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Wysokinski WE, Houghton DE, Vlazny DT, Ashrani AA, Froehling DA, Kamath PS, Meverden RA, Hodge DO, Peterson LG, Lang TR, McBane RD, Casanegra AI. Influence of primary cancer site on clinical outcomes of anticoagulation for associated venous thromboembolism. Thromb Res 2023; 221:37-44. [PMID: 36463701 DOI: 10.1016/j.thromres.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/29/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The outcome of anticoagulation for cancer-associated venous thromboembolism (Ca-VTE) differs according to cancer location, but data are limited and inconsistent. MATERIALS AND METHODS Patients with acute venous thromboembolism (VTE) enrolled between 03/01/2013 and 04/30/2021 were followed prospectively to assess VTE recurrence, major bleeding (MB), clinically relevant non-major bleeding (CRNMB), and death. RESULTS There were 1702 (45.3 %) patients with Ca-VTE including: gastrointestinal (n = 340), pancreatic (n = 223), hematologic (n = 188), genitourinary (n = 163), lung (n = 139), ovarian (n = 109), breast (n = 97), renal (n = 75), prostate (n = 73), hepatobiliary (n = 70), brain (n = 57), and other cancers (n = 168); 2057 VTE patients had no cancer (NoCa-VTE). Hepatobiliary cancer had the highest VTE recurrence (all rates 100 person-years) of all cancers and higher compared to NoCa-VTE (13.69, p = 0.01), while the MB rate, although numerically higher (15.91), was not different (p = 0.09). Another 3 cancers had higher VTE recurrence but similar MB rates compared to NoCa-VTE: genitourinary [(9.59, p = 0.01) and (7.03, p = 1.0)], pancreatic [(9.74, p < 0.001) and (5.47, p = 1.00)], and hematologic [(5.29, p = 0.05) and (3.59, p = 1.0)]. Renal cancer had the highest rate of MB among all cancers and was higher than that of NoCa-VTE (16.49; p < 0.001), with no difference in VTE recurrence (1.62; p = 1.0). VTE recurrence and MB rates were not significantly different between NoCa-VTE and gastrointestinal, lung, breast, prostate, and brain cancers. CRNMB rates were similar and mortality higher in Ca-VTE patients, except for prostate and breast cancer, compared to NoCa-VTE. CONCLUSIONS Significant differences in clinical outcomes indicate that anticoagulation strategies may need to be tailored to the primary cancer location.
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Affiliation(s)
- Waldemar E Wysokinski
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America.
| | - Damon E Houghton
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Danielle T Vlazny
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Aneel A Ashrani
- Hematology/Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - David A Froehling
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Patrick S Kamath
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States of America
| | - Ryan A Meverden
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, United States of America
| | - Lisa G Peterson
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Teresa R Lang
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Robert D McBane
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
| | - Ana I Casanegra
- Cardiovascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of America
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Wysokinska EM, Houghton DE, Vlazny DT, Ashrani AA, Froehling DA, Meverden R, Hodge DO, Peterson LG, McBane RD, Wysokinski WE, Casanegra AI. Incidental pulmonary embolism in cancer and noncancer patients: Prospective cohort study. Eur J Haematol Suppl 2022; 110:88-98. [PMID: 36210612 DOI: 10.1111/ejh.13877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical picture and outcome of incidental pulmonary embolism (iPE) compared to symptomatic pulmonary embolism (sPE) remain unclear. METHODS Demographics, recurrent venous thromboembolism (VTE), mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared between iPE and sPE patients who were followed prospectively at Mayo Thrombophilia Clinic (March 1, 2013 to August 1, 2020). RESULTS Out of 3576 VTE patients, 1417 (39.6%) had PE: 562 (39.7%) iPE and 855 sPE. Patients with cancer were more likely to have iPE (400 iPE vs. 314 sPE) compared to those without cancer (162 iPE vs. 541 sPE). VTE recurrence rate (all per 100 person-years) was similar in all iPE and sPE patients (3.34 vs. 3.68, p = .50), with cancer (4.16 vs. 4.89, p = .370), and without cancer patients (0.89 vs. 2.80, p = .25). Higher mortality observed in all patients with iPE compared to sPE (46.45 vs. 23.47, p < .001) and with cancer (56.41 vs. 45.77, p = .03) became not significant after adjustment for age, antiplatelet therapy, metastases, and cancer location. Noncancer iPE patients had higher mortality (15.95 vs. 7.18, p = .006) even after adjustment (p = .05). The major bleeding rate was also higher in all patients iPE compared to sPE (7.10 vs. 3.68, p = .03), but not after adjustment (p = .974); higher major bleeding rate in noncancer patients (6.49 vs. 1.25, p = .007) remained significant after adjustment (.02). CRNMB rate was similar to iPE and sPE patients. CONCLUSION iPE represents a more serious clinical condition compared to sPE as indicated by the higher mortality and major bleeding but these differences reflect underlying comorbidities rather than the seriousness of the embolic event.
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Affiliation(s)
| | - Damon E Houghton
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Danielle T Vlazny
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Aneel A Ashrani
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Froehling
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Meverden
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Lisa G Peterson
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D McBane
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar E Wysokinski
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana I Casanegra
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
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3
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Hirao-Try Y, Vlazny DT, Meverden R, Houghton DE, Casanegra AI, Froehling DA, Hodge DO, Peterson LG, McBane RD, Wysokinski WE. Single versus multiple and incidental versus symptomatic subsegmental pulmonary embolism: clinical characteristics and outcome. J Thromb Thrombolysis 2022; 54:82-90. [PMID: 34993715 DOI: 10.1007/s11239-021-02623-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/30/2022]
Abstract
It remains unexplored if the clinical picture and outcome of subsegmental pulmonary embolism (SSPE) differ between single versus multiple, and incidental versus symptomatic embolism. Consecutive patients anticoagulated for SSPE at the Mayo Thrombophilia Clinic (03/01/2013-12/31/2020) were followed forward to assess venous thromboembolism (VTE) recurrence, mortality, major bleeding, and clinically relevant non-major bleeding (CRNMB); expressed as a rate per 100 person-years. Among 3878 VTE patients, 1541 had pulmonary embolism including 224 (14.6%) with SSPE either single (n = 139) or multiple (n = 85; 46 bilateral and 39 unilateral emboli); 134 had incidental and 90 symptomatic SSPE. Patients with single were less often symptomatic and less often had coexisting DVT than multiple SSPE. Patients with incidental had a two-fold higher frequency of cancer compared to symptomatic SSPE. During the study period, 1 patient with single and 2 with multiple SSPE had VTE recurrence (rate of 1.14 vs 3.63, p = 0.280). Single SSPE patients experienced 2 episodes of major bleeding (rate of 2.36) while the multiple SSPE group had no major bleeding. Seven patients in each group had CRNMB events (rate of 8.20 vs 13.58 for single and multiple SSPE, respectively, p = 0.282). Patients with single SSPE had a higher death rate compared to multiple SSPE (43.07 vs 22.22, p = 0.031) but no difference was noted after adjusting for cancer (p = 0.388). Also, incidental had similar clinical outcomes to symptomatic SSPE.Interpretation Anticoagulated SSPE patients with single and multiple as well as incidental and symptomatic have a different clinical profile but similar clinical outcomes.
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Affiliation(s)
- Yumiko Hirao-Try
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Danielle T Vlazny
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Ryan Meverden
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Damon E Houghton
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Ana I Casanegra
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - David A Froehling
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, FL, USA
| | - Lisa G Peterson
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Robert D McBane
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Waldemar E Wysokinski
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA. .,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA.
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Houghton DE, Vlazny DT, Casanegra AI, Brunton N, Froehling DA, Meverden RA, Hodge DO, Peterson LG, McBane RD, Wysokinski WE. Bleeding in Patients With Gastrointestinal Cancer Compared With Nongastrointestinal Cancer Treated With Apixaban, Rivaroxaban, or Enoxaparin for Acute Venous Thromboembolism. Mayo Clin Proc 2021; 96:2793-2805. [PMID: 34425962 DOI: 10.1016/j.mayocp.2021.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/13/2021] [Accepted: 04/27/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the bleeding risk in patients with gastrointestinal (GI) cancer with that in patients with non-GI cancer treated with anticoagulation for acute cancer-associated venous thromboembolism (Ca-VTE). PATIENTS AND METHODS Consecutive patients with Ca-VTE seen at the Mayo Thrombophilia Clinic between March 1, 2013, and April 20, 2020, were observed prospectively to assess major bleeding and clinically relevant nonmajor bleeding (CRNMB). RESULTS In the group of 1392 patients with Ca-VTE, 499 (35.8%) had GI cancer including 272 with luminal GI cancer (lower GI, 208; upper GI, 64), 176 with pancreatic cancer, and 51 with hepatobiliary cancer. The rate of major bleeding and CRNMB in patients with GI cancer was similar to that in 893 (64.2%) patients with non-GI cancer treated with apixaban, rivaroxaban, or enoxaparin. Apixaban had a higher rate of major bleeding in luminal GI cancer compared with the non-GI cancer group (15.59 vs 3.26 per 100 person-years; P=.004) and compared with enoxaparin in patients with luminal GI cancer (15.59 vs 3.17; P=.04). Apixaban had a lower rate of CRNMB compared with rivaroxaban in patients with GI cancer (3.83 vs 9.40 per 100 person-years; P=.03). Patients treated with rivaroxaban in the luminal GI cancer group had a major bleeding rate similar to that of patients with non-GI cancer (2.04 vs 4.91 per 100 person-years; P=.37). CONCLUSION Apixaban has a higher rate of major bleeding in patients with luminal GI cancer compared with patients with non-GI cancer and compared with enoxaparin in patients with luminal GI cancer. Rivaroxaban shows no increased risk of major bleeding in patients with GI cancer or luminal GI cancer compared with patients with non-GI cancer. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03504007.
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Affiliation(s)
- Damon E Houghton
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Danielle T Vlazny
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - David A Froehling
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan A Meverden
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Lisa G Peterson
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Vlazny DT, Pasha AK, Kuczmik W, Wysokinski WE, Bartlett M, Houghton D, Casanegra AI, Daniels P, Froehling DA, White LJ, Hodge DO, McBane RD. Outcome of anticoagulation in isolated distal deep vein thrombosis compared to proximal deep venous thrombosis. J Thromb Haemost 2021; 19:2206-2215. [PMID: 34060224 DOI: 10.1111/jth.15416] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated, distal deep vein thrombosis (IDDVT) is thought to have low rates of propagation, embolization, and recurrence compared with proximal DVT (PDVT), but the data are limited. OBJECTIVES The objective of this study was to assess outcomes among patients with IDDVT compared with PDVT. PATIENTS/METHODS Consecutive patients with ultrasound-confirmed acute DVT (March 1, 2013-August 1, 2020) were identified by reviewing the Mayo Clinic Gonda Vascular Center and VTE Registry databases. Patients were divided into two groups depending on the DVT location (isolated, distal vs. proximal DVT). Outcomes including venous thromboembolism (VTE) recurrence, major bleeding, and death were compared by thrombus location and anticoagulant therapy, warfarin vs. direct oral anticoagulant (DOAC). RESULTS Isolated, distal deep vein thrombosis (n = 746) was more often associated with recent surgery, major trauma, or confinement (p < .001), whereas patients with PDVT (n = 1176) were more frequently unprovoked, had a prior history of VTE, or active cancer (p < .001). There was no overall difference in VTE recurrence or major bleeding between groups during follow-up. Patients with IDDVT had a higher death rate at 3 months (p = .001) and when propensity scored for cancer (p = .003). Independent predictors of mortality included warfarin (vs. DOAC) therapy, increasing age, and active cancer. DOAC therapy resulted in lower VTE recurrence, major bleeding, and death rates in both groups. CONCLUSION Outcomes of IDDVT including VTE recurrence and bleeding rates were similar to PDVT despite higher early mortality rates. Outcomes for both groups were positively influenced by the use of DOACs.
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Affiliation(s)
- Danielle T Vlazny
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ahmed K Pasha
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | | | - Damon Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Paul Daniels
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - David A Froehling
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Department, Mayo Clinic, Rochester, MN, USA
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Wysokinski WE, Froehling DA, Houghton DE, McBane RD, Vlazny DT, Bott‐Kitslaar DM, Kuczmik W, Sutkowska K, Bator K, Hodge DO, Peterson LG, Casanegra AI. Effectiveness and safety of apixaban and rivaroxaban for acute venous thromboembolism therapy in patients with extremes in bodyweight. Eur J Haematol 2020; 105:484-494. [DOI: 10.1111/ejh.13471] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Waldemar E. Wysokinski
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - David A. Froehling
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Damon E. Houghton
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Robert D. McBane
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Danielle T. Vlazny
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Dalene M. Bott‐Kitslaar
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | | | | | - Kaja Bator
- Wroclaw Medical University Wroclaw Poland
| | - David O. Hodge
- Department of Health Sciences Research Mayo Clinic Jacksonville FL USA
| | - Lisa G. Peterson
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
| | - Ana I. Casanegra
- Gonda Vascular Center Thrombophilia Clinic Division of Vascular Medicine Department of Cardiovascular Medicine Mayo Clinic Rochester MN USA
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7
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Wysokinski WE, Houghton DE, Casanegra AI, Vlazny DT, Bott‐Kitslaar DM, Froehling DA, Hodge DO, Peterson LG, Mcbane RD. Comparison of apixaban to rivaroxaban and enoxaparin in acute cancer-associated venous thromboembolism. Am J Hematol 2019; 94:1185-1192. [PMID: 31378995 DOI: 10.1002/ajh.25604] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
To provide direct comparison between apixaban and rivaroxaban in patients with acute cancer-associated venous thromboembolism (Ca-VTE), consecutive patients treated with apixaban, rivaroxaban, or enoxaparin at Mayo Thrombophilia Clinic (March 1, 2013 to January 31, 2018)) were followed prospectively. The primary effectiveness outcome was venous thromboembolism (VTE) recurrence, and the secondary was mortality. The primary safety outcome was major bleeding, the secondary clinically relevant safety outcome was non-major bleeding (CRNMB), and the third a composite of major and CRNMB. There were 750 patients treated for acute Ca-VTE with apixaban (n = 224), rivaroxaban (n = 163), and enoxaparin (n = 363) within 14 days of diagnosis and for at least 3 months, or until study event. Recurrent VTE was diagnosed in 11 receiving apixaban, 7 receiving rivaroxaban (apixaban vs rivaroxaban hazard ratio (HR) 1.31, 95% confidence interval (95% CI) 0.51-3.36) and 17 in the enoxaparin receiving group (apixaban vs enoxaparin HR 1.14, 95% CI: 0.54, 2.42 and rivaroxaban vs enoxaparin HR 0.85, 95% Cl: 0.36, 2.06). There were 82 deaths in apixaban, 74 rivaroxaban (apixaban vs rivaroxaban HR 1.67, 95% Cl: 1.20, 2.33) and 171 in enoxaparin group (rivaroxaban vs enoxaparin HR 0.73, 95% Cl: 0.56, 0.96). Major bleeding occurred in 11 apixaban, 12 rivaroxaban (apixaban vs rivaroxaban HR 0.73, 95% Cl: 0.32, 1.66) and 21 enoxaparin group (apixaban vs enoxaparin HR 0.89, 95% Cl: 0.43, 1.84 and rivaroxaban vs enoxaparin HR 1.23, 95% Cl: 0.61, 2.50). The CRNMB rate was higher in rivaroxaban compared to apixaban (P = .03) and LMWH (P = .01) groups. Recurrence of VTE and major bleeding were similar in apixaban, rivaroxaban, and enoxaparin groups. Rivaroxaban was associated with higher CRNMB but lower mortality compared to apixaban and enoxaparin.
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Affiliation(s)
| | - Damon E. Houghton
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Ana I. Casanegra
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Danielle T. Vlazny
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | | | - David A. Froehling
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - David O. Hodge
- Department of Health Sciences ResearchMayo Clinic Jacksonville Florida
| | - Lisa G. Peterson
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Robert D. Mcbane
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
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8
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Bott-Kitslaar DM, McBane RD, Casanegra AI, Houghton DE, Froehling DA, Vlazny DT, Ashrani AA, Hodge DO, Vargas ER, Bartlett MA, Saadiq RA, Daniels PR, Shields RC, Lenz CJ, Lang TR, Wysokinski WE. Apixaban and Rivaroxaban in Patients With Acute Venous Thromboembolism. Mayo Clin Proc 2019; 94:1242-1252. [PMID: 30737059 DOI: 10.1016/j.mayocp.2018.09.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare the clinical efficacy and safety of apixaban with those of rivaroxaban for the treatment of acute venous thromboembolism (VTE). PATIENTS AND METHODS Consecutive patients enrolled in the Mayo Thrombophilia Clinic Registry (between March 1, 2013, and January 30, 2018) and treated with apixaban or rivaroxaban for acute VTE were followed forward in time. The primary efficacy outcome was VTE recurrence. The primary safety outcome was major bleeding; the second safety outcome was clinically relevant nonmajor bleeding (CRNMB); and the third was a composite of major bleeding or CRNMB. RESULTS Within the group of 1696 patients with VTE enrolled, 600 (38%) were treated either with apixaban (n=302, 50%) or rivaroxaban (n=298, 50%) within the first 14 days of VTE diagnosis and who completed at least 3 months of therapy or had a study event. Recurrent VTE was diagnosed in 7 patients (2.3%) treated with apixaban and in 6 (2%) treated with rivaroxaban (adjusted hazard ratio [aHR], 1.4; 95% CI, 0.5-3.8). Major bleeding occurred in 11 patients (3.6%) receiving apixaban and in 9 patients (3.0%) receiving rivaroxaban (aHR, 1.2; 95% CI, 0.5-3.2). Clinically relevant nonmajor bleeding was diagnosed in 7 patients (2.3%) receiving apixaban and in 20 (6.7%) receiving rivaroxaban (aHR, 0.4; 95% CI, 0.2-0.9). The rates of composite major bleeding or CRNMB were similar (aHR, 0.6; 95% CI, 0.3-1.2). Most study events occurred in patients with cancer. CONCLUSION In the setting of a standardized, guideline-directed, patient-oriented clinical practice, the efficacy and safety of apixaban and rivaroxaban for the treatment of acute VTE were comparable.
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Affiliation(s)
- Dalene M Bott-Kitslaar
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - David A Froehling
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Danielle T Vlazny
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Aneel A Ashrani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Emily R Vargas
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Matthew A Bartlett
- General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rayya A Saadiq
- General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul R Daniels
- General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Raymond C Shields
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Charles J Lenz
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Teresa R Lang
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Department of Cardiovascular Diseases, Thrombophilia Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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Guerra H, Pittock SJ, Moder KG, Froehling DA, Flanagan EP. Neuromyelitis optica spectrum initially diagnosed as antiphospholipid antibody myelitis. J Neurol Sci 2016; 361:204-5. [PMID: 26810544 DOI: 10.1016/j.jns.2016.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 10/16/2015] [Accepted: 01/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Hilda Guerra
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin G Moder
- Department of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - David A Froehling
- Department of Cardiovascular Medicine and Internal Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Mauck KF, Froehling DA, Daniels PR, Dahm DL, Ashrani AA, Crusan DJ, Petterson TM, Bailey KR, Heit JA. Incidence of venous thromboembolism after elective knee arthroscopic surgery: a historical cohort study. J Thromb Haemost 2013; 11:1279-86. [PMID: 23648016 PMCID: PMC3827585 DOI: 10.1111/jth.12283] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 04/22/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The incidence of symptomatic venous thromboembolism (VTE) after knee arthroscopy is uncertain. OBJECTIVES To estimate the incidence of symptomatic VTE after arthroscopic knee surgery. METHODS In a population-based historical cohort study, all Olmsted County, MN, USA, residents undergoing a first arthroscopic knee surgery during the 18-year period of 1988-2005 were followed for incident deep venous thrombosis or pulmonary embolism. The cumulative incidence of VTE after knee arthroscopy was determined using the Kaplan-Meier product limit estimator. Patient age at surgery, sex, calendar year of surgery, body mass index, anesthesia characteristics, and hospitalization were tested as potential predictors of VTE using Cox proportional hazards modeling, both univariately and adjusted for age and sex. RESULTS Among 4833 Olmsted County residents with knee arthroscopy, 18 developed postoperative VTE, all within the first 6 weeks after surgery. The cumulative incidence rates of symptomatic VTE at 7, 14, and 35 days were 0.2%, 0.3%, and 0.4%, respectively. The hazard for postoperative VTE was significantly increased for older patient age (hazard ratio = 1.34 for each 10-year increase in patient age; P = 0.03) and hospitalization either before or after knee arthroscopy (hazard ratio = 14.1; P < 0.001). CONCLUSIONS The incidence of symptomatic VTE after arthroscopic knee surgery is very low. Older age and hospitalization are associated with increased risk. Routine prophylaxis to prevent symptomatic VTE is likely not needed in this patient population.
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Affiliation(s)
- K F Mauck
- Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Elkin PL, Froehling DA, Wahner-Roedler DL, Brown SH, Bailey KR. Comparison of natural language processing biosurveillance methods for identifying influenza from encounter notes. Ann Intern Med 2012; 156:11-8. [PMID: 22213490 DOI: 10.7326/0003-4819-156-1-201201030-00003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An effective national biosurveillance system expedites outbreak recognition and facilitates response coordination at the federal, state, and local levels. The BioSense system, used at the Centers for Disease Control and Prevention, incorporates chief complaints but not data from the whole encounter note into its surveillance algorithms. OBJECTIVE To evaluate whether biosurveillance by using data from the whole encounter note is superior to that using data from the chief complaint field alone. DESIGN 6-year retrospective case-control cohort study. SETTING Mayo Clinic, Rochester, Minnesota. PARTICIPANTS 17,243 persons tested for influenza A or B virus between 1 January 2000 and 31 December 2006. MEASUREMENTS The accuracy of a model based on signs and symptoms to predict influenza virus infection in patients with upper respiratory tract symptoms, and the ability of a natural language processing technique to identify definitional clinical features from free-text encounter notes. RESULTS Surveillance based on the whole encounter note was superior to the chief complaint field alone. For the case definition used by surveillance of the whole encounter note, the normalized partial area under the receiver-operating characteristic curve (specificity, 0.1 to 0.4) for surveillance using the whole encounter note was 92.9% versus 70.3% for surveillance with the chief complaint field (difference, 22.6%; P < 0.001). Comparison of the 2 models at the fixed specificity of 0.4 resulted in sensitivities of 89.0% and 74.4%, respectively (P < 0.001). The relative risk for missing a true case of influenza was 2.3 by using the chief complaint field model. LIMITATIONS Participants were seen at 1 tertiary referral center. The cost of comprehensive biosurveillance monitoring was not studied. CONCLUSION A biosurveillance model for influenza using the whole encounter note is more accurate than a model that uses only the chief complaint field. Because case-defining signs and symptoms of influenza are commonly available in health records, the investigators believe that the national strategy for biosurveillance should be changed to incorporate data from the whole health record. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Peter L Elkin
- Mount Sinai School of Medicine, New York, New York, USA.
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12
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Wahner-Roedler DL, Welsh GA, Trusko BE, Froehling DA, Temesgen Z, Elkin PL. Using natural language processing for identification of pneumonia cases from clinical records of patients with serologically proven influenza. AMIA Annu Symp Proc 2008:1165. [PMID: 18998814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 07/08/2008] [Indexed: 05/27/2023]
Abstract
The purpose of this study was to determine whether influenza vaccination protects against pneumonia in patients who develop influenza. By parsing a data set of records of 1455 patients with serologically proven influenza using SNOMED CT we found that of the vaccinated patients 19.3% developed pneumonia and of the unvaccinated 20.7%. These data suggest that influenza vaccine does not prevent pneumonias in patients who develop influenza despite immunization with influenza vaccine.
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Brown SH, Rosenbloom ST, Bauer BA, Wahner-Roedler D, Froehling DA, Bailey KR, Lincoln MJ, Montella D, Fielstein EM, Elkin PL. Direct comparison of MEDCIN and SNOMED CT for representation of a general medical evaluation template. AMIA Annu Symp Proc 2007; 2007:75-79. [PMID: 18693801 PMCID: PMC2655894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/24/2007] [Accepted: 10/11/2007] [Indexed: 05/26/2023]
Abstract
BACKGROUND Two candidate terminologies to support entry of general medical data are SNOMED CT and MEDCIN. We compare the ability of SNOMED CT and MEDCIN to represent concepts and interface terms from a VA general medical examination template. METHODS We parsed the VA general medical evaluation template and mapped the resulting expressions into SNOMED CT and MEDCIN. Internists conducted double independent reviews on 864 expressions. Exact concept level matches were used to evaluate reference coverage. Exact term level matches were required for interface terms. RESULTS Sensitivity of SNOMED CT as a reference terminology was 83% vs. 25% for MEDCIN (p<0.001). The sensitivity of SNOMED CT as an interface terminology was 53% vs. 7% for MEDCIN (P< 0.001). DISCUSSION The content coverage of SNOMED CT as a reference terminology and as an interface terminology outperformed MEDCIN. We did not evaluate other aspects of interface terminologies such as richness of clinical linkages.
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Froehling DA, Daniels PR, Swensen SJ, Heit JA, Mandrekar JN, Ryu JH, Elkin PL. Evaluation of a quantitative D-dimer latex immunoassay for acute pulmonary embolism diagnosed by computed tomographic angiography. Mayo Clin Proc 2007; 82:556-60. [PMID: 17493420 DOI: 10.4065/82.5.556] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the sensitivity and specificity of a quantitative plasma fibrin D-dimer latex immunoassay (LIA) for the diagnosis of acute pulmonary embolism. SUBJECTS AND METHODS Study subjects were Mayo Clinic Rochester inpatients and outpatients with suspected acute pulmonary embolism; all had undergone quantitative D-dimer LIA testing and multidetector-row computed tomographic (CT) angiography between August 3, 2001, and November 10, 2003. Multidetector-row CT angiography was the diagnostic reference standard. RESULTS Of 1355 CT studies, 208 (15%) were positive for acute pulmonary embolism. Median D-dimer levels were significantly higher for patients with acute pulmonary embolism (1425 ng/mL) than for patients without (500 ng/mL) (P<.001). The highest specificity that optimizes sensitivity for acute pulmonary embolism was achieved by using a discriminant value of 300 ng/mL, which yielded a sensitivity of 0.94 (95% confidence interval [CI], 0.89-0.97), a specificity of 0.27 (95% CI, 0.25-0.30), and a negative predictive value of 0.96 (95% CI, 0.93-0.98). CONCLUSION The quantitative D-dimer LIA with a discriminant value of 300 ng/mL had high sensitivity and high negative predictive value but low specificity for the diagnosis of acute pulmonary embolism. On the basis of these results, we believe that a negative quantitative D-dimer LIA result and a low pretest probability of thromboembolism together are sufficient to exclude acute pulmonary embolism.
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Affiliation(s)
- David A Froehling
- Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Ryu JH, Pellikka PA, Froehling DA, Peters SG, Aughenbaugh GL. Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome. Respir Med 2007; 101:1537-42. [PMID: 17254761 DOI: 10.1016/j.rmed.2006.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 12/06/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the frequency, clinical presentation and outcome associated with saddle pulmonary embolism (PE) diagnosed by computed tomographic angiography (CTA). PATIENTS Retrospective review of 546 consecutive patients diagnosed to have acute PE by CTA from 1 September 2002 to 31 December 2003. RESULTS Fourteen of 546 patients (2.6%) had saddle PE; 10 were men (71%). None of these patients had pre-existing cardiopulmonary disease. Most common presenting symptoms included dyspnea (72%) and syncope (43%). Hypotension was documented in 2 patients (14%). The most common risk factor for PE was obesity (64%). CTA revealed saddle PE and additional filling defects in the main pulmonary arteries in all patients. Echocardiography was performed within 48 h of the PE diagnosis in 10 patients and revealed right ventricular dysfunction in 8 (80%). All patients were initially managed in the hospital, median length of stay of 4 days (range, 1-45 days). Standard anticoagulant therapy with heparin and warfarin was administered to all patients. Five patients (36%) received additional therapy; thrombolytic therapy was administered to 1 patient (7%) and 4 patients (29%) received an inferior vena cava filter. None of the patients died during their hospitalization. Four patients (29%) died following their hospitalization after intervals of 1, 5, 6, and 12 months, respectively. Causes of death were known in 3 patients, all of whom died from progressive malignancy. CONCLUSION Saddle PE in patients without pre-existing cardiopulmonary disease is associated with a relatively low in-hospital mortality rate and may not necessitate aggressive medical management.
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Affiliation(s)
- Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905, USA.
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Carter JS, Brown SH, Bauer BA, Elkin PL, Erlbaum MS, Froehling DA, Lincoln MJ, Rosenbloom ST, Wahner-Roedler DL, Tuttle MS. Categorical information in pharmaceutical terminologies. AMIA Annu Symp Proc 2006; 2006:116-20. [PMID: 17238314 PMCID: PMC1839555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Drug information sources use category labels to assist in navigating and organizing information. Some category labels describe drugs from multiple perspectives (e.g., both structure and function). The National Drug File - Reference Terminology (NDF RT) is a drug information source that augments a "legacy" categorization system with a formal reference model specifying Chemical Structure, Cellular or Sub-Cellular Mechanism of Action, Organ- or System-Level Physiological Effect, and Therapeutic Intent categories. We examined drug category names from three sources to better understand their information content and evaluate NDF RT's semantic coverage. On average, category names contain more than 1.5 attributes. NDF RT's reference model covers more than 76% of the information identified in drug category labels. A new NDF RT reference axis of drug formulations could improve NDF RT's coverage to 85%. The distinction between Physiological Effect and Therapeutic Intent, prompted many questions among category reviewers, suggesting that further clarification of these reference concepts is required. Careful review of existing categorization schemes may guide structured terminology and ontology development efforts toward greater fidelity to deployed information sources.
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Batsis JA, Craici IM, Froehling DA. Central venous catheter thrombosis complicated by paradoxical embolism in a patient with diabetic ketoacidosis and respiratory failure. Neurocrit Care 2005; 2:185-8. [PMID: 16159064 DOI: 10.1385/ncc:2:2:185] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Paradoxical embolus should be suspected in young patients with cerebrovascular events who do not have any vascular risk factors. There is significant controversy as to how best to treat his phenomenon. METHODS A case observation in a tertiary care center. RESULTS A 46-year-old was admitted to the intensive care unit (ICU) for unresponsiveness secondary to diabetic ketoacidosis and acute respiratory distress syndrome. He was intubated, and central access was obtained through the right internal jugular vein. Initial computed tomography (CT) scan of his brain was unremarkable. Four days later, he suddenly became increasingly unresponsive. Repeat CT scan of the brain revealed large bilateral posterior infarcts. Transesophegeal echocardiogram revealed a patent foramen ovale (PFO), and Doppler ultrasound revealed a thrombus in the low right jugular vein. He was anticoagulated for 3 months with no intervention for his PFO. CONCLUSION This case emphasizes the potential complications of the use of central lines in ICUs, particularly in patients with diabetic ketoacidosis in whom sluggish blood flow may predispose to a procoagulant state.
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Affiliation(s)
- John A Batsis
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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18
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Froehling DA, Elkin PL, Swensen SJ, Heit JA, Pankratz VS, Ryu JH. Sensitivity and specificity of the semiquantitative latex agglutination D-dimer assay for the diagnosis of acute pulmonary embolism as defined by computed tomographic angiography. Mayo Clin Proc 2004; 79:164-8. [PMID: 14959909 DOI: 10.4065/79.2.164] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the sensitivity and specificity of the semiquantitative latex agglutination plasma fibrin D-dimer assay for the diagnosis of acute pulmonary embolism by using computed tomographic (CT) angiography as the diagnostic reference standard. PATIENTS AND METHODS From January 1, 1998, to June 26, 2000, patients who had both semiquantitative latex agglutination plasma fibrin D-dimer testing and CT angiography for suspected acute pulmonary embolism were selected for the study. A D-dimer value greater than 250 ng/mL was considered positive for thromboembolic disease. Diagnosis of acute pulmonary embolism was based solely on the interpretation of the CT angiogram. The D-dimer assay results were then compared with the CT angiographic diagnoses. RESULTS Of 946 CT studies, 172 (18%) were positive for acute pulmonary embolism. The D-dimer assay was positive for 612 (65%) of the 946 patients. For acute pulmonary embolism, the D-dimer assay had a sensitivity of 0.83 (95% confidence interval [CI], 0.76-0.88), a specificity of 039 (95% CI, 036-0.43), a negative likelihood ratio of 0.44 (95 % CI, 032-0.62), and a negative predictive value of 0.91 (95% CI, 0.87-0.94). CONCLUSIONS The semiquantitative latex agglutination plasma fibrin D-dimer assay had moderate sensitivity and low specificity for the diagnosis of acute pulmonary embolism. When used alone, the results of this test were insufficient to exclude this serious and potentially fatal disorder. Approximately two thirds of our patients had positive D-dimer assays and required further evaluation to exclude acute pulmonary embolism.
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Affiliation(s)
- David A Froehling
- Division of Area General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
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Ensminger SA, Regner KR, Froehling DA. 35-year-old woman with cough, fever, and anorexia. Mayo Clin Proc 2003; 78:753-6. [PMID: 12934787 DOI: 10.4065/78.6.753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- S Allen Ensminger
- Resident in Internal Medicine, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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Froehling DA, Bowen JM, Mohr DN, Brey RH, Beatty CW, Wollan PC, Silverstein MD. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000; 75:695-700. [PMID: 10907384 DOI: 10.4065/75.7.695] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the canalith repositioning procedure (CRP) with a sham maneuver for the treatment of benign paroxysmal positional vertigo. PATIENTS AND METHODS We recruited 50 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination (Dix-Hallpike maneuver). Patients were randomized to either the CRP (n = 24) or a sham maneuver (n = 26). Measured outcomes included resolution of vertigo and positional nystagmus at follow-up examination. RESULTS The mean duration of follow-up was 10 days for both groups. Resolution of symptoms was reported by 12 (50%) of the 24 patients in the CRP group and by 5 (19%) of the 26 patients in the sham group (P = .02). The results of the Dix-Hallpike maneuver were negative for positional nystagmus in 16 (67%) of 24 patients in the CRP group and in 10 (38%) of 26 patients in the sham group (P = .046). CONCLUSION The CRP is effective treatment of benign paroxysmal positional vertigo, and this procedure can be performed by general internists on outpatients with this disorder.
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Affiliation(s)
- D A Froehling
- Division of Area General Internal Medicine, Mayo Clinic, Rochester, Minn. 55905, USA
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Froehling DA, Silverstein MD, Mohr DN, Beatty CW. The rational clinical examination. Does this dizzy patient have a serious form of vertigo? JAMA 1994; 271:385-8. [PMID: 8283588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D A Froehling
- Division of Area General Internal Medicine, Mayo Clinic, Rochester, MN 55905
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Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991; 66:596-601. [PMID: 2046397 DOI: 10.1016/s0025-6196(12)60518-7] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A retrospective review of our population-based medical records linkage system for residents of Olmsted County, Minnesota, revealed 53 patients (34 women and 19 men; mean age, 51 years) with newly diagnosed benign positional vertigo in 1984. The age- and sex-adjusted incidence was 64 per 100,000 population per year (95% confidence interval, 46 to 81 per 100,000). The incidence of benign positional vertigo increased by 38% with each decade of life (95% confidence interval, 23 to 54%). One patient had an initial stroke during follow-up; thus, the relative risk for new stroke associated with benign positional vertigo was 1.62 (95% confidence interval, 0.04 to 8.98) in comparison with the expected occurrence based on incidence rates for an age- and sex-adjusted control population. The observed survival among the 53 Olmsted County residents with benign positional vertigo diagnosed in 1984 was not significantly different from that of an age- and sex-matched general population. Patients with benign positional vertigo seem to have a good prognosis.
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Affiliation(s)
- D A Froehling
- Division of Area Medicine, Mayo Clinic, Rochester, MN 55905
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