound, ventilation-perfusion scan or angiography). SEARCH STRATEGY The databases searched included CINAHL, Ovid MEDLINE, Web of Science, EMBASE and the Cochrane Control Register of Clinical Trials. Studies published after June 1986 were considered for inclusion in this review. Search for unpublished studies was performed. METHODOLOGICAL QUALITY Studies selected for inclusion were critically appraised by two independent reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI). DATA EXTRACTION Data was extracted from articles using standardized data extraction instruments from the JBI. DATA SYNTHESIS Quantitative results were pooled in statistical meta-analysis using the Joanna Briggs software for meta-analysis. RESULTS Two studies with a total of 831 participants were included. Both the studies were randomized, placebo-controlled, double-blind trials. No studies of combat trauma patients met the inclusion criteria for this review. A meta-analysis was performed. In blunt force trauma patients, the incidence of thromboembolism formation on administering rFVIIa revealed an overall relative risk of 1.17 with a 95% confidence interval (CI) from 0.77 to 1.79; results not statistically significant (P = 0.4594); large CI and imprecise estimate. In penetrating trauma patients, the incidence of thromboembolism formation on administering rFVIIa revealed an overall relative risk of 0.77 with a 95% CI from 0.27 to 2.20; results not statistically significant (P = 0.6242); very large CI and imprecise estimate. CONCLUSIONS The estimates of the effects are imprecise, results are compatible with effects in opposite directions, increase or decrease of thromboembolism formation, and an increase of thromboembolism formation cannot be excluded. IMPLICATIONS FOR PRACTICE When rFVIIa is administered to trauma patients, there does not appear to be an increased risk of thromboembolism formation favoring one type of injury over the other (blunt force versus penetrating trauma). Owing to large CIs and imprecise estimates, the overall risk of thromboembolism cannot be excluded. The use of rFVIIa does appear to decrease the overall need for blood products in trauma patients with no statistically significant improvement in survival rates. With the high cost of rFVIIa, its use is limited to those facilities that can afford it. In situations wherein blood supply is limited, rFVIIa could conserve limited supplies of blood products with no difference in thromboembolism risk between blunt force versus penetrating trauma, but the high cost will ultimately limit its use to facilities that can afford it. The use of rFVIIa in blunt force and penetrating trauma patients has a JBI Grade B Recommendation (Appendix I). IMPLICATIONS FOR RESEARCH This review excluded patients receiving pharmacologic anticoagulation such as warfarin sodium or heparin. The actions of these drugs will most likely counteract the desired coagulation effect of rFVIIa. Many studies do not account for the effects of rFVIIa in trauma patients receiving pharmacologic anticoagulation and this could be a future area of research.
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Affiliation(s)
- Raymond Devlin
- 1Louisiana Center for Evidence-based Nursing at LSUHSC School of Nursing: an Affiliate Center of the Joanna Briggs Institute
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Raleigh L, Cole SP. Con: Factor Concentrate Usage in Cardiac Surgery—A Paucity of Data Limits Their Universal Adoption. J Cardiothorac Vasc Anesth 2018; 32:1068-1071. [DOI: 10.1053/j.jvca.2017.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 11/11/2022]
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Lombardo S, Millar D, Jurkovich GJ, Coimbra R, Nirula R. Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis. Trauma Surg Acute Care Open 2018; 3:e000134. [PMID: 29766126 PMCID: PMC5887758 DOI: 10.1136/tsaco-2017-000134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI). METHODS Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching. RESULTS There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa. DISCUSSION rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma. LEVEL OF EVIDENCE Level III. STUDY TYPE Therapeutic/care management.
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Affiliation(s)
- Sarah Lombardo
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - D Millar
- Division of Trauma, Critical Care and Acute Care Surgery, Department of General Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Gregory J Jurkovich
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of San Diego, San Diego, California, USA
| | - Ram Nirula
- Acute Care Surgery Section, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Louro J, Andersen K, Dudaryk R. Correction of Severe Coagulopathy and Hyperfibrinolysis by Tranexamic Acid and Recombinant Factor VIIa in a Cirrhotic Patient After Trauma: A Case Report. ACTA ACUST UNITED AC 2018; 9:144-147. [PMID: 28509781 DOI: 10.1213/xaa.0000000000000550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coagulopathy induced by trauma or cirrhosis is a well-recognized entity. Viscoelastic testing has been used in either condition for goal-directed transfusion and detection of fibrinolysis since conventional coagulation tests do not correlate with clinical risk of bleeding. Hemostatic resuscitation may not be adequate for a trauma patient with liver disease due to complex alterations in coagulation systems and occasionally require adjuvant therapy. We report a case of trauma-induced coagulopathy presenting as severe hyperfibrinolysis in a cirrhotic patient who was refractory to hemostatic resuscitation but was rapidly corrected by the administration of tranexamic acid and recombinant Factor VIIa.
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Affiliation(s)
- Jack Louro
- From the *Department of Clinical Anesthesiology, University of Miami, Miami, Florida; and †Anesthesiology Resident, University of Miami, Jackson Memorial Hospital, Miami, Florida
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Godier A, Greinacher A, Faraoni D, Levy JH, Samama CM. Use of factor concentrates for the management of perioperative bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16:170-174. [PMID: 29168325 DOI: 10.1111/jth.13893] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- A Godier
- Department of Anesthesiology and Intensive Care Medicine, Fondation Adolphe de Rothschild and INSERM UMRS-1140 Faculté de Pharmacie, Descartes University, Paris, France
| | - A Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - D Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - J H Levy
- Departments of Anesthesiology, Surgery, and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - C M Samama
- Department of Anesthesiology and Intensive Care Medicine, Assistance Publique-Hôpitaux de Paris, Cochin University Hospital, Paris Descartes University, Paris, France
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Dzeshka MS, Pastori D, Lip GYH. Direct oral anticoagulant reversal: how, when and issues faced. Expert Rev Hematol 2017; 10:1005-1022. [PMID: 28901221 DOI: 10.1080/17474086.2017.1379896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The number of atrial fibrillation (AF) patients requiring thrombo-prophylaxis with oral anticoagulation is greatly increasing. The introduction of non-vitamin K oral anticoagulants (NOACs) in addition to standard therapy with dose-adjusted warfarin has increased the therapeutic options for AF patients. Despite a generally better safety profile of the NOACs, the risk of major bleedings still persists, and the management of serious bleeding is a clinical challenge. Areas covered: In the current review, risk of major bleeding in patients taking NOACs and general approaches to manage bleeding depending on severity, with a particular focus on specific reversal agents, are discussed. Expert commentary: Due to short half-life of NOACs compared to warfarin, discontinuation of drug, mechanical compression, and volume substitution are considered to be sufficient measures in most of bleeding cases. In case of life-threatening bleeding or urgent surgery, hemostasis can be achieved with non-specific reversal agents (prothrombin complex concentrates) in patients treated with factor Xa inhibitor until specific antidotes (andexanet α and ciraparantag) will receive approval. Thus far, idarucizumab has been the only reversal agent approved for dabigatran.
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Affiliation(s)
- Mikhail S Dzeshka
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Grodno State Medical University , Grodno , Belarus
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome , Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Guzzetta NA, Williams GD. Current use of factor concentrates in pediatric cardiac anesthesia. Paediatr Anaesth 2017; 27:678-687. [PMID: 28393462 DOI: 10.1111/pan.13158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/29/2022]
Abstract
Excessive bleeding following pediatric cardiopulmonary bypass is associated with increased morbidity and mortality, both from the effects of hemorrhage and the therapies employed to achieve hemostasis. Neonates and infants are especially at risk because their coagulation systems are immature, surgeries are often complex, and cardiopulmonary bypass technologies are inappropriately matched to patient size and physiology. Consequently, these young children receive substantial amounts of adult-derived blood products to restore adequate hemostasis. Adult and pediatric data demonstrate associations between blood product transfusions and adverse patient outcomes. Thus, efforts to limit bleeding after pediatric cardiopulmonary bypass and minimize allogeneic blood product exposure are warranted. The off-label use of factor concentrates, such as fibrinogen concentrate, recombinant activated factor VII, and prothrombin complex concentrates, is increasing as these hemostatic agents appear to offer several advantages over conventional blood products. However, recognizing that these agents have the potential for both benefit and harm, well-designed studies are needed to enhance our knowledge and to determine the optimal use of these agents. In this review, our primary objective was to examine the evidence regarding the use of factor concentrates to treat bleeding after pediatric CPB and identify where further research is required. PubMed, MEDLINE/OVID, The Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched to identify existing studies.
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Affiliation(s)
- Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
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Zirlik A, Bode C. Vitamin K antagonists: relative strengths and weaknesses vs. direct oral anticoagulants for stroke prevention in patients with atrial fibrillation. J Thromb Thrombolysis 2017; 43:365-379. [PMID: 27896543 PMCID: PMC5337242 DOI: 10.1007/s11239-016-1446-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vitamin K antagonists (VKAs) have been the mainstay of anticoagulation therapy for more than 50 years. VKAs are mainly used for the prevention of stroke in patients with atrial fibrillation (AF) and the treatment and secondary prevention of venous thromboembolism. In the past 5 years, four new agents-the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban and the direct thrombin inhibitor dabigatran [collectively known as direct oral anticoagulants (DOACs) or non-VKA oral anticoagulants]-have been approved for these and other indications. Despite these new treatment options, the VKA warfarin currently remains the most frequently prescribed oral anticoagulant. The availability of DOACs provides an alternative management option for patients with AF, especially when the treating physician is hesitant to prescribe a VKA owing to associated limitations, such as food and drug interactions, and concerns about bleeding complications. Currently available real-world evidence shows that DOACs have similar or improved effectiveness and safety outcomes compared with warfarin. Treatment decisions on which DOAC is best suited for which patient to maximize safety and effectiveness should take into account not only clinically relevant patient characteristics but also patient preference. This article reviews and highlights real and perceived implications of VKAs for the prevention of stroke in patients with non-valvular AF, with specific reference to their strengths and weaknesses compared with DOACs.
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Affiliation(s)
- Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Qi X, Ye C, Guo X. Recombinant factor VIIa for variceal bleeding in liver cirrhosis: still only a hope. Arch Med Sci 2017; 13:496-499. [PMID: 28261306 PMCID: PMC5332460 DOI: 10.5114/aoms.2017.65331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/06/2015] [Indexed: 02/07/2023] Open
Affiliation(s)
- Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - Chun Ye
- Department of General Surgery, General Hospital of Shenyang Military Area, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
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Abstract
Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.
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Affiliation(s)
- Emily J Baird
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode UH2, Portland, OR 97239, USA.
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Davis AK. When more is less efficacious: fibrinogen concentrate in complex cardiac surgery. Br J Anaesth 2017; 117:415-417. [PMID: 28077524 DOI: 10.1093/bja/aew300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A K Davis
- Haematology Unit, Alfred Hospital, Melbourne, VIC, Australia
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Development and validation of a prehospital prediction model for acute traumatic coagulopathy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:371. [PMID: 27846895 PMCID: PMC5111191 DOI: 10.1186/s13054-016-1541-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/20/2016] [Indexed: 12/22/2022]
Abstract
Background Acute traumatic coagulopathy (ATC) is a syndrome of early, endogenous clotting dysfunction that afflicts up to 30% of severely injured patients, signaling an increased likelihood of all-cause and hemorrhage-associated mortality. To aid identification of patients within the likely therapeutic window for ATC and facilitate study of its mechanisms and targeted treatment, we developed and validated a prehospital ATC prediction model. Methods Construction of a parsimonious multivariable logistic regression model predicting ATC — defined as an admission international normalized ratio >1.5 — employed data from 1963 severely injured patients admitted to an Oregon trauma system hospital between 2008 and 2012 who received prehospital care but did not have isolated head injury. The prediction model was validated using data from 285 severely injured patients admitted to a level 1 trauma center in Seattle, WA, USA between 2009 and 2013. Results The final Prediction of Acute Coagulopathy of Trauma (PACT) score incorporated age, injury mechanism, prehospital shock index and Glasgow Coma Score values, and prehospital cardiopulmonary resuscitation and endotracheal intubation. In the validation cohort, the PACT score demonstrated better discrimination (area under the receiver operating characteristic curve 0.80 vs. 0.70, p = 0.032) and likely improved calibration compared to a previously published prehospital ATC prediction score. Designating PACT scores ≥196 as positive resulted in sensitivity and specificity for ATC of 73% and 74%, respectively. Conclusions Our prediction model uses routinely available and objective prehospital data to identify patients at increased risk of ATC. The PACT score could facilitate subject selection for studies of targeted treatment of ATC. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1541-9) contains supplementary material, which is available to authorized users.
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Cooper JD, Ritchey AK. Response to treatment and adverse events associated with use of recombinant activated factor VII in children: a retrospective cohort study. Ther Adv Drug Saf 2016; 8:51-59. [PMID: 28255432 DOI: 10.1177/2042098616673991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) is United States (US) Food and Drug Administration (FDA)-approved for patients with hemophilia with inhibitors or congenital factor VII deficiency. Initial reports of off-label use highlighted its efficacy, though newer reports have not repeated these findings. In both types of publication, though, secondary thromboses have been seen in adult patients. The data in children are less clear. METHODS This study analyzed all rFVIIa use at a large children's hospital for characteristics and outcomes. Recipients of rFVIIa were identified retrospectively via the electronic medical record. Data on patient diagnosis, lab data, other treatments, adverse events, and outcomes were collected. RESULTS Over 33 months, 66 patient episodes were treated with a total of 606 doses (median = 2). The most common indication (36.4%) was gastrointestinal bleeding (24/66 patients). Only one patient received a dose for an approved labeled indication. For control of bleeding, 33.3% of courses were unsuccessful (19/57). Bleeding from multiple sites was associated with treatment failure. In 16.7% of patients (11/66), unexpected adverse thromboses developed within 1 week of completing a course of rFVIIa. Thromboses in both intra- and extra-corporeal sites were included if they compromised patient care. CONCLUSIONS In the majority of cases reviewed, rFVIIa was successful in stopping or slowing serious bleeding episodes. It was least effective when a patient had diffuse bleeding at the time of administration. The thrombosis rate of 16.7% was higher than expected, though causality cannot be declared. Further investigation is needed to determine the risk-benefit ratio in children.
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Affiliation(s)
- James D Cooper
- Assistant Professor, Department of Pediatrics, Division of Hematology/Oncology/BMT, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Arthur K Ritchey
- Professor and Vice-Chair for Clinical Affairs, Department of Pediatrics, Division of Hematology/Oncology/BMT, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Habib AM. Comparison of low- and high-dose recombinant activated factor VII for postcardiac surgical bleeding. Indian J Crit Care Med 2016; 20:497-503. [PMID: 27688624 PMCID: PMC5027741 DOI: 10.4103/0972-5229.190365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim of the Study: A retrospective observational study to compare safety and efficacy of high and low doses of recombinant activated factor VIIa (rFVIIa) in severe postcardiac surgical bleeding. Patients and Methods: From 2004 to 2014, all patients who received rFVIIa for bleeding after cardiac surgery were included and arranged in two groups; Group 1: Low dose (40–50 mcg/kg) (n = 98) and Group 2: High dose (90–120 mcg/kg) (n = 156). Results: There was no significant difference in demographic and surgical characteristics of both groups on admission to Cardiac Surgical Intensive Care Unit (CSICU). There was no significant difference between the two groups regarding the reduction in chest tube bleeding in the first 6 h or the transfusion requirement in the 24 h after admission to CSICU. A total of 15 patients (5.9%) had thromboembolic adverse events. (Seven (7.1%) patients in Group 1 compared to 8 (5.1%) patients in Group 2, P = 0.58). There were no significant differences in all-cause mortality at 30 days (2% in Group 1 vs. 3.2% in Group 2, P = 0.6) and at hospital discharge between the two study groups (6.1% in Group 1 vs. 8.3% in Group 2, P = 0.5), respectively. There was no significant difference between the two groups regarding the need for re-exploration, days on mechanical ventilation, CSICU, or hospital stay. Conclusion: In this report, Low-dose rFVIIa showed equivalent efficacy and safety to high-dose rFVIIa. Further prospective randomized studies are needed to confirm these findings.
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Affiliation(s)
- Aly Makram Habib
- Department of Intensive Care, Adult Cardiac Intensive Care Unit, Prince Sultan Cardiac Centre, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Kwon JO, MacLaren R. Comparison of Fresh-Frozen Plasma, Four-Factor Prothrombin Complex Concentrates, and Recombinant Factor VIIa to Facilitate Procedures in Critically Ill Patients with Coagulopathy from Liver Disease: A Retrospective Cohort Study. Pharmacotherapy 2016; 36:1047-1054. [PMID: 27547916 DOI: 10.1002/phar.1827] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE To evaluate fresh-frozen plasma (FFP), four-factor prothrombin complex concentrates (PCCs), and recombinant factor VIIa (rFVIIa) for lowering international normalized ratio (INR) and facilitating procedures in critically ill patients with hepatic impairment. DESIGN Retrospective cohort study. SETTING Intensive care units at a large university-affiliated teaching hospital. PATIENTS Forty-five adults with hepatic impairment who were admitted between September 1, 2011, and December 31, 2015, and had an admission INR of 1.5 or greater, required an invasive intervention or minor surgical procedure, and received FFP alone (15 patients), PCCs (15 patients), or rFVIIa (15 patients). MEASUREMENTS AND MAIN RESULTS The primary outcomes were rates of achieving an INR less than 1.5 at the time of the procedure and an absolute change in INR from 12 hours before the procedure to the time of the procedure. Secondary outcomes were the time to the procedure, blood product use, bleeding rates, and adverse events. The mean ± SD doses of FFP, PCCs, and rFVIIa were 1.1 ± 0.5 units, 2523 ± 861 units, and 2.6 ± 0.9 mg, respectively, administered 2.1 ± 1.4 hours (p<0.05, FFP vs PCCs or rFVIIa), 1.3 ± 0.5 hours, and 1.3 ± 0.6 hours before the procedure, respectively. Achieving an INR less than 1.5 was more likely to occur with PCCs (80%, p=0.03) and rFVIIa (87%, p=0.01) compared with FFP (27%). INR reduction was greater with PCCs (1.6 ± 0.9, p<0.05) and rFVIIa (1.8 ± 0.7, p<0.01) compared with FFP (0.5 ± 0.8). Use of blood products (FFP, cryoprecipitate, packed red blood cells, and platelets) was significantly greater in the FFP group both before and after the procedural intervention. Hypervolemia was less likely to occur in the PCCs (40%, p=0.02) or rFVIIa (33%, p<0.01) groups than in the FFP group (93%). Overall, 33 (73%) of the 45 patients experienced minor bleeding. Three patients (7%) experienced clotting of a central line or dialysis filter, and all were in the PCCs or rFVIIa groups. CONCLUSION Unlike FFP, PCCs and rFVIIa effectively and safely reduced INR in critically ill patients with coagulopathy associated with liver impairment to expedite interventions. The amount of blood products used was significantly lower in the PCC and rFVIIa groups, possibly reducing the risk of hypervolemia. Bleeding rates, however, were similar across groups.
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Affiliation(s)
- Jennifer O Kwon
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.
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Abstract
PURPOSE OF REVIEW Blood coagulation exists to halt excessive blood loss. It is paradoxical that surgery and trauma simultaneously represent major risk factors for both hemorrhagic and thrombotic complications. A summary of the available evidence used to guide contemporary approaches to perioperative care will be reviewed. RECENT FINDINGS Although the advent of factor-specific products has safely allowed for intervention on patients with congenital hemostatic defects, the presence of an increasingly complex surgical population (chronic liver disease, traumatic injuries, and requirements for chronic anticoagulation) has renewed concerns about hemorrhagic risks. However, the past three decades of clinical sciences have supported a re-emphasis on the prevention of venous thromboembolism (VTE), a major cause of morbidity and mortality in hospitalized surgical patients. There is now an abundance of data confirming the robust risk:benefit ratio of antithrombotic prophylaxis in the vast majority of surgical patients, regardless of their medical comorbidities. SUMMARY Perioperative hemorrhage is a natural risk of any surgical intervention and deserves careful evaluation and prompt intervention. However, in order to support ongoing efforts in the prevention of medical errors, the application of evidence-based guidelines for the prophylaxis of VTE in surgical patients must become a standard part of daily practice.
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In vitro reversal of supratherapeutic rivaroxaban levels with coagulation factor concentrates. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:481-6. [PMID: 27177413 DOI: 10.2450/2016.0205-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/09/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND A bleeding patient undergoing therapy with new oral anticoagulants is every clinician's nightmare as no specific reversal agent is available yet. This in vitro study investigated the effect of prothrombin complex concentrate (PCC), recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (aPCC) on supratherapeutic rivaroxaban concentrations using standard laboratory parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT] and PT ratio) and thromboelastometry (clotting time [CT]). MATERIALS AND METHODS Blood samples from 10 healthy volunteers were collected and spiked with a supratherapeutic dose of rivaroxaban. Afterwards PCC, rFVIIa and aPCC were added in two doses. The laboratory parameters were measured and thromboelastometry was performed. RESULTS The addition of the reversal agents had the following statistically significant effects (all p<0.01): +25 IU/kg PCC: CT -15 s, aPTT +5 s; +50 IU/kg PCC: aPTT +11 s; +90 μg rFVIIa: CT -141 s; +25 IU/kg aPCC: CT -142 s, aPTT -9 s, PT ratio +14%, PT -10.5 s; +50 IU/kg aPCC: CT -118 s, aPTT -7 s, PT ratio +17%, PT -12.2 s. DISCUSSION rFVIIa and aPCC, but not PCC, appear to shorten coagulation times significantly in standard laboratory and thromboelastometry assays. These results need confirmation through evaluation of these agents in the clinical setting.
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43
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Habib AM, Mousa AY, Al-Halees Z. Recombinant activated factor VII for uncontrolled bleeding postcardiac surgery. J Saudi Heart Assoc 2016; 28:222-31. [PMID: 27688669 PMCID: PMC5034489 DOI: 10.1016/j.jsha.2016.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 02/09/2016] [Accepted: 03/01/2016] [Indexed: 01/10/2023] Open
Abstract
A retrospective observational study to review the safety and efficacy of rFVIIa in persistent hemorrhage in post cardiac surgical patients. Methods Patients who had bleeding of 3 ml/kg/h or more for 2 consecutive hours after cardiac surgery were arranged into two groups; control group, who received conventional treatment and rFVIIa group, who received conventional treatment and rFVIIa. Results There was no significant difference in demographic and surgical characteristics of both groups. The chest tube output significantly decreased in the rFVIIa group compared to the other group 4 hours after admission {1.4 (IQR: 1–2.2) ml/kg/h vs 3.9 (IQR: 3.1–5.6) ml/kg/h; p = 0.004} and continues to be significant till 9 hours after CSICU admission {0.6 (IQR: 0.4–1.1) ml/kg/h vs 1.9 (IQR: 1.2–2.2) ml/kg/h; p = 0.04}. The median number of blood products units transfused to rFVIIa group was significantly lower compared to control group in the period from 3–12 hours after CSICU admission. 13 (5.5%) patients in rFVIIa group had Thromboembolic adverse events (TAE) compared to 7 (2.4%) patients in other group p = 0.27. 8 patients in the rFVIIa group needed reexploration compared to 19 patients in the other group, p = 0.01. No significant difference was noticed between the 2 groups regarding: new onset renal failure, median number of mechanical ventilator days, pneumonia, mediastinitis, ICU and hospital lengths of stay, survival at 30 days and at discharge. Conclusion In this analysis, rFVIIa succefully reduced the chest tube bleeding and blood products transfused during severe post cardiac surgical bleeding. However, safety of rFVIIa remains unclear. Prospective controlled trials are still needed to confirm the role of rFVIIa.
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Affiliation(s)
- Aly Makram Habib
- Cardiac Surgical Intensive Care Unit, King Faisal Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
- Corresponding author was working at King Faisal Heart Center till June 2015 before he moves to: Adult Surgical Intensive Care Unit, Intensive Care Department, Prince Sultan Cardiac Center, Prince Sultan Military Medical City, Post office Box 7897-x966, Riyadh 11159, Saudi Arabia.
| | - Ahmed Yehia Mousa
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Zohair Al-Halees
- Cardiac Surgery Section, King Faisal Heart Center, King Faisal Specialist Center and Research Center, Riyadh, Saudi Arabia
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Omar HR, Enten G, Karlnoski R, Ching YH, Mangar D, Camporesi EM. Recombinant Activated Factor VII Significantly Reduces Transfusion Requirements in Cardiothoracic Surgery. Drugs R D 2016; 15:187-94. [PMID: 25862216 PMCID: PMC4488183 DOI: 10.1007/s40268-015-0093-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The off-label use of recombinant activated factor VII (rFVIIa) for intractable bleeding is associated with a risk of thrombotic events. The objective of this study was to evaluate the incidence and predictors of rFVIIa-related thrombotic events and its efficacy in the reduction of transfusion requirements during various surgeries. Methods Ninety-two cases received rFVIIa for uncontrollable bleeding despite medical and surgical hemostasis. The incidence and risk factors of thrombotic events were analyzed. Blood products transfused in the 24 h before and after rFVIIa injection were calculated. Subgroup analysis was performed to see which types of surgeries benefited most from rFVIIa. Results The main indication for rFVIIa administration was uncontrollable bleeding during cardiothoracic surgery followed by coagulopathy due to liver failure followed by neurosurgical procedures. Requirements of blood products after rFVIIa decreased significantly by 45 % (p = 0.012), 52 % (p = 0.0001), and 75 % (p = 0.0001) for red blood cells, plasma, and cryoprecipitate, respectively. Subgroup analysis showed that cardiothoracic surgery was the sole group that benefited from rFVIIa with a reduction in transfusion of red blood cells (p = 0.013), plasma (p = 0.0001), and cryoprecipitate (p = 0.0001). Thrombotic events occurred in 9.8 % of the cases mostly on the arterial side (89 %) and have not contributed to mortality. Conclusion rFVIIa can significantly reduce transfusion requirements when given for intractable bleeding during cardiothoracic surgery at the expense of thrombotic events in approximately one tenth of the cases. Further prospective studies are necessary to study if this effect of rFVIIa is translated to a favorable outcome. Electronic supplementary material The online version of this article (doi:10.1007/s40268-015-0093-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Medical Center, 1410 N. Fourth Street, Clinton, IA, 52732, USA,
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45
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Carvalho M, Rodrigues A, Gomes M, Carrilho A, Nunes AR, Orfão R, Alves Â, Aguiar J, Campos M. Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings: Recommendations From the Share Network Group. Clin Appl Thromb Hemost 2016; 22:121-37. [PMID: 25424528 PMCID: PMC4741263 DOI: 10.1177/1076029614559773] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Several clinical settings are associated with specific coagulopathies that predispose to uncontrolled bleeding. With the growing concern about the need for optimizing transfusion practices and improving treatment of the bleeding patient, a group of 9 Portuguese specialists (Share Network Group) was created to discuss and develop algorithms for the clinical evaluation and control of coagulopathic bleeding in the following perioperative clinical settings: surgery, trauma, and postpartum hemorrhage. The 3 algorithms developed by the group were presented at the VIII National Congress of the Associação Portuguesa de Imuno-hemoterapia in October 2013. They aim to provide a structured approach for clinicians to rapidly diagnose the status of coagulopathy in order to achieve an earlier and more effective bleeding control, reduce transfusion requirements, and improve patient outcomes. The group highlights the importance of communication between different specialties involved in the care of bleeding patients in order to achieve better results.
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Affiliation(s)
- Manuela Carvalho
- Transfusion Medicine and Blood Bank Department, H. São João, Centro Hospitalar São João, Porto, Portugal
| | - Anabela Rodrigues
- Transfusion Medicine Department, H. Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Manuela Gomes
- Transfusion Medicine Department, H. Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Alexandre Carrilho
- Anesthesiology Department, H. São José, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - António Robalo Nunes
- Transfusion Medicine Department, H. Pulido Valente, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Rosário Orfão
- Anesthesiology Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Ângela Alves
- Anesthesiology Department, H. Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - José Aguiar
- Anesthesiology Department, H. Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Manuel Campos
- Clinical Hematology Department, H. Santo António, Centro Hospitalar do Porto, Porto, Portugal
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Vilhelmsson A, Davis C, Mulinari S. Pharmaceutical Industry Off-label Promotion and Self-regulation: A Document Analysis of Off-label Promotion Rulings by the United Kingdom Prescription Medicines Code of Practice Authority 2003-2012. PLoS Med 2016; 13:e1001945. [PMID: 26812151 PMCID: PMC4727894 DOI: 10.1371/journal.pmed.1001945] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 12/15/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND European Union law prohibits companies from marketing drugs off-label. In the United Kingdom--as in some other European countries, but unlike the United States--industry self-regulatory bodies are tasked with supervising compliance with marketing rules. The objectives of this study were to (1) characterize off-label promotion rulings in the UK compared to the whistleblower-initiated cases in the US and (2) shed light on the UK self-regulatory mechanism for detecting, deterring, and sanctioning off-label promotion. METHODS AND FINDINGS We conducted structured reviews of rulings by the UK self-regulatory authority, the Prescription Medicines Code of Practice Authority (PMCPA), between 2003 and 2012. There were 74 off-label promotion rulings involving 43 companies and 65 drugs. Nineteen companies were ruled in breach more than once, and ten companies were ruled in breach three or more times over the 10-y period. Drawing on a typology previously developed to analyse US whistleblower complaints, we coded and analysed the apparent strategic goals of each off-label marketing scheme and the practices consistent with those alleged goals. 50% of rulings cited efforts to expand drug use to unapproved indications, and 39% and 38% cited efforts to expand beyond approved disease entities and dosing strategies, respectively. The most frequently described promotional tactic was attempts to influence prescribers (n = 72, 97%), using print material (70/72, 97%), for example, advertisements (21/70, 30%). Although rulings cited prescribers as the prime target of off-label promotion, competing companies lodged the majority of complaints (prescriber: n = 16, 22%, versus companies: n = 42, 57%). Unlike US whistleblower complaints, few UK rulings described practices targeting consumers (n = 3, 4%), payers (n = 2, 3%), or company staff (n = 2, 3%). Eight UK rulings (11%) pertaining to six drugs described promotion of the same drug for the same off-label use as was alleged by whistleblowers in the US. However, while the UK cases typically related to only one or a few claims made in printed material, several complaints in the US alleged multifaceted and covert marketing activities. Because this study is limited to PMCPA rulings and whistleblower-initiated federal cases, it may offer a partial view of exposed off-label marketing. CONCLUSION The UK self-regulatory system for exposing marketing violations relies largely on complaints from company outsiders, which may explain why most off-label promotion rulings relate to plainly visible promotional activities such as advertising. This contrasts with the US, where Department of Justice investigations and whistleblower testimony have alleged complex off-label marketing campaigns that remain concealed to company outsiders. UK authorities should consider introducing increased incentives and protections for whistleblowers combined with US-style governmental investigations and meaningful sanctions. UK prescribers should be attentive to, and increasingly report, off-label promotion.
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Affiliation(s)
- Andreas Vilhelmsson
- Department of Clinical Sciences, Division of Social Medicine and Global Health, Faculty of Medicine, Malmö University, Lund, Sweden
- Department of Gender Studies, Faculty of Social Sciences, Lund University, Lund, Sweden
| | - Courtney Davis
- Department of Social Science, Health and Medicine, King’s College London, London, United Kingdom
| | - Shai Mulinari
- Department of Sociology, Faculty of Social Sciences, Lund University, Lund, Sweden
- * E-mail:
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Niessner A, Tamargo J, Morais J, Koller L, Wassmann S, Husted SE, Torp-Pedersen C, Kjeldsen K, Lewis BS, Drexel H, Kaski JC, Atar D, Storey RF, Lip GYH, Verheugt FWA, Agewall S. Reversal strategies for non-vitamin K antagonist oral anticoagulants: a critical appraisal of available evidence and recommendations for clinical management—a joint position paper of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2015; 38:1710-1716. [DOI: 10.1093/eurheartj/ehv676] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/20/2015] [Indexed: 12/25/2022] Open
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48
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. [Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. ACTA ACUST UNITED AC 2015; 63:e1-e22. [PMID: 26688462 DOI: 10.1016/j.redar.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/17/2015] [Indexed: 12/23/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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49
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 2015; 39:483-504. [PMID: 26233588 DOI: 10.1016/j.medin.2015.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 12/30/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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50
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Abstract
PURPOSE OF REVIEW This review provides a summary of the most recent clinical trials evaluating the hemostatic agents for the treatment of coagulopathy associated with critical bleeding. In particular, antifibrinolytic agents (i.e., aprotinin, tranexamic and ε-aminocaproic acids), desmopressin, recombinant activated factor VII, fibrinogen and prothrombin complex concentrates are evaluated. RECENT FINDINGS Among the various therapeutic options available, tranexamic acid is emerging as the most promising. Indeed, a recent randomized trial has shown a benefit survival of the early administration of tranexamic acid in patients with trauma-induced coagulopathy. SUMMARY Although preliminary data document a potential therapeutic role for prohemostatic pharmacologic approaches, further evidence arising from randomized controlled trials is needed to assess the safety and efficacy of such agents in the setting of critical bleeding.
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